Mindfulness in medicine: Key experiences for a young physician

Formative experiences, including a surgical complication exacerbated by inattention to a hospitalized patient whose pain was overlooked amid fascination with a rare disease, revealed how easily clinicians can focus on pathology while missing the person in front of them. Ronald M. Epstein, MD, FAAHPM, describes a pivotal mindfulness breakthrough in his own practice, prompted by patient feedback about electronic records, leading him to intentionally prioritize eye contact and listening at the start of visits, which improved recall, efficiency and his sense of professional fulfillment.

Melissa Lucarelli, M.D., FAAFP: In your book, you describe your experience as a young physician, noticing differences in how doctors operate literally in surgery, as well as various examples of physicians unintentionally overlooking important medical details. Without betraying any patient confidentiality, would you describe one of these examples for us and perhaps share some of your own mindfulness breakthroughs that led to better patient care during your years of medical practice?

Ronald M. Epstein, M.D., FAAHPM: Towards the beginning of my book, I recount this story, but it really sits with me still, because it was an incredible learning experience for me. I was a medical student, a third-year student on my surgery rotation, and this was an open procedure, they didn't have robots back then. And it was a retroperitoneal lymph node dissection for a young adult with testicular cancer. And they did that in order to stage the disease. The surgeon first dissected around one kidney, then switched sides of the table to table to dissect the other kidney. And so I was standing across the table from the surgeon, looking right at the kidney he had just worked on, and I noticed it was beginning to turn blue. And as a medical student, I didn't know very much, but I generally knew that pink was good and blue is bad. So I tried to mention this to the surgeon, and I broke this cardinal rule — I was first of all getting really anxious, because you're not supposed to speak unless spoken to in the operating room. I mean, I think things have loosened up a little bit since then, but that was kind of an unspoken rule. But I did, and I said, you know, I think there's something going on here, I think, you know, the kidney is looking blue. And the surgeon basically ignored me, and kind of said something like, you know, shut up, kid, or the equivalent. And then after a while, I noticed the kidney was beginning to turn a dusky purple, and I was the person who had the best view of it. So I mentioned it to the nurse who was standing next to me, who mentioned it to the resident who was standing next to the surgeon, mentioned to the surgeon. At that moment, the surgeon panicked. He tried to untwist the kidney, the blood supply got cut off, unsuccessful, had to call in a vascular surgeon and it took a while, actually, to restore blood flow and I know a few days later this young adult’s kidney function was not quite normal.

But it was really interesting to me because I was on rounds the next day with a surgeon, and he said an unavoidable problem occurred in the operating room. And so the kid getting twisted may have been unavoidable, but his lack of attention and the subsequent delay in acting wasn't. And this was a very reputable surgeon at a major Boston teaching hospital, and I just realized any of us could fall into that trap.

Just another quick example we had on our service, someone with a very rare and interesting disease, because the genetic basis of it was unknown, and this was the 1980s and not much was known about genetics. It was hairy cell leukemia, which is now better understood, and everyone was so fascinated with this “fascinoma” that they failed to see that there was this woman lying alone in the bed, never having visitors, and in pain, right? So that completely went by them. And on rounds, I said, well, what about a little bit of pain medication for and they very happily did that, but it was stunning to me how they saw the disease and didn't see the person. So I could go on and on about this.

I think the awakening for me there's one event. I had a patient who I had been caring for for more than 10 years, and knew him, really liked each other, we shared a lot of interests. And he came into the office one day and said, you know, it's kind of hard to say, but ever since you got this new computer system — I mean, I really like you as a doctor, and part of what I like is that you're a really good listener, but ever since you got this new computer system, I just kind of feel like you haven't been listening in the same way, and thought I should tell you. My first feeling was kind of this sense of someone kind of stabbing me through the heart, because my professional identity is I teach communication skills and this kind of mindless lapse, is it was just — and then I was just like, suddenly, really grateful, because he actually pointed out something that was really true. And so my fix in that moment was to say, OK, I'm going to try this little experiment for the first minute or minute and a half of every visit. I'm not going to turn on the computer, I'm not going to do anything but look this person in the eye and just listen to what they have to say, and, you know, interrupt if I need to after a minute or so. I discovered several things. One is that I actually remembered what patients said better. The second is that the visits were no longer. And the third was, I felt a lot better at the end of the day. I felt a sense of lightness and like I was really doing the job I was supposed to be doing. And that sense of gratitude really kind of, I don't know, it kind of cut through a lot of the, for lack of a better word, crap that one has to do when interacting with the health care system and everything else. I've continued doing that, that's just became a habit. I think of it as a like a little mini-rebellion, because we were taught in the E-record training, that the first thing you do when you go into the room is you turn on the computer and you log in. And I thought, wait a second, they're not going to send me to jail if I don't do that, and let's just see what happens. So for me, that was a mindfulness exercise, right? It was deciding to be present, attentive, curious, with a beginner's mind, and doing that intentionally. And that, for me, is the most important step, is that intention.