Physicians

Ron Epstein Talks Mindfulness & What Mindful Practice Offers Healthcare

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mindful practice

Ron Epstein, MD, Professor of Family Medicine at the University of Rochester Medical Center, has played a key role in bringing mindfulness to American healthcare. His research focuses on improving communication between patients and physicians and promoting mindful practice and self-awareness in clinicians. His 1999 Journal of the American Medical Association article was one of the first on mindfulness in a major medical journal. mindful practice for patient care

Mindful Practice: Dr. Gail Gazelle Talks Mindfulness With Ron Epstein

Gail Gazelle: Thanks for taking the time to speak with me about the importance of mindfulness in healthcare. How did you become interested in the topic?

Ron Epstein: When I was 17, a friend taught me how to meditate. I found that it gave me a sense of grounding and connection. I continued my contemplative practice. Many years later, while developing an assessment system for our new curriculum in Rochester, I began thinking, “What is it that makes a good doctor?” I knew that it was more than just skills and factual knowledge. A student can list the causes of cryoglobulinemia but that doesn’t necessarily make him or her a wise clinician. It is more – it is the ability to be attentive, curious and present and to cultivate a “beginner’s mind.” So I started asking students different types of questions – reflective questions – such as “What are you assuming about this patient or this situation that might not be true?” “Are you having strong feelings about the patient that could affect your decision-making?” Typically students hadn’t been asked questions like these. It made them stop, think, and be self-aware and present.

Being a good doctor involves the ability to listen deeply and to be present with someone who is in distress. But, no one teaches those skills; even in communication skills courses we learn what to say but less attention is about how to listen. When I took a careful look at myself I could see that there were times when I practiced well and when I didn’t, and it had to do with the same sort of mind states in my meditation practice – when I’m at my best, I’m more self-aware. Mindfulness goes beyond cognitive reflection. When you’re in the presence of someone who’s depressed you may feel a heavy feeling in your chest. You might feel a tensing of your neck with someone who’s agitated. Being open to your own somatic markers and your own emotions is important– not only for you as a clinician, but for your patients. You bring your whole self to the care you provide. Mindfulness involves awareness of the physical, emotional, and cognitive–and also of your own mental state– are you tired or distracted, how well is your mind working right now?

It’s possible to cultivate these qualities. The brain works differently when you’re being mindful as opposed to not, and meditation practice is a kind of deep learning, that we now know can promote neuroplasticity.

Gail Gazelle: Where do you meet resistance about mindful practice in the medical profession?

Ron Epstein: Those physicians who consider that their stress only has to do with the work environment may have difficulty looking inside themselves to appreciate the ways in which their reactions to stress are healthy or unhealthy. If their clinical environment feels out of their control then they wonder if their efforts really make a difference. Some might even ask, if the world of medicine is so crazy and you’re helping people be more accepting, are you being complicit? My answer is no. I think that in becoming more self-aware, people become more energized to change themselves– and change the system. mindful practice for patient care

It’s also important to realize that mindfulness does not necessarily create a state of peace, it’s cultivating awareness of things as they are. That can be difficult. It’s building awareness and resilience at the same time. mindful practice for patient care

With meditation, you become more comfortable being present with a wider range of emotions, learning that you actually have a greater degree of control and choices about your reactions. You can choose how you respond. You can temporarily set your distress aside – metaphorically putting it on a shelf next to you. You see that you are not your anger, or your sadness, or your pain. You begin to understand that anger or distressing physical sensations are things you have the ability to work with.

Gail Gazelle: True. It’s important that we don’t let our feelings define us. Is it fundamentally the separation, the “I am not this?”

Ron Epstein: It’s the ability to notice “there I go again. So and so said something and my blood pressure went up by thirty points, isn’t that interesting.” With mindful practice, you get the capacity to be a little bit more able to make choices in situations that you thought were choiceless. I think it’s allowed me to engage on a personal level or principled way, without getting caught up in the fear, emotion, and the distress. So all of that’s there but I can step back and think: what’s wrong with this situation, well this situation is unhealthy. And then choose how to respond. I also think it’s important to be public about being mindful –it encourages and emboldens others to do the same.

Gail Gazelle: What does mindfulness offer when you can’t control the external circumstances, for example, when practice demands are impacting patient care?

Ron Epstein: I think you can first offer clarity regarding what you can impact and what you can’t. In virtually every environment you have some choices. The environment may be very toxic in American medicine but medicine has always been difficult, albeit in different ways.

