An Interview with Ronald Epstein
- Tyler Cymet
- November 19, 2019
Use mindfulness to heal thyself, the author urges fellow physicians.
Ronald Epstein has devoted his life to making healthcare in America better by making healthcare providers better — teaching fellow physicians to connect with the people they care for while keeping themselves curious and open. His book, Attending: Medicine, Mindfulness, and Humanity, addresses the multifaceted issue of provider wellness for a general audience.
Does mindfulness make medicine more effective?
There is good evidence that mindful practitioners listen better, and their patients notice. They exhibit less implicit bias and stereotyping and are better able to see patients as individuals and to individualize care. Mindfulness tends to increase compassion. On the technical side, mindfulness is associated with greater patient safety and fewer errors. More-mindful clinicians wash their hands more often, make fewer medication errors, have fewer needlestick injuries, and, on nursing units, patients experience fewer falls.
In mindful practice, rules guide the physician but don’t control the physician. In business, it is the rules that increase efficiency. How do you see this conflict finding harmony?
Here you are talking about the difference between competence and mastery. Competent clinicians follow the rules; masters know when and under which circumstances to break them. Consider management of patients with diabetes. Slavish, decontextualized adherence to treatment guidelines for glycemic control can cause harm due to hypoglycemia in the frail elderly with minimal long-term benefit. Mindfulness is associated with greater discernment.
In the book, you note that experts know the answers, but only masters know the right questions. Will there always be questions, or will algorithms eventually render them moot?
I cannot see an end to questioning, to exploring. As you’re probably aware, in the late 19th century, some claimed to have solved all of the major problems of physics. Clearly, Einstein and Niels Bohr disagreed.
With a call for greater attention to the mental health and wellbeing of healthcare providers, where do you see self-care being addressed?
Health professionals are experiencing unprecedented types of stressors for which we have not been adequately prepared and about which some leaders in healthcare are dismissive or willfully ignorant. Calls to “become more resilient” ring hollow in environments that are toxic and unsupportive and address the burnout question with window-dressing. Thus, it is essential to address the drivers of clinician distress — overwork, meaningless administrative tasks, dysfunctional information technology, feeling isolated from peers, and being held accountable for the bottom line.
That said, even in toxic environments, it is possible to become more aware, develop a sense of community, and employ skills of mindfulness and reflection so that clinicians can make choices about their relationship to the workplace and effect change in the environments in which they have leadership roles. The best approach, of course, is to marry institutional adaptations with individual skill-building.
Are there levels of mindfulness?
While there are scales that measure mindfulness and correlate with some clinically relevant outcomes (burnout, empathy, teamwork, attentiveness), none lay claim to distinguishing masters from adept novices. Some brain-imaging research claims to have made some of those distinctions, but the field is still new, and the findings often have not yet been replicated. On a personal note, a few years ago, I asked a meditation teacher how I would know whether my practice was “deepening.” Her answer: “You’re not the Dalai Lama.” We all have work to do and room to grow.
When providing care, how do doctors find their comfort zone between paying attention to everything vs. focusing on a specific issue?
In Attending, I start with an example of a surgeon who is so preoccupied with the narrowly focused task that he misses something quite obvious and life-threatening. An otherwise highly skilled surgeon, he lacked the capacity to regulate his attention. He did not achieve an adequate balance between focused attention on detail and an openness to the unexpected.
One needs both top-down and bottom-up attention to survive in the world. Over the past two decades, we’ve learned that attention can be trained, and we’ve probably been doing that training tacitly and inconsistently. This does not mean paying attention to everything — that is impossible. It does mean alternating focusing with scanning the wider environment, using one’s peripheral vision as well as one’s macular vision.
Tyler Cymet, DO, is the chief of Clinical Education at the American Association of Colleges of Osteopathic Medicine and is a clinical associate professor at the New York Institute of Technology, College of Osteopathic Medicine and sees patients in the emergency department at the University of Maryland Capital Region. He is also the author of Health Info to Go: General Medicine and Addictionary: Guide to Drug User Terminology.