Attending

by Ronald Epstein

  16 G. E. Simon and O. Gureje, “Stability of Somatization Disorder and Somatization Symptoms among Primary Care Patients,” Archives of General Psychiatry 56(1) (1999): 90–95.

  17 This story has multiple sources, including P. Reps and N. Senzaki, Zen Flesh, Zen Bones: A Collection of Zen and Pre-Zen Writings (Clarendon, VT: Tuttle Publishing, 1998).

  18 D. J. Levitin, The Organized Mind: Thinking Straight in the Age of Information Overload (New York: Dutton Adult, 2014); Croskerry, “From Mindless to Mindful Practice”; P. Croskerry and G. Norman, “Overconfidence in Clinical Decision Making,” American Journal of Medicine 121(5) (2008): S24–S29; and P. Croskerry, “The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them,” Academic Medicine 78(8) (2003): 775–80.

  19 J. Dewey, Experience and Nature (New York: Dover, 1958).

  20 For an eloquent discussion of fragile categories and their philosophical and pragmatic implications, see W. James, Pragmatism (Cambridge, MA: Harvard University Press, 1975). For a Buddhist perspective on the emptiness of categories, see F. J. Streng, Emptiness: A Study in Religious Meaning (Nashville, TN: Abingdon Press, 1967).

  21 C. Barks, The Essential Rumi (London: Castle Books, 1997).

  22 G. Norman, M. Young, and L. Brooks, “Non-analytical Models of Clinical Reasoning: The Role of Experience,” Medical Education 41(12) (2007): 1140–45.

  23 See T. J. Kaptchuk, The Web That Has No Weaver: Understanding Chinese Medicine (New York: Congdon & Weed, 1983).

  24 See J. Greenberg, K. Reiner, and N. Meiran, “ ‘Mind the Trap’: Mindfulness Practice Reduces Cognitive Rigidity,” PLoS ONE 7(5) (2012): e36206.

  25 This intervention had many of the same elements as our physician training programs.

  26 See J. Connelly, “Being in the Present Moment: Developing the Capacity for Mindfulness in Medicine,” Academic Medicine 74(4) (1999): 420–24.

  27 D. A. Schön, Educating the Reflective Practitioner (San Francisco: Jossey-Bass, 1987).

  5. BEING PRESENT

  1 Philosopher Michel Foucault described how a “clinical gaze,” in contrast to usual social interactions, objectifies and disempowers patients, especially in hospital settings. See M. Foucault, The Birth of the Clinic: An Archaeology of Medical Perception (New York: Random House, 1994). Philosopher Emmanuel Levinas describes how ethical behavior starts with apprehending another’s face, more so than principles, words, and ideas. For further discussion of Levinas’s ethical mandate of immediacy in health care contexts, see R. Naef, “Bearing Witness: A Moral Way of Engaging in the Nurse-Person Relationship,” Nursing Philosophy 7(3) (2006): 146–56; P. Komesaroff, “The Many Faces of the Clinic: A Levinasian View,” in Handbook of Phenomenology and Medicine, ed. S. K. Toombs (Dordrecht, Netherlands: Kluwer Academic Publishers, 2001), 317–30; and J. V. Welie, “Towards an Ethics of Immediacy: A Defense of a Noncontractual Foundation of the Care Giver–Patient Relationship,” Medicine, Health Care, and Philosophy 2(1) (1999): 11–19.

  2 A. L. Suchman and D. A. Matthews, “What Makes the Patient-Doctor Relationship Therapeutic? Exploring the Connexional Dimension of Medical Care,” Annals of Internal Medicine 108(1) (1988): 125–30.

  3 M. K. Marvel et al., “Soliciting the Patient’s Agenda: Have We Improved?,” JAMA 281(3) (1999): 283–87.

  4 I am grateful to Steve McPhee, M.D., who generously shared with me his thoughts on presence and his inspiration by the works of Harper and Marcel. See R. Harper, On Presence: Variations and Reflections (Philadelphia: Trinity Press International, 1991).

