Mindful Medical Practice: Clinical Narratives and Therapeutic Insights

169 Pages·2015·2.092 MB·English

by  Patricia Lynn Dobkin (eds.)

Mindful Medical Practice
Patricia Lynn Dobkin
Editor
Mindful Medical Practice
Clinical Narratives and Therapeutic Insights
2123
Editor
Patricia Lynn Dobkin
Associate Professor
McGill University
Department of Medicine
Affiliated with McGill Programs in Whole Person Care
Montreal, Québec
Canada
http://www.mcgill.ca/wholepersoncare
ISBN 978-3-319-15776-4 ISBN 978-3-319-15777-1 (eBook)
DOI 10.1007/978-3-319-15777-1
Library of Congress Control Number: 2015933644
Springer Cham Heidelberg New York Dordrecht London
© Springer International Publishing Switzerland 2015
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduc-
tion on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic
adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted
from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied
specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser
of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright
Law of the Publisher’s location, in its current version, and permission for use must always be obtained from Springer.
Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to
prosecution under the respective Copyright Law.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
While the advice and information in this book are believed to be true and accurate at the date of publication, neither
the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be
made. The publisher makes no warranty, express or implied, with respect to the material contained herein.
Printed on acid-free paper
Springer is part of Springer Science+Business Media (www.springer.com)
In loving memory of my infant son, Nicolas
v
Kindness
Before you know what kindness really is
you must lose things,
feel the future dissolve in a moment
like salt in a weakened broth.
What you held in your hand,
what you counted and carefully saved,
all this must go so you know
how desolate the landscape can be
between the regions of kindness.
How you ride and ride
thinking the bus will never stop,
the passengers eating maize and chicken
will stare out the window forever.
Before you learn the tender gravity of kindness,
you must travel where the Indian in a white poncho
lies dead by the side of the road.
You must see how this could be you,
how he too was someone
who journeyed through the night with plans
and the simple breath that kept him alive.
Before you know kindness as the deepest thing inside,
you must know sorrow as the other deepest thing.
You must wake up with sorrow.
You must speak to it till your voice
catches the thread of all sorrows
and you see the size of the cloth.
Then it is only kindness that makes sense anymore,
only kindness that ties your shoes
and sends you out into the day to mail letters and
purchase bread,
only kindness that raises its head
from the crowd of the world to say
it is I you have been looking for,
and then goes with you everywhere
like a shadow or a friend.
from The Words under the Words: Selected Poems by Naomi Shihab Nye
© 1995. Reprinted with the permission of Far Corner Books, Portland, Oregon.
vii
Acknowledgments
I wish to extend my gratitude to people who have enabled me to conceive of and complete
this book. First, Dr. Tom Hutchinson, the Director of McGill Programs in Whole Person
Care, encouraged me to develop mindfulness programs at McGill University in the Faculty
of Medicine. He is an inspirational world-class leader of Whole Person Care. Second, my
brother, Dr. Dennis Dobkin, has always counseled me to abide by my inclinations – even in
those heady hippy days when at 19 years old I trekked off to India and discovered Auroville, a
UNESCO recognized model city of peace. Aurobindo, the sage who founded the Pondicherry
Ashram, taught that work can be a spiritual practice. His vision led me to here, now. Dr. Paul
M. Jurkowski ignited my heart with loving kindness – this was instrumental in transforming
my life.
My mindfulness teachers have been essential to my being able to teach MSBR and Mind-
ful Medical Practice. They are: Dr. Jon Kabat-Zinn, Dr. Saki Santorelli, and Florence Meleo-
Meyer at the Center for Mindfulness in Medicine, Health Care, and Society; Dr. Gregory
Kramer, whose Insight Dialogue retreats have touched me deeply; Dr. Ronald Epstein and his
colleagues who are world leaders in Mindful Practice. Various instructors at the Insight Medi-
tation Society in Barre, Massachusetts have been guides along the way as well. His Holiness
the Dalaï Lama has been a model of engaged social justice; his writings and visits to Canada
have been vital to my awakening.
Ms. Portia Wong at Springer Press has been helpful in transforming chapters into one co-
herent book. Ms. Angelica Todireanu at McGill Programs in Whole Person Care has provided
excellent technical support as well.
I dedicate this book to Mark S. Smith. I am grateful for his deep understanding me and this
work. He has offered me the inner and outer space to write in peace, dream in colour, and
share the joys of life together. His love is a precious jewel that adorns my heart.
ix
Foreword
Ronald M. Epstein, MD
University of Rochester Medical Center
A monk asked Zhaozhou to teach him.
Zhaozhou asked, “Have you eaten your meal?”
The monk replied, “Yes, I have.”
“Then go wash your bowl”, said Zhaozhou.
At that moment, the monk understood.
