7: Mindful Practice

Excellent patient care requires not only the knowledge and skills to diagnose and treat disease but also the ability to form therapeutic relationships with patients and their families, recognize and respond to emotionally demanding situations, make decisions under uncertainty, and deal with technical failures and errors. These capabilities require that clinicians have self-awareness to distinguish their values and feelings from those of their patients, recognize faulty reasoning early in the diagnostic thinking process, be attentive to when a technical procedure is not going as it should, recognize the need to gather more data, and be able to incorporate disconfirming data into an evolving assessment of the patient. Often, there is no tool or instrument that can help physicians with these situations on a moment-to-moment basis other than their own cognitive and emotional resources.

Mindful practice refers to a clinician’s capacity for reflection, self-monitoring and self-awareness during an actual clinical practice in order to practice with clarity, insight, expertise, and compassion. Clinicians generally value the principles of mindful practice—attentive observation, critical curiosity, presence, and capacity to see a familiar situation with new eyes (“beginner’s mind”). Yet, during training and practice, clinicians spend little time “sharpening the saw”—developing, refining, and calibrating their own capacity for self-understanding as they think and feel their way through the complex demands of clinical practice. For psychotherapists, athletes, and musicians, self-calibration and self-awareness are considered fundamental to excellence and are often explicit aspects of training. Yet, for clinicians, there is often the assumption that knowledge and technical expertise are sufficient, when on reflection most clinicians value “adaptive expertise” and cultivating habits of mind that allow them to self-calibrate and reflect continuously during everyday work. This chapter will suggest why mindful practice is important and indicate ways in which it can be cultivated.

Mindful practice is fundamental to excellent patient care. It means being attentive, on purpose, to one’s own thoughts and feelings during everyday clinical practice and educational activities. Mindfulness implies a nonjudgmental stance in which the practitioner can observe not only the patient’s situation but also his or her own reactions to it. A mindful practitioner can see a situation from several angles at the same time. Mindful practice implies curiosity rather than premature closure and presence rather than detachment. Mindfulness is especially helpful when dealing with difficult relationships with patients and families, challenging clinical situations, and in recognizing the need for self-care. Furthermore, recent research among students, residents, and practicing clinicians suggests that mindfulness is associated with better communication, better quality of technical (e.g., fewer errors) and interpersonal (e.g., empathy) care, and greater clinician well-being (e.g., lower burnout).

In contrast, mindless practice involves self-deception, often with the illusion of competence. Blind certainty, ignoring of disconfirming data, and arrogance without self-examination or reflection dooms us to “seeing things not as they are, but as we are.” An example of mindlessness is the common practice of reporting findings that were not actually observed, because “they must be true.”

Mindfulness is especially important in the diagnosis and treatment of mental disorders because there are few anchors other than the clinician’s own judgment to assess the severity or pervasiveness of anxiety, depression, or psychosis in a particular patient. However, mindfulness also applies to other cognitive and technical aspects of health care. Self-monitoring and mindfulness are equally essential to expertise in other domains of medicine as they are to primary care or behavioral medicine. For example, hepatobiliary surgeon Carol-Anne Moulton eloquently describes ways in which expert surgeons remain “attentive in automaticity.” They work quickly, yet recognize aberrant and problematic situations, and slow down accordingly, thus switching from automatic to deliberative thinking. In this chapter, I will explore several aspects of mindful practice and some ways of recognizing and practicing mindfulness in clinical settings.

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.

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.

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.”

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.

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.

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.

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.

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.

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).

Although it is self-evident that self-awareness is a necessary ingredient in developing and maintaining clinical expertise, achieving a state of moment-to-moment self-awareness in a chaotic and busy health care environment is not straightforward. For several years, a variety of training venues in medicine, psychology, and other disciplines have offered small group settings for trainees and practitioners to present difficult situations for group discussion, with the intent that the resulting insights then might inform future clinical practice. These sessions have been associated with improvement in communication skills and satisfaction with clinical practice. One program (Krasner et al., 2009) reported the results of an intensive course in “mindful communication,” which included a variety of self-awareness and body-awareness exercises, narratives about meaningful clinical experiences, appreciative interviews, didactic material, and discussion. Participating physicians not only reported lower burnout and lower psychological distress but also greater empathy and psychosocial orientation in care. Some small group formats are listed in Table 7-1, each with a particular focus but with the common thread of providing both support and insight.

