The practice of mindfulness

Dr. Vincent Hanlon (biography and disclosures) Disclosures: Presented sessions on different physician health themes including mindfulness for physicians, residents, and medical students at the University of Alberta, the University of Calgary, and various physician CPD events. 

What I did before

I began practicing emergency medicine in 1985. I had completed my family medicine training the year before. In those early years of practice I was only partially aware of some professional and personal weaknesses (and strengths), which I brought with me into the emergency workplace.

As a medical student, resident and physician I was competitive and achievement-oriented, somewhat perfectionistic, a little narcissistic, and in need of approval—an average physician. After completing the first six years of medical education I felt entitled to a good living. I experienced fluctuating degrees of anxiety, especially in the hours before night work and post-work fatigue often mixed with euphoria.

I had limited awareness of the need to, and less knowledge of how to combine, in mutually satisfying ways, my responsibilities as spouse and parent with my work as a physician. For example, it took me years (according to my spouse) to understand that giving orders may be appropriate at work, but not at home.

What changed my practice

Two years into my practice a “non-medical” friend gave me a copy of The Experience of Insight: A Simple and Direct Guide to Buddhist Meditation by Joseph Goldstein [1]. What changed my practice, at least indirectly, was a gift from a friend. Goldstein describes leading a 30 day Buddhist mindfulness meditation retreat, particularly what he taught participants about the practice of mindfulness on each successive day of the retreat.

About a year later, with the encouragement of two physician colleagues who were, like me, developing serious interests in mindfulness, I attended a weekend mindfulness retreat in Edmonton. The leader of that retreat was an oral and maxillofacial surgeon who was also a long-time practitioner and teacher of mindfulness. That our retreat leader was a mindful surgeon added some credibility to the activity.

Around the same time, I became aware of the Emergency Medical Abstracts conferences and monthly abstract review sessions hosted by two American emergency physicians, Rick Bukata and Jerry Hoffman. I mention the EMA only to emphasize that practice-changing influences may be multiple, simultaneous, overlapping or discrete. In the late 80s, however, there were no articles for Rick and Jerry to review on mindfulness in the ED, and the term “physician health” had not yet been invented.

What is mindfulness? Jon Kabat-Zinn, founder of the Mindfulness Based Stress Reduction (MBSR) clinic, offers a definition: “Mindfulness is the awareness that emerges through paying attention to the unfolding of experience moment by moment.” Kabat-Zinn describes this paying attention as done on purpose, in the present moment, and that it’s non-judgmental—meaning it’s done with as much openness, curiosity and acceptance as possible [2].

Why might refining our ability to pay attention be beneficial? Sherry Turkle is the Abby Rockefeller Mauzé Professor of the Social Studies of Science and Technology at the Massachusetts Institute of Technology. She is the author of several books that explore our relationship with connective technologies including Alone Together: Why We Expect More From Technology And Less From Each Other. In a chapter called “Always On” she observes that, “Even a simple cell phone brings us into the world of continual partial attention [3].”

How does one cultivate a practice of mindfulness? Beginner and advanced practitioners of mindfulness may combine Informal, formal and intensive approaches to building their practice. Informal practice involves utilizing opportunities to be mindful in the moment-to-moment unfolding of our days. Formal practice usually involves sitting quietly paying attention to one’s breathing for 15 or 20 minutes once or twice a day. The standard MBSR course includes 16 hours of mindfulness training—in eight 2 hour sessions over a two month period. Intensive practice dedicates longer blocks of practice time by attending retreats.

As a mind-body awareness practice, mindfulness is a psychodynamic skill that can be honed through practice. Mindfulness is about making choices. I remember one retreat leader who encouraged me to spend at least as much time practicing mindfulness as I did buying or reading books about the activity. The basic approach is simple, but not always easy.

As my practice of mindfulness developed, my practice of emergency medicine changed. My anticipatory anxiety before work and the euphoria afterwards didn’t disappear, but I was more accepting of and less in thrall to these emotional states. As I became more mindful in my daily life, my reactivity in the ED lessened. I became a little better shifting between simple and complex problems, and living with frightened patients, demanding co-workers, or unhelpful consultants. I became less judgmental and more accepting of others (and my own) idiosyncrasies. I was able to live less uncomfortably with the uncertainties of diagnosis and treatment. Although not always successful I focused as best I could on the patient in front of me, rather than perseverating about someone I had just seen, or being distracted by thoughts of many unknown patients waiting to be seen.

This change in my practice was motivated primarily by a deepening mindfulness practice, rather than by my evidence-based cognitive evaluations leading to behavioural change. The clinical utility I perceived in mindfulness arose initially out of my own experience.

In the intervening 30 years since beginning my practice of mindfulness, the evidence for some of the beneficial effects of a mindfulness practice on the practice of medicine have gradually appeared in the medical literature. Ronald Epstein, a family physician and teacher, gathers up a lot of this evidence (using as touchstones many examples from his clinical experience) in his book Attending: Medicine, Mindfulness, and Humanity [4].

