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The term “mindfulness” is increasingly an integral part of the health care vocabulary as more medical practitioners discover how it helps create better treatment outcomes. Mindfulness “clearly is a wave across the country,” says Ronald Epstein, a physician and professor of family medicine, psychiatry and oncology at the University of Rochester Medical Center. He details his ideas in his recent book, Attending: Medicine, Mindfulness, and Humanity, which he discussed on the Knowledge@Wharton show on Wharton Business Radio on SiriusXM channel 111. (Listen to the podcast at the top of this page.) Below is an edited transcript of the interview.
Knowledge@Wharton: Why hasn’t mindfulness been a part of medical science?
Ronald M. Epstein: It has — and it hasn’t. There are references to it [one can trace] even to the ancient Greeks. There were statements saying that a doctor needs to know a patient through and through in order to better take care of them. That has always been an undercurrent in medicine, because we’re so focused on other people — on patients, and on people who are suffering.
Knowledge@Wharton: What was the tipping point to write this book now?
Epstein: Mindfulness and self-awareness were always a part of my life from a very young age. But it wasn’t until I’d been in practice for about 10 years that I realized that this was a fundamental and missing ingredient in medical education and medical practice, and that the public needed to hear about it.
Knowledge@Wharton: In terms of it being a “missing ingredient” from medical education, is it something that many institutions are realizing now, and are they starting to incorporate it?
Epstein: [That is occurring] more and more. Most medical schools now have at least an elective opportunity for medical students to participate in some kind of mindfulness workshop or a mindfulness course. At a few medical schools, including ours, [that is part of] required content for all students. As people go on through training, there are more and more opportunities for practicing physicians to learn to be more mindful, to be more attentive, and to be more present. It clearly is a wave across the country.
“It’s not that you just do mindfulness, or sit on a cushion, or do meditation, or take a mindful attitude, but it becomes a habit.”
Knowledge@Wharton: This has been in your mind for quite some time. In fact, you lay out instances such as when you were going through your learning stages as a doctor, of other doctors that you saw making mistakes.
Epstein: They were big and obvious mistakes. When I was a third-year student, I noticed a physician who ignored something that was completely obvious within the operating field, partly because it was surprising. It was something that he wasn’t expecting. It reminded me many years later of that video that’s gone viral, where people are playing basketball, and then a gorilla comes across the screen, and half the people don’t even see the gorilla.
This invisible gorilla in medicine is not only in the operating room, but also in the clinic. I noticed that doctors pay attention to certain symptoms more than others. They tend to ignore things that later seem obvious and are often keys to understanding what’s going on with patients.
Knowledge@Wharton: This is obviously something that varies from doctor to doctor, and some are more aware of it than others.
Epstein: I think so. It’s really an ability to be aware of yourself while being aware of what’s going on outside.
Knowledge@Wharton: My kids are 10 and eight years old and have a mindfulness class in school this year, which caught me off guard. Is this push to bring mindfulness forward something that we’re seeing in many different places?
Epstein: Yes, my kids, too, [had such a class] when they were in elementary school. They were in somewhat of an alternative school setting, but they clearly had mindfulness content. Increasingly, in education, this is viewed as something important, because learning is about knowing your own mind and how it works, how you take in information, how you process information, and what biases you have. I would extend that to everything that you do in life. In your work setting, in terms of relationships, knowing yourself is important.
Knowledge@Wharton: Many people would say that being able to deal with not-so-normal situations, especially when you’re younger, will help you as you get through college and head out into the business world.
Epstein: I think of these as habits of mindfulness. It’s not that you just do mindfulness, or sit on a cushion, or do meditation, or take a mindful attitude, but it becomes a habit. It becomes the way that you deal with the world in general.
Knowledge@Wharton: In your research, you mention experiences with Zen Buddhism in understanding mindfulness better.
Epstein: My interest in the mind goes back to when I was a teenager and I studied Zen Buddhism. I eventually ended up at a Zen center in California for a few months, which was a formative time for me. I brought not only the practice — the practicality of doing lots of sitting meditation may or may not appeal to people — but the underlying attitude towards one’s own mind, the possibility of knowing one’s self better and using that self-knowledge to be more effective and more compassionate.
