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Mindful practice depends on the ability to be aware in the moment. The champion tennis player is being mindful when he or she is not only attentive to the ball but also to his or her state of balance, expectations for what will happen next, physical sensations such as pain or discomfort, and level of anxiety. All of these factors can affect performance and can be modified by specific attention to them. Like tennis players, physicians’ lapses in awareness and concentration can have dire consequences. For physicians, these lapses directly affect the patient’s welfare. The result of lapses may include avoidance, overreactions, poor decisions, misjudgments, and miscommunications that affect survival and quality of life for the patient. Thus, physicians have a moral obligation to their patients and themselves to be as aware, present, and observant as possible.
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By cultivating the ability to be attentive to the unexpected, mindful practice can improve the quality of care and help prevent errors. Case Illustration 1 presents some observations that led to a change in care resulting in an improved outcome. Being aware in the moment and receptive to new information—especially information that is unexpected, unwanted, or upsetting—can help the clinician be more attentive to patients’ needs and, thus, be more likely to meet them. The clinician’s job in Case 1 would have seemed easier, at least in the short run, if he had ignored his intuitions.
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Mindful practice involves allowing awareness of our own areas of ignorance, as well as our areas of expertise. Yet many clinicians are not as aware as they should be of the accuracy of their first impressions and tacit judgments. Clinicians, whether beginners or experts, often are aware of things before they are named, categorized, or organized into a coherent diagnosis. For example, the unusual gait of a patient walking toward the chair in the examining room may be the first clue to a neurodegenerative disorder, and such first impressions can often be quite accurate. Educators, psychologists, and cognitive scientists have called these automatic nonconscious mental processes “unconscious competence,” the “unthought known,” or “preattentive processing.”
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Conversely, the capacity for inattentiveness and self-deception can be impressive. The same capacity for automatic nonconscious processing can backfire if unexamined biases and preconceived ideas dominate clinical reasoning without some capacity for deliberation. Thus, the goal might be to be attentive in automaticity. A patient of mine, hospitalized with urinary infection, was suspected of having adrenal insufficiency because of hyperpigmented skin. He was later noted to only have hyperpigmented forearms and face, whereas the rest of the body was pale. Yet, the residents and attending physicians continued to evaluate the possibility of adrenal insufficiency in spite of being made aware of the faulty observation. A classic article on curiosity in clinical education reported a story about a patient who was presented on rounds as “below knee amputation (BKA) times 2”; clearly no one had noticed that he actually had two legs, and, through several hospital admissions, did not correct the mistranscribed “diabetic keto-acidosis (DKA).” Although these examples are dramatic, similar misperceptions are perpetuated with regard to patient personality or psychological states. For example, one study showed that patients asking for antidepressant medications tend to receive them regardless of whether they fulfill diagnostic criteria for depression. Patients who are labeled “difficult,” “uncooperative,” or “demanding” (such as Mrs. Grady, Case Illustration 2) seem to be stuck with such labels for life, and disconfirming data tend to be ignored. Furthermore, the “difficult patient” is approached as if the difficulty is only the patient’s, rather than considering that the physician’s expectations and attitudes may also contribute to the difficulties.
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Mindfulness means being simultaneously attentive to external data as well as to internal data—the clinician’s own thoughts, feelings, and inner states. Negative thoughts about a patient might promote a pejorative label (“somatizer”); negative feelings might provoke anger or disgust; and negative inner states might induce boredom or hostility. Positive feelings also present difficulties. Sexual attraction toward a patient obviously can be problematic, but so can an unusually keen interest in a patient’s illness. As a medical student, I was assigned a patient with hairy-cell leukemia, a disease whose genetic basis was just being uncovered. Although she was considered an “exciting” and “fascinating” case, I was disappointed, when meeting her, that she was a sad, weak, pale woman dying of cancer, hardly matching my excitement and that of my colleagues.
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Mindfulness of thoughts allows clinicians to follow intuitions while also accommodating for biases and cognitive traps in the process of making clinical decisions. Awareness of feelings is particularly useful in diagnosing mental disorders; clinicians tend to feel “down” when in the presence of a depressed patient, or confused in the presence of patients with subtle delusions and mild dementia. Awareness of their own fatigue can help clinicians recognize when their cognitive, attentional, or technical capacities are not at their best; the fatigued resident in the emergency room late at night might then get corroboration for an important finding on physical examination (such as the degree of nuchal rigidity in a febrile child) from a trusted colleague.
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Mindfulness improves learning. Trainees who are more aware of the difference between what they believe and their actual performance can make adjustments and improvements. Key features of mindful learning are the ability to see novelty in familiar situations and the ability to consider facts provisional and contextual. Studies show that mindfulness and self-awareness training can improve reasoning and communication skills. Mindfulness can be a corrective for those who otherwise might believe that they are expert and are surprised when that notion is challenged by an outside observer or objective test. Other types of professionals—not only medical personnel—also can suffer from the illusion of competence. Musicians know the delusion of the “practice-room virtuoso”—an illusion which is often shattered when the performer is put in front of a discerning audience. Clinicians, however, usually practice unobserved, so the opportunities for external validation and learning are much scarcer than for the musician—and the stakes are much higher than a wrong note.
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Mindful practice involves cultivating the ability to monitor and modulate one’s own emotional reactivity. Faced with emotionally challenging situations, humans often overreact by blaming (oneself, another clinician, or patient) or becoming overinvolved. Others may underreact by avoiding, minimizing, or distancing. In contrast, mindful practitioners can observe their own reactions, and thus have choices about the way they might respond that enhances quality of care and quality of healing relationships. Clinicians thus respond with empathy based on an understanding of the patient’s experience rather than making assumptions about the patient leading to further alienation (see Chapter 2). This same awareness can inform the small ethical decisions that clinicians make during everyday practice—such as which patient’s phone call to return first, or whether to acquiesce to a patient’s slightly unreasonable demand.
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Finally, mindfulness involves monitoring the clinician’s own needs. Self-awareness can directly enhance clinicians’ own well-being by helping them feel more in touch and in tune with themselves. Self-awareness can also motivate the clinician to seek needed help and support. Mindful self-care can lead to greater well-being and job satisfaction; clinicians who report greater job satisfaction and well-being tend to express empathy more readily, report making fewer errors, and have patients who report greater satisfaction. The self-reinforcing process of self-care and well-being can contribute to productivity and reduce burnout and attrition (see Chapter 6).