Author: Martina Stippler
Our lives have become faster. You feel it in your workplace. You feel it when you talk to others. You can't miss it when you read the newspapers or watch the news. In this fast-paced world, it is more difficult than ever to find time to think, reflect, and be mindful. How does this impact us as physicians and surgeons?
Ronald M. Epstein, MD, a practicing family physician and professor of family medicine, psychiatry and oncology at the University of Rochester School of Medical and Dentistry, wrote a timely book titled Attending: Medicine, Mindfulness, and Humanity (Scribner, 2018). It explores how mindfulness, or lack thereof, can diminish our effectiveness as doctors and our own wellbeing. I had a conversation with Dr. Epstein to explore this notion further.
Dr. Ronald M. Epstein
Dr. Martina Stippler: Your book touches on so many things we neurosurgeons are dealing with: patient care, outcomes, burnout, and personal well-being. How would you describe mindfulness to someone who hasn't read your book?
Dr. Ronald Epstein: Mindfulness refers to a quality of attention and presence, in which you are monitoring and directing your attention and focus, and are being present in the moment. There are other definitions but all definitions of mindfulness have to do with it being purposeful and nonjudgmental, and with being present.
MS: I love the quotes you include in your book, such as one from William Osler that says, "We miss more by not seeing than by not knowing." From your perspective, how can mindfulness prevent us from making medical mistakes?
RE: We often see those things we are expecting and are prepared to see. Mindfulness is a way of freeing the mind from those expectations so that we have a wider set of choices in what we perceive and see. The book begins with an example from an operating room in which a highly competent surgeon doesn't see something that is plainly obvious to a third-year medical student. The power of the surgeon's expectations is such that even when it is pointed out to him, he doesn't see the impending disaster in the operation room.
I think we all can see things we expect to see while things we don't expect to see fly by us. But in medicine, and surgery in particular, not seeing something could be fatal. Mindfulness allows you to modulate and moderate your attention so you better see what is in front of you without prejudging the sensory input before you register its meaning.
MS: I think you also included an example of a surgeon who was mindful. Can you remark on that?
RE: It is remarkable that among surgeons, the good ones who have learned to regulate their attention often can't tell you how and why they did it. I'm fascinated by that. A surgical colleague of mine, Dr. Carol Ann Moulton in Toronto, has described how expert surgeons can slow down in the operating room when they should, even though they can't necessarily describe why they slowed down. The surgeon I describe in the book recognized intuitively that something was not quite right, and followed that intuition with some degree of curiosity. In the process, the surgeon slowed down and recognized something that for a less experienced surgeon might lead to an error.
In retrospect, it became apparent that his focused attention allowed him to be aware of something maybe a split second before other people noticed. That's an indicator of the quality of attention he was bringing to his work.
MS: Let's move now from the OR to a clinic visit. My institution allows me 15 minutes for follow-up patients, and 30 minutes with new patients. I want to be present, compassionate, and empathic-addressing the patient as a whole. How can I do that in 15 minutes?
RE: This might sound a bit mysterious, but perceived time is not the same as elapsed time. Although the clock says it's been 15 minutes, those 15 minutes could be filled with superficiality and lack of focus, or those 15 minutes could involve really honing in on the heart of the matter. By establishing clear communication and attentive focus, good physicians can use those 15 minutes more effectively. For example, we've known in psychology for hundreds of years that patients who are emotionally upset are unable to take in information very well.
In my research on communication I listen to audio recordings of visits between doctors and patients. When patients bring up something emotional, physicians usually pass right by it. I think a mindful physician can pick up on a patient's fear, worry, or mistrust and address that briefly. This lowers the patient's level of anxiety so the patient is more receptive to what the physician has to say. And vice versa. Osler also said that if you only listen well enough, the patient tells you the diagnosis. Physicians sometimes come in with a preconceived idea and don't really listen. The capacity for deep listening and presence allows you to use each moment to the best degree possible.
Of course, there are limitations. I'm a primary care physician and I also do palliative care. In my primary care office, I have 15 to 20 minutes per patient. Most are older and have a long list of concerns. It's not ideal, but given the constraints we have, there are ways we can maximize the effectiveness of the time we have.
MS: I found your description of the difference between empathy and compassion interesting. Can you talk about how we should train the new generation of doctors differently?
RE: I think it's a major step forward that medical practice has addressed empathy, because it wasn't really part of the formula during my medical education. Largely medicine was about "patient presents you with symptoms, you diagnose them and prescribe a treatment." We know now that patients often come to doctors seeking explanations, seeking to feel understood. The medical encounter involves many skills in addition to assigning a diagnosis.
In my view, empathy and compassion exist along a spectrum. Having a cognitive understanding of another person's distress can deepen the relationship in a certain way, but resonating with another person's pain can make you feel paralyzed and distressed yourself. In the past ten years, we've learned that doing compassionate things, and expressing compassion is more effective.
