by Laura Martin, LCSW, MBSR and Mindful Medicine teacher
I am proud to represent Mindful Medicine at the annual conference of the Center for Mindfulness at UMass Medical School! Though there is still a little snow on the ground here in Worcester, Massachusetts, inside it’s a warm and vibrant environment with many teachers, scientists, and mindfulness practitioners who have devoted much of their lives to this practice of mindfulness. So inspiring! This year, the conference’s theme will be on ethics.
Today, however, was a day of practice. A day-long retreat with Jon Kabat-Zinn, the originator of MBSR (Mindfulness-Based Stress Reduction), and Judson Brewer, MD, the resident researcher at the UMass Center for Mindfulness:
“This daylong retreat will be conducted using the laboratory of our own body-mind. Periods of guided practice that punctuate particular aspects of experience will be integrated with brief presentations and discussions of directly relevant research findings. In this way, our subjective, lived experience will be intimately linked to current scientific understandings of the underlying neurobiological processes.”
Between the two of them, they were able to put these centuries-old practices into context, creating a balanced and multi-dimensional view of some of the most recent brain science. One example: One of Dr Brewer’s projects has been getting experienced meditators and meditation novices into fMRI machines and measuring their Default Mode Network (DMN), which include the Posterior Cingulate Cortex (PCC) and the Medial Prefrontal Cortex (MPFC).
The Default Mode Network is activated by self-referential thoughts and activities: “What am I going to have for dinner? Why did she say that to me? What will they think of me?” These may be very familiar thoughts in our moments of disconnection and getting lost in thought or getting “caught up” in meditation! Jon referred to it as “The Story of Me.” We don’t need an fMRI to see that this is a habit that causes suffering: When we are insisting things be Our Way. When we are defending territory. When we are frightened about losing face or social status.
In studying these markers in the brain — the activity of the Default Mode Network — Dr Brewer was able to observe that in novices, these areas tend to be very active. Experienced meditators, however, were able to actually quiet these areas with meditation in real time, showing occasional spikes of DMN activity when the meditators were concerned how they were faring in the process of being tested.
DMN activity is characterized by a narrative process, and is relative to time — past and future. When the default mode network is less active, there is a more experiential process at work. Things just happening and in flow. This is one of the aspirations of MBSR: Non-striving. It’s paradoxical, but indeed, trying harder to achieve a certain state of mind leads us further away from what is actually happening in the moment.
Experienced meditators have learned to let go; not get so caught up in their conceptual self. Over time and with practice, this letting go, this effortlessness that can happen in meditation can also be applied to the activities of life. Mindfulness becomes a way of being.
And this is really what it’s all about. The science of meditation and mindfulness is not about trying to make pretty fMRI pictures, or “tune up” the insula, or try to get a thinner *amygdala. Trying to get somewhere else is not mindfulness. Science is a practice, and is never a finished story, just like we are. What we are really doing is being with things as they are, discovering who we really are; something much more vast than “The Story of Me”.
below- Judson Brewer, MD (left) and Jon Kabat-Zinn, PhD
” The heart is like a garden. It can grow compassion or fear, resentment or love. What seeds will you plant there? “
The development of medical insurance and pharmaceutical industries has profoundly changed the way medicine is practiced.
Patients and Providers have experienced erosion of connection and autonomy.
The medical-industrial complex has created a dehumanized and depersonalized experience for patients and providers.
One way of looking at this dehumanizing transformation is to compare it to the development of “mono-culture” in modern agriculture in the inner continental United States, a region that – for eons, in its natural state -thrived with diverse and rich grassland ecology. Keep in mind the interconnections of our practices ripple throughout the world. Unhealthy conventional farming practices not only impact the local lands, but the “mono-culture” products (corn syrup and corn-based additives for starters) contribute to obesity and chronic disease for those eating the processed foods. Run-off of chemicals and waste poison our waters all the way to our oceans. The land degrades from its natural state. All the connections become degraded!
STRIPS is beginning to reverse this sad state of affairs back to the natural condition, healthier for all.
The majority of physicians practice within the medical monoculture. By bringing full presence and empathetic connection to each patient encounter, physicians create “strips” of care within this unwieldy giant complex.
Teaching mindfulness and compassion skills to physicians is the beginning of returning to the natural state of human beings caring for other human beings.
We may not be able to turn back the tide on the medical industrial complex completely, but we can create “STRIPS” of mindfulness and compassion, one interaction at a time. Sowing these seeds of caring connection creates growing islands of natural goodness that heal the de-humanization occurring in our present medical complex, returning authentic compassionate care to our current so-called “health care” system.
Please add to our conversation by posting your comments on our FB page.
By David Schroeder, M.D., cardiologist
Practicing the art of mindful medicine
Co-founded Mindful Medicine, a nonprofit to help providers lower their stress, overcome “compassion fatigue” and rediscover the joy of medicine
Medical degree, Rutgers Medical School; residency and cardiology fellowship, Oregon Health & Science University
When did you start practicing mindfulness?