Domains that are amenable to training include:

• Clinicians’ habits (meditation, body awareness, exercise, interactions with others, and so on).

• Clinicians’ beliefs and attitudes (health beliefs, beliefs about human behavior and relationships, attitudes toward patient autonomy or psychosocial aspects of care, family, cultural influences, and so on).

• Clinicians’ feelings and emotions (joy, fulfillment, vigor, attraction, anger, frustration, conflict, setting boundaries, and so on).

• Challenging clinical situations (difficult decisions, sharing bad news, facing mistakes, apologizing to patients, dying patients, demanding or “difficult” patients, conflict within the health care team, and so on).

• Clinician self-care (impairment, balance between home and work, burnout, healthy approaches to stress, finding meaning in work, and so on).

Other educational strategies can enhance the capacity for reflection and mindfulness. Reviewing video-recordings of patient sessions are surprising and instructive, whether reviewed individually or with a tutor. Learning contracts or agreements can focus learning on areas of deficiency, including becoming more self-aware. Peer evaluations of work habits and interpersonal attributes with medical students can foster greater awareness of how students function on the clinical team and interact with their colleagues and patients. Keeping a journal not only promotes reflection on one’s actions but also appears to be therapeutic in itself, offering a venue for self-expression so needed by busy and overwhelmed clinicians.

However, these individual and small group activities may not necessarily translate the insights gained into the moment-to-moment drama of clinical practice. Mindful practice refers not only to reflection on one’s actions but goes one step further by emphasizing habits of mind during actual practice. Mindful practice refers not only to the social and emotional domains of practice but also to the cognitive processes of data gathering and making decisions as well as the technical skills employed during physical examinations, surgery, and procedures. Following are some general suggestions on how to enhance mindfulness in practice, for oneself and for trainees:

• Priming. This involves creating the expectation for mindfulness. By observing what they do during clinical practice, clinicians can be more present, curious, and attentive. Sometimes, it is as simple as pausing and taking a breath before entering the patient’s room or taking time to look at the patient rather than at the chart or screen. Clinicians use these techniques to bring themselves into the present, and then can be invited to pay attention to how those techniques enhance their capabilities as clinicians and to expand their ways of applying those or similar techniques to other aspects of their practice. Trainees can be expected to pay attention not only to the patient but also to their own thoughts and emotions during the clinical encounter. These thoughts and emotions are fodder for discussion following an encounter, whether it occurs in hospital or in outpatient settings. Writing narratives about these experiences can help practitioners recognize their own mental states and learn to be aware of how they contribute to creating a coherent patient story while eliciting what often seems like fragmented information from the patient.

• Availability. Just as clinicians can make themselves psychologically and physically available to their patients, teachers should carve out time and space in which they are available to observe and discuss students’ progress toward greater self-awareness, whether in a small group setting or individually.

• Asking reflective questions. Reflective questions explore the inner landscape; only clinicians themselves can answer them. They are designed not to elicit facts or answers but rather to foster reflection in the moment. Teachers can ask reflective questions, but more importantly, clinicians themselves can adopt a habit of self-questioning. Examples of reflective questions are shown in Table 7-2. The internal dialogue that they foster can contribute to mindful practice.

• Active engagement. When in learning situations, mindful practice can and should be observed directly. Students’ reports of what they said and did during a clinical encounter are biased by their own values, expectations, and anxiety; thus the presence of a tutor or observer has no substitute. Imagine if in music instruction or tennis lessons, the student simply reported on his or her progress and difficulties, giving a narrative account of how the piece of music or tennis match went. Ludicrous as it sounds, we often do exactly that in medical education.

