Family medicine should be one of the most satisfying professions. We enjoy close relationships with our patients and their families, we learn and apply ever-changing science to help serve others, and although physicians in some other specialties earn higher salaries, our average income puts us in the top 2 percent of people in the United States (and the top 0.04 percent in the world).1,2,3 Yet, more than 60 percent of family physicians are burned out.4
Certainly, much of the solution to this problem involves addressing complex issues at the health system level, as well as reducing inefficiency and improving workflow in our practices. Another part of the solution, one that individual physicians have greater ability to control, involves skills you can start using today to become less frustrated and more fulfilled. In the first article of this two-part series, we will cover mindfulness, and in the second article, we will cover reframing – two techniques that can dramatically improve both physician and patient satisfaction.
What is mindfulness?
Mindfulness has been studied for thousands of years, and yet it is a popular “new” topic in psychology. In general, mindfulness is simply being aware, present, and engaged in the moment. In the medical office setting, this means being fully present and connecting with each patient, efficiently reviewing labs and messages, calmly returning phone calls, clearly communicating with staff, and so on.
In contrast, when we are not mindful, we often feel rushed and annoyed, and we just want to get our day over with. We spend a lot of time complaining (to ourselves or to others) about how the present moment should be different. We may think, “I wish I didn't have to wake up so early,” “Why is traffic so heavy?” “I wish my children would behave better,” “Work is way too busy!” “My colleagues just don't understand,” and on and on. Compare those moments with your best moments – seeing the ocean for the first time, looking into the eyes of your newborn baby, skiing in fresh powder, etc. If you were to superimpose a complaining mindset onto your peak experiences, they would no longer be peak experiences.
For example, imagine two people walking on the beach at sunset. One is fully present and is having a peak experience. The other is thinking about work or family problems and is feeling miserable. Both people are in the same circumstance, but they are having different experiences. Similarly, two doctors may have similar schedules, similar staff, and similar patients, but one might feel burned out while the other feels challenged and fulfilled.
What helps create peak experiences and fulfilling moments is mindfulness – the moment-to-moment, non-judgmental awareness in which we appreciate this instant as it unfolds. One way to bring more appreciation and joy to our work, or to any other aspect of our lives, is to bring more mindfulness into it.
Most of us understand that living in the present is a good idea. However, in practical terms, what can we do to become more mindful?
Although it may sound simple, one of the most effective ways to start being more mindful is to consciously pay attention to a single breath. Try this exercise: Take a deep breath, and see if you can feel your abdomen expanding as you inhale and then relaxing as you exhale. Note that your chest may expand and relax as well. See if you can enjoy just one breath. (If you're not used to this style of breathing, it may be easier if you try it lying down.) Once you are successful focusing on the sensation of a single breath, try maintaining the same focus for several breaths in a row.
You may also mindfully focus on your body. With each inhalation you can feel the abdomen expanding, and then with each exhalation focus on relaxing a different area of your body, such as your neck, shoulders, jaw, and the muscles between your eyes. Additionally, as you breathe, you can take note of your posture, which should be relaxed yet healthy. Imagine your body is like a shirt hanging on a clothes valet stand. Your spine is like the upright pole, your shoulders are like the hanger, and the rest of your body is like the shirt, hanging soft and relaxed.
Whenever you find yourself rushing, feeling impatient, or thinking about how the present moment should be different, try to let go of those thoughts by focusing on your current breath or perhaps another sensation – such as the taste or aroma of your food, the sound of music, or the feeling of your feet on the ground as you walk. The idea isn't to stay permanently focused on your breathing or your senses but to use it as a tool to bring your focus back to the present. If your attention wanders, gently bring your attention back to what you are doing right now. Your mind might wander five times in a minute. Patiently refocusing your attention each of those times will build the neural networks to increase both your ability to be mindful and your ability to be patient.
Part of being mindful is accepting current physical sensations as well as thoughts and emotions. Sometimes those things might be uncomfortable or even scary, and we might naturally want them to stop, but resisting them rarely, if ever, makes them go away. More often, this leads people to feel more stressed about being stressed, more depressed about being depressed, more scared about being scared, and so on. For instance, when you are stressed, you may feel your heart racing. Unfortunately, it often happens that the more you try to make your heart slow down, the faster it beats. Similarly, if you are awakened in the middle of the night, obsessing about how awful you'll feel in the morning only makes it harder to get back to sleep. Instead, if you think of this as the perfect time to practice mindful breathing and meditation, you'll be much more likely to fall back to sleep. Calmly noticing and accepting sensations as they are in the present moment is usually the first step to diminishing them.
People often blame uncomfortable physical sensations, thoughts, and emotions on some external circumstance in their lives, thinking that life would be better if only a patient, electronic health record system, or work schedule were different. To cope with or avoid these things, people often resort to habitual nonproductive behaviors like biting their nails, overeating, smoking, or drinking. We also tend to want to justify our negative emotions, so we begin to list all the reasons why we might be feeling the way we do. These behaviors may bring some temporary relief, but in the end they often make matters worse.
Rather than resisting, avoiding, and justifying, we can train ourselves to be mindful in the midst of uncomfortable sensations and circumstances. The more you practice mindfulness, the more it becomes a natural part of your day-to-day life. Once you are more mindful, you can work toward improving your circumstances in a calmer and more effective manner.
