Suzana KE Makowski MD MMMAssistant Professor of MedicinePalliative Care in the Cancer Center of ExcellenceDirector, Lois Green Learning CommunityUniversity of Massachusetts (Worcester, MA)

Ronald M Epstein MDProfessor of Family Medicine, Psychiatry, Oncology and NursingDirector, Rochester Center to Improve Communication in Health CareUniversity of Rochester Medical Center (New York, USA)

Just being: An Introduction to Mindfulness and Its Role in Tending to the Dying

Disclosure Statement Dr. R. Epstein and Dr. S. Makowski have no

relevant financial relationships

What is Mindfulness?

A process of regulating attention to bring a quality of non-elaborative awareness to current experience, with an orientation of curiosity, experiential openness, and acceptance.(Bishop)

Empathy as emotional labor

To cultivate an acute ability to empathize with others, once needs patience, curiosity, and willingness to subject one’s mind to the patient’s world…

Larson, Yao JAMA 2006

Exquisite Empathy

“Highly present, sensitively attuned, well-boundaried, heartfelt empathic engagement”

Kearney et al, JAMA 2009

Self-awareness

To hold contradictory truths simultaneously

Clashing discords

Loss of eQuiLibRium

Great Questions

Longing

Learning to stay through discomfort

So I think healing has to do with slowing down, coming into the present, listening, accepting, forgiving, entering into community with, and healing is prevented by the opposites of those things.”

- Balfour Mount, MD

This being human is a guest house.Every morning a new arrival.

A joy, a depression, a meanness,some momentary awareness comesas an unexpected visitor

Welcome and entertain them all!Even if they are a crowd of sorrows, who violently sweep your houseempty of its furniture,still, treat each guest honorably.He may be clearing you out for some new delight.

The dark thought, the shame, the malice,meet them at the door laughing,and invite them in.

Be grateful for whoever comes,because each has been sentas a guide from beyond.

Jelalludin Rumi (1207-1273)

The Guest House

Unexpected Visitors in Medicine

Ambiguity and uncertainty

Conflict between patient and clinician needs

Strong emotions: the patient’s and yours

Blame

Errors

Unanticipated serious illness

Impermanence of knowledge

Intractable problems

Lack of control

Real or imagined threats induce a similar stress response:

Imagined scenarios involving threat or failure

Comparison of actual situation with ideal Degradation of self or present situation Recall of disturbing events Self-criticism Rumination Emotional avoidance Pessimism, denial

Burnout Definition

Depersonalization Emotional exhaustion Sense of low personal accomplishment

Effects Affects work life, relatively spares personal life Numbing, distancing, not noticing, empathic failure Associated with errors, leaving practice, suicidal ideation

High prevalence 25% - 60% of practicing physicians 76% of internal medicine residents 49.6% of students – 11.2% with suicidal ideation

Shanafelt et al. 2003 and 2005; Dyrbye LN et al 2008

Mindlessness: denial, self-deception and delusion

… “the tendency of the mind to seek premature closure .. That quality of the mind that imposes a definition on things and then mistakes the definition for the actual experience”

Epstein M 1995

Looking but failing to see

Mindful practice

Moment-to-moment purposeful attentiveness to one’s own mental processes during every day work with the goal of practicing with clarity and compassion

Epstein RM 1999

Three ways of paying attention

Gusnard DA et al 2001

Alerting = vigilance for the expected

Orienting = assigning relevance to certain information, ignoring other information

Executive = noticing and integration of unanticipated events

A mindful moment – attending to the quality of attention

Mindfulness lessons from Brahms

WHY SHOULD MINDFULNESS MATTER TO CLINICIANS?

Physician well-being

(resilience vs. burnout)

Quality of care(vigilance vs.

mindless errors)

Quality of caring(presence vs.abandonment)

Shanafelt, T. D., et al. (2002). Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med, 136, 358-367; Shanafelt, T. D., et al. (2005). Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med, 20, 559-564.

