27 D. C. Johnson et al., “Modifying Resilience Mechanisms in At-Risk Individuals: A Controlled Study of Mindfulness Training in Marines Preparing for Deployment,” American Journal of Psychiatry 171(8) (2014): 844–53; G. Wu et al., “Understanding Resilience,” Frontiers in Behavioral Neuroscience 7(10)(2013); and Russo et al., “Neurobiology of Resilience.”
28 K. Olson, K. J. Kemper, and J. D. Mahan, “What Factors Promote Resilience and Protect against Burnout in First-Year Pediatric and Medicine-Pediatric Residents?,” Journal of Evidence-Based Complementary and Alternative Medicine 20(3) (2015): 192–98; K. J. Kemper and M. Khirallah, “Acute Effects of Online Mind-Body Skills Training on Resilience, Mindfulness, and Empathy,” Journal of Evidence-Based Complementary and Alternative Medicine 20(4) (2015): 247–53; J. T. Thomas, “Intrapsychic Predictors of Professional Quality of Life: Mindfulness, Empathy, and Emotional Separation” (Lexington: University of Kentucky, 2011); and Johnson et al., “Modifying Resilience Mechanisms.”
29 H. B. Beckman et al., “The Impact of a Program in Mindful Communciation on Primary Care Physicians,” Academic Medicine 87(6) (2012): 1–5; and M. S. Krasner et al., “Association of an Educational Program in Mindful Communication with Burnout, Empathy, and Attitudes among Primary Care Physicians,” JAMA 302(12) (2009): 1284–93. The Big Five personality factors are neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. Focused attention is one facet of conscientiousness and mental stability is one facet of (lack of) neuroticism.
30 A. Caspi and B. W. Roberts, “Personality Development across the Life Course: The Argument for Change and Continuity,” Psychological Inquiry 12(2) (2001): 49–66.
31 The opposite—workaholics who get fulfillment only at work and see home life as dull—are equally deprived of the richness that life can offer.
32 See http://www.marclesser.net/tag/work-life-balance. I mentioned Marc Lesser in chapter 9. Marc is a Zen priest who runs mindfulness programs for Fortune 500 companies.
33 K. W. Brown and R. M. Ryan, “The Benefits of Being Present: Mindfulness and Its Role in Psychological Well-Being,” Journal of Personality and Social Psychology 84(4) (2003): 822–48; and N. Weinstein and R. M. Ryan, “When Helping Helps: Autonomous Motivation for Prosocial Behavior and Its Influence on Well-Being for the Helper and Recipient,” Journal of Personality and Social Psychology 98(2) (2010): 222–44.
34 Shanafelt et al., “Career Fit and Burnout.”
35 For a copy, see C. Maslach, S. Jackson, and M. Leiter, “Maslach Burnout Inventory: Third Edition,” in Evaluating Stress: A Book of Resources, eds. C. P. Zalaquett and R. J. Wood (Lanham, MD: Scarecrow Press, 1998), 191–218; and C. Maslach, W. B. Schaufeli, and M. P. Leiter, “Job Burnout,” Annual Review of Psychology (2001): 52397–422.
36 Our understanding of what these structures do and how they interact is still rudimentary, and we are a long way from knowing, for example, whether the activation of some of these structures is the cause or the effect of particular mental states. And, while neuroimaging is merely a marker for changes in the brain—you cannot actually “see” a thought or an emotion—the results of these experiments are nonetheless compelling. See B. K. Hölzel et al., “How Does Mindfulness Meditation Work? Proposing Mechanisms of Action from a Conceptual and Neural Perspective,” Perspectives on Psychological Science 6(6) (2011): 537–59; D. Vago and D. Silbersweig, “Self-Awareness, Self-Regulation, and Self-Transcendence (S-Art): A Framework for Understanding the Neurobiological Mechanisms of Mindfulness,” Frontiers in Human Neuroscience 6(296) (2012): 1–6; and R. J. Davidson et al., “Alterations in Brain and Immune Function Produced by Mindfulness Meditation,” Psychosomatic Medicine 65(4) (2003): 564–70; Y.-Y. Tang, B. K. Hölzel, and M. I. Posner, “The Neuroscience of Mindfulness Meditation,” Nature Reviews Neuroscience 16(4) (2015): 213–25; and A. Brewer and K. Garrison, “The Posterior Cingulate Cortex as a Plausible Mechanistic Target of Meditation: Findings from Neuroimaging,” Annals of the New York Academy of Sciences 1307(1) (2014): 19–27.