• Thinking out loud. When facing a challenging clinical situation it can be useful to describe one’s observations, impressions, or clinical reasoning to a colleague or tutor, or to put them down on paper in the form of a written narrative. Similarly, experienced clinicians can think out loud in the presence of learners to demonstrate how recognizing one’s own ignorance, biases, and predispositions can lead to more deliberative responses rather than mindless reactions. These methods help clinicians hear the story or rationale as if it were told by a third person, allowing them to examine their own thinking processes and emotional reactions, identify what might be missing in their perception of the situation, and correct faulty logic. These methods can allow for reflection that cannot be accomplished simply by moving forward with problem solving.

• Practice. Medicine, like music and tennis, must be practiced; the same is true of mindfulness. There is both formal and informal practice. Formal practice includes mindfulness exercises, such as meditation, yoga, movement exercises, and body awareness exercises. Equally important are informal practices that can be incorporated into daily work, and may be unobserved by others.

  Most important is the practice of stillness. Even momentary stillness during a busy day can open the mind, allow for new possibilities, and allow greater self-awareness. The stillness may be short informal practices—a momentary pause before seeing the next patient, or a “huddle” before commencing a surgical operation. Touching the doorknob before going into an examination room, a clinician might develop a habit of stopping momentarily, taking a breath, being aware of potentially distracting thoughts, feelings and preconceptions, allowing him or her to set aside what has just occurred and be more attentive to the next patient. Longer episodes of stillness might include formal meditation exercises or other contemplative activities. A daily meditation practice can provide a powerful means for learning how to be centered, observant, and attentive. Meditation involves watching one’s thoughts, feelings, and bodily sensations (such as breathing) without necessarily trying to change them. By learning to evoke similar states of attentiveness, even briefly, during clinical practice, the clinician can learn to approach new situations with a lowered reactivity and to tolerate ambiguity. Meditation can be an entirely secular activity and need not have religious or spiritual overtones.

  For clinicians and educators, “mantras” for daily practice can be cultivated. Clinicians might use the “it might not be so” mantra when facing a new patient or new diagnosis; the clinician develops a habit of trying to see the situation from another angle that might question an emerging hypothesis. “Unexpecting” is a practice of becoming aware of one’s own expectations or eliciting those of a learner, and then actively imagining another outcome (the “it might not happen that way” mantra). The goal of using these techniques is not to adopt a different, contrasting perspective; rather their purpose is to debias one’s thinking, recalibrate feelings, and train the mind to consider two or more perspectives at the same time.

• Praxis. Clinical skill is not truly learned and known until it is used. Increasing expertise is associated with the development of habits that become second nature. At that point, an expert clinician may not be able to describe easily exactly why he or she is making each decision, because many of the early steps in the decision process may have become automatic or tacit. Just as a habitual approach to history taking or physical examination becomes second nature, mindfulness training should have as its goal developing habits of reflection, self-questioning, and awareness in the moment during clinical practice.

• Assessment and confirmation. As is true for any newly acquired skill, some kind of assessment and confirmation of achievement are important for learning and reinforcement. Facilitated self-assessment, assessment by peers, and feedback from supervising clinicians are important to identify markers of and barriers to practicing mindfully. A supervisor might evaluate, for example, the degree to which the learner was able to articulate his or her reactions to a particular patient. Patients and peers can assess presence and attentiveness.

Mindful practice is a process and a goal, not a static state of mind. Even the most accomplished practitioners cannot claim to be mindful all the time. Efforts toward becoming more attentive, curious, and present, and approaching familiar situations with a “beginner’s mind,” can lead clinicians to be better listeners and diagnosticians, and to critique their own technical skills more objectively. Many medical schools and some residency programs offer training in mindfulness and self-awareness, in recognition that these approaches help in the process of professional development, reduce burnout, and improve communication. Resources for mindfulness and self-awareness training are also available through organizations such as the Center for Mindfulness at the University of Massachusetts (www.umassmed.edu/cfm/index.aspx) and the American Academy on Communication in Healthcare (www.aachonline.org), the Northwest Center for Physician Well Being (www.tfme.org), and the Mindful Practice Programs at the University of Rochester (www.mindfulpractice.urmc.edu). Research using functional magnetic resonance imaging (MRI) scanning, cognitive testing, and other techniques is only beginning to uncover reasons why mindful practice improves performance, compassion, and well-being in a variety of professional activities.