What I found teaching medical students is they would feel (empathize with) the patient's pain-and then feel helpless. Compassion is defined as resonating with another person's emotion and then being moved to act to relieve their suffering. It's the acting to relieve suffering that gives us this sense of fulfillment and satisfaction. Neurobiologically, we get a greater dose of dopamine in the brain and therefore feel empowered and better about the work we're doing.
MS: I see a lot of back pain patients. Sometimes, it is not possible for me to relieve suffering. You used the term "othering." I remember this as I see horrible stories unfolding-people losing their jobs and going on disability while having little kids at home. Most of them want narcotics. How can we deal with that distress, be more compassionate and not "other" patients.
RE: That's a really good question, and you bring up a serious yet common issue. Clearly, narcotics are useful medications, but sometimes have substituted for conversations that can help the patient feel healed and whole. Prescribing a pill often backfires because patients temporarily feel better, but then their lives begin to fall apart.
This is one place in which it helps to be mindful and try to understand why the patient is really there. Is it because his or her job is intolerable? Is it because a patient can't function and do certain things they otherwise might do? Is it 100 percent due to physical pain, or are there other components to work on that might attenuate the effect pain is having on a person's life? Often, you can't get rid of the pain, but you can restore functioning and quality of life.
MS: As a neurosurgeon, you are often confronted with bad outcomes. They could be secondary to the nature of the disease or the risk of surgery. When communicating bad outcomes to the patient and family, you said, "It's a fine line to walk between falling short and falling apart." How can mindfulness help us deal with this?
RE: First, physicians can recognize when something doesn't turn out the way we want it to, or whenever there's a tragic end, we have feelings that are perfectly natural, human feelings. However, we often don't have a convenient outlet. You can't ask a patient or a patient's family to take care of your emotional distress. On the other hand, if you simply ignore the feelings and try to suppress them, you will become less effective, unhappy, and perhaps see an increase in your blood pressure.
If you can recognize your distress, you can do something about it. Mindfulness is not only as an individual quality, but a quality of a community. It helps to find a community of people who have had the courage to look inside themselves and share the range of emotions they have internally with others.
However, I don't think those opportunities are frequent enough in medicine. During our Mindful Practice Workshops here in Rochester, we're finding physicians who have been carrying stories of errors or bad outcomes with them for decades. They've never told anyone, and it's been eating away at them. Part of what we try to do is say, "here's a way of dealing with things that are hard to talk about. Not by pushing those things away, but by exploring them and developing an attitude of self-forgiveness, self-compassion, and acceptance."
MS: René Leriche put it so eloquently. Every surgeon carries with himself (or herself) a small cemetery where he goes from time to time to pray. The longer I'm a surgeon and talk to other surgeons, I realize it is a quite lonely place.
RE: I think there is kind of a lone ranger myth about physicians, and maybe more so among surgeons. You're kind of a John Wayne figure who comes in, and either saves the day or doesn't, and then you ride off into the sunset by yourself. I don't think medicine benefits from that. The work and stakes are too high, and by not living with shortcomings in a kind and self-forgiving way, you're depriving your patients of the best you can offer them.
MS: Do you think understanding and recognizing one's feelings helps when having tough discussions with family?
RE: I do, because it allows you to separate what happened to the patient from your identity as a worthwhile human being. When I have a patient who dies or doesn't do well, I can sit with the family and explain calmly, in a way they can understand, the sequence of events while also feeling emotionally present with them.
I think families don't want only facts. They want a person. That's a cultivated skill. I've seen technically-skilled surgeons with this ability and I've seen surgeons equally skilled technically who fall short. You can bet that surgeons who are more adept at recognizing and displaying their emotions are the ones patients trust more.
MS: I love your definition of work/life balance.You say that those who see life as everything outside work implicitly assume when you're at work, you're not fully alive. Why do you say this is a trap?
RE: Studies of physicians show we seek a sense of meaning and purpose. By extracting what is deeply important to you from your work life, you deprive yourself of a tremendous degree of richness. The kind of human sensibilities one might have in private life will enrich your work as a clinician. Building too much of a wall between work and home is a mistake in terms of how we feel about our profession and the sustainability of the health care work force.
MS: When we don't have "work/life balance," when outcomes are out of our control, when health care systems are determining care, how can mindfulness help prevent burnout?
RE: Mindfulness is about awareness and training your mind so you can look at all sides of yourself without shrinking, turning away, and, in fact, turning toward things that might be difficult. In doing so, you empower yourself to take action that's in your own best interest. It's the ability to be present.
All physicians, at least in the US, work in a health care environment that is somewhat hostile. Mindfulness will not cure a broken electronic health record or a lot of the ills in medicine right now. But it allows us, in my view, to retain our sense of purpose, dignity, meaning, and effectiveness given the constraints that the system places on us. And when you're able to be more mindful, you can recognize your role as a leader in changing aspects of the system that really need to be changed.
The Congress of Neurological Surgeons and I thank you, Dr. Epstein, for have taken your time for this interview.
Dr. Epstein directs the Center for Communication and Disparities Research and codirects Mindful Practice programs. He is an internationally recognized educator, writer and researcher whose landmark article, "Mindful Practice" has revolutionized physicians' views of their work.