when i say When I say . . . mindfulness Ben Lovell

Mindfulness is a purposeful, non-anxious, reflective presence that can be applied to any aspect of medical practice. Epstein1

CONSIDER TWO SCENARIOS

A junior doctor is in the midst of a hectic on-call shift in a busy emergency department. She attempts to care for two critically ill patients, whilst simultaneously attending to others with various minor complaints. She struggles to gain any real support from her senior clinicians. She begins to forget small tasks, such as prescribing an analgesic or requesting an X-ray. Her heart rate and blood pressure rise as the nurse in charge informs her that another unwell patient who requires her urgent attention has arrived. She begins to panic and fears she may start to cry. As she picks up an electrocardiogram, her trembling hands betray the fact that she hasn’t eaten for several hours. A relatively senior doctor has a professional disagreement with a colleague, relating to patient care. It quickly escalates to a confrontation, in which the doctor feels disrespected and patronised. Following this incident, our doctor seethes quietly, ruminating on what was said and what it might mean. Distracted and disgruntled, he has trouble concentrating on his clinic patients’ stories and symptoms. He barely registers his junior doctors’ presentation of patients on the afternoon ward round and frequently asks them to repeat parts of the history. He abandons work early that evening, demotivated and dispirited, leaving many tasks for completion the following day.

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These two scenarios demonstrate how a doctor’s focus can become removed from the situational task at hand. The concept of mindfulness gained prominence at the end of the 20th century following Epstein’s seminal paper ‘Mindful practice’.2 Epstein describes mindfulness as ‘discipline and an attitude of mind’ and ‘a logical extension of the concept of reflective practice’.2 A mindful doctor is receptive to data incoming through all sensory channels, and is simultaneously running an unconscious process of integration, comparison and assimilation with his or her pre-existing knowledge, ideas and behaviours.3 Mindful practitioners are aware of their own mental processes, psychological and physical status, and preconceived judgements and beliefs. They are flexible and attentive, and able to act with sound reasoning and compassion.4 To be mindful is to be adaptive, and to be able to face unfamiliar situations with assurance. As we are complex, evolved social animals, the human mind is vulnerable to the three Ds of distraction, diversion and derailment. Further, it may simply wander off in search of interest elsewhere on the psychological plane (daydreaming: the fourth D). These elements negatively affect concentration, dragging the ordered mind toward chaos. Lack of mindfulness has been implicated as a causative factor in a large proportion of incidents of medical error.5,6 This is hardly surprising: a ‘mindless’ doctor is unlikely to be a competent one. Reviewing the two vignettes as outsiders, we can appreciate the massive potential for catastrophe: a patient is forgotten; an insulin dose is miscalculated, an important physical sign is overlooked. Yet our two beleaguered doctors, deep in the eye of the storm, cannot perceive these lurking mistakes-in-waiting: they are not

Correspondence: Ben Lovell, Simulation Centre, Royal Free Hospital, Pond Street, London NW3 2QG, UK. Tel: 00 44 7590 384534; E-mail: [email protected]

doi: 10.1111/medu.12660

ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 653–655

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B Lovell mindful of what they are doing. A maintained focus on the task-in-hand protects our patients from medical harm. The mindful practitioner’s awareness is not only focused within, but without. Doctors who undertake steps to develop mindful practice become more attuned to their patient; they are able to recognise and interpret the verbal and non-verbal signals indicating emotional distress, comprehend unspoken concerns and preconceptions, and improve reciprocal communication within a clinical consultation.7 The provision of humanistic, holistic care to patients is a chief intent of health care workers. Clinicians who remain ‘present’ within a consultation, have curiosity and an empathic understanding of the patient and his or her illness, and are able to intuitively comprehend the patient’s spoken and unspoken communication, have more satisfied patients.7 Mindfulness improves the quality of care delivered by its practitioners. Mindfulness has been incorporated into psychological therapeutic techniques, and guided mindfulness practice has been demonstrated to lower stress and anxiety levels in medical students.8,9 Therefore, the patient is not the only beneficiary of mindful practice: it may have a role in preventing burnout within the medical profession. Burnout is the mental and physical exhaustion encountered by those in intellectually and physically demanding occupations.10 Associated features of this complex condition include cynicism, depersonalisation and loss of empathy, which may cause a physician to become unable to care about his or her patients.11 Links have been drawn between these distressing features and the sense of loss of meaning in one’s work.12 Mindfulness has been posited as a method of reclaiming meaning, of re-establishing control over one’s professional life, and of staving off the emotional exhaustion that may herald burnout.13 The dual goals of providing considered and compassionate care to patients, and promoting well-being in clinicians lie at the heart of the practice of mindfulness, and provide a solid basis for mature, professional medical practice.4 Medical schools have begun to incorporate mindfulness training into the undergraduate curriculum, the way they integrated reflective practice 20 years ago.4 The discipline can be learned and honed, but requires mentoring and guidance, and much of this learning takes place within the framework of rolemodelling.2 Therefore practising doctors should exhibit and explain mindful practice to their