37 See D. C. Johnson et al., “Modifying Resilience Mechanisms”; E. A. Stanley et al., “Mindfulness-Based Mind Fitness Training: A Case Study of a High Stress Pre-deployment Military Cohort,” Cognitive and Behavioral Practice 18(4) (2011): 566–76; E. A. Stanley, “Mindfulness-Based Mind Fitness Training (MMFT): An Approach for Enhancing Performance and Building Resilience in High Stress Contexts,” in The Wiley Blackwell Handbook of Mindfulness, eds. A. Ie, C. T. Ngnoumen, and E. J. Langer (Hoboken, NJ: Wiley, 2014), 964–85; A. P. Jha et al., “Examining the Protective Effects of Mindfulness Training on Working Memory Capacity and Affective Experience,” Emotion 10(1) (2010): 54–64; and A. P. Jha et al., “Minds ‘at Attention’: Mindfulness Training Curbs Attentional Lapses in Military Cohorts,” PLoS ONE 10(2) (2015): e0116889.
11. BECOMING MINDFUL
1 E. A. Maguire, K. Woollett, and H. J. Spiers, “London Taxi Drivers and Bus Drivers: A Structural MRI and Neuropsychological Analysis,” Hippocampus 16(12) (2006): 1091–101.
2 K. Woollett and E. A. Maguire, “Acquiring ‘the Knowledge’ of London’s Layout Drives Structural Brain Changes,” Current Biology 21(24) (2011): 2109–14.
3 This famous postulate of neuroscience is attributed to Carla Shatz at Stanford University (see C. J. Shatz, “The Developing Brain,” Scientific American 267(3) (1992): 60–67) and is based on a theory of learning proposed by Donald Hebb in 1949. See D. Hebb, The Organization of Behavior (New York: Wiley, 1949). “Wiring together” is positive when it promotes acquisition of skills or habits of mind, but problematic when “firing together” reinforces unwanted mental rumination, obsessions, compulsions, anxiety, and depression.
4 K. A. Ericsson, “An Expert-Performance Perspective of Research on Medical Expertise: The Study of Clinical Performance,” Medical Education 41(12) (2007): 1124–30. Much of the argument in the next few paragraphs is summarized in A. S. O. Leung, C. A. Moulton, and R. M. Epstein, “The Competent Mind: Beyond Cognition,” in The Question of Competence: Reconsidering Medical Education in the Twenty-First Century, eds. B. D. Hodges and L. Lingard (Ithaca and London: Cornell University Press, 2012), chap. 7, 155–76.
5 G. L. Engel, “What If Music Students Were Taught to Play Their Instruments as Medical Students Are Taught to Interview?,” Pharos of Alpha Omega Alpha Honor Medical Society (1982): 4512–13.
6 H. L. Dreyfus, On the Internet (Thinking in Action) (New York: Routledge, 2001).
7 See Leung, Moulton, and Epstein, “Competent Mind.”
8 For a discussion of adaptive expertise, see G. Hatano and K. Inagaki, “Child Development and Education in Japan,” in Two Courses of Expertise, eds. H. Stevenson, H. Azuma, and K. Hakuta (New York: Freeman, 1986), 262–72. For a richer discussion of context, see 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) (2016): 657–62.
