‘What do I need to bring to this next encounter?’ — Why mindfulness is vital for physicians

For busy physicians, mindfulness may be the tool that transforms multitasking to monotasking, which in turn becomes understanding, relationships and the treatments that patients seek.

A decade ago, Ronald M. Epstein, M.D., FAAHPM, set down a career’s worth of experience and research in his book, “Attending: Medicine, Mindfulness, and Humanity,” which was published in 2017. He outlined his principles for physicians to become master clinicians through deeper connections with patients. Greater mindfulness does not necessarily cost physicians a lot of time or money, but it does require some training and intention.

Since 2017, the U.S. health care system has evolved, but not always in a good way. In some workplaces mindfulness may be needed now more than ever.

Medical Economics editorial advisory board member Melissa Lucarelli, MD, FAAFP, spoke with Epstein about how physicians can add mindfulness to their armamentaria. This transcript has been edited for length and clarity.

Melissa Lucarelli, M.D., FAAFP: For those who are unfamiliar, would you please describe what your book calls the four foundations of mindfulness: attention, curiosity, beginner’s mind and presence?

Ronald M. Epstein, M.D., FAAHPM: Attention refers to how we can actually regulate what we pay attention to and how we pay attention. We’re trained to pay attention to certain things and not to others. And also, sometimes we’re more open to surprise than other times. And often, it’s in those lapses of attention that errors happen, and also misunderstandings happen. When you ask patients what they really want in a visit with a doctor, uniformly, the thing that rises to the top is to feel understood and to understand, and then secondarily, to get a treatment that will help them with their condition. So they’re really looking for a relationship as well as a prescription. And so attention to that, to those two aspects, is particularly important.

Curiosity is an important ingredient in paying attention and being present because if you’re really not interested in what you’re doing and the patient who’s in front of you, the patient will know that; they’ll kind of get a sense that you’re just phoning it in. Curiosity drives good medical judgment. Asking yourself a question of, well, what am I assuming about this person or the situation that might not be true? That’s a curiosity kind of question that really opens the door to considering other possibilities.

Beginner’s mind is a concept that’s borrowed from a Zen teacher named Shunryū Suzuki, and the idea here is that our expertise is liberating as well as constraining. It’s really this difference in perception that we develop, and so other things can just fly right past us, because it’s really not part of our professional field of vision.

And then presence is really the hardest thing to define, but we all know when it’s there and when it isn’t. Just think about how you feel present during a movie or a play or a musical performance, and how you can tell, especially if it’s something that’s live, how you can tell that person is really present there and with you. And I think all of us who have been ill remember these moments of presence.

Melissa Lucarelli, M.D., FAAFP: I first read your book when it was sent to me as a free gift from my malpractice insurance carrier. How do you think your book is relevant to medical risk management, and why did they send that to me?

Ronald M. Epstein, M.D., FAAHPM: Well, I can tell you a couple things. One is that we do workshops for physicians, anything from half a day to three days, just helping them find ways of being more mindful in clinical practice. And our risk management department has arranged that for anyone taking one of these workshops of three hours or more, they get a 15% discount on their medical malpractice. That could be quite substantial. And the reason they’re doing that is, the argument is that if physicians are more present, if they communicate better, even if errors do occur, they’re less likely to get sued, and they’re less likely to get sued for as much. And there’s some good data on looking through malpractice claims. A colleague of mine, Howard Beckman, did that a number of years ago, and embedded in almost all of the complaints is a failure of communication. And so errors happen all the time in medicine, and only a very small part, a small percentage of them, ever end up in court or even with a complaint. And so improving that level of attentiveness, presence and communication is really foundational.

Melissa Lucarelli, M.D., FAAFP: There’s a lot of time pressure on practicing physicians as we do our work in the clinic or in the hospital, and yet, you describe circumstances in which just a few seconds of preparation or awareness might lead to better patient care now and save time later. How do you respond when someone suggests that increased mindfulness requires hours of meditation every day, or that it sounds like yet another thing on their to-do list?

Ronald M. Epstein, M.D., FAAHPM: I think it’s possible to develop some pretty simple practices that take virtually no time in your practice. Learning anything new, first of all, feels awkward, and second of all, there’s a learning curve. So one thing that I suggest people just try out is pausing for a moment when you touch the doorknob or door handle, when you’re going from one patient encounter to another, whether in the hospital or in an outpatient setting. And when you do that, in that pause, just take a breath and then imagine what it is that you want to carry into that room and what you want to leave outside. So as a family doctor, I could, in a typical day, see an 80-year-old with advanced lung cancer as one patient, and the next patient could be a healthy 6-month-old coming in for a well child check. Now I don’t want to bring in that 80-year-old, I don’t want to carry that person and that mood and that event with me. So I kind of imagine there’s a little shelf outside every room, and I just kind of put that 80-year-old and his problems on that little shelf. I can come back and retrieve it, and I do, because when I write my notes. But just that little mental exercise of saying, what do I need to bring with me to this next encounter?

Melissa Lucarelli, M.D., FAAFP: Recently, a Medical Economics guest article argued that “when the system is broken, no amount of mindfulness can fix it.” Since you wrote about imagining a mindful health care system, how would you respond, and particularly around the idea of organizational mindfulness?

Ronald M. Epstein, M.D., FAAHPM: I would give slightly different answers now than I wrote; I actually wrote the book about 10 years ago, and so the landscape has changed, and also I’ve changed. One thing is the role of leaders, and I had really underestimated that for most of my career, until I really started meeting with leaders and also seeing how they work and visiting a lot of different institutions around the world. If leaders are aligned to what really matters in medicine, then that can create an organizational culture that would permit that kind of collective mindfulness to emerge. However, if you’re in a situation — I’ve been in situations where I’ve been asked to give a keynote lecture in a health system that clearly is not only dysfunctional, but toxic, expecting that my whatever hour-long talk would fix things, and it can’t. I mean, it’s just completely impossible. And I think that organizational mindfulness, that if you think of an organization as an organism with the same kind of capacities for self-awareness and repair and self-monitoring, then you can really see how some organizations themselves are more mindful than others. I’m working very closely with some organizations that seem to be more on that more mindful spectrum, and what they can accomplish in terms of staff well-being, I think, is much more meaningful.

Melissa Lucarelli, M.D., FAAFP: During a recent Medical Economics panel, I brought up value-based care as an alternative for independent practices like mine who are struggling to remain viable in a fee-for-service market. What are your thoughts about productivity-based compensation for medical care?

Ronald M. Epstein, M.D., FAAHPM: It depends what you mean by productivity. If you mean it’s throughput, that is, how many patients you can see in a day, I guess that would be one metric. If the ultimate product of health care is health, then that raises a different set of questions. So, for example, in some value-based care systems, they might reward you for ordering hemoglobin A1c levels more frequently, either in people with or without diabetes. But what I’ve seen, both locally as well as elsewhere, is that people who perform well on that metric may not actually follow up on those A1c levels, and may have patients whose diabetic control is no different than it was before that metric was in place. So now holding physicians individually accountable for someone’s health, in some sense, is unfair, right? Because I can give advice to someone with diabetes, and they can go out and buy whatever they want in the grocery store. So some of that, some of those metrics really need to be collective. It’s a complex answer, but I suspect that the throughput answer is not really going to generate health. In fact, I have no evidence that that will improve the health of the population, and perhaps there’s some evidence that it might worsen it.