Knowledge@Wharton: There’s an interesting line in the book — “Doctors are trained to cling to categories.” Obviously, a part of that is that doctors have specialties and they follow that path. But it sounds like doctors can be their own worst enemy in terms of maybe [diagnosing] a potential disease.
Epstein: Absolutely, and this is one of the biggest problems in diagnostic errors. In psychology they call it “premature closure.” That is, you find a set of symptoms, grab at the first thing that seems to fit with those symptoms, and then your mind closes — even if there’s disconfirming data, and even if things don’t continue to add up.
I tell a couple of stories in the book that exemplify that. A friend of mine had bladder cancer and had a catheter put in. The catheter was removed, and later he was found not to be urinating normally. He went to an emergency room. It was a hot day, and the emergency room doctors thought that he must be dehydrated. Here’s a relatively young, fit-looking guy who’s not peeing very much. So they started an IV and gave him more and more and more fluid, not recognizing the fact that he had just had bladder surgery, and there might be an obstruction. In fact, that was the case, but it took three changes of shift and about 18 hours of IV fluids before anyone realized it.
Knowledge@Wharton: Are you able to determine, through your research for this book and maybe other studies, the impact we may have from not having this approach of mindfulness among doctors and nurses, and the health care sector in general? I would think if you’re making these mistakes, there is obviously an economic impact that will happen patient by patient.
Epstein: I can’t even begin to calculate what the economic impact would be. But I do know what the human impact would be for each patient, if they feel that they’ve not been understood and the treatment they’re receiving is not necessarily the ideal treatment for what [medical condition] they have. It really just takes once to have an experience like that.
I’m a practicing family physician, and in family medicine, probably you encounter more ambiguity than in other areas of medicine, just because people can come in with anything. I’m humbled every day, realizing that it’s a very inexact science that I’m practicing. It’s a human endeavor and with some scientific trappings, if you will.
But adopting that sense of not knowing, and that sense of humility, in some ways is very protective, because then I’m always not too sure of myself. I’m sure of myself; I’m confident. I’ve been in practice for a number of years, but I’m not so sure of myself that the door to other possibilities is closed.
“Health care has become much more productivity-oriented and less of a human enterprise.”
Knowledge@Wharton: It has to be a challenge, when most of the people you treat have the expectation that this is a perfect science.
Epstein: What you’re saying is absolutely true. When I’m a patient, I want things to be exact and perfect, and everything to go smoothly. But the reality is that that’s a desirable goal but not achievable 100% of the time.
Knowledge@Wharton: I guess this filters down to other people within the hospital structure, as well.
Epstein: Absolutely, and it filters down to anyone who’s in a high-risk profession. It would filter down to air traffic controllers. It would filter down to police officers and the military — anyone who has to make judgments under uncertainty.
Knowledge@Wharton: You mention that we’re seeing a higher rate of doctors either leave this field because of burnout, or they change what they are doing within the medical field. That is a concern that the medical industry has to continue to deal with on a day-to-day basis.
Epstein: The degree to which health care professionals are burned out affects the quality of care that they provide. This has been proven over the past 20 years, and it clearly is a connection. The burnout problem is not just about the well-being of clinicians, but it’s also really about the safety of the public. When you think about that, having a resilient and self-aware and engaged health care workforce is in everybody’s best interest.
Two things have happened over the past 10 or 15 years. One is that health care has become much more productivity-oriented and less of a human enterprise. No one goes into medicine to be working on an assembly line. People go into medicine because they like people, and they enjoy the interactions they have with people. [But] we’re spending less and less of our time face-to-face with people and more and more of our time doing administrative tasks. Some of those administrative tasks are related directly to the computerization of medical records.
Knowledge@Wharton: Can this at times be a learned experience, as well — to be able, to a degree, to change your mindset as a doctor … so that you are more aware of this?
Epstein: I see this as an individual enterprise, as well as a collective one. On an individual level, for example, I know that what I enjoy about seeing patients is face-to-face contact, so I don’t even turn the computer on until the patient and I have had a couple of minutes to talk face-to-face, without a computer screen.