  5 The idea of an observing self has been approached from educational, psychoanalytic, philosophical, and, more recently, neuroscientific perspectives. Here are some entry points into a rich literature: M. Epstein, Thoughts without a Thinker: Psychotherapy from a Buddhist Perspective (New York: Basic Books, 1995); R. M. Epstein, D. J. Siegel, and J. Silberman, “Self-Monitoring in Clinical Practice: A Challenge for Medical Educators,” Journal of Continuing Education in the Health Professions 28(1) (2008): 5–13; and B. J. Baars, T. Z. Ramsoy, and S. Laureys, “Brain, Conscious Experience and the Observing Self,” Trends in Neurosciences 26(12) (2003): 671–75.

  6 J. E. Connelly, “Narrative Possibilities: Using Mindfulness in Clinical Practice,” Perspectives in Biology and Medicine 48(1) (2005): 84–94; J. Coulehan, “Compassionate Solidarity: Suffering, Poetry, and Medicine,” Perspectives in Biology and Medicine 52(4) (2009): 585–603; J. L. Coulehan, “Tenderness and Steadiness: Emotions in Medical Practice,” Literature and Medicine 14(2) (1995): 222–36; and R. Charon, “Narrative Medicine: Form, Function, and Ethics,” Annals of Internal Medicine 134(1) (2001): 83–87.

  7 This story is discussed in an article and cited with permission in R. M. Epstein, “Making the Ineffable Visible,” Families, Systems, & Health 33(3) (2015): 280–82.

  8 K. J. Swayden et al., “Effect of Sitting vs. Standing on Perception of Provider Time at Bedside: A Pilot Study,” Patient Education & Counseling 86(2) (2012): 166–71.

  9 K. Zoppi, “Communication about Concerns in Well-Child Visits” (Ann Arbor: University of Michigan, 1994).

  10 A. L. Back et al., “Compassionate Silence in the Patient-Clinician Encounter: A Contemplative Approach,” Journal of Palliative Medicine 12(12) (2009): 1113–17; and J. Bartels et al.,“Eloquent Silences: A Musical and Lexical Analysis of Conversation between Oncologists and Their Patients,” Patient Education & Counseling (forthcoming, 2016).

  11 C. Lamm, C. D. Batson, and J. Decety, “The Neural Substrate of Human Empathy: Effects of Perspective-Taking and Cognitive Appraisal,” Journal of Cognitive Neuroscience 19(1) (2007): 42–58.

  12 C. Barks, The Essential Rumi (London: Castle Books, 1997); and J. E. Connelly, “The Guest House (Commentary),” Academic Medicine 83(6) (2008): 588–89.

  13 G. Riva et al., “From Intention to Action: The Role of Presence,” New Ideas in Psychology 29(1) (2011): 24–37.

  14 J. Leff et al., “Computer-Assisted Therapy for Medication-Resistant Auditory Hallucinations: Proof-of-Concept Study,” British Journal of Psychiatry 202(6) (2013): 428–33.

  15 This understanding—that the mind is relational—is a radical departure from earlier notions of how the mind works. Giuseppe Riva and philosopher Evan Thompson and neuroscientist Antonio Damasio all suggest—from very different philosophical points of view—that “mind” emerges as a property of the relationship among a brain, a body, and the world, and from that embodied extended mind a sense of self and a sense of presence emerge.

  16 See E. Thompson and M. Stapleton, “Making Sense of Sense-Making: Reflections on Enactive and Extended Mind Theories,” Topoi 28(1) (2009): 23–30.

  17 To understand more about intersubjectivity, I’d suggest starting with M. Buber, I and Thou (New York: Scribner, 1970); and N. Pembroke, “Human Dimension in Medical Care: Insights from Buber and Marcel,” Southern Medical Journal 103(12) (2010): 1210–13.