9 The parallels between jazz and clinical practice have been described in two wonderful articles listed below. Importantly, the ability to improvise depends on years of practice and assimilating the rules of harmony and structure of the music. See P. Haidet, “Jazz and the ‘Art’ of Medicine: Improvisation in the Medical Encounter,” Annals of Family Medicine 5(2) (2007): 164–69; and A. F. Shaughnessy, D. C. Slawson, and L. Becker, “Clinical Jazz: Harmonizing Clinical Experience and Evidence-Based Medicine,” Journal of Family Practice 47(6) (1998): 425–28.
10 W. James, The Principles of Psychology (Cambridge, MA: Harvard University Press, 1981).
11 Y.-Y. Tang et al., “Short-Term Meditation Training Improves Attention and Self-Regulation,” Proceedings of the National Academy of Sciences 104(43) (2007): 17152–56; and Y.-Y. Tang et al., “Central and Autonomic Nervous System Interaction Is Altered by Short-Term Meditation,” Proceedings of the National Academy of Sciences 106(22) (2009): 8865–70.
12 D. M. Levy et al., “The Effects of
Mindfulness Meditation Training on Multitasking in a High-Stress Information Environment,” in Proceedings of Graphics Interface 2012 (Toronto: Canadian Information Processing Society, 2012), 45–52; R. J. Davidson and A. W. Kaszniak, “Conceptual and Methodological Issues in Research on Mindfulness and Meditation,” American Psychologist 70(7) (2015): 581–92; B. K. Hölzel et al., “How Does Mindfulness Meditation Work? Proposing Mechanisms of Action from a Conceptual and Neural Perspective,” Perspectives on Psychological Science 6(6) (2011): 537–59; and Y.-Y. Tang, B. K. Hölzel, and M. I. Posner, “The Neuroscience of Mindfulness Meditation,” Nature Reviews Neuroscience 16(4) (2015): 213–25.
13 A description of ten stages of attention training, practices used to achieve them, and their implications for living one’s life can be found in B. A. Wallace, The Attention Revolution: Unlocking the Power of the Focused Mind (Somerville, MA: Wisdom Publications, 2006). The ten stages of attention are directed, continuous, resurgent, close, tamed, pacified, fully pacified, and single-pointed attention, then attentional balance and “shamatha.”
14 A. W. Kaszniak, “Meditation, Mindfulness, Cognition, and Emotion: Implications for Community-Based Older Adult Programs,” in Enhancing Cognitive Fitness in Adults, eds. P. E. Hartman-Stein and A. LaRue (New York: Springer, 2011), chap. 5, 85–104.
15 The word mindfulness also can be confusing. People commonly use it to describe a relatively fixed personality trait, a state of mind that can be achieved, and also a specific set of practices such as meditation. Any number of everyday activities can become mindful practices—one can play tennis mindfully, run mindfully, cook and eat mindfully, read poetry mindfully, and listen to or make music mindfully. I prefer what is now considered to be the original meaning of the Pali word sati—“remembering”—remembering who you are and what is important, every moment of every day.
16 Jon Kabat-Zinn is responsible for having secularized meditation traditions that originated in South and Southeast Asia and made them accessible to the general Western public. See J. Kabat-Zinn, Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness (New York: Bantam Dell, 1990).
17 For two explorations of how one can engage in awareness practice without adhering to an organized belief system, see S. Batchelor, Buddhism without Beliefs: A Contemporary Guide to Awakening (New York: Riverhead Books, 1997); and S. Harris, Waking Up: A Guide to Spirituality without Religion (New York: Simon & Schuster, 2015).
18 These pathways are not as well elaborated as attentional pathways and represent a cutting edge of neuroscience research. O. M. Klimecki et al., “Differential Pattern of Functional Brain Plasticity after Compassion and Empathy Training,” Social Cognitive and Affective Neuroscience 9(6) (2014): 873–79.
19 D. A. Schroeder et al., “A Brief Mindfulness-Based Intervention for Primary Care Physicians: A Pilot Randomized Controlled Trial,” American Journal of Lifestyle Medicine (2016): 1–9.