Gail Gazelle: We’re in a challenging time for physicians. How can mindfulness help? mindful practice guidelines

Ron Epstein: Mindfulness allows you to have a clearer sense of who you are, of what is important, and where to direct your efforts. Sometimes it makes clear the choice to go somewhere else. It’s a sense of control. In the most difficult situations, you can still be present, and that presence itself is something patients value. It is something that can’t be taken from you: the capacity to listen, and the capacity of being honest with yourself.

Gail Gazelle: I know you think big about what mindful practice can offer healthcare. Would you share your thoughts on the topic?

Ron Epstein: I do think big. There are some health systems that are committed to becoming more mindful. Several medical schools now have required mindfulness programs for medical students.

I recently worked with a health system that has compassion as their mission statement, and they seem to be taking it very seriously. They believe that if they achieve financial success but are not compassionate, they have failed. At a 2-day workshop for 300 of their clinical staff, the CEO was there the whole time, and I never saw her take out her smartphone. She was present, communicating her availability and commitment. That is important. mindful practice guidelines

Practicing mindfully helps patients feel like they’re being listened to and attended to. I believe it can reduce errors resulting from inattention and haste, and it can promote caring and professionalism when things go wrong. Perhaps it can limit the use of mindless aggressive care for people who will only be damaged by it, enhance the sustainability of the healthcare workforce, and reduce turnover, all of which would cost us less.

Mindfulness programs in the corporate world may increase productivity, but more importantly, they can help people feel a greater sense of meaning in their work lives. I recently spoke with a cardiologist friend who was tired and bored after a day reading stress tests and EKGs. Mindfulness could alleviate the boredom by taking that moment when the patient is getting on and off the treadmill to acknowledge the humanness of that person, to see the novelty in the familiar, and to appreciate the connections he has with his staff. mindful practice guidelines

Gail Gazelle: So it takes it from isolation to the greater purpose. Isn’t that what’s most important?

Ron Epstein: Yes, because sometimes we forget what it’s all about. Ultimately, medicine is about people. mindful practice guidelines

Physician Burnout: Are You Engaged Yet?

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When you wake up in the morning, are you ready to take on the day, or do you want to pull the covers up over your head and crawl into a cave?

As noted in a recent  New York Times  article, “Why You Hate Work,” a 2013 Harvard Business Review study of 12,115 white-collar workers revealed that 70% of workers do not have time for creative or strategic thinking at work, and 50% do not find meaning and significance in their workplace.

This problem of finding purpose or engagement at work affects all white-collar workers, including physicians in nearly every specialty and field. A pioneer in burnout research, Christina Maslach defines burnout as a three-dimensional syndrome made up of exhaustion, cynicism, and lack of sense of meaning and accomplishment. Does any of this resonate for you or the physicians you know?

As a physician coach, I have worked with many clients suffering from physician burnout who are not only dissatisfied in their work, but feel disillusioned and without purpose.

I recently worked with a mid-career neurologist who was frustrated by the never-ending changes in her workplace. It seemed as if the rules changed by the week, with hard-to-understand updates to the EMR, and rotating practice managers, one more challenging to work with than the next. My client became so lost in frustration and negativity that she wondered why she was even practicing medicine anymore.

Engagement is the antithesis of physician burnout, and is defined as a positive, fulfilling, state of mind characterized by vigor, dedication, and a sense of flow in one’s day.

The New York Times article points out that employees are more satisfied and productive when their foundational needs are met, including creativity, value, and a sense of connection and purpose at work.

When engaged, white collar employees are more motivated, feel more personally invested, and tend to become absorbed in their work. When they come up against challenges, they are inspired to find creative ways to problem-solve. In addition, these employees find greater work-life balance, and have an overall sense of optimism and happiness. This is critical for physicians, given that they experience levels of burnout of 30-60%.

Engagement is increasingly recognized as vital for self-determination and productivity in the workplace. Organizations that encourage employee engagement are experiencing higher profits, improved safety records, and higher retention rates. Simple workplace measure such as providing breaks and acknowledging hard work can go a long way in increasing engagement.

Through physician coaching, my neurologist client experienced renewed motivation to effect change in her workplace.  She pushed leadership to develop a wellness committee. We worked on many strategies to help her manage the changes and stresses of her position. Over time, she learned to focus more on her strengths, celebrate small daily accomplishments, and gradually re-engage.

If you find yourself overcome by disengagement and burnout, please check out my new FREE ebook, Building Your Resilient Self: 52 Tips to Move from Physician Burnout to Balance. I created this resource specifically for physicians. In the book you’ll find specific strategies to prevent and counter physician burnout.