Wisdom, William James once said, is about “a large acquaintance with particulars” more than
overarching principles [1]. It is about finding our way in not just any situation, but this situa-
tion in which we encounter ourselves, right now. In medicine, these situations involve patients
and their families, with their sufferings and misfortunes. Overarching principles of clinical
practice—the teachings—provide a beacon to help us know when we are off course, but the
wisdom of clinical practice lies beyond our general knowledge of diagnoses and treatments;
it has more to do with how we respond to the exigencies of the moment—the contexts, the
individual players and the range of outcomes that are possible for and desired by this patient.
Zhaozhou’s answer to the young monk seeking wisdom was to wash his bowl—the task that
the moment demands of us. In that way, each patient encounter is also in the present moment;
each encounter might be part of a long-range strategy informed by knowledge and evidence,
but is always a drama that is being written, enacted and interpreted in the moment.
This book is about being mindful in clinical practice. Importantly, mindfulness is emer-
gent—it manifests as a desired attitude of mind without having been willed into being. Like
love, empathy and many other things that are important in life, mindfulness is something that
we value and can make space for, but can never fully define nor evince because the act of over-
specifying its shape, form, dynamism and trajectory limits it to something less than it is—as
Laozi said some 2500 years ago, the Tao that can be named is not the real (or eternal) Tao. I
won’t argue here what the Tao is, nor mindfulness, but those who have picked up this book
have some idea that mindful practice is an intentional attitude of mind that strives for clarity
and compassion—by adding the qualifier “medical” it defines the context and the protago-
nists—those who heal and those who seek healing.
The immediacy of clinical care is seen and enacted through stories that we tell ourselves
and others, stories that reveal our own perspectives. Reading stories about healers and patients
teaches us about the lenses through which they—and we—see the world. Stories are a vehicle
for wisdom. Narratives, as Rita Charon reminds us, serve to enlighten and to heal [2]. The
stories in this book have a particular focus and a particular purpose. They recount clinicians’
experiences of being attentive and present in ways that are heartfelt, revelatory and insightful.
Yet, they do more. They invite the reader to think and construct narratives about their own
clinical lives with the purpose of deepening their self-understanding, become better listeners,
appreciate that stories unfold and almost never take the linear form that dominates medical
case histories. A good clinical story brings to light the dual purpose of the clinician-patient
xi
xii Foreword
relationship—broadly defined, to interpret and categorize disease on the one hand and to inter-
act with a suffering human being in a way that restores health on the other.
Thanks to the work of pioneers such as Jon Kabat-Zinn, mindfulness is a household word
in North America, enshrined on the cover of Time magazine, discussed in earnest in corporate
boardrooms and schools, infused into psychotherapy and engaged in practice by millions who
want to experience greater balance, health and wellbeing. Since 1999, when the Journal of the
American Medical Association first published Mindful Practice [3], the word “mindful” has
also entered the lexicon of mainstream medical practice. It has a positive valence, even for
those who doubt that it is possible to achieve. Starting in 2006, with colleagues at the Univer-
sity of Rochester, I have tried to answer the challenge of how to help clinicians become more
mindful. This is no small task. Building on the work of philosophers, reflective physicians
and cognitive scientists, I have also drawn on my own experience—as a student of Zen Bud-
dhism (fortunately still a beginner after 42 years of practice), as a musician (my first attempt
at a career), as a chef (mindlessness manifests as burnt pine nuts) and as a healer. What has
emerged is that to cultivate mindfulness in action in clinical settings—what I call “mindful
practice” and which Patricia Dobkin and colleagues now call “mindful medical practice”—
requires preparation outside the workplace and enactment within it [4–9]. Usually, preparation
means some form of contemplative practice including but not limited to meditation, and the
enactment means some way to situate a practice of mindfulness in the context of healing.
Yet, meditation—with all its variations, power and allure—is not enough. Moving from
mindfulness to mindful practice requires grounding in what the educator Donald Schön calls
“the swampy lowlands”—the muddy amorphousness of everyday being in and with the world
[10]. Here is where stories come in—stories about, written by, told by, elicited from and lis-
tened to by clinicians about life experiences in health care contexts, full of their contradictions
and paradoxes, memory lapses, misapprehensions, emotional overlays and painfully poignant
turns of events; things that could never be captured in any other way. These stories are not
“pretty” and mindfulness does not flow from them like honey—these are pithy stories, infused
with grit and passion, foibles and humor, desperation and redemption.
This brings me to wonder—what is a mindful story? Medical journals are filled with nar-
ratives—about hope and loss, connection and unfulfilled promises, transformation and the
relentless unfolding of fate. All stories are meant to change how you look at the world. But,
do they all reveal mindfulness? I raise the question because I don’t have the answer. Yet,
close reading sometimes provides clues. Does a mindful story have to involve transformation
in some way? Does it involve a revolutionary change in thinking or experience—or does it
simply uncover what has always been there but has remained unknown and unseen? Does the
protagonist—when it is the patient—have to be, in Arthur Frank’s words, “successfully ill”,
and find meaning in his or her suffering? Does the healer have to be moved in some emotional
way? Can a mindful story be about placing a suture, reading an x-ray or responding to a medi-
cation alert on the computer screen—things that have little intrinsic emotional content? Does
the self-reflection implicit in the modern incarnations of the concept of mindfulness have to
be conscious, verbal and explicit? Or can it remain outside of everyday awareness, unspoken
and mysterious? Can mindfulness be humdrum? Does mindfulness have to be unexpected?
