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Gold Foundation Interview with Ron and Mick
Tell us about how you came to create Mindful Practice®.
RON: About 10 years after completing residency and into a role as a medical educator, I became restless. Something important was missing from medical care and medical education, something beyond the facts, skills and techniques that we all acquired during training.
I explored what qualities I exhibited when I was practicing at my best and took note of those same qualities in physicians whom I, and others, considered exemplary. These qualities included attentiveness, curiosity, presence and beginner’s mind (the ability to see a familiar situation with new eyes). In 1999, I wrote a personal manifesto describing those qualities, which I called “Mindful Practice,” and the paper was published in JAMA that year. I was astounded at the response – hundreds of letters sharing personal stories of clinicians, educators and students that reflected some of those same qualities.
Now that I had surveyed the landscape of mindful practice, how could I help clinicians become more mindful? I fell back on my prior training as a musician and my prior experiences as a student of Zen Buddhism for inspiration. Then I met Mick Krasner, who was wrestling with some of the same questions – how do we bring attention and presence into the clinical encounter? Into teaching? Even into administrative meetings and research?
We took a skills development approach. To understand our inner landscapes, contemplative traditions, including meditation, had a lot to offer. To understand how we relate to our colleagues and patients, using narratives about meaningful experiences in clinical practice and teaching proved was helpful, especially when coupled with guidance to promote deep listening and dialogue. And to enhance positive potential – healing, shared understanding, well-being—we borrowed techniques from appreciative inquiry.
MICK: For me, having been in medical practice at that time for about 10 years, similar to Ron, I was finding myself truly concerned about my ability to flourish in my career and balance the personal experiences of raising a family and becoming part of my community. Having a committed contemplative practice helped, and I began engaging in more formal training to teach mindfulness-based stress reduction. As I began teaching this powerful and transformative approach to patients, community members, and at times other health professionals, not only did I find myself more in touch with the meaning, purpose and joy in my work life, I found myself responding to requests from physician/colleagues who were participants in these courses to think of expanding into more mindfulness-based training specifically designed for health professionals.
I began to realize then that not only was I concerned and experiencing distress in domains of my work life, so were many of my colleagues. Based on our collective experience and those of a few other colleagues, we created a new mindfulness-based intervention, now called Mindful Practice. We feel it engages the best of physicians’ and other health professionals’ inclinations toward service, compassion, attention, awareness, meaning and quality.
What benefits have you seen in your own lives?
RON: I’ve been in clinical practice for 35 years, and often think of what has sustained me for so long doing work that is cognitively difficult, emotionally intense, and administratively burdensome. I keep coming back to four elements: finding meaning, feeling part of a community, riding the waves with aplomb and changing the work environment. Mindful Practice helps me find all of these elements through clarifying and focusing on what is most important, providing attentive and effective care even in difficult environments, and helping me to feel engaged in a community of practice and social change.
MICK: It may sound cliché, but I cannot imagine living my life without mindfulness, or practicing medicine without Mindful Practice. It has helped me to understand and live the true uncertainty of the work we do and the lives we live, to connect more authentically and therapeutically with patients, colleagues and staff, to obtain more joy at home and at work.
It is interesting to use the word joy, and not happiness. For me, happiness can be a transient feeling, but joy, in the eudaimonic sense, is more about the deeper satisfaction that is not so dependent on outcome, but relies more on a healthier and more proper relationship with what is truly life satisfying, meaning giving, and relationship supporting. I can honestly say that I experience this to a much greater extent with the practice of mindfulness in my life.
Why would health professionals want to add more training into their already busy lives?
RON: What choices do we have? Physicians are distressed. While it is critical to address the dysfunction of the current healthcare system, those remedies, even if enacted today, will take years to come to fruition. And, furthermore, healthcare will remain intrinsically complex and emotionally demanding. The author Stephen R. Covey emphasizes “sharpening the saw” when considering habits of highly effective people. Mindful Practice is sharpening the saw of our attention, being clear about our sense of purpose, managing challenges and uncertainty, and caring for ourselves in the interest of being more effective in what we can do.