To help practice mindfulness when you feel emotionally stuck, you can try the Three-Minute Breathing Space exercise, which has been popularized through Mindfulness-Based Cognitive Therapy.
THREE-MINUTE BREATHING SPACE
The Three-Minute Breathing Space is a quick meditation exercise that has been popularized through Mindfulness-Based Cognitive Therapy.
First minute: Describe your emotion in one simple word such as sad, happy, angry, relaxed, or “high energy” (encompassing both anxiety and excitement). Describe any body sensations in simple terms and notice your thoughts, allowing them to come and go. For that one minute, be willing to accept your current emotion, physical sensations, and thoughts.
Second minute: Focus on one breath at a time. When your mind drifts, patiently bring your focus back to the sensation of one breath at a time.
Third minute: Expand your focus to the sensation of your whole body in the process of breathing.
For a guided version of this meditation, visit StressRemedy.com/audio (currently the 11th exercise listed).
Practicing mindfulness at the office
Dr. Adams just got off the phone with his wife about a problem at home and is about to see his next patient. Meanwhile, Dr. Berger just saw a patient with a serious cancer diagnosis and is about to see her next patient. For both physicians, it is important to let go of distractions to fully connect with their next patient.
Dr. Francis W. Peabody, a physician author and educator in the early 1900s, stated that “the secret of the care of the patient is in caring for the patient.” Patient and physician satisfaction as well as quality of care are largely derived from the experience of care and connection. Being mindful and fully present is essential to establishing this connection. You can practice mindfulness by incorporating one or more of the following actions into your day:
As you walk to the exam room, make a point of feeling your feet touch the floor and the ground “massaging” them with each step.
Right before going in to see your patient, take a mindful breath or feel your hand against the door handle.
When your patient begins to tell you his or her problem, sit at eye level, make eye contact, and fully focus on your patient.
When you listen to your patient's heart or breath sounds, let go of any distracting thoughts and just fully listen.
When you wash your hands, feel the warm water.
At your lunch or coffee break, take a moment to smell the aroma and enjoy the taste of the food or drink.
Prior to seeing a patient, establishing an intention for the visit may also help you be more mindful. Mindful communication involves connection and curiosity. If you start a visit thinking you're about to see “yet another diabetic patient,” focusing on the disease instead of the person, you'll be bored, frustrated, and headed down the path toward burnout. But if your intention is to be curious and to connect, you will have a more mindful visit. To start, briefly seek areas of commonality: Do you both have children? Have you both struggled with a parent's illness? Do you have any similar experiences of suffering, challenges, or joys? Also, be curious about the other person: What is it like to be a migrant farmer? How does this patient deal with chronic pain or anxiety? What kind of support does this patient have at home?
Of course, you can't spend hours interviewing patients, but you can bring an attitude of curiosity and connection to even brief encounters. Before visits, say to yourself something like, “I want to care for Tom today with curiosity and compassion.” This simple statement of your intent before a visit can increase the likelihood that your interaction will be the kind that makes medicine special.
The importance of compassion
One component of burnout is compassion fatigue, or an indifference to others' suffering as a result of frequent and overwhelming acts of caring. Without a true feeling of compassion, practicing medicine becomes joyless and unsatisfying, which can lead to increased burnout, which can lead to more compassion fatigue – a vicious cycle.
Even if you are not suffering from chronic compassion fatigue, you likely have times in which compassion is difficult to muster. Certain times of your day or week may be more difficult, and you are likely to have less compassion when you are burdened by your own personal problems. You may also feel less compassion for certain difficult patients.
Mindfulness and meditation can help you begin to restore compassion and increase your own happiness. In a study of Buddhist monks who were adept in the practice of meditation designed to enhance compassion, researchers used electroencephalogram and functional magnetic resonance imaging scans and found that the monks had astoundingly high activity in the left prefrontal cortex of the brain, which is associated with happiness.5
One type of meditation the monks used is a loving-kindness or “Metta” meditation. Essentially, it involves closing your eyes and visualizing a person or figure toward whom you have natural compassion – a family member, close friend, religious figure, etc. Then, say a blessing over that person such as, “May you be safe and protected, may you be happy, and may you be healthy.” Next, with as much of the same feeling as possible, wish the same to yourself. Then, wish the same to someone you feel more neutral toward, someone you find more difficult to feel compassion toward, and finally all people. Over time, this exercise can strengthen your ability to be compassionate. (For a 14-minute guided version of this meditation, visit StressRemedy.com/audio.)
In the midst of your busy day, you probably do not have time for a 14-minute meditation, but a 30-second “mini Metta” practice can be helpful. Close your eyes, take a mindful breath, and visualize yourself hugging or holding a loved one while wishing them, “May you be happy and healthy.” Then, visualize your next patient and wish them the same.
Enjoying practice – and life
Practicing mindfulness isn't the solution to all of your problems at work or at home, but it can help you reduce frustration and increase fulfillment. It can also allow you to more fully experience your life and not simply survive each workday. As Henry David Thoreau wrote, “I wished to live deliberately, to front only the essential facts of life, and see if I could not learn what it had to teach, and not, when I came to die, discover that I had not lived.”