Authors: Krystin Miller, MD; Kelsey Vargas, MD; Guy Carmelli, MD
Editor: Simiao Li-Sauerwine, MD, MSCR

A Case

John, a senior resident in emergency medicine, just opened the chart of Mr. Smith on a busy Monday afternoon shift. He thought the name sounded familiar, and in fact he had seen the patient before. The patient has visited the emergency department several times for chronic back pain, most recently one week ago. Prior clinicians have documented concern for drug-seeking behavior. Begrudgingly, John prepares to go see the patient. Today, the patient’s chief complaint is back pain and leg pain. 

John takes a very abbreviated history from the patient. John feels like this is a difficult patient encounter, as the patient is grumpy and uncooperative and is asking repeatedly for pain meds. Mr. Smith answers simple yes or no questions but fails to provide additional details. However, John doesn’t push back with any follow-up questions. At the same time as he is interviewing Mr. Smith, John is filling out his chart and also interrupting the patient several times to ask a nearby nurse about his other patients.

John determines Mr. Smith is having low back pain that is radiating to his feet. The patient was witnessed during examination to have an antalgic gait. Mr. Smith has no “red flag symptoms” including trauma, malignancy, incontinence to bowel or bladder or new neurologic deficits. The patient was examined fully dressed, but John feels he has obtained an adequate exam for the complaint. John determines there is no indication for further testing or imaging at this time. John communicates with the attending that the patient’s pain is likely an exacerbation of his underlying degenerative disc disease and sciatica. He would like to offer the patient acetaminophen for pain and discharge to home without further diagnostics. 

Prior to the attending seeing the patient, the patient’s nurse approaches the team and states, “I’ve taken care of Mr. Smith before, and he just doesn’t seem himself. His vitals today are abnormal. He has a slight fever with tachycardia and his blood pressure is lower than he usually runs. I am concerned we might be missing something here.” 

The attending sends John back to the bedside to re-evaluate the patient. 

Background

Ronald Epstein is the founder of mindfulness in medicine. Ronald Epstein matured in an age of counterculture and the partnered threats of conflict in the mid-20th century. This era of turmoil led to a life-long practice that has become integral in his daily practice.⁴ Epstein’s father served as an army physician and Epstein himself went through the motions of what was expected: attending university with the expectations of becoming a doctor. However, while he was finishing up college, he felt that something was missing. Early 20th-century medicine had evolved into viewing the human body as a machine, and the mechanics (i.e. doctors) fixed machines. This practice was at odds with how Epstein viewed the overall goals of medicine. In 1971, he took a course in Transcendental meditation and this gave him a glimmer of light. He eventually left school and moved to the West Coast where his journey through meditation began.

His route back to medicine was to discover research on the medical benefits of meditation, eventually choosing Harvard Medical School, a powerhouse of innovative research. His research unearthed studies suggesting that blood pressure, chronic pain, anxiety, and other medical conditions could benefit from meditation. He graduated medical school and became a family medicine practitioner who incorporates traditional holistic teachings into patient care. He turned meditation into mindfulness in practice– incorporating the fundamentals of meditation into clinical shifts and the struggles that physicians face day-to-day.² 

The foundation of Zen Buddhism cultivates present moment-to-moment awareness and awareness of self. It begins with a quiet setting, relaxing in a comfortable position, and focusing on breathing. When the mind starts to wander, it purposefully brings itself back to the focus on each individual breath. Each wander becomes shorter until the mind is clear enough to be in the present moment alone. Mindfulness is attending to the ordinary, the obvious, and the present.² To see the ordinary in a day full of critically ill patients is to see the family member that continues to ask for updates because they are scared and confused and to understand that your frustration is not with this family member, but with the workload, the lack of resources, and the inability to save each patient.

A second purpose of Zen is awareness of self— to understand one’s own thoughts, feelings, and flaws.⁴ Zen is the ability to allow the emergence of feelings without attempting to change or judge them, permitting these feelings to “just be.” However, a second foundation is living selflessly, understanding that there are times when a feeling does require change. One of Epstein’s stated goals was to “have more intentional unselfish awareness moments than selfish ones.” It is considered a universal human capacity to foster clear thinking and open-heartedness.¹

Applying this process to patient care requires the provider to actively observe the patient, themselves, and themselves with the patient. Physicians are human, therefore one should attempt to understand inherent biases that are brought to a patient encounter in order to empathize and connect with the patient for improved care.