Physician well-being

(resilience vs. burnout)

Quality of care(vigilance vs.

mindless errors)

Quality of caring(presence vs.abandonment)

Mindful practice

Mindful practitioners

Qualities

Attentive observation

Critical curiosity

Beginner’s mind

Presence

Attitudes/behaviors

Motivation

Clear perception

Openness

Attenuation of reactivity

Mental stability

“Slowing down when you should”

Promoting mindfulness

Formal practice

Informal practice

Situational awareness

Mindful health systems

Informal practice (mindful moments) Stop – breathe – be

20 breaths

Doorknobs and mirrors

Just listening

Mindfulpractice

Narrative

Appreciative inquiry

Greaterself-awarenessLower reactivity

Interpersonal mindfulnessProvidescontext

Builds on strengths –Mental stability

Increased attentiveness, curiosity,responsivenessand presence

More effectivecommunicationwith patients and staffRadical honesty with self

Improved physician self-efficacy, vitality

satisfaction, andconfidence

Reduced physicianstress and burnout

Improved patient

satisfaction

Improved practiceEfficiency

Improved qualityof care

Mindful practice, narrative and appreciative inquiry: effects on communication, clinician well-being and clinical care

Asking reflective questionsQuestions that “open up” and “tend not toward edification”

“What feelings are affecting my ability to observe?”

“What am I assuming that might not be true?”

“How are prior experiences and expectations affecting how I view the situation?”

“Did I use ‘fuzzy logic’ or ‘cognitive alibis’ to justify my actions?”

“What would a trusted peer say about the way I managed this situation?”

“Am I really done, or am I engaging in premature closure?”

One of the things that comes out of this too, is that when you establish a practice of

thinking more honestly, thinking more clearly, speaking more honestly,that definitely leaks out into your work everyday…it certainly opens you up to being more ready with patients,

colleagues, family, to have those kinds of conversations and to have that kind of a more intimate, more honest

interaction with people and that certainly was the case for me that came out in the

rest of my work…It certainly made it much more immediate and easy to do in

my practice.

Participant

…and patients notice

Inner-city HIV-infected patients Observational study Mindful Attention Awareness Scale correlated

with: Patient-centered communication, positive

emotional tone, psychosocial orientation Patient ratings of communication, satisfaction

Beach et al, 2010

Interpersonal mindfulness

What did you learn…

About listening and being heard?

About being mindful in stressful/challenging situations?

About how you practice?

Two Kinds of Intelligence

There are two kinds of intelligence: One acquired, as a child in school memorizes facts and concepts from books and from what the teacher says, collecting information from the traditional sciences as well as from the new sciences.

With such intelligence you rise in the world. You get ranked ahead or behind others in regard to your competence in retaining information. You stroll with this intelligence in and out of fields of knowledge, getting always more marks on your preserving tablets.

There is another kind of tablet, one already completed and preserved inside you. A spring overflowing its springbox. A freshness in the center of the chest.

This other intelligence does not turn yellow or stagnate. It’s fluid, and it doesn’t move from outside to inside through the conduits of plumbing-learning.

This second knowing is a fountainhead from within you, moving out.

Rumi

Acknowledgments

Collaborators:Mick Krasner MDFred Marshall MDScott McDonald MDTim Quill MDTony Suchman MDHoward Beckman MDBen Chapman PhDChris Mooney MAMelissa WendlandNancy AdamsMary Jane Milano

Consultants / muses:Michael Baime MDRita Charon MDRon HoffmanJon Kabat-Zinn PhDSaki Santorelli MAPenny Williamson ScD

Funders / supporters:Physicians Fdn for Health Systems

ExcellenceNY Chapter, American College of

PhysiciansMonroe County Medical SocietyRochester Individual Practice

AssociationArthur Vining Davis FoundationsArnold P. Gold FoundationMannix Fund for Medical Education

Just being: Mindful Practice and the Ethics of the MomentRon Epstein MD

Departments of Family Medicine, Psychiatry and OncologyRochester Center to Improve Communication in Health CareUniversity of Rochester, NY, USAronald_epstein@urmc.rochester.edu

Participants

70 Primary care physicans

54% Male, 46% Female

49% Internists, 41% FP, 10% Peds

71% suburban , 25% urban

15.9 years in practice