What Is Trying to Happen Here? Using Mindfulness to Enhance the Quality of Patient Encounters | to pdf >>
Abstract
Mind can be considered as a process that regulates the flow of sensory inputs and information, much of it largely unobserved. Mindful self-awareness is a disciplined means of directing attention to the thoughts, affect, intentions, and physiologic shifts that occur moment to moment. These, along with the perception of signals observed from another person, shape behavior in an ongoing interaction. The flow of inputs and information has implications for the formation of an empathetic relationship. Empathy is known to be an essential aspect of successful clinician-patient communication. This article describes the characteristics and practices of mindful self-awareness as a way of promoting optimal outcomes in patient encounters.
What is Trying to Happen Here?
Clinicians know from experience how difficult it is to be fully attentive to a patient during an encounter. Attentiveness is challenged by many things, including overloaded schedules and time limitations, patients poorly prepared to provide information or unable to provide information, patients presenting a plethora of detail and complications requiring more time than has been allotted, and patients consistently noncompliant. Often these are viewed as obstacles to quality care over which clinicians have no control. They are clearly factors in the patient–clinician encounter and cannot be ignored. Rather than viewing these as problems that negatively affect the encounter, it is valuable to develop the skill of attending to them and, more importantly, to the impact they have on our own internal states, in a way that shapes better outcomes.
Self-Awareness in Patient Encounters
Mindfulness is a disciplined form of self-awareness and has been described as a key method both for increasing competency in connecting with one’s inner life and for developing compassion for others.1,2 In any given moment of activity, action, cognition, emotion, and memory are present and interdependent. Being mindful allows an individual to actively observe these interdependent states and make behavioral adjustments in real time. A goal of making such adjustments in a patient encounter is to create an attuned communication with another so that a more compassionate, informed way of interacting is possible. When two people are effectively interacting with each other, their mental states are brought into resonance with one another. For this to happen, it is important to be sensitive not simply to signals from the other but also to the internal signals that represent one’s own mental state as the encounter proceeds.
Mindful awareness is one means to achieve better communication competency in a patient encounter that is crucial both to the processes and outcomes of medical care.3-6 Evidence has demonstrated that such competency can be taught in the form of skill sets. The Four Habits model7 is one example. In this model, skills are nested and interrelated, starting with eliciting and prioritizing the patient’s concerns and demonstrating appropriate empathy to encourage the patient’s participation in decision making and education. Empathy is a key element in that it represents attunement to another. An empathic relationship may be disrupted by a person’s unobserved flow of thoughts, feelings, intentions, and physiologic change, typically running unchecked and at the same time guiding their action. The Four Habits model appropriately directs a clinician to monitor the effects of external behaviors directed toward the patient. Mindfulness builds on this as a way to monitor internal states, as these vary in an encounter.
Mindfulness has emerged as an important approach in psychologic treatment for a range of problems, from negative mood syndrome to the reduction of suffering that accompanies chronic pain and/or disease.8-11 Patients who effectively practice this skill can derive benefits in several domains, including mental coherence, physical health, and interpersonal functioning. Furthermore, treatment outcome studies show that empathy, interpersonal sensitivity, and compassion can be improved with consistent practice of mindful awareness.12 For clinicians, such disciplined self-awareness is a logical extension of a reflective practice.
Mindfulness Illustrated
Before considering the elements of mindfulness, consider this brief scenario:
Ms Smith comes to the clinic, again complaining of vague abdominal pains. She will be seen by Dr Turner, who has dealt with her and this complaint on numerous occasions in the past. On the way into the room, Dr Turner thinks, “Here we go again. I don’t know how many times I have gone over this with her and explained that there is nothing wrong. It is all in her head.” Soon after Ms Smith begins to describe her symptoms to Dr Turner, she begins to cry. Dr Turner hands her a box of tissues and thinks, “I don’t do tears.”
Two aspects of this scenario are important to consider: First, Dr Turner is making predictions about the outcome without data. Nothing has happened yet. Second, he is focused on his own discomfort and annoyance with his patient’s emotional expression. Dr Turner may think that he is responding to the observable aspects of the encounter--the history with the patient and the patient’s presentation. Also present are his thoughts, affect, physiologic arousal, and intentions, and he reacts automatically as these change. Because he is not mindful of his internal states, he is largely inattentive to the flow of this encounter as it is happening. He is poorly attuned to his patient.
