Is Mindfulness Relevant to Medical Education?
Good doctors are empathic, compassionate and reflective. They are able to take care of others as well as themselves. Yet, there is little agreement on how medical schools encourage these qualities.
‘We miss more by not seeing, than by not knowing’ (Osler, 1901).
Mindfulness is one approach that is gathering interest. Some even argue that it should be an addition to the medical curricula. And yet, within medical education, there is no consensus on its usefulness and there are mixed views about its application.
Medicine is both an art and a science. The doctor’s role is to allow healing through sharing information, being present and kind; not just looking to ‘cure’. Medical students need to appreciate that advances in the understanding of disease and treatments will not eradicate suffering. This involves tolerating ambiguity and uncertainty, which is a difficult feat for students who are taught to question anything that is not evidence based or peer reviewed.
Recently, there has been a call to integrate ‘medical humanities’ into medical education; the interdisciplinary fields created when the perspectives of humanities, social sciences and the arts are brought to bear on medical practice.
‘Medicine’ and ‘meditation’, etymologically, come from the same root; to consider, advise, reflect, to take appropriate measures. It is suggested that mindfulness qualities emulate a ‘humanistic approach’, and could be viewed as a vehicle to promote the ‘healer’s role’; a means of regaining the equilibrium between the two pillars of curing and healing. Thus, meeting suffering in a compassionate manner. Mindfulness fosters and is fostered by insight, presence and reflection and offers an explicit way of transmitting the importance of ‘being’ in the clinical setting.
Epstein (1999, 2018) proposes that the embodiment of four mindful ‘habits of mind’ lead to insightful, clear actions and competence and mirror the clinical skills required to provide competent, quality patient care.
- Attentive Observation
Attending is a moral imperative, which aligns with honouring humanity as well as providing best care. A competent doctor is able to attend to the patient whilst attending to their own mental processes;allowing for the early recognition of cognitive biases, errors, and emotional reactions. Such ‘meta-awareness’helps a doctor recognise when they are distracted and is in contrast to working on “automatic pilot”.
A deep curiosity promotes an understanding for patients’ unique needs, values, and circumstances; a moral inquiry on which empathy is developed. A doctor who can be curious about their own experience (through mindful exploration of subtle transitions in the body and mind) is more likely to tolerate uncertainty and turn towards a challenging patient-doctor encounter. Conversely, a lack of attentive observation can hinder curiosity, which in turn can lead to over-investigation, inefficient time management, and poor clinical reasoning.
- Beginner’s Mind
‘In the beginner’s mind the possibilities are many, in the expert’s mind they are few’ (Suzuki, 2011).
A ‘beginner’s mind’ is a quality of mindfulness where the mind feels open and aware; an intentional setting aside of knowledge, preconceptions, expectations and judgements. For a doctor, this is very important as it creates ‘space’ in the mind for new ideas and encourages exploration and curiosity. As a patient you feel that the doctor has listened deeply, alert to your concerns. You feel cared for as a person, rather than a case or problem to be solved. Care is more efficient and effective. Similarly, I know, as a doctor, that such an approach allows for more meaningful relationships with my patients.
However, for many doctors progressing through training, empathy and the understanding of a patient’s subjective experience illness, lessen as they grow in ‘expertise’. Could that rise in ‘expertise’ obscure a doctor from the patient’s experience of suffering/illness? Mindful practice, requires us to set the ‘expert’ aside, and see a patient’s experience from a different perspective. Being a skilled doctor involves knowing how and when to create such ‘space’.
Presence is a quality of being which is difficult to describe. It is not possible to force such a quality; it requires ‘making space’ from which presence can emerge. It is often communicated non-verbally and creates intimacy and connection. Being present means being emotionally accessible to the self and to others, seeing the patient as a ‘whole’ person. Such shared presence, even for a moment, can be long enough to enable the patient to feel acknowledged and for the doctor to understand the full picture of a patient’s experience of suffering/illness. In this way, consulting is guided by insight and compassion. When a doctor consults on ‘automatic pilot’ and is unconsciously distracted by internal thought processes, they are less likely to communicate in an empathic and clear manner.
Presence is a habit of mind and a learned skill that can be honed through contemplative practices (Epstein, 2003). Making time for such ‘stillness’ is challenging within medical education. Therefore, the study of the humanities within medical training may offer an opportunity for such contemplation.
Medical Student Wellbeing
Psychological distress can have a damaging effect on health and a student’s capacity to study and perform in clinical practice. Medical students start university with a lower prevalence of burnout and depression and higher quality of life than similarly aged students who pursue other careers. Once in medical school, however, students experience more burnout and depressive symptoms and report lower quality of life than their peers in other fields  . Empathy declines dramatically as medical students progress through training. Students can become apathetic to learning, detach and focus on the security of knowledge acquisition rather than on the development of humanistic and relational skills (which have equal importance in clinical practice). Clinical, ethical and professional practice can suffer, to the detriment of patient care.
These disturbing findings question whether medical schools adequately prepare students for the stressful, demanding job of being a doctor. Undoubtedly, there are systemic issues within training. However, if students enter into challenging, stressful work climates without sufficient resources and resilience to cope with them, there is a high risk that clinical performance will suffer, and a high risk of absence, illness and attrition of expensively trained professionals. Additionally, such difficulties increase demands on an already stretched healthcare system. Therefore, it is extremely worrying that there is no consensus around effective wellbeing interventions for medical students.