20 S. B. Goldberg et al., “The Secret Ingredient in Mindfulness Interventions? A Case for Practice Quality over Quantity,” Journal of Counseling Psychology 61(3) (2014): 491–97.
21 For very readable introductions into this complex realm, see A. R. Damasio, Descartes’ Error: Emotion, Reason, and the Human Brain (New York: G. P. Putnam’s Sons, 1994); and A. R. Damasio, The Feeling of What Happens: Body and Emotion in the Making of Consciousness (New York: Harcourt Brace, 1999). While some of the neuroscientific research is now a bit dated, Damasio’s everyday-life descriptions are compelling and still accurate. See also E. Thompson, Mind in Life: Biology, Phenomenology, and the Sciences of Mind (Cambridge, MA: Belknap Press of Harvard University Press, 2007); and F. J. Varela, E. Thompson, and E. Rosch, The Embodied Mind: Cognitive Science and Human Experience (Cambridge, MA: MIT Press, 1991).
22 In his essay “The Depth of a Smile,” my Catalan family-physician colleague Francesc Borrell-Carrió described what he called a “smile of accommodation.” See F. Borrell-Carrió, “The Depth of a Smile,” Medical Encounter 15(2) (2000): 13–14.
23 A. M. Glenberg et al., “Grounding Language in Bodily States: The Case for Emotion,” in Grounding Cognition: The Role of Perception and Action in Memory, Language, and Thinking, eds. D. Pecher and R. A. Zwaan (Cambridge: Cambridge University Press, 2005).
24 L. Nielsen and A. Kaszniak, “Awareness of Subtle Emotional Feelings: A Comparison of Long-term Meditators and Nonmeditators,” Emotion 6(3) (2006): 392–405.
25 P. M. Niedenthal, “Embodying Emotion,” Science 316(5827) (2007): 1002–5.
26 G. Kramer, Insight Dialogue: The Interpersonal Path to Freedom (Boulder, CO: Shambhala Publications, 2007).
27 D. L. Cooperrider and D. Whitney, Appreciative Inquiry: A Positive Revolution in Change (San Francisco: Berrett-Koehler, 2005).
28 R. M. Epstein, “Making the Ineffable Visible,” Families Systems and Health 33(3) (2015): 280–82; and J. Zlatev et al., The Shared Mind: Perspectives on Intersubjectivity (Amsterdam and Philadelphia: John Benjamins, 2008).
29 J. L. Coulehan, “Tenderness and Steadiness: Emotions in Medical Practice,” Literature and Medicine 14(2) (1995): 222–36.
30 See G. C. Spivak, L. E. Lyons, and C. G. Franklin, “ ‘On the Cusp of the Personal and the Impersonal’: An Interview with Gayatri Chakravorty Spivak,” Biography 27(1) (2004): 203–21; and R. M. Epstein, “Realizing Engel’s Biopsychosocial Vision: Resilience, Compassion, and Quality of Care,” International Journal of Psychiatry in Medicine 47(4) (2014): 275–87.
31 M. K. Kearney et al., “Self-Care of Physicians Caring for Patients at the End of Life: ‘Being Connected . . . a Key to My Survival,’ ” JAMA 301(11) (2009): 1155–64.
32 Coulehan, “Tenderness and Steadiness.”
33 W. Steig, Doctor De Soto (New York: Square Fish, 2010).
12. IMAGINING A MINDFUL HEALTH CARE SYSTEM
1 See Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century (Washington, DC: National Academies Press, 2001); D. M. Berwick, T. W. Nolan, and J. Whittington, “The Triple Aim: Care, Health, and Cost,” Health Affairs 27(3) (2008): 759–69; and T. Bodenheimer and C. Sinsky, “From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider,” Annals of Family Medicine 12(6) (2014): 573–76.