Mindfulness involves an awareness of experience that is accepting rather than focusing on suppression of unwanted thoughts or feelings. Learning first to recognize thoughts as thoughts, and then, having recognized them, learning to accept them, can free a person from a distorted sense of reality. It can allow for greater clarity about a context within which we find ourselves and can provide a basis for a more flexible, values-driven approach to problem solving. Extending this to a patient encounter, good outcomes depend in part on focused, nonjudgmental attention to the complexity the patient brings interacting with the complexity the clinician brings. Langer13 has described mindfulness as a state of “could be,” of holding onto uncertainty rather than trying to avoid it. Thus, patients who could be viewed as difficult could just as well be seen as interesting, challenging, or provocative. Issues that remain unresolved at the encounter’s end could as well become research questions or opportunities for growth. Here is a revision of the scenario presented above:
Dr Turner breathes deeply before entering the room to see Ms Smith. He notes that the patient is here for vague complaints of abdominal pain. Dr Turner acknowledges having the thought of having been in this situation before with Ms Smith, and then focuses his attention on this encounter. As Ms Smith begins to cry during the encounter, Dr Turner acknowledges his own feeling of discomfort. He accepts that in this moment she feels discomfort, and he does not react to it by trying to control the situation to make his own unpleasant feeling go away. Rather than try to stop Ms Smith’s crying, he acknowledges that this seems very important to Ms Smith and asks if she would like to have a tissue before they continue.
Focused attention to experiences that occur from moment to moment gives an unfinished quality to encounters as we discover that in each moment, things are changing and that stability is a construct of the mind. It is for that reason that thoughts such as “Here we go again” or “It’s the same thing again” are erroneous. It is efficient to detect aspects of a situation that appear similar to previous situations and that allow for routine or automatic responding. Automatic responding biases cognition and saves time, in large part because we do not focus on detail but can quickly call on stored routines appropriate to the situation. To be aware of the features present and how they change through an encounter takes more time and energy and may therefore be considered inefficient. However, to impose stability is to fall prey to a mental habit that attempts to force control on a field in flux. Most people who begin to develop a habit of mindful attention report that it is a difficult practice to maintain. This is so not because it is intrinsically hard or complex but because it is elusive.
Here is a third illustration:
Dr Menendez is aware that she is not paying attention to Mr Jones, having already reached a conclusion about his complaint today and what to do about it. Rather than reacting to that thought and pushing the encounter to an end, she tells herself, “That’s a thought.” She refocuses on her breathing and returns her full attention to what is happening in front of her. In the remainder of the exchange, the two agree on what the next appropriate steps would be, and she is able to secure Mr Jones’s agreement to implement them.
Attention shifts rapidly and must be actively returned to the thing we have chosen to attend to--in this case, the patient. This is best accomplished not by fighting to push competing stimuli away but rather by acknowledging the thought that is interfering and that it is something we could be paying attention to but are not and by refocusing on the original target.
Developing the Habit of Mindful Attention
Mindfulness is a skill that requires practice, and meditation is an effective means of practice. Breath meditation, for example, provides a target that attention can always be returned to. When doing breath meditation, the practice is to observe your breathing without trying to do anything, accomplish anything, or go anywhere. It is the challenge of simply being an observer in that event. Intrusions, in the form of thoughts and environmental stimuli, will compete for attention. These can be reacted to in a mindless manner, by trying to push them out of focus or by losing focus by following the new input. To attend mindfully, however, means to acknowledge these intrusions and return attention to the original target.
Several ways of practicing mindfulness have been described for physicians.14,15 Hayes and Spencer16 emphasize the importance of daily practice, suggesting that one:
1. Set aside the time for practice and keep it. You will never find time to practice; you must make the time.
2. Avoid confusing the practice with relaxation or distraction. Tenseness, stress, and distractions are as appropriate to observe as are relaxation and focus.
3. Avoid using feeling too bad (or too busy or too distracted, etc) as a basis for letting the practice go. These too are all things to notice.
It is easy to be drawn into our predictions and evaluations and fall back to mindless, reactive responding guided by habitual patterns of thinking.
Practice should be for some extended period, such as 45 minutes daily, and many find that it is also helpful to include shorter periods of practice in the day as a means of fostering a sense of well-being and mental coherence.
|
Table 1. Attitudes characteristic of mindful behavior |
|
Nonjudging |
|
Patience |
|
Beginner’s mind |
|
Trust |
|
Nonstriving |
|
Acceptance |
|
Letting go |
Attitudes of Mindfulness in Clinical Practice
How can this practice be applied to encounters with patients? Kabat-Zinn17 described seven attitudes that inform a mindful approach to experience. These are summarized in Table 1 and described separately here with reference to clinical practice:
1. Nonjudging means to be an impartial witness to your own experience and, in the process, to notice the never-ending stream of evaluating and reacting to experiences that you engage in. When we are unaware of how automatically this happens, it is easy to get locked into reactions that often have no objective basis. We assume that “this is the way things are supposed to be.” Evaluation typically makes things worse. An encounter that begins with the provider thinking that “this patient is always so difficult” will probably not end well. It is likely that the patient will leave unsatisfied, thinking that they have not been heard this time.