  18 As I’ve mentioned before, this skill “works” only if one has the ability to maintain enough differentiation between oneself and the other person to understand which experiences are yours and which are the other’s—otherwise it disintegrates into shared delusion.

  19 D. B. Baker, R. Day, and E. Salas, “Teamwork as an Essential Component of High-Reliability Organizations,” Health Services Research 41(4, pt. 2) (2006): 1576–98.

  20 J. Chatel-Goldman et al., “Non-local Mind from the Perspective of Social Cognition,” Frontiers in Human Neuroscience 7 (2013): 107; and J. Zlatev et al., “Intersubjectivity: What Makes Us Human?,” in The Shared Mind: Perspectives on Intersubjectivity, eds. J. Zlatev, T. P. Racine, C. Sinha, and E. Itkonen (Amsterdam and Philadelphia: John Benjamins, 2008), chap. 1, 1–14.

  21 W. B. Ventres and R. M. Frankel, “Shared Presence in Physician-Patient Communication: A Graphic Representation,” Families, Systems, & Health 33(3) (2015): 270–79.

  22 See R. Klitzman, When Doctors Become Patients (New York: Oxford University Press, 2008).

&nb
sp; 23 Dozens of studies document implicit bias in health care. Here are a few: D. J. Burgess, “Are Providers More Likely to Contribute to Healthcare Disparities under High Levels of Cognitive Load? How Features of the Healthcare Setting May Lead to Biases in Medical Decision Making,” Medical Decision Making 30(2) (2010): 246–57; J. A. Sabin, F. P. Rivara, and A. G. Greenwald, “Physician Implicit Attitudes and Stereotypes about Race and Quality of Medical Care,” Medical Care 46(7) (2008): 678–85; D. J. Burgess, S. S. Fu, and M. van Ryn, “Why Do Providers Contribute to Disparities and What Can Be Done About It?,” Journal of General Internal Medicine 19(11) (2004): 1154–59; M. van Ryn, “Research on the Provider Contribution to Race/Ethnicity Disparities in Medical Care,” MedCare 40(1) (2002): I140–I151; and J. Sabin et al., “Physicians’ Implicit and Explicit Attitudes about Race by MD Race, Ethnicity, and Gender,” Journal of Health Care for the Poor and Underserved 20(3) (2009): 896–913.

  24 W. J. Hall et al., “Implicit Racial/Ethnic Bias among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review,” American Journal of Public Health 105(12) (2015): e60–e76.

  25 R. M. Epstein et al., “Understanding Fear of Contagion among Physicians Who Care for HIV Patients,” Family Medicine 25(4) (1993): 264–68; and J. Shapiro, “Walking a Mile in Their Patients’ Shoes: Empathy and Othering in Medical Students’ Education,” Philosophy, Ethics, and Humanities in Medicine 3(1) (2008): 1.

  26 J. A. Bartz et al., “Oxytocin Selectively Improves Empathic Accuracy,” Psychological Science 21(10) (2010): 1426–28; and C. K. De Dreu, “Oxytocin Modulates Cooperation within and Competition between Groups: An Integrative Review and Research Agenda,” Hormones and Behavior 61(3) (2012): 419–28.

  27 For an interesting discussion of tribalism in modern culture, see J. Greene, Moral Tribes: Emotion, Reason, and the Gap between Us and Them (New York: Penguin Press, 2013).