Mindfulness is not a panacea. It is not a cure for burnout or the antidote for toxic workplaces. It won’t solve the competencies issue for dysfunctional residency training programs. It is not the answer to the lack of resilience experienced by some of our colleagues. The primary reason for developing a mindfulness practice is simply to be more mindful, to be more present to your own life and the lives of important people in your life—patients, coworkers, partners, children. As such, the practice of mindfulness does have the secondary potential to be a stress reliever, communication enhancer, resilience builder, and compassion reinforcer.

What I do now

I no longer practice emergency medicine but I continue to work at my practice of mindfulness. As it changed the way I worked in the ED, so it continues to affect my life beyond medicine. My ability to show up and pay attention to the daily unfolding of my life and relationships benefits from ongoing daily practice, and suffers from inconsistent effort.

Over the past several years I have given introductory sessions on mindfulness to medical colleagues. Gradually in these sessions I’ve reduced the time I spend highlighting articles from the literature about mindfulness in medicine. I choose instead to do some simple mindfulness exercises, and to consider opportunities where we can be more mindful each day. Here are some examples of this informal practice of mindfulness applied to both the personal and professional parts of our lives.

• Mindfully say goodbye to your partner before leaving for work.
• Mindfully put your phone on airplane mode for the duration of a teaching session, a patient encounter, or a conversation with your partner.
• Mindfully introduce yourself to a patient; mindfully call them by name at least once.
• Mindfully wash your hands between patients.
• Mindfully take a food or toilet break during your work day; mindfully decide to text or not to text while eating, or in the bathroom.
• Mindfully give or receive patients during handovers.
• Mindfully greet your partner or your child upon returning home.
• Mindfully review any occurrences of silence and stillness in your day.

I remain uncertain about whether there is a best way to invite colleagues and friends to familiarize themselves with the practice of mindfulness. Goldstein tells us, “The critical balance we need to discover in meditation practice—and indeed in all aspects of our life—is the equipoise between effort and surrender. On the surface these two qualities seem to contradict each other. How can we make effort, be purposeful, and at the same time surrender to what is happening, to the natural unfolding of our experience? [5]” 

References

1. Goldstein J. The Experience of Insight: A Simple and Direct Guide to Buddhist Meditation Insight Meditation. Boston, MA: Shambhala Dragon Editions; 1987.
2. Kabat-Zinn J. Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice. 2003; 10(2); 144-56. (Request with CPSBC or view UBC) DOI: 10.1093/clipsy.bpg016
3. Turkle, S. Alone Together: Why We Expect More From Technology And Less From Each Other. New York, NY: Basic Books; 2011; 161. (Request with CPSBC or view UBC)
4. Epstein R. Attending: Medicine, Mindfulness, and Humanity. New York, NY: Scribner; 2017.
5. Goldstein J. Insight Meditation: The Practice of Freedom. Boston, Mass: Shambhala Dragon Editions; 1993.

Resources

1. Apple Store: OMM Training LLC. (2017). One-Moment Meditation (Version 1.4.4) [Mobile application software]. Retrieved from http://itunes.apple.com Google Play: The One Moment Company LLC. (2017). One-Moment Meditation (Version 1.1.8) [Mobile application software]. Retrieved from https://play.google.com
2. Beckman H, Wendland M, Mooney C, et al. The impact of a program in mindful communication on primary care physicians. Academic Medicine. 2012;87:815-819. (View with CPSBC or UBC) DOI: 10.1097/ACM.0b013e318253d3b2
3. Siegel, RD. The Mindfulness Solution: Everyday Practices for Everyday Problems. New York, NY: The Guilford Press; 2010.
4. Santorelli, S. Heal Thy Self: Lessons on Mindfulness in Medicine. Harmony; 2000.
5. Nguyen AH, O’Hara M, Thich NH. Walking Meditation. [CD/DVD]. Boulder, CO: Sounds True, Inc.; 2006.
6. McDonald, B. The Science of Mindfulness, Quirks & Quarks with Bob McDonald. CBC Radio Podcasts. 2017. http://www.cbc.ca/radio/quirks/the-science-of-mindfulness-1.3934579 [Accessed 29 Jan. 2018]. (View)
7. Puddicombe A. All it takes is 10 mindful minutes. TED Talks. 2012. https://www.ted.com/talks/andy_puddicombe_all_it_takes_is_10_mindful_minutes. Accessed January 29, 2018. (View)
8. Monthly Newsletter: The American Mindfulness Research Association (View)
9. Mindfulness-based stress reduction. HealthLinkBC. https://www.healthlinkbc.ca/health-topics/abl0293. Updated August 19, 2016. Accessed January 29, 2018. (View)
10. General Practice Services Committee. Cognitive Behavioural Interpersonal Skills Manual. http://www.gpscbc.ca/sites/default/files/uploads/AMH_004.0_CBIS_Manual_v3.0_PR.pdf. Published July 2015. Accessed January 29, 2018. (View)
11. Practice Support Program. PSP Mental Health Module Making it Real. http://www.gpscbc.ca/sites/default/files/uploads/AMH_001.0_Algorithm.pdf. Updated November 2017. Accessed January 29, 2018. (View)

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