Ron Epstein, MD, Professor of Family Medicine at the University of Rochester Medical Center, has played a key role in bringing mindfulness to American healthcare. His research focuses on improving communication between patients and physicians, and promoting mindful practice and self-awareness in clinicians. His 1999 Journal of the American Medical Association article was one of the first on mindfulness in a major medical journal.
Gail Gazelle: Thanks for taking time to speak with me about the importance of mindfulness in healthcare. How did you become interested in the topic?
Ron Epstein: When I was 17, a friend taught me how to meditate. I found that it gave me a sense of grounding and connection. I continued my contemplative practice. Many years later, while developing an assessment system for our new curriculum in Rochester, I began thinking, “What is it that makes a good doctor?” I knew that it was more than just skills and factual knowledge. A student can list the causes of cryoglobulinemia but that doesn’t necessarily make him or her a wise clinician. It is more – it is the ability to be attentive, curious and present and to cultivate a “beginner’s mind.” So I started asking students different types of questions – reflective questions – such as “What are you assuming about this patient or this situation that might not be true?” “Are you having strong feelings about the patient that could affect your decision-making?” Typically students hadn’t been asked questions like these. It made them stop, think, and be self-aware and present.
Being a good doctor involves the ability to listen deeply and to be present with someone who is in distress. But, no one teaches those skills; even in communication skills courses we learn what to say but less attention is about how to listen. When I took a careful look at myself I could see that there were times when I practiced well and when I didn’t, and it had to do with the same sort of mind states in my meditation practice – when I’m at my best, I’m more self-aware. Mindfulness goes beyond cognitive reflection. When you’re in the presence of someone who’s depressed you may feel a heavy feeling in your chest. You might feel a tensing of your neck with someone who’s agitated. Being open to your own somatic markers and your own emotions is important– not only for you as a clinician, but for your patients. Your bring your whole self to the care you provide. Mindfulness involves awareness of the physical, emotional, and cognitive–and also of your own mental state– are you tired or distracted, how well is your mind working right now?
It’s possible to cultivate these qualities. The brain works differently when you’re being mindful as opposed to not, and meditation practice is a kind of deep learning, that we now know can promote neuroplasticity.
Gail Gazelle: Where do you meet resistance about mindful practice in the medical profession?
Ron Epstein: Those physicians who consider that their stress only has to do with the work environment may have difficulty looking inside themselves to appreciate the ways in which their reactions to stress are healthy or unhealthy. If their clinical environment feels out of their control then they wonder if their efforts really make a difference. Some might even ask, if the world of medicine is so crazy and you’re helping people be more accepting, are you being complicit? My answer is no. I think that in becoming more self-aware, people become more energized to change themselves– and change the system.
It’s also important to realize that mindfulness does not necessarily create a state of peace, it’s cultivating awareness of things as they are. That can be difficult. It’s building awareness and resilience at the same time.
With meditation, you become more comfortable being present with a wider range of emotions, learning that you actually have a greater degree of control and choices about your reactions. You can choose how you respond. You can temporarily set your distress aside – metaphorically putting it on a shelf next to you. You see that you are not your anger, or your sadness, or your pain. You begin to understand that anger or distressing physical sensations are things you have the ability to work with.
Gail Gazelle: True. It’s important that we don’t let our feelings define us. Is it fundamentally the separation, the “I am not this?”
Ron Epstein: It’s the ability to notice “there I go again. So and so said something and my blood pressure went up by thirty points, isn’t that interesting.” With practice you get the capacity to be a little bit more able to make choices in situations that you thought were choiceless. I think it’s allowed me to engage on a personal level or principled way, without getting caught up in the fear, emotion, and the distress. So all of that’s there but I can step back and think: what’s wrong with this situation, well this situation is unhealthy. And then choose how to respond. I also think it’s important to be public about being mindful –it encourages and emboldens others to do the same.
Gail Gazelle: What does mindfulness offer when you can’t control the external circumstances, for example, when practice demands are impacting patient care?
Ron Epstein: I think you can first offer clarity regarding what you can impact and what you can’t. In virtually every environment you have some choices. The environment may be very toxic in American medicine but medicine has always been difficult, albeit in different ways.
Gail Gazelle: We’re in a challenging time for physicians. How can mindfulness help?
Ron Epstein: Mindfulness allows you to have a clearer sense of who you are, of what is important, and where to direct your efforts. Sometimes it makes clear the choice to go somewhere else. It’s a sense of control. In the most difficult situations you can still be present, and that presence itself is something patients value. It is something that can’t be taken from you: the capacity to listen, and the capacity of being honest with yourself.
Gail Gazelle: I know you think big about what mindful practice can offer healthcare. Would you share your thoughts on the topic?
Ron Epstein: I do think big. There are some health systems that are committed to becoming more mindful. Several medical schools now have required mindfulness programs for medical students.
I recently worked with a health system that has compassion as their mission statement, and they seem to be taking it very seriously. They believe that if they achieve financial success but are not compassionate, they have failed. At a 2-day workshop for 300 of their clinical staff, the CEO was there the whole time, and I never saw her take out her smartphone. She was present, communicating her availability and commitment. That is important.
Practicing mindfully helps patients feel like they’re being listened and attended to. I believe it can reduce errors resulting from inattention and haste, and it can promote caring and professionalism when things go wrong. Perhaps it can limit the use of mindless aggressive care for people who will only be damaged by it, enhance the sustainability of the healthcare workforce, and reduce turnover, all of which would cost us less.
Mindfulness programs in the corporate world may increase productivity, but more importantly, they can help people feel a greater sense of meaning in their work lives. I recently spoke with a cardiologist friend who was tired and bored after a day reading stress tests and EKGs. Mindfulness could alleviate the boredom by taking that moment when the patient is getting on and off the treadmill to acknowledge the humanness of that person, to see novelty in the familiar, and to appreciate the connections he has with his staff.
Gail Gazelle: So it takes it from isolation to the greater purpose. Isn’t that what’s most important?
Ron Epstein: Yes, because sometimes we forget what it’s all about. Ultimately, medicine is about people.