The wife of a hospitalised friend called me one Saturday morning in tears. Gary had been diagnosed two weeks earlier with early-stage bladder cancer and underwent cystoscopic surgery. The catheter was removed a few days later then was put back in because of urinary retention. His urologist removed the catheter, again, on a Thursday afternoon. By Friday afternoon, Gary was in pain and wasn’t urinating. His urologist’s office was closed, so Gary went to Emergency.
I can imagine what the ED doc was thinking: a robust healthy male on a hot summer afternoon who complained of decreased urination. They started an IV, suspecting dehydration. Laura explained that Gary was still not urinating so they increased the rate. Two shifts of doctors and nurses came and went and the IV continued.
I got through to a nurse on the hospital floor who assured me that Gary had a good night. I asked her to see for herself. According to Gary, she took one look at him, felt his bladder, said it was “about to burst.” She put in another catheter and drained 2 litres of fluid. Shortly afterward, he developed a fever. A kidney infection.
This was a reputable hospital with a well-respected clinical staff. Sometimes errors are unavoidable because of faulty or incomplete data. Sometimes situations are very complex in ways that are only apparent later. Sometimes they’re due to systems problems. But none of those things was an issue in Gary’s case. Instead, the problem was rooted in decision-making. When under pressure, threat, cognitive load, or when lazy or exhausted, we try to solve problems quickly, resulting in premature closure—hastily applying a definition to a situation and confusing it with reality. Quick thinking sometimes serves us well. Ninety percent of the time when I see someone during flu season who has body aches, fever, chills and respiratory symptoms, my first impressions are right on. The trick is to know which 10% of patients are the outliers, when I need to shift gears, slow down, move from fast to slow thinking, and consider other possibilities.
My colleague, Carol-Anne Moulton, a hepatobiliary surgeon and medical educator, has observed surgeons in the OR and discovered what elevates them to greatness. The surgeons who stand out as masters of their trade—the ones you’d send a family member to—slow down when they should. They see the speed bumps and potholes just a little sooner than their colleagues. Perhaps they feel that something just doesn’t add up. They catch a glimpse of something in the periphery. They attend to the unexpected. Encountering difficulties, they are curious rather than rigid or defensive. They adopt a “beginner’s mind,” seeing familiar situations with new eyes. They are fully present. Attentiveness, curiosity, beginner’s mind and presence are the building blocks of what I’ve come to call “mindful practice.” It’s not just for surgeons and ED docs; paediatricians, obstetricians, psychiatrists, and pathologists need to be mindful, too.
Some clinicians are naturally this way. Most of us, however, have to learn to be more mindful, and to ward off distraction, mind wandering, and complacency. Through our research over the past ten years, we’ve found ways to help clinicians learn to be more mindful; they can build three cornerstones of attention—unwavering focus on a task, vigilance for the unexpected, and choosing what to attend to when there are multiple stimuli competing for limited cognitive resources.
Attention training is not just a solo activity. When teams share mental models of a situation and communicate effectively, they can be collectively vigilant, observant, curious and present. Increasingly, team training has emphasised not only coordination of technical skills and communication but also coordination of their thinking processes. As social creatures, we think collaboratively and resonate emotionally, eventually achieving some degree of “shared mind.” Organisations themselves can be mindful—or not.
Just as team training was a radical and disruptive innovation thirty years ago, mindfulness is a new paradigm to reduce errors and burnout and to provide better care. Medicine has been slow, however, to adopt mindfulness approaches compared to the performing arts, sports and the military. But just as athletes gain an edge by being focused and mindful, clinicians can develop new habits, too. They can learn to ask themselves, “What are you assuming about this situation that might not be true?” Each time they put their hand on the door handle to enter a patient’s room, they can learn to take a breath and mentally set aside what has happened in the prior encounter so that they can be more available to the patient they’re about to see. They can learn to be aware of stress and its manifestations in the body (such as tension in the neck or an unsettled gut), clues they’re at risk for premature closure. They can learn to listen to others—and themselves—more deeply. Whether these practices reduce errors will require further study; yet, basic science and laboratory research suggest that they should. In my experience, mindfulness practice can transform the stressful life of a physician—leaving them coming back for more.
Ronald Epstein MD is a family physician, author of several groundbreaking articles on mindful practice in medicine and runs workshops for students, residents, practicing clinicians and educators on mindful practice. This blog is adapted from his first book, Attending: Medicine, Mindfulness, and Humanity (Scribner, 2017). Learn more at www.ronaldepstein.com.