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trainees. Epstein suggests that medical educators should encourage four key habits in their students: attentive observation (of oneself and the patient); critical curiosity (honest examination of the patient’s and one’s own limitations and preconceptions); informed flexibility (holding contradictory ideas simultaneously and keeping an open mind), and presence (undistracted attention on the task and compassion for the patient).1 Like any habit, these four concepts can be acquired and, it is hoped, assimilated into a practitioner’s professional identity. Although role-modelling assists in the display and description of mindful practice within the student– teacher framework, being mindful requires personal practice. Some institutions have developed simulation and role-playing learning experiences centred around the development of learners’ skills.14 Approaches include reflective writing, mindful meditation and cognitive therapy-based stress reduction. These instructional techniques are designed to promote lifelong mindful practice and have shown measurable short-term success in improving empathy and reducing anxiety in undergraduates.15 To those who would dismiss mindfulness as an educational fad, a new-age philosophy, or self-indulgence, it must be stressed that the underlying philosophy is pragmatic. It is a tool for improving both doctor and patient health, and is the antithesis to multitasking, over-reaching, and rigid adherence to algorithms and protocols without reference to the individual patient. It promotes awareness in place of agitation, reflection in place of reflexivity, and humility in place of hubris.

REFERENCES 1 Epstein R. Mindful practice in action (I): technical competence, evidence-based medicine, and relationship-centred care. Fam Sys Health 2003;21: 1–9. 2 Epstein R. Mindful practice. JAMA 1999;282:833–9. 3 Berner ES. Mind wandering and medical errors. Med Educ 2011;45:1068–9. 4 Dobkin PL, Hutchinson TA. Teaching mindfulness in medical school: where are we now and where are we going? Med Educ 2013;47:768–79. 5 Smallwood J, Mrazek MD, Schooler JW. Medicine for the wandering mind: mind wandering in medical practice. Med Educ 2011;45:1072–80. 6 Hilton S. Mind wandering in medical practice. Med Educ 2011;45:1066–7.

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when i say 7 Beach MC, Roter D, Korthuis PT et al. A multicentre study of physician mindfulness and health care quality. Ann Fam Med 2013;11:421–8. 8 Warnecke E, Quinn S, Ogden K, Towle N, Nelson MR. A randomised controlled trial of the effects of mindfulness practice on medical student stress levels. Med Educ 2011;45:381–8. 9 Rosenzweig S, Reibel DK, Greeson JM, Brainard GC, Hojat M. Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Med 2003;15:88–92. 10 Prins JT, Gazendam-Donofrio SM, Tubben BJ, van der Heijden FMMA, van de Wiel HBM, HoekstraWeebers JEHM. Burnout in medical residents: a review. Med Educ 2007;41:788–800. 11 Abdulaziz S, Baharoon S, Al Sayyari A. Medical residents’ burnout and its impact on quality of care. Clin Teach 2009;6:218–24.

12 Dunn PM, Arnetz BB, Christensen JF, Homer L. Meeting the imperative to improve physician wellbeing: assessment of an innovative program. J Gen Intern Med 2007;22:1544–52. 13 Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B, Mooney CJ, Quill TE. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 2009;302:1284–93. 14 Hutchinson T, Dobkin P. Mindful medical practice: just another fad? Can Fam Physician 2009;15:778–9. 15 Kearney MK, Weininger RB, Vachon ML, Harrison RL, Mount BM. Self-care of physicians caring for patients at the end of life: ‘Being connected. . . a key to my survival’. JAMA 2009;301:1155–64. Received 2 October 2014; editorial comments to author 10 November 2014, accepted for publication 14 November 2014

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When I say … mindfulness.

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