Bringing Mindful Awareness into Clinical Work

Clinician burnout is an increasing problem in the U.S. health care system.[1] Burnout is characterized by emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment.[2] Mindfulness interventions have been shown to ameliorate this problem in a broad range of health care providers.[3] Additionally, mindful clinicians deliver better care and have more satisfied patients.[4]

Presented here are several techniques to introduce mindful awareness into clinical practice.  Practice of these techniques will help you to establish a state of nonjudgmental, moment-to-moment awareness that pervades your clinical activities.  This sets the stage for a deeper, more fulfilling experience of your clinical work.

Myriad demands and preoccupations divide the clinician’s attention in a typical clinical setting.  We ruminate about the previous patient encounter, worry about staying on time, consider what to do for patients we have seen or will see, and manage constant interruptions of our activities.  Mindful awareness practice asks you to recognize that you can only complete one task at a time, while simultaneously honoring your amazing capability to effectively and efficiently manage the task at hand through engaging your full attention.  Savor these opportunities to “drop in” to the present moment; continued practice will facilitate your best work.

This tool offers several suggestions for how health care professionals can cultivate mindful awareness in their day-to-day patient care. Employing mindful awareness techniques in times of stress will help you regain a sense of calm and centeredness.  They can help you prevent burnout and boost resilience.  Scheduled practice throughout the day will help you develop a mindful way of being.  Try the various techniques, and adapt them to your practice environment.

PAUSE, PRESENCE, PROCEED[5]

This technique can be used at any point during your clinical activities. Any time you feel your breathing accelerate or find yourself feeling overwhelmed, take a brief moment to refocus your attention with this simple practice.

1.   PAUSE

  • Stop what you’re doing and consider where your mind is right now. What are you thinking?  What are you feeling?

2.   PRESENCE

  • Bring your attention into this moment.
  • Take a deep breath. Feel your abdomen expand as you inhale.  Feel it relax as you exhale.
  • Consider the patient or some challenge with which you are confronted in this moment. What is this situation asking of you?

3.   PROCEED

  • You have taken the time to drop in to this moment, anchored your awareness in the breath, and considered what is requested of you right now. At this point, you’re primed to move forward with reasoned, skillful, and compassionate action.
  • Use mindful speech, mindful action, and positive intention to meet the demands of this moment.
  • Be gentle with yourself.

NESTED MINDFUL AWARENESS CUES

In developing a mindful clinical presence, we can use elements common to the majority of our clinical encounters to prompt present-moment awareness.  The following three practices involve physical cues that we can learn to associate with mindful awareness in the patient encounter.

THRESHOLDS

The threshold of an examination or hospital room is literally and figuratively a place of transition.  Literally, thresholds mark the transition from one space to another.  Figuratively, we can conceptualize the threshold of the patient room as the transition point between the busy clinical day and the impending patient encounter.  We can choose to leave the concerns of the day at the door and bring our full attention and awareness into the patient encounter.

Moreover, we can extend the metaphorical threshold to describe the circumstances of the patient.  Often patients in a clinical setting are in periods of transition as they learn of new or worsening diagnoses.  We meet patients at these thresholds, and we usher them through.  These difficult times require our undivided attention so that we may employ our full complement of knowledge, skills, compassion, and empathy. In considering the significance of the threshold to the patient room, we can prompt ourselves to engage our full attention in the patient encounter.

THE CLINICIAN’S SEAT

Once you’ve crossed the threshold into the room, the chair on which you sit can serve to remind you to maintain the mindful presence you established as you entered the room.  You might have a habit of plopping down heavily onto the stool at the beginning of the patient encounter.  See what happens when you approach your seat with intention.  Note your posture as you sit down.  Once seated, make an effort to take one deep, cleansing breath to ensure the clutter of distractions from outside the room has not followed you into this patient encounter.  Once you have taken your seat, you can begin the practice of full-body listening.

LISTENING WITH YOUR WHOLE BODY

Clinical encounters increasingly demand that we attempt to multitask, especially as computers become more prevalent at the point of care.  We are expected to listen and type, to counsel and place orders, and to simultaneously elicit and electronically record data.  How often do you find yourself only half listening as a patient speaks?

Listening with the whole body prompts us to fully regard the patient in front of us with our complete and undivided attention. Incorporate the following:

  1. Look at the patient. This sounds deceptively simple, but as outlined above, many factors interrupt this connection during modern patient encounters. Try to position yourself so that you do not have to turn your head to look directly at the patient.
  2. Listen intently and completely to the patient’s voice.
  3. Maintain closed lips and a relaxed jaw. Separate the upper teeth from the lower teeth to relax the jaw.  Try not to interrupt.
  4. Open the torso. Position the torso squarely in front of the patient; ideally you won’t have to turn to be able to directly face the patient.  Maintain the shoulders in a comfortably relaxed position, trying not to roll them forward or slouch.
  5. Try not to cross the arms in front of the torso. Rather, leave them comfortably at your sides to maintain a posture of openness.  Rest the hands on the thighs.
  6. Sit with the spine comfortably straight. See how it feels to lean forward slightly.
  7. Plant both feet squarely on the floor, so that you don’t have to turn or shift to directly face the patient.

The physicality of this stance promotes engagement of your attention.  Ideally, the majority of your time with the patient will be spent in this posture of full-body listening, excluding of course the time spent on physical examination.  See how long you can maintain this posture of full-body listening before you are compelled to change your stance.

