Mindfulness in medicine: Four foundations for physicians

Ronald M. Epstein, M.D., FAAHPM, explains that the four foundations of mindfulness — attention, curiosity, beginner’s mind and presence — shape how physicians perceive patients, make clinical judgments and avoid errors, emphasizing that patients most value feeling understood and engaged in a genuine relationship. Drawing on decades in primary care and personal experience as a patient, he describes how curiosity sustains interest in long-term patients, expertise can narrow perception, and authentic presence, even brief moments of human connection, can profoundly influence the clinical encounter, especially in an era dominated by screens.

Melissa Lucarelli, M.D., FAAFP: So, 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. And in the book — and I can give some examples as we talk — 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. I was in primary care practice for 35 years, and I had some of the same patients for 35 years with some of the same complaints for 35 years, and this sounds familiar, I’m sure. And so I had to find a way of remaining interested in that person with diabetes. You know, I had a lot of people with diabetes and, you know, I practice, but none of them were really the same, right? They all had their own quirks, their own individual circumstances, and somehow developing a curiosity about what. What their life is like and how going to the grocery store is for them, as opposed to for me going to the grocery store.

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. I’ll just give you an example. When I was doing my dermatology rotation in medical school, I was taking public transport in Boston, and I stopped seeing people’s faces. All I saw were zits and moles and rashes, and I found myself worrying, like, let’s say I thought I saw something I was sure was a melanoma, what would I do? But, 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 the…our professional field of vision. Michel Foucault calls it the clinical gaze.

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. I’ll just give you a very brief example. I was in the emergency room with abdominal pain several years ago, and the doctors did everything correctly, all the right tests, and the information they gave me was correct. But the one moment that I remember that kind of made me feel like I was in good hands was the transport guy who was taking me from the emergency room to the CT scanner. And he stopped at one point during this long trajectory down the labyrinth and just looked me in the eye and said, “How are you doing?” And that — suddenly I felt myself relax. It kind of changed the whole tenor of the encounter. I never knew his name, but I can see his face clearly now; it’s maybe 10 years ago that this happened. So, those kinds of things are really important. With screens, with computer screens, being present is a bit more challenging, so how do you navigate that relationship? So those things, they’re very pragmatic, and we can talk more about each of them as we go along.