  28 With training, people can experience greater emotional resonance. As tribal beings, though, we squelch the resonance if we label the other person as “not like me.” To make matters worse, the tendency to stereotype—and therefore distance—worsens when people are under high cognitive load, such as in the emergency room. T. J. Allen et al., “Stereotype Strength and Attentional Bias: Preference for Confirming versus Disconfirming Information Depends on Processing Capacity,” Journal of Experimental Social Psychology 45(5) (2009): 1081–87; Burgess, “Are Providers More Likely to Contribute?”; and Burgess, Fu, and van Ryn, “Why Do Providers Contribute to Disparities?” An often-quoted study by Knox Todd examined prescriptions for pain medications in a busy Los Angeles emergency room prescribed for Latinos and non-Latinos with long-bone fractures of equivalent severity. Latinos received far fewer prescriptions and for lower doses, and twice as many Latinos as Anglos received no pain medication at all: K. H. Todd, N. Samaroo, and J. R. Hoffman, “Ethnicity as a Risk Factor for Inadequate Emergency Department Analgesia,” JAMA 269(12) (1993): 1537–39. Perhaps the physicians unconsciously viewed Latino patients as more stoic or that they were more likely to abuse medications. I’m not sure why and the study didn’t ask. Cognitive load and unexamined bias surely had something to do with it. Bias is not restricted to ethnicity. Physicians use fewer tests for heart disease in women and blacks compared to white males with equivalent risk factors—K. A. Schulman et al., “The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization,” New England Journal of Medicine 340(8) (1999): 618–26—and provide less adequate breast cancer treatments to black women as compared to white women with the same disease characteristics: V. L. Shavers and M. L. Brown, “Racial and Ethnic Disparities in the Receipt of Cancer Treatment,” Journal of the National Cancer Institute 94(5) (2002): 334–57. Similar biases exist for patients who are overweight and of low educational level.

  Bias is not acceptable for doctors and other professionals; our mandate is to serve everyone, including patients whose life experiences are vastly different from our own. Because people generally disavow bias, the first, and challenging, step is awareness. A somewhat controversial and fascinating test for measuring implicit biases—biases that are below the level of awareness—was developed using computer technology that measures how long you take to respond to questions associating race, for example, with positive and negative words. Called the implicit-association test, the scores correlate with our judgments about people’s character, abilities, and potential. A free version can be found at https://implicit.harvard.edu/implicit/takeatest.html. For a good read about the test and its implications, see M. Banaji and A. Greenwald, Blindspot: Hidden Biases of Good People (New York: Delacorte Press, 2013). Also see J. F. Dovidio et al., “On the Nature of Prejudice: Automatic and Controlled Processes,” Journal of Experimental Social Psychology 33(5) (1997): 510–40; and A. G. Greenwald, D. E. McGhee, and J. L. K. Schwartz, “Measuring Individual Differences in Implicit Cognition: The Implicit Association Test,” Journal of Personality and Social Psychology 74(6) (1998): 1464–80. For example, a well-meaning and otherwise excellent doctor might believe that he treats men’s and women’s pain similarly, but the way he associates pain with gender during the test may reveal biases of which he is unaware and that influence his prescribing practices. People’s reactions to the IAT range from bland acceptance to vehement denial; those who deny their biases, not surprisingly, have fewer means for accommodating and diminishing the effects of bias.

  29 Specifically the areas of the brain that involve self-other differentiation and cognitive appraisal (i.e., the dorsomedial prefrontal cortex and right inferior frontal cortex). Social neuroscientists Claus Lamm and Jean Decety have demonstrated changes on functional MRI scans when people make the effort to appreciate the pain of those who are not like them. See C. Lamm, A. N. Meltzoff, and J. Decety, “How Do We Empathize with Someone Who Is Not Like Us? A Functional Magnetic Resonance Imaging Study,” Journal of Cognitive Neuroscience 22(2) (2010): 362–76.

  30 J. Decety, C. Yang, and Y. Cheng, “Physicians Down-Regulate Their Pain Empathy Response: An Event-Related Brain Potential Study,” NeuroImage 50(4) (2010): 1676–82.

  31 R. L. Reniers et al., “Empathy, ToM, and Self-Other Differentiation: An fMRI Study of Internal States,” Social Neuroscience 9(1) (2014): 50–62; and Lamm, Batson, Decety, “Neural Substrate of Human Empathy.”