MICK: To paraphrase Hippocrates, the art and craft of medicine take a lifetime, life is short, the opportunities are fleeting, and our judgment complex and difficult. To put this into real-life experience, a physician who took the original Mindful Practice program 12 years ago, a physician with over 20 years of practice experience, highly analytical, evidence-driven, and well-respected among colleagues, shared the following at the last session (I will paraphrase): I have been in practice for many years, and have had to engage in CME every year. I am not sure I have ever used anything I learned in a CME course in my practice or in my life. This course is the first experience I have ever had that was truly CONTINUING MEDICAL EDUCATION. And I use what I have learned here daily.
Are these workshops suitable for people who already have meditation routine or other mindfulness habit worked into their lives?
RON: Mindful Practice workshops build skills that can be applied during everyday work in whatever work setting you find yourself. Formal meditation is valuable for many of us, and we strongly encourage participants to develop some kind of regular contemplative practice, even if only for a few minutes per day. However, the mindfulness that really “counts” is what you can do while at work and at home, dealing with the complexities and stresses intrinsic to our lives. Mindful Practice programs focus on approaching the most challenging aspects of our work lives with awareness, attention, curiosity, beginner’s mind and presence. Imagine a mindful resuscitation attempt. A mindful path through a difficult conflict with a patient or colleague. A mindful response to an unanticipated surgical complication. A mindful approach to a student in difficulty. Even experienced meditators need a new set of skills to be able to adapt the sense of focus and presence that they develop during contemplative practice to the complex world of medical practice.
MICK: The approaches taught in Mindful Practice are definitely suitable and would be useful for participants with any level of meditation/mindfulness/contemplative experiences. Because we have combined some of the powerful aspects of narrative medicine and appreciative inquiry in this approach, and because there is so much about the approach that is relational and interactive, Mindful Practice adds new dimensions to contemplative practices that at times can be individual and self-directed experiences. And the tools that we share in Mindful Practice can be truly helpful in bridging the “on the cushion” meditative practice to “with the patient” medical practice, tools that can be practiced and used on a daily basis, requiring very little “time” yet benefiting the little time we do have with our patients, colleagues and staff.
What sorts of changes have you seen participants experience after going through your workshops? Could you tell us a story or two?
RON: We have studied the effects of a longitudinal mindful practice workshop, very similar in format to our intensive multi-day workshops. Our results, published in JAMA (Krasner et al., 2009), showed that participating physicians experienced lower burnout and greater well-being, and approached patient care in a more patient-centered and empathic way. Furthermore, they were better able to regulate their emotions and be more attentive. They reported a greater sense of community, that they learned useful skills that could applied to clinical situations, and that they learned to care for themselves in the interest of caring for their patients. Several others around the world have published similar findings. The stresses and rates of burnout have only increased since then, making programs that address physician distress, isolation and need to re-connect with a deep sense of purpose even more urgently needed.
MICK: Aside from the findings discussed in our published research, over a thousand physicians and other health professionals have participated in some form of multi-day Mindful Practice trainings with us. It is difficult to generalize, but a few examples stand out. One is a physician who was an associate dean of students at a North American medical school, who having completed our basic, advanced and internship trainings, is now writing a book about how Mindful Practice has changed her life as a physician. An obstetrician in Sweden, who has been involved at a national level in OB-GYN simulation training, has made Mindful Practice a centerpiece of physician wellness, and has led 7 groups of colleagues in year-long training programs modeled after our original Mindful Practice program. A physician member of a community health center in Southern California applies Mindful Practice to improve quality metrics among colleagues. A psychologist in Newfoundland uses Mindful Practice as a way to address the dynamic of shame in the informal curriculum of medical education. And a couple (an orthopedic surgeon and a health psychologist) are using Mindful Practice to engage their physician colleagues at a hospital in Melbourne, Australia.
Blogs by Ron Epstein, MD
An account of an illness, quality of attention and what mindful care looks like, from Minimally Disruptive Medicine, Nov. 21, 2016
Presence: Restoring coherence amid uncertainty
The impact of the burnout epidemic on patients and the care they receive, from Arianna Huffington’s new website, Thrive Global, Nov. 30, 2016
Is Your Doctor Burned Out?