That’s a personal decision I’ve made, because that’s what gives me satisfaction at work, and it makes a big difference for me. However, health care institutions have a huge responsibility because in the design of health care, they have not taken human factors into account. They have not taken into account the degree to which we can assimilate information. They’ve not taken into account the fact that multitasking is impossible — that we alternate between tasks. We don’t do two things at the same time. And they don’t take into account what gives patients and physicians the most satisfaction about their visits. It’s about having real conversations.
Knowledge@Wharton: What are some of the things that you would like to see incorporated in medical education to better prepare doctors and nurses for this?
Epstein: Some of these things are really simple. There are courses in communicating with patients, but there’s no education in how to prepare yourself psychologically for a potentially difficult encounter that you might have with a patient — or even a routine one. I teach medical students, resident [doctors] and practicing physicians simple things, like when your hand is on the door handle and about to go into the patient’s room, what do you do? You can use that as a mindful moment. You can take a breath. You can mentally set aside what’s happened before with a previous patient. You can practice presence. You can practice being present. The more you do this, the more it becomes second nature, so that each time you enter a patient’s room, your mind is just that much more fresh, more open, more receptive and the patient sees that you’re present — that you’re really there.
“If you can recognize when you’re beginning to burn out and what those signs are, then you can begin to take action before things get out of hand.”
Knowledge@Wharton: You also talk about how these approaches can help health care systems.
Epstein: Yes, and some health systems have done this mindfully, and others have not. Some systems are actively looking at patients’ experience and clinicians’ experience of care. Other systems are taking a production-oriented approach, in which physicians and other health care professionals are viewed as merely widgets in a very large machine.
Knowledge@Wharton: What is it that doctors and nurses need to be aware of? You have a chapter in the book called “Healing the Healer.”
Epstein: The first step for anyone in a high-stress profession is to recognize the earliest warning signs they have that they’re beginning to burn out. So for someone it might be a headache. For someone else, it might be a sense of an upset stomach. For some people, it may be feeling tired. Some people might not sleep as well. Some people might make more typos when they’re typing on the computer. If you can recognize when you’re beginning to burn out and what those signs are, then you can begin to take action before things get out of hand. It’s a collection of these simple actions that you can take during the workday that can make a difference.
Sometimes the solutions are simple, like just reminding yourself to slow down or finding a quieter place to work, where you’re less likely to be distracted — or taking a break, or doing something to help you connect better to your work.
Knowledge@Wharton: It could be just as simple as realizing you’re at a point where you need to take a vacation or a couple of days.
Epstein: Absolutely, or even a mini-vacation. If I finish seeing patients at 7:00 at night, and I’m exhausted and beginning to see double, I’ll say, “Well, wait a second. Finishing these charts — I could try to do this now and possibly risk making some errors, or I could just leave it until early the next morning and finish them then.” Without that awareness, you keep plowing ahead, and you feel worse about yourself, and the work that you do is of lower quality. So it’s just about becoming aware. I call it “turning towards,” because it means that these are not pleasant feelings, when you’re beginning to feel burned out. But if you push them away and don’t acknowledge them, it’s just going to get worse.
Knowledge@Wharton: You talk about doctors being able to practice compassion.
Epstein: I think compassion takes work. I believe that humans fundamentally have a compassionate side, but when you’re dealing with suffering and tragedy, sometimes it feels too much to take that in, and you create a wall. We often forget that by creating a wall, we actually need energy to create that wall, and that energy becomes exhausting. So it may seem that it’s self-protective and trying to preserve yourself, but creating walls like that just sometimes makes matters worse. Now this doesn’t mean that you don’t need time for yourself, that you don’t need space. That’s important, as well. But recognition is the first thing. The second is that there are exercises you can do to learn to be more compassionate.
In a research study that is ongoing at Duke University, they ask people to write down every day three things for which they feel grateful. Just the act of writing those things down helps you — it’s more energizing. It makes you realize what you have and others don’t, and creates what are called more “pro-social attitudes” — attitudes that are concerned with the welfare and well-being of other people.
Knowledge@Wharton: It sounds like you have had to take the course “Physician, heal thyself” from time to time, as well.
Epstein: We all do. Yes, that’s the little secret. We all do.