2. Patience is the knowledge that things unfold in their own time. Instead of listening for a few key words that “tune us in” and then reacting, patience is the wisdom to listen actively to what the patient is saying without pushing to get through the encounter quickly and efficiently. Patience develops from recognition that this encounter is going somewhere and that we will know where it is going when we get there. Certainly it is helpful to initially frame the encounter by jointly agreeing what issues will be attended to during that time. Once that is accomplished, patience is reflected in the awareness that you do not need to control the duration, flow, or direction of the encounter, because that will be accomplished jointly.
3. Cultivate beginner’s mind. Clinicians accumulate a great deal of knowledge through formal learning, observation, and experience. This is what makes for experts, and they are consulted because of that expertise. Instead of thinking as an expert, train yourself to consider the situation as a novice: to hear and see everything fresh for the first time. How clinicians respond to their patients and how they reach a treatment decision are typically overlooked because so much experience has preceded any particular encounter. A disadvantage of expertise is that to know something is to exclude something else. Studies show that physicians are more accurate at making diagnoses than are third-year interns, but they are worse at recalling the information that they used to reach the diagnosis.18,19 Because no moment is the same as any other moment, beginner’s mind helps you to stay alert to the unique possibilities that each moment presents. Are you really encountering this patient in an active manner, or is the encounter a reaction to your thoughts about the history of this person or the problem?
4. Trust means that you learn how to honor your own feelings rather than to distrust or suppress them. “I hate it when patients cry” is a thought that typically produces discomfort and effort on our part to stop the crying, thereby ending our discomfort. Alternatively, this is an opportunity to increase responsibility for yourself because you are listening to and trusting yourself to have those thoughts as thoughts, and the feelings that come with them as feelings. As we learn to trust ourselves, we are able to trust others more as well and to recognize the basic goodness in them, fostering an empathetic relationship.
5. Nonstriving shifts focus away from imposing goals on an encounter. Rather than striving for a predetermined outcome, we shift our focus, seeing and accepting what is happening in that moment. In practice, that is attending to the question “What is trying to happen here?” by being open to the many possible answers that can emerge during the encounter. It is not uncommon that we tell patients what they should do or what would be good for them, only to later become frustrated that they do not do it: “You need to lose weight.” “You need to stop smoking.” “You should exercise daily.” Movement toward quality outcomes, articulated out of values (for example, to live a healthy, balanced life) will occur as you open yourself to all of the possibilities present in a patient encounter rather than narrowly pursuing a specific outcome because it is consistent with your goal. Work with the patient to understand where both of you are going and what path you are taking to get there. When the focus is broadly directed toward possibilities rather than on a goal, you become aware of the many ways of achieving a quality outcome for the patient encounter.
6. Acceptance is not a passive response to the conditions you encounter but a willingness to see things as they actually are, in that moment, not as you wish or expect them to be. Acceptance does not imply that you like the way things are. For example, you could have the thought “This patient will never get better because s/he always refuses to follow my recommendations.” Aware of that thought, you could bring the patient into problem solving. “I have suggested one way we could solve this problem. How do you see that working for you?” If the patient does not see it working, it won’t. In that moment, that is real, and to accept it is to move on to other possibilities. Each moment creates new opportunities to see and hear things freshly and work together with the patient toward high-quality outcomes.
7. Letting go occurs when you neither try to hold on to nor to reject your experience. It is the skill of letting the experience be what it is and observing it. It is the wisdom that comes from recognizing that you are not stuck.
Becoming mindful is a process, and as your practice deepens, greater levels of mindfulness can be achieved. Epstein20 described six levels of mindful practice that may be observed in clinical settings (Table 2). At level 0, there is no mindful awareness. Attention is on external conditions. At level 1, a clinician is likely to view problems as external and be detached from them so that it is easy to avoid responsibility and self-reflection while assuming some degree of responsibility. Level 2 is the result of a transfer of information to guide the practitioner. Reflective knowledge is less important than are explicit cognitive models that can be learned and implemented. At level 3 greater curiosity about one’s internal activity is developed without a reaction to suppress these activities or to label them as good or bad. Level 4 has the component parts of understanding of the nature of the problem, understanding how to solve the problem, and understanding the interconnection between the clinician and the knowledge that s/he possesses. At level 5, the clinician has learned to generalize insight and use it to overcome other challenges similar to challenges previously encountered. New behaviors and attitudes are incorporated into one’s repertoire. Compassion is authentic and the practitioner has a full presence in patient encounters.