2 For three of the most influential documents, see Institute of Medicine, Crossing the Quality Chasm: Berwick, Nolan, and Whittington, “Triple Aim”; and Bodenheimer and Sinsky, “From Triple to Quadruple Aim.”
3 See K. E. Weick and K. H. Roberts, “Collective Mind in Organizations—Heedful Interrelating on Flight Decks,” Administrative Science Quarterly 38(3) (1993): 357–81. The actual reference to this particular story is G. I. Rochlin, T. R. La Porte, and K. H. Roberts, “The Self-Designing High-Reliability Organization: Aircraft Carrier Flight Operations at Sea,” Naval War College Review 51(3) (1998): 97.
4 L. T. Kohn, J. M. Corrigan, and M. S. Donaldson, To Err Is Human: Building a Safer Health System (Washington, DC: National Academy Press, 2000).
5 K. E. Weick and T. Putnam, “Organizing for Mindfulness: Eastern Wisdom and Western Knowledge,” Journal of Management Inquiry 15(3) (2006): 275–87; and K. E. Weick and K. M. Sutcliffe, “Mindfulness and the Quality of Organizational Attention,” Organization Science 17(4) (2006): 514–24.
6 See Weick and Sutcliffe, “Mindfulness and the Quality of Organizational Attention”; D. J. Good et al., “Contemplating Mindfulness at Work: An Integrative Review,” Journal of Management (2015): 1–29; T. J. Vogus and K. M. Sutcliffe, “Organizational Resilience: Towards a Theory and Research Agenda” (paper presented at the 2007 IEEE International Conference on Systems, Man and Cybernetics, Montreal, Quebec, 2007); T. J. Vogus and K. M. Sutcliffe, “Organizational Mindfulness and Mindful Organizing: A Reconciliation and Path Forward,” Academy of Management Learning & Education 11(4) (2012): 722–35; and K. M. Weick and K. M. Sutcliffe, Managing the Unexpected: Assuring High Performance in an Age of Complexity (San Francisco: Jossey-Ba
ss, 2001).
7 T. J. Vogus and K. M. Sutcliffe, “The Safety Organizing Scale: Development and Validation of a Behavioral Measure of Safety Culture in Hospital Nursing Units,” Medical Care 45(1) (2007): 46–54.
8 This approach was made famous by Toyota in the 1990s. See the Harvard Business Review article at https://hbr.org/1999/09/decoding-the-dna-of-the-toyota-production-system.
9 In case you’re worried, the patient went immediately to the emergency room and recovered well.
10 T. J. Vogus and K. M. Sutcliffe, “The Impact of Safety Organizing, Trusted Leadership, and Care Pathways on Reported Medication Errors in Hospital Nursing Units,” Medical Care 45(10) (2007): 997–1002; and Vogus and Sutcliffe, “Safety Organizing Scale.”
11 Here are some references to Suchman’s work, which clearly has relevance to other enterprises, not just health care: A. L. Suchman, “Organizations as Machines, Organizations as Conversations: Two Core Metaphors and Their Consequences,” Medical Care 49 (2011): S43–S48; K. Marvel et al., “Relationship-Centered Administration: Transferring Effective Communication Skills from the Exam Room to the Conference Room,” Journal of Healthcare Management/American College of Healthcare Executives 48(2) (2002): 112–23, and discussion, 23–24; A. L. Suchman, “The Influence of Health Care Organizations on Well-Being,” Western Journal of Medicine 174(1) (2001): 43; A. L. Suchman, D. J. Sluyter, and P. R. Williamson, Leading Change in Healthcare: Transforming Organizations Using Complexity, Positive Psychology, and Relationship-Centered Care (Abingdon, UK: Radcliffe Publishing, 2011); and A. L. Suchman and P. R. Williamson, “Principles and Practices of Relationship-Centered Meetings” (Rochester, NY: Relationship Centered Health Care, 2006.)
12 D. L. Cooperrider and D. Whitney, Appreciative Inquiry: A Positive Revolution in Change (San Francisco: Berrett-Koehler, 2005).
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