  32 P. Fonagy et al., Affect Regulation, Mentalization, and the Development of Self (New York: Other Press, 2002).

  33 See the discussion of social epigenetics in chapter 3, “Curiosity.”

  34 A. Lutz et al., “Bold Signal in Insula Is Differentially Related to Cardiac Function during Compassion Meditation in Experts vs. Novices,” NeuroImage 47(3) (2009): 1038–46.

  35 Evan Thompson and other cognitive scientists and philosophers have called this embodied cognition, or embodied mind. F. J. Varela, E. Thompson, and E. Rosch, The Embodied Mind: Cognitive Science and Human Experience (Cambridge, MA: MIT Press, 1991).

  36 Cognitive science has finally caught up with millennia of experience with contemplative practices, helping us to understand, from a scientific standpoint, the connection between awareness of our physical selves and awareness of our thoughts and emotions—that first we experience the smile, then identify the emotion of happiness. A. R. Damasio. The Feeling of What Happens: Body and Emotion in the Making of Consciousness (New York: Harcourt Brace, 1999).

  37 C.-M. Tan, Search Inside Yourself (New York: HarperCollins, 2012). Reprinted from https://siyli.org/two-siyli-ways-to-change-your-mind-2.

  6. NAVIGATING WITHOUT A MAP

  1 R. A. Rodenbach et al., “Relationships between Personal Attitudes about Death and Communication with Terminally Ill Patients: How Oncology Clinicians Grapple with Mortality,” Patient Education & Counseling 99(3) (2015): 356–63.

  2 The idea that people left to decide for themselves is not always autonomy-supportive and can actually undermine a sense of self-determination was proposed in S. Sherwin, No Longer Patient: Feminist Ethics and Health
Care (Philadelphia: Temple University Press, 1992).

  3 E. B. Larson and X. Yao, “Clinical Empathy as Emotional Labor in the Patient-Physician Relationship,” JAMA 293(9) (2005): 1100–1106.

  4 See J. R. Adams et al., “Communicating with Physicians about Medical Decisions: A Reluctance to Disagree,” Archives of Internal Medicine 172(15) (2012): 1184–86.

  5 S. Glouberman and B. Zimmerman, “Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like?,” in Romanow Papers: Changing Health Care in Canada, eds. P.-G. Forest, G. P. Marchildon, and T. McIntosh (Toronto: University of Toronto Press, 2002).

  6 Here decision aids for patients that include values checklists, informational videos, and patient testimonials can be helpful. See G. Elwyn et al., “Developing a Quality Criteria Framework for Patient Decision Aids: Online International Delphi Consensus Process,” BMJ 333(7565) (2006): 417.

  7 See T. E. Quill and H. Brody, “Physician Recommendations and Patient Autonomy: Finding a Balance between Physician Power and Patient Choice,” Annals of Internal Medicine 125(9) (1996): 763–69. Also, for reasons I explored in chapter 4, physicians sometimes recommend treatments that they would not choose for themselves. See D. Gorenstein, “How Doctors Die: Showing Others the Way,” New York Times, November 19, 2013, http://www.nytimes.com/2013/11/20/your-money/how-doctors-die.html?_r=2.

  8 C. E. Lindblom, “The Science of ‘Muddling Through,’ ” Public Administration Review 19(2) (1959): 79–88.

  9 See https://en.wikiquote.org/w/index.php?title=H._L._Mencken&oldid=2093748.

  10 K. M. Weick and K. M. Sutcliffe, Managing the Unexpected: Assuring High Performance in an Age of Complexity (San Francisco: Jossey-Bass, 2001).

  11 S. Weiner and A. Schwartz, “Contextual Errors in Medical Decision Making: Overlooked and Understudied,” Academic Medicine: Journal of the Association of American Medical Colleges 91(5) (2015).

  12 This quote appears in the preface to W. James, The Varieties of Religious Experience: A Study in Human Nature (New York: W. W. Norton, 1902: repr., 1961).