Modern takes or advances in this theory

Outcome based medical education echos constructive alignment theory, by orienting training on intended learning outcomes. As described by Biggs and Tang (2011), in outcomes-based teaching the question changes from which topics are taught to “What do I want my students to be able to do” after curriculum completion². Medical schools have begun implementing such learning activities as problem based learning sessions, portfolio education exercises, and narrative exercises into undergraduate medical education. Medical simulation has become increasingly integrated into medical education at both undergraduate, graduate, and post-graduate continuing education levels and can serve as both a learning activity with team based learning or for assessment such as OSCEs for undergraduate medical education. 

In more recent times of crises during the COVID-19 pandemic a need surged for education on management practices and personal protective practices across the world. Institutions have used this same framework to first identify the learning outcomes of safe care for potential COVID-19 patients, developed quickly implemented learning activities through teleconferences, discussions, and simulations to align for assessment of these critical skills. Assessment in some settings includes auditing by Infection Protection and Control (IPAC) experts.

Other Examples of Where this Theory Might Apply

Historically a Buddhist practice, mindfulness itself requires no religious or cultural affiliation, and rather can be used in any setting as our innate ability to foster clear thinking and open heartedness.¹ The underlying philosophy of mindfulness is based on the interdependence of action, cognition, memory and emotion.¹ Being that medicine is an intersection between art and science, mindfulness practices made an easy transition into the field of medicine. 

The current era of medicine is filled with constant distractions, whether by email, cell phones, or other technological devices. The new age of medicine comes with increased demands to improve productivity often at the expense of the patient-physician relationship. Many physicians state that they lack sufficient time with patients to explore the depth of their experiences and how it relates to their medical presentation.³ Rather, pressure from administration and the medical system leads many practitioners to rely on instincts and first impressions to make quick decisions. 

Mindfulness, a practice of nonjudgmental moment-to-moment awareness, is one way for physicians to become aware of these patterns of behavior, habits, and reactions.³ Patient-centered care emphasizes understanding the patient as a person and encouraging a more participatory patient-physician relationship.⁵ This type of relationship has the appearance of increased time requirements in a world where practitioners are suffering through multi-tasking and quick paces. However, one can make a meaningful connection by sitting down, engaging with the patient, and not rushing through depersonalized conversations. One uninterrupted encounter with the patient answering questions and explaining diagnoses and plans generally takes less time that multiple short, interrupted interactions where neither the patient nor the practitioner feel satisfied with the outcome. 

Modern medicine makes room for different applications of mindfulness to suit the individual’s needs. Practitioners may keep a journal, meditate, or even review recordings of patient encounters.² In medical education, learner self-evaluation forms are a great way for the student or resident to reflect on their experience and compare perceptions with their teachers and/or mentors.² Furthermore, peer evaluations and critical incident reports can bring awareness to aspects of professionalism, difficult situations, gaps in medical knowledge and social skills for students, residents, and practicing physicians.² 

Studies have been published showing the many positive benefits of practicing mindfulness. One publication showed that introducing a mindfulness-based stress reduction educational intervention to medical students led to a decrease in total mood disturbance.⁶ Another study showed that mindfulness training in students can reduce psychological distress and feelings of burnout, improve well-being and mood, and increase patient empathy.^7,8 Finally, a qualitative study of primary physicians who received a mindfulness communication program showed that the physicians consequently felt a reduction in professional isolation, improvement in attentiveness, and an increase self awareness.⁹

Other Examples of Where this Theory Might Apply

Limitations of this Theory

Habits of mind, including use of attentiveness, curiosity, flexibility and presence, are important features for patient care and physician well being. Epstein discussed his 8-fold approach for teaching mindful practice in medicine:¹⁰

1)  Priming- Setting the expectation of student self-observation.

2)  Availability- Creating a quiet, uninterrupted space to interact.

3)  Asking reflective questions– Questions designed to foster curiosity.

4)  Active engagement– Being physically and mentally present with the student.