Can presence amid dissolution, destruction and disaster be mindful even though the outcome
is worse than anyone could possibly have imagined? Can mindfulness be giddy, silly, super-
ficial, transient, fleeting? Does mindful intentionality have to involve forethought, or can our
intentions reveal themselves after the fact? Can you think you’re being mindfully present and
be dead wrong, engaging in an elaborate self-deception? Do you really have to slow down to
be mindful? These questions are not necessarily issues to debate, but rather questions to hold
closely, to jiggle your thinking, to make sure you’re not too sure of yourself.
Stories are important because they expand awareness. While general principles and ideals
can be monochromatic, good stories are always ambiguous. They always have several sides
to them. They never answer all the questions they raise. Is John Kearsley’s “Carmen’s Story”
Foreword xiii
really just about Carmen? The way it is written—and many others in this volume—it has mul-
tiple protagonists—clinicians, patients, family members, others. Is mindful practice “about”
any one of them, or is the emergent mindfulness the space that their interaction reveals as each
member of the quartet (or duo or trio) tacitly takes a new view of an evolving situation? Is
mindfulness contagious, as it seemed to be in “The Opera of Medicine,” Mick Krasner’s story
about his relationship with his father and the person whose presence brought them together in
unexpected ways? You see where I am going: asking reflective questions leads us deeper into
ourselves and opens up the possibility to see the ordinary with new eyes.
Stories require a teller and a listener. Today I read an article showing that electronic devices,
including the one that I am using right now, activate the same brain circuits as do addictions.
Ironically, I read the article on the screen. That’s okay for research articles, but when I’m read-
ing stories in a deeper way, I realize that reading on the screen requires a focus beyond my own
capacity, so I print them out. Reading them out loud demands another kind of attention—audi-
tory information is qualitatively different from that which comes in just through the eyes. This
is to say that these stories are an invitation to read them mindfully, in whatever way you have
to in order to have them reveal themselves to you. These stories by health professionals, mostly
physicians, were written with the willing or unwitting help of patients and their families, and
in some cases, colleagues and trainees. As a reader, you are part of the community of listen-
ers, witnesses and re-tellers of the stories, in whatever transformed or imperfect ways you can
imagine.
As you read, when you think you have come up with an interpretation of what’s going on—a
label, a category—perhaps stop for a moment and pay attention to the difference between the
words on the page and the evolving story in your mind. This is much the same activity as we
engage in with patients in order to hear them and help them disclose their suffering to us. In
that way, the mindful practice of reading can inform the mindful practice of doctoring. The
other day, I saw a patient who reported a “funny sensation right here” while walking up stairs,
gesturing to a large area of the anterior chest and upper abdomen, and yet when I was on the
phone to the emergency department (ED), I said that the patient was having “chest pressure.”
Only later did I recognize the unconscious distortion; the patient never used either of those
words—“chest” or “pressure”—to describe her symptoms. It was too late. I didn’t call the ED
back. I knew that the words “chest pressure” would paradoxically result in her getting better
care, even though they were not quite true to what the patient said. It makes me anxious to
think about trying to explain to a rushed humorless triage nurse about the “funny sensation
right there;” “chest pressure” is so much more convenient. A mindful moment, not shared with
those who mattered to the patient, so now you are the witnesses. In that way, we witness each
others’ foibles and inspirations. A good story records these kinds of events in a deep way, often
compassionate, sometimes funny, or just plain sad.
Perhaps mindful practice is just remembering who you are and focusing on what is impor-
tant. Giving space for the telling of and listening to stories of mindful practice can transform
medicine by helping clinicians gain a deeper awareness of who they are, and by opening up
new possibilities of how they can offer what patients want and need. And, by creating a sense
of community, the telling of stories is the way that humans have always transformed their
individual visions into a shared enterprise.
1 James W. The Varieties of Religious Experience: A Study in Human Nature, reprint edition
1961. New York: W.W. Norton & Co.; 1902.
2 Charon R. Narrative medicine: form, function, and ethics. Ann Intern Med. 1/2/2001
2001;134(1):83–87.
3 Epstein RM. Mindful practice. Jama. 9/1/1999 1999;282(9):833–839.
4 Epstein RM. Mindful practice in action (I): technical competence, evidence-based medicine
and relationship-centered care. Families Systems and Health. 2003 2003;21:1–10.
5 Epstein RM. Mindful practice in action (II): cultivating habits of mind. Families Systems
and Health. 2003 2003;21(1):11–17.