By recognising wellness as a philosophy, not an activity, a culture instead of a program, medical schools can begin to generate solutions that will promote and sustain the wellbeing of future doctors, to the benefit of the healthcare system as a whole. Due to the proven benefits to health more generally, including the prevention of recurrent depression and anxiety, mindfulness shows much promise. Whilst, at present, there is no robust evidence to support mindfulness as a wellbeing intervention and/or a means to optimise clinical performance, research is only in its infancy and there is emerging evidence to support its use. In fact, studies have already demonstrated the beneficial effects of mindfulness more widely within the university student population. Including wellbeing (Galante et al. 2018), resilience (Pidgeon et al. 2014) and memory and learning (Jared, 2014). Additionally, it is highly encouraging that within the doctor population, mindfulness has been shown to reduce symptoms of burn-out, depression and anxiety and improve quality of life, wellbeing and patient care (Epstein, 1999; Krasner et al. 2009; Beckman, 2012). Importantly, mindfulness may even reduce errors by limiting ‘mind-wandering’ (Berner, 2011; Hilton, 2011; Smallwood et al. 2011).
Therefore, it is reasonable to hypothesise that mindfulness could help medical students emotionally manage the distressing aspects of medical training and promote wellbeing.
While medical training teaches the scientific and technical aspects of medicine well, the rising concerns within the medical student population indicate that the humane aspects of medical education remain relatively neglected. Science provides us with safe, effective tools to deploy in medical practice, whereas the humanities teach us how to use them wisely. Doctors work in complex, emotionally demanding settings where high-risk ethical and moral decisions are made and require sufficient resources and resilience to cope with these demands. Empathy and compassion are foundational to the humanisation of medical care and the absence of them is the denial of another person’s wellbeing and dignity (Haslam, 2015).
In an already packed medical curricula, some argue that there is insufficient space to include mindfulness training. However, as the evidence base supporting its use rises, this position may be about to change. In my view, a ‘mindful consultation’ is relevant to patient care, and therefore medical education. It should be the seen as the norm rather than the exception. Currently, it appears that this will demand a paradigm shift in medical education and a culture change in the delivery of medical care more generally.
Dr Lucy Harrison
Lucy Harrison is a GP who specialises in teaching MBCT. She is a student on the OMC Masters in MBCT.
Beckman, H. 2012, “The impact of a program in mindful communication on primary care physicians.”, Academic medicine, vol. 87, no. 6, pp. 815-9.
Berner, E.S. 2011, “Mind wandering and medical errors commentaries”, Medical education, vol. 45, no. 11, pp. 1068-1069.
Epstein, R.M. 2003, “Mindful Practice in Action (I): Technical Competence, Evidence-Based Medicine and Relationship-Centered Care”, FAMILIES SYSTEMS AND HEALTH, vol. 21, no. 1, pp. 1-10.
Epstein, R. 2018, Attending : medicine, mindfulness, and humanity, Scribner, New York
Epstein, R. 1999, “Mindful Practice”, JAMA: Journal of the American Medical Association, vol. 282, no. 9, pp. 833-839.
Galante, J. & Galante 2018, “A mindfulness-based intervention to increase resilience to stress in university students (the Mindful Student Study): a pragmatic randomised controlled trial”, The Lancet Public Health, vol. 3, no. 2, pp. e81.
Haslam, D. 2015, ““More than kindness””, J of Compassionate Health Care Journal of Compassionate Health Care, vol. 2, no. 1.
Hilton, S. 2011, “Mind wandering in medical practice”, MEDICAL EDUCATION -OXFORD-, vol. 45, no. 11, pp. 1066-1067.
Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B, Mooney CJ,Quill TE, 2009, “Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians.”, JAMA, vol. 302, no. 12, pp. 1284-93.
Osler, W. 1901, “The Natural Method of Teaching the Subject of Medicine.”, JAMA: The Journal of the American Medical Association, vol. XXXVI, no. 24, pp. 1673.
Pidgeon, Aileen M., Rowe, Natasha F., Stapleton, Peta, Magyar, Heidi B., Lo,Barbara C.Y., 2014, “Examining Characteristics of Resilience among University Students: An International Study”, JSS Open Journal of Social Sciences, vol. 02, no. 11, pp. 14-22.
Ramsburg, Jared T., Youmans,Robert J., 2014, “Meditation in the Higher-Education Classroom: Meditation Training Improves Student Knowledge Retention during Lectures”, Mindfulness Mindfulness, vol. 5, no. 4, pp. 431-441.
Rosenzweig, S. & Rosenzweig 2010, “Mindfulness-based stress reduction for chronic pain conditions: Variation in treatment outcomes and role of home meditation practice”, Journal of psychosomatic research, vol. 68, no. 1, pp. 29-36.
Rotenstein, L. 2016, “Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis”, JAMA: Journal of the American Medical Association, vol. 316, no. 21, pp. 2214-2236.
Smallwood, Jonathan, Schooler, Jonathan W., Turk, David J., Cunningham, Sheila J., Burns, Phebe, Macrae,C.Neil, 2011, “Self-reflection and the temporal focus of the wandering mind”, Consciousness and Cognition Consciousness and Cognition, vol. 20, no. 4, pp. 1120-1126.
Student British Medical Journal (2015) (online) Available from: https://www.bmj.com/company/wp-content/uploads/2014/07/student-bmj-survey.pdf(accessed November 11th 2018).
Suzuki, S. 2006, Zen mind beginner’s mind, Shambhala, Boston and London