5)  Modeling- Showing actions while “thinking aloud” to make the tacit explicit.

6)  Practice- Disciplined repetition in controlled settings.

7)  Praxis- Motivating students to put knowledge into practice.

8)  Assessment and confirmation– Evaluate mindfulness and presence.

Evidence-based decision models are benefited by mindful practice– applying data from groups of patients to the care of one patient.⁵ However, this practice is limited by incomplete tacit patient information.² Mindfulness can bridge the gap between evidence-based and relationship-centered care, overcoming the limitations of both approaches. Mindfulness helps a provider formulate a clinical question, find appropriate sources and then bring the information back to the bedside.

There are many examples of mindfulness practices in the hospital. One example is the “sterile cockpit rule.”¹¹ In air travel, this rule prohibits any flight crew member from engaging in any non-flight related activity or conversation during a critical phase of flight. Similarly, this can be used in the operating room, during resuscitations, or prior to procedures. This mindfulness practice of being in the moment and free from distractions is an excellent clinical tool and application of the theory. 

Returning to the case…

On re-evaluation, John confirms the patient is indeed febrile, tachycardic and now hypotensive. John decides to take a much more detailed history and perform a more thorough examination of Mr. Smith after he is completely changed into a hospital gown. John discovers that the patient has been sleeping in a homeless camp for the past month and has been out of his diabetes and hypertension medications for approximately 6 months. Over the last 3-4 weeks, the patient has developed wounds on both of his feet, which he was initially embarrassed to tell anyone about. He has been feeling progressively worse, with fever and chills for about one week now. Ultimately, the patient gets admitted to the hospital for sepsis and requires podiatric intervention.

John and the attending debrief about the patient encounter, and the attending asks John some reflective questions. 

“What assumptions did you make when you first opened the chart?”

“What did you miss in that first interview with the patient?”

John reflects on the assumptions he made about the patient and his personal biases that he brought to the encounter – multiple ED visits, chronic pain, non-specific complaints, prior clinicians report of drug seeking behavior. He also stated that he rushed through the interview and wasn’t attentive to the patient’s non-verbal cues during the interview. While the patient was a difficult historian, John reflects that he did not ask appropriate prompting questions to build rapport and gain the patient’s trust. 

“What changed the second time you went into the room, John?”

John mentioned that he was more actively engaged and brought a new mindset to the encounter. He started from square one, with a blank slate, ignoring previous documentation that could lead to the formation of biases. During the second encounter, John also worked to leave his personal judgements and opinions at the door, and be more present and in the moment during the interaction. 

John and the attending concluded with a discussion on mindful practice with an emphasis on being aware of our own judgements and categorizations during clinical encounters. Mindful practitioners are able to put these aside to demonstrate compassion, treat the patient as a whole person, and be attentive to the patient’s needs. 

References

1. Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. JAMA. 2008;300:1350-1352.
2. Epstein RM. Mindful practice. JAMA. 1999;282:833-839.
3. Connelly JE. Narrative possibilities: Using mindfulness in clinical practice. Johns Hopkins University Press. 2005;48:84-94.
4. Epstein RM. Just being. West J Med. 2001;174:63-65.
5. Epstein RM. Mindful practice in action (I): Technical competence, evidence-based medicine, and relationship-centered care. Families Systems & Health. 2003;21(1): 1-9.
6. Rosenzweig S, Reibel DK, Greeson JM, Brainard GC, Hojat M. Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Med. 2003;15(2):88–92
7. Shapiro SL, Schwartz GE, Bonner G. Effects of mindfulness-based stress reduction on medical and premedical students. J Behav Med. 1998;21(6):581-599.
8. 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. 2009;302:1284–93.
9. Beckman BH, Wendland SM, Mooney EC, Krasner LM, Quill MT, Suchman MA, et al.  The impact of a program in mindful communication on primary care physicians. Acad. Med. 2012;87:815–819.
10. 10.Epstein RM. Mindful practice in action (II): Cultivating habits of mind. Families Syststems & Health. 2003;21:11-17.
11. Ornato JP, Peberdy MA. Applying lessons from commercial aviation safety and operations to resuscitation. Resuscitation. 2014;85:173–176.