STETHOSCOPE PRACTICE

The stethoscope is a window into the intimate details of the patient’s inner state.  Those who listen with stethoscopes are allowed to access privileged information.  This is an opportune time to re-engage if our attention has lapsed.

With your stethoscope on the patient’s skin, close your eyes momentarily and focus all of your attention on the sounds you hear.  We are already trained to listen carefully for pitch, regularity, and the quality of sound we encounter when listening with our stethoscopes.  This is an opportunity for mindful awareness already built into the clinical day.  This level of engagement can then be carried into the remainder of the encounter.

CIRCLES OF SUFFERING

The circle of suffering is a visual metaphor to help clinicians attend to their patients’ suffering while staying grounded in the strength of the clinician’s own mindful presence.  This visualization practice is especially useful in the context of clinical encounters and patient relationships where the burden of suffering threatens to completely overwhelm both the patient and the clinician.  Follow these steps:

  1. Imagine the patient is encircled in his or her suffering.
  2. Imagine yourself encircled in the constituents of your mindful presence—empathy, loving-kindness, compassion, and equanimity.[6]
  3. Visualize your circle and the patient’s circle touching.
  4. Now imagine yourself placing one foot in the patient’s circle of suffering. Your other foot remains planted firmly in your circle.  You have now established a mindful presence in the patient’s circle, and this presence is sustained by your grounding in your own circle.
  5. You may fine-tune your leaning toward or away from the patient. For example, if you find your attention waning you may lean forward toward the patient.  Conversely, if you find yourself feeling entangled or overly taxed by the interaction, you may lean back.  Your footing does not change.

For further exposition and reflection on the circles of suffering technique, visit http://www.fammed.wisc.edu/category/media/mindfulness/.

MEDITATION ON COMPASSION

Mindful awareness training typically includes training in compassion.  Mindful awareness theory holds that compassion aids the practitioner in sustaining moment-to-moment, nonjudgmental awareness.  Compassion is said to fortify us against suffering and injustice, difficulties that otherwise would send us on a downward spiral into rumination and despair. Research is beginning to bear out a causal relationship between compassion meditation and positive affect.[6][7]Current research also suggests that compassion may be associated with longer life.[8]

The following meditation can help you to cultivate compassion in the clinical setting.

  1. The first repetition is directed toward oneself. Visualize the words reaching your own heart as you speak:

May I be happy.

May I be free from suffering.

May I be peaceful and at ease.

  1. Subsequent repetitions are directed at loved ones. Visualize their faces as you speak the words:

May you be happy.

May you be free from suffering.

May you be peaceful and at ease.

  1. Following recitations for members of your inner circle, expand the practice outward to include people about whom you feel neutral, and then people for whom you feel negative emotions. You can direct it to entire groups, such as all of your patients or all Veterans.  You can also focus more globally.  Some people will repeat this for “all sentient beings.”

For a similar guided meditation, visit University of Wisconsin-Madison’s Mindfulness Meditation Podcast Series and click “7. Guided Loving Kindness.”

GROUP PRACTICE

Chances are if you are feeling stressed, overwhelmed, and burned-out, there are others in your practice environment who are experiencing similar feelings.  Practicing mindful awareness in a group setting with colleagues can help the group vent emotions, maintain good mental hygiene, and support healthy group dynamics.  Consider setting aside time for group practice in your workplace.  The format of the session can be developed to meet the specific needs of your practice.  Activities might include a 3-minute pause (featured in “Practicing Mindful Awareness with Patients: 3-Minute Pauses” tool), group emotional check-in, reflections on the group’s experience with mindful awareness practice in the clinical setting, guided loving-kindness meditation, or guided body scan (covered in the “Mindful Awareness Practice in Daily Living” tool).  Your group may also develop practices based on members’ own unique clinical context.  Truly, the sky is the limit.

Author(s)

“Bringing Mindful Awareness into Clinical Work” was written by Adrienne Hampton, MD, (2014, updated 2018).

This Whole Health tool was made possible through a collaborative effort between the University of Wisconsin Integrative Health Program, VA Office of Patient Centered Care and Cultural Transformation, and Pacific Institute for Research and Evaluation.

References

  1. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281.
  2. Callahan K, Christman G, Maltby L. Battling burnout: strategies for promoting physician wellness. Adv Pediatr. 2018;65(1):1-17.
  3. Goodman MJ, Schorling JB. A mindfulness course decreases burnout and improves well-being among healthcare providers. Int J Psychiatry Med. 2012;43(2):119-128.
  4. Beach MC, Roter D, Korthuis PT, et al. A multicenter study of physician mindfulness and health care quality. Ann Fam Med. 2013;11(5):421-428.
  5. Rakel D. Integrative Medicine. In: 3rd ed. London: Elsevier Health Sciences; 2012.
  6. Hofmann SG, Grossman P, Hinton DE. Loving-kindness and compassion meditation: potential for psychological interventions. Clin Psychol Rev. 2011;31(7):1126-1132.
  7. Engen HG, Singer T. Compassion-based emotion regulation up-regulates experienced positive affect and associated neural networks. Soc Cogn Affect Neurosci. 2015;10(9):1291-1301.
  8. Konrath S, Fuhrel-Forbis A, Lou A, Brown S. Motives for volunteering are associated with mortality risk in older adults. Health Psychol. 2012;31(1):87-96.

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