In 2006 I was diagnosed with obstructive sleep apnea. At age 36, it was difficult to accept that I now had a chronic disease for which no amount of wishful thinking or healthy habits was going to fix. In addition, I was adapting to a relatively new role as father. As I struggled with these feelings of stress and changed identity, I found mindfulness.
What is it, exactly?
It’s the simple practice of maintaining moment-to-moment awareness of your breath, body sensations, thoughts and feelings. It’s surprisingly effective. Almost immediately I felt less stress, slept better and gained valuable perspective on my life. My sleep apnea is now treated – I no longer wake up to breathe – but I have continued a daily mindfulness practice. I’ve found that awareness of my breathing promotes waking up to the world around me.
Does this help you as a physician?
It’s been my experience – and this is supported by medical literature – that being truly present has enhanced my ability to understand my patients, and it has improved communication. Mindfulness skills do not add much time to a clinic visit and, in my opinion, they enhance the patient’s experience. I feel like I do a better job and have more fun doing it.
Is this why you helped create Mindful Medicine?
I and a group of like-minded physicians and mindfulness teachers thought other providers might benefit from these skills. Nearly half of all physicians in the United States have symptoms of burnout, which is associated with lower quality of life for the physician and worse outcomes for their patients. The opposite of burnout is engagement, which is something that mindfulness promotes. With Mindful Medicine, we hope to create a vehicle that supports mindfulness for the health care community.
Tell us about your group’s research on mindfulness
Several recent non-controlled pilot studies have shown improvement in physician well-being following mindfulness training. We’re planning a small, randomized-controlled trial that will extend these findings to include patient outcomes as well. Providence has generously supported us with a research grant to investigate this in primary care physicians. Stay tuned!
Do you offer courses for patients?
Not yet. Our teachers currently offer mindfulness and compassion training for the general public. In the future we would like to expand so that all health care staff can participate. Eventually courses specifically for patients might even be available.
Mindful Medicine is holding a physicians retreat Oct. 17-19 in Portland. Space is limited, click here to register
Your roots are with Providence?
The physician co-founders of Mindful Medicine work at Providence Portland Medical Center, and are inspired by the Mission that explicitly celebrates compassionate service. We are grateful to the support from, among others, Jennifer Zelensky, Dr. Craig Wright, Dr. Ben LeBlanc, Providence Portland Medical Foundation and the Providence Clinical Transformation Council. That said, our goal is to reach interested physicians in the entire region, no matter their affiliation.
Besides mindfulness, how do you live a healthy life?
I am pretty committed to good diet, exercise, sleep and appropriate relaxation. I love running to work when my schedule permits, and being active outdoors with my family. Most nights I practice yoga in my daughter’s bedroom as she is falling asleep. I try to eat a whole food diet, largely plant-based, and am encouraged by Dr. Miles Hassell’s book, “Good Food, Great Medicine.” I make sure to leave room for warm chocolate chip cookies and ice cream!
Bedside manner. What an understated term for a doctor’s ability to relate with another human being. While looking around online to research what differentiates “good” beside manner from “bad,” I came across this gem written in 1892.
“The true basis of the good bedside manner is a large heart. Some expansiveness of the intellect is undoubtedly an advantage but a humane and sympathizing nature outweighs all other qualities.” (JAMA Vol. XVIII No. 7, Feb 13, 1892)
How do we cultivate having a “large heart?” It does not seem to result from having a large head. Ego and preoccupation with self-interest often interferes with our ability to be humane. Fortunately, the metaphorical heart is a muscle that can be developed and strengthened through the right kind of exercise.You know what’s coming next…
Contemplative skills such as mindfulness and compassion have been growing and strengthening hearts for thousands of years. We now know more than ever about how the “heart” is literally in the brain. Mindfulness and compassion training has been demonstrated to change the structure of the brain in areas related to empathy, sustaining positive emotions, attentional regulation, and emotional regulation. These are key bedside manner skills and can be developed into enduring traits. The metaphorical heart is literally in your head, and it is biologically who you are. Your bedside manner is more than something you do, a way to simply be better at your job. It is an expression of your brain, your wellness, your character, of you as a human being. So bring your full humanity and large heart to what you do. Because when you do, that is who you are.
A very close friend recently shared an interesting quote by Thich Nhat Hanh:
“Our notions about happiness entrap us. We forget they are just ideas…we fail to see the opportunity for joy is just in front of us when we are caught in a belief that happiness should take a particular form.”
This quote has me thinking of how I might be entrapped by my thoughts and ideas. How much of my personal and professional life is swayed by thought patterns. Not actually by reality but by getting “stuck” on an idea of how things “should” unfold. The medical profession is ripe with opportunities for this type of disappointment.
Patients come to their physicians to find relief from unpleasant symptoms in their bodies, to heal an illness, or just to check in to make sure things are on track for good health. We have tremendous responsibilities and power with our assessments, diagnoses, and treatment plans, and this can create a powerful sense of “I-ness” and “my-ness.” “I” can fix this. “My” plan is… The credit is “mine.”