Future Considerations
Mindfulness is a disciplined form of awareness that can help a practitioner be a more fully active participant in a patient encounter in that moment. Rather than reacting in an automatic, habitual way to the encounter, the clinician focuses greater attention on internal and external aspects of the encounter to resonate with the patient, promoting empathy and a more effective attunement to them. A mindful clinician can demonstrate this to patients as one way of encouraging them to use active awareness to produce flexible, adaptive, and values-based solutions to problems. Much suffering is the result of a rigid, habitual approach to a problem derived from the false belief that control and avoidance will protect us from discomforting thoughts and feelings.
Advances in social neuroscience have implicated neural pathways that may be involved in an empathetic understanding of another and the possible ways that the practice of enhanced awareness may affect neural plasticity. The human brain is markedly social. Building on this idea, Siegel2 proposed the “Mirror Neuron-Mindfulness Hypothesis.” Mindfulness promotes nonjudgmental attention to internal states of affect, thought, intention, and physiologic arousal to promote well-being. Mirror-neurons integrate perceptual learning, with motor responding creating an internal representation of the intentional states of others. When this system functions effectively, it facilitates effective participation in rapid social interactions that depend on shared sets of neural profiles that contribute to the meaning of the interaction. Siegel suggested that being empathic with patients may do much more than make them feel better at that moment. It may help stimulate neural activation with a coherence that helps patients improve their capacity for self-regulation. This hypothesis suggests intriguing research possibilities that could help us better understand how to work with patients in ways that promote optimal outcomes.
Mindfulness awareness facilitates flexibility and adaptation in a social encounter. There is an increased awareness of new possibilities as they arise in thought. Clinical experience indicates that it is not enough to tell someone that attention to their own thoughts and feelings is good for them. A practitioner must also be able to demonstrate ways in which patients can develop this skill, and remaining mindful in an encounter is an effective demonstration of the skill. It provides a way for a practitioner to become more attuned to a patient during an encounter. The enhanced self-awareness that comes through a habit of mindfulness represents empirical practice at its best. When mindful, you are observing your thoughts and feelings and as the signals come from the patient, adjusting your behavior as the encounter proceeds. These are all valid data to observe and contribute to the likelihood of reaching an optimal outcome in each patient encounter.
Acknowledgment
Katharine O’Moore-Klopf of KOK Edit provided editorial assistance.
References
1. Schmidt S. Mindfulness and healing intention: concepts, practice, and research evaluation. J Altern Complement Med 2004;10 Suppl 1:S7–14.
2. Siegel D. An interpersonal neurobiology approach to psychotherapy. Psychiatric Annals 2006 Apr;36:248–56.
3. Frankel RM, Stein T. Getting the most out of the clinical encounter: the Four Habits model. Perm J 1999 Fall;3(3) 79-88.
4. Keller VF, Carroll JG. A new model for patient-physician communication. Patient Educ Couns 1994;23:2-8.
5. Stein TS, Kwan J. Thriving in a busy practice: physician–patient communication training. Eff Clin Pract 1999 Mar–Apr;2(2):63–70.
6. Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA 1997 Feb 26;277(8):678–82.
7. Stein T, Frankel RM, Krupat E. Enhancing clinician communication skills in a large healthcare organization: a longitudinal case study. Patient Educ Couns 2005 Jul;58(1):4-12.
8. Kabat-Zinn J, Lipworth L, Burney, R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J Behav Med 1985 Jun;8(2):163–90.
9. Kabat-Zinn J, Chapman-Waldrop A. Compliance with an outpatient stress reduction program: rates and predictors of program completion. J Behav Med 1988 Aug;11(4):333–52.
10. Shapiro SL, Schwartz GE. Intentional systemic mindfulness: an integrative model for self-regulation and health. Adv Mind Body Med 2000 Spring;16(2):128-34.
11. Kabat-Zinn J. An out-patient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psychiatry 1982;4:33–47.
12. Kabat-Zinn J. Coming to our senses: healing ourselves and the world through mindfulness. New York: Hyperion; 2005.
13. Langer EJ. Mindfulness. Reading, MA: Addison-Wesley; 1989.
14. Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA 1997 Aug 13;278(6):502–9.
15. Novack DH, Kaplan C, Epstein RM, et al. Personal awareness and professional growth: a proposed curriculum. Medical Encounter 1997;13(8):2–8.
16. Hayes S, Spencer S. Get out of your mind and into your life. Oakland, CA: New Harbinger Press; 2005.
17. Kabat-Zinn J. Full catastrophe living. New York: Dell; 1990.
18. Patel VL, Groen GJ. The general and specific nature of medical expertise. In: Ericsson KA, Smith J, editors. Toward a general theory of expertise. Cambridge, UK: Cambridge University Press; 1991. p 93–125.
19. Schmidt HG, Boshuizen HP. On the origin of intermediate effects in clinical case recall. Mem Cognit 1993 May;21(3):338–51.
20. Epstein RM. Mindful practice. JAMA 1999 Sep 1;282(9):833–9.
