Mindfulness in Medicine David N. Korones. MD

This artricle first appeared on the UPAYA newsletter 09/07/2010

 

 

 

As an oncologist and palliative care physician, I was vaguely aware of the concept of mindfulness, “the quality of being fully present and attentive in the moment during everyday activities.’’ Originally a Buddhist practice, its purpose was “to alleviate suffering and cultivate compassion.’’ Hence, it is not surprising that this discipline might have application in medicine for our patients as well as ourselves.

Mindfulness techniques appear to be effective in helping patients cope with pain, disability, and stress, and, similarly, may reduce stress in health care providers and enhance their ability to care for their patients.1,2 Physicians and patients can learn mindfulness…

techniques in a series of sessions devoted to gaining an understanding of this discipline and how to practice it. But until recently, whenever I heard the word, “mindfulness,” and heard others extol its virtues, I did not really understand what it meant, or what relevance it had to me or the work I do. In fact, the whole concept of mindfulness confused me, even intimidated me. It just seemed sort of “out there,” abstract, even a bit weird.

Then a few years ago, at my medical school at the University of Rochester, I was asked if I would be interested in teaching mindfulness to our residents. I am not certain why I was asked; perhaps it was because I am a relatively senior clinician, perhaps because I practice oncology and palliative care, or perhaps because they took one look at me and felt that I could use a good dose of mindfulness. They went on to explain that if I was interested, I would be required to take a course in mindfulness-based stress reduction to get a better sense of what it was all about, and be able to more effectively teach the residents.

I am not sure why I signed up, but I did. I told myself (and others) that I was doing it not for myself, not to help me with the stress of my work, but rather, so I could qualify to teach the concept to others. But, in retrospect, I do not think it would take a rocket scientist or a psychiatrist’s in-depth probing to find that I was doing this because I was stressed, and this was my own obtuse way of reaching out for help.

So with considerable trepidation, I signed up, and when I rushed across town from a particularly intense day of work and walked into my first evening class, I was not at all sure what I was getting myself into. There was our instructor (a physician himself) sitting cross-legged, barefoot, in jeans, ringing a gentle-sounding, high-pitched gong to get our attention. I remember thinking, “Oh, my God, get me out of here!” But I stayed and listened to the 20 or so people from various walks of health care explain why they were there. They were good people, and like me, they felt that the weight of their work was sometimes so crushing it could interfere with their ability to do that work effectively, and live their lives well.

The next thing I knew, I, too, was sitting crosslegged, listening to the ring of the bell, closing my eyes, quieting my beleaguered brain, and just being there. And as the weeks rolled by, and I would rush over to class after hectic days of work, and sit, eyes closed, legs crossed, I began to feel this wave of something that is hard to explain: a sort of combination of relaxation, relief, rest, rejuvenation, a feeling of being unfettered, uncluttered. It felt good. This class that I had so dreaded gradually grew to be one I cherished.

But other than serving as the spiritual equivalent to a good glass of wine (which also works quite well), how has mindfulness helped me on a day-to-day basis with my patients, with coping with my work and with my life? While there are many intangible ways, I can think of three very specific ways it has made a difference.

Focus. I will never forget the time, about 20 years ago, that I brought my son to the pediatrician for a regular well-child visit. As is so often the case for pediatricians’ offices, the place was a zoo; a lot of noise, bedlam, and utter chaos. I remember how our pediatrician found us in the waiting room, ushered us back to an examination room, closed the door, and the noise and the chaos quickly fell away. I will never forget how focused he was on my boy; I would guess that he did not spend more than 5 minutes with us, but it seemed like all the time in the world. In retrospect, I think my pediatrician was practicing mindfulness. We might not have called it that at the time, but I believe that is what it was. He was so focused, so free of distraction, so totally in the present. I walked out of that office feeling good about my son and the care he received; all my questions had been answered and all issues addressed.

Mindfulness techniques have helped me bring some of this focus to my patients. Just as in class, when we are taught to focus on our breathing, and when our minds wander to bring it back to the breathing, so, too, with my patients, when my mind wanders to the person I just saw, or the particularly challenging one whom I will see next, I try to reel it back in to the person who is right in front of me. My practice of this is not perfect and it does not work all the time, but my sense is that my patients appreciate this focus.

Time. A second way mindfulness has helped is awareness of time. I am sure that all busy clinicians struggle daily with the constant tension of trying to find a balance between giving our patients all the time they need, and at the same time, not keeping a waiting room full of people sitting for hours. In a desperate attempt to remain on schedule, I used to constantly steal a glimpse at the clock on the computer in the examination room, or subtly tug at my sleeve and take a quick look at my watch. It was not that I wanted the time to go by, but simply that I needed to know what time it was, so I could pace myself for the rest of the visit. In retrospect, I think that every time I did that, I would lose a little focus, and I suspect my patients would attest that my glimpses were not so subtle as I imagined. Now I do not do that any more (or, at least, not as often). I think we all have a better sense of time than we credit ourselves as having. I find that if I keep my focus on my patient and the tasks we need to accomplish in the time allotted to us, the time will usually take care of itself.

Getting away. This last is a more personal aspect of mindfulness: getting away. It used to be that when I went on vacation for a week, I would spend the first 2 or 3 days coming down, and then a few days before the vacation’s end, “patient care stuff” would trickle into my consciousness. By a day or two before my return, that trickle would become a torrent, and by the time I returned home, I was already anxious again. Now, for reasons I think are related to mindfulness (although I cannot say this for sure), as soon as I hit the road, as soon as the wheels of that plane lift up off the runway, I am out of here! I am disconnected from the Web, the cell phone, the e-mails, the text messages and the electronic laboratory reports, notes, and images. I am on the road, I am on vacation, I am not in the hospital; I am where I am.

I must confess that I still do not completely understand mindfulness. It is somewhat heavy and abstract, and for someone like myself, who considers himself forever mired in the stage of concrete operations, that can be a challenge. But there are things about mindfulness that I now better understand and appreciate. I understand that mindfulness is, quite simply, a way of being present for my patients and for myself. I also understand that mindfulness is a discipline. It is a way of thinking (or perhaps more accurately, a way of being), and, like any discipline or new approach, it requires training and ongoing practice. It is not as simple as a sip of wine in the evening, which may serve to dissipate the tension that has built during the day. It is better; it is a disciplined, practiced approach that enables us to deal with tension as it arises.

And now, armed with this better understanding of mindfulness, I try to incorporate it into my practice and into my own life. I also try to impart its value to our trainees, whose own stresses may be different, but are considerable. I explain to them my initial skepticism, and how even though on the surface, it might seem that it is just one more thing they have to do, it may help them cope with all those other things that overwhelm them. Somehow, as I tell them, it works. It helps me keep the focus on my patients, it helps keep the satisfaction in my work, it helps me to rejuvenate, and it keeps me sane.

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AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
The author(s) indicated no potential conflicts of interest.

REFERENCES

1.Krasner MS, Epstein RM, Beckman H, et al: Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 302:1284-1293, 2009
2.Ludwig DS, Kabat-Zinn J: Mindfulness in medicine. JAMA 300:1350-1352, 2008

—from Journal of Clinical Oncology: The Art of Oncology, University of Rochester, Rochester NY (Source: www.jco.ascopubs.org, accessed August 17, 2010)