Sometimes doctors get a bad rap for our poor connections with others, due in large part to a perceived focus more on ourselves and our expertise than on the patient sitting in the room with us. Even when we intentionally practice patient-centered care, as humans we tend to have a certain self-referencing attitude which, unchecked, can cause undue suffering. I’m constantly learning how – by mindfully paying attention in the present moment – I can notice when my thoughts create more suffering than necessary. It also helps to have a trusted other to help us see beyond the “I” and “my” lens.
Last night was a perfect time to explore some of these issues. I enjoyed an enlightening dinner with a good friend. It is so important to have time just relaxing and having fun together. I lamented to my friend Donald about the birthday party I had gone to recently where someone I care about deeply had snubbed me. That never feels good. The “snub” set off a cycle of thinking that was not healthy at all. Neuroscientists might have said my “affect network” had been activated, or my cortex was suffering from lack of reward or recognition. Even knowing the brain science, it felt crummy.
Donald curiously asked what emotions had been activated. By the way, Donald knows a thing or two about mindfulness and emotions. He is an author and therapist who travels the country teaching other therapists about mindfulness, and sharing tools to help people be successful in their mental health practices and in their own lives. A well-informed friend with whom to share my pain.
The two primary emotions I felt quite strongly were: irritation and sadness. Irritated and sad that this other person had not treated me as I desired to be treated. My hopes and expectations and connection needs went unmet, and it felt unpleasant.
Donald had a great idea. He suggested I tell the story again and this time not use any of these words: I, me, my and mine. Easy right? No, actually; quite difficult. Just look above and see how many personal pronouns “I” have already used!
The next iteration of the story was without all of the personal pronouns. It was a completely different and fascinating experience to tell “my “ story without all the self-referencing “I-ness.” The events were described as “this person” experienced this or “these eyes” saw this or “this body” felt that. It totally took the personal (and painful) nature out of the story. We both were amazed how different the story was. The two of us laughed whole-heartedly, which felt very therapeutic and completely took the sting out of a perceived snub from the night before. There was more joy, more depth of experience and more recognition of all the other people present at the party.
It turns out that “I” so easily get caught up in a story going on in my mind. We are not our thoughts but just people who experience thoughts. Mindfulness is so helpful because it can take us out of our mind and into our actual experience-rich life. As the bumper sticker says, “Don’t believe everything you think!”
It has been fun to play with this “No I, Me, My, or Mine” game today. Maybe you can try it as well. See if you can find that part of your mind that is producing thoughts that make everything so personal. See if you can create a little separation from those thoughts and make things less personal. It might cast a new light on your experiences.
This comes back to our practice of being physicians and health professionals. What happens when we are with clients that can trigger reactivity in us and make things personal? How does that affect the quality of care we deliver? How does it impact our personal lives?
“I” challenge “you” to play the ”No I, me, my or mine” game. Please let us know what you learn. The lesson for me: It is more fun to be a part of “we” than just stuck in my own mind with a “me.” Life is better when shared with meaningful connections to our friends and dear ones.
P.S. My friend Donald Altman, M.A., LPC has a new book, “The Mindfulness Toolbox”, with many “mindfulness gems” to use in the medical practice.
Let’s help the people who help people. This simple inspiration to help is at the heart of Mindful Medicine. We are a group of mindfulness teachers and physicians dedicated to physician wellness and resiliency. Our doctors are suffering, and they need help.
According to a study published in JAMA in 2012 nearly half of all physicians surveyed had symptoms of burnout.
“Burnout can have serious personal repercussions for physicians, including problematic alcohol use, broken relationships, and suicidal ideation. When considered with the mounting evidence that physician burnout adversely affects quality of care, these findings suggest a highly prevalent and systemic problem threatening the foundation of the US medical care system. The fact that almost 1 in 2 US physicians has symptoms of burnout implies that the origins of this problem are rooted in the environment and care delivery system rather than in the personal characteristics of a few susceptible individuals. Policy makers and health care organizations must address the problem of physician burnout for the sake of physicians and their patients.”
Our doctors are burning out at alarming rates, and the impact of burnout on their capacity to care for themselves and their patients is a problem that affects us all. Mindful Medicine is dedicated to being part of the solution. We believe that physicians and the health care systems in which they work need to address the causes of burnout, how to prevent or reduce it, and most importantly, how to create a healthcare culture that actively fosters wellness and resiliency in its providers as well as consumers, a system of healthcare truly characterized by health and care. Our doctors deserve better care. The systems they work in deserve better health. We think we can help.
We are dedicated to teaching physicians evidence-based, secular mindfulness skills to improve self-care as well as patient care, including skills to reduce stress, increase compassion for self and others, and improve cooperative problem solving with patients and coworkers. We want to help doctors rediscover the joys of practicing medicine and create a positive community of doctors based on peer support, mutual respect, and wellbeing. Our goal is mindful doctors participating in and being supported by mindful community. We hope this will help the people who help people. Stay tuned!