Mindful practice. ronald epstein[1]

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Mindful PracticeRonald M. Epstein, MD

REFLECTION AND SELF-AWARE-ness help physicians to exam-ine belief systems and values,deal with strong feelings,

make difficult decisions, and resolve in-terpersonal conflict.1,2 Organized ac-tivities to foster self-awareness are partof many family medicine residency pro-grams3 and some other residency4,5 andmedical school curricula.5-8 Exem-plary physicians seem to have a capac-ity for critical self-reflection that per-vades all aspects of practice, includingbeing present with the patient,9 solv-ing problems, eliciting and transmit-ting information, making evidence-based decisions, performing technicalskills, and defining their own values.10

This process of critical self-reflec-tion depends on the presence of mind-fulness. A mindful practitioner attends,in a nonjudgmental way, to his or herownphysical andmentalprocessesdur-ing ordinary everyday tasks to act withclarity and insight.11-15 This article firstdescribes the nature of professionalknowledge,competence,andvaluesandthenpresentscurrent thinkingabout thephilosophical, psychological, and prac-tical aspects of mindfulness. It also ex-ploreshowmindfulness is integral to theprofessional competence of physiciansand suggests ways to cultivate mindful-ness in medical training. In doing so,however, I recognize that mindful prac-tice, although supported by empiric ob-servation of clinical practice,16-21 educa-tional research,22-26 philosophy,11,27 andcognitivescience,11,28-30 is fundamentallypersonal and subjective.

Consider a situation that I recentlyfaced with a patient who required an ex-panded view of professional knowl-edge and mindful reflection to achievea satisfactory resolution. A 42-year-oldmother of 2 small girls, despondent overjob difficulties, was contemplating ge-netic screening for breast cancer as sheapproached the age at which her motherwas diagnosed as having the same dis-ease. Aside from the difficulties in tak-ing an evidence-based approach to as-signing quantitative risks and benefitsto the genetic screening procedure (Howmuch should I trust the available infor-mation?) and uncertainty about the ef-fectiveness of medical or surgical inter-ventions (Would knowing the resultsmake a difference, and, if so, to whom?),the case raised important relationship-

centered questions about values (Whatrisks are worth taking?), the patient-physician relationship (What ap-proach would be most helpful to the pa-tient?), pragmatics (Is the geneticistcompetent and respectful?), and capac-ity (To what extent is the patient’s de-sire for testing biased by her fears, de-pression, or incomplete understandingof the illness and tests?).

For me, book knowledge and clini-cal experience were insufficient. I hadto rely on my personal knowledge of the

Author Affiliations: Departments of Family Medi-cine and Psychiatry, University of Rochester School ofMedicine and Dentistry, Rochester, New York.Corresponding Author and Reprints: Ronald M.Epstein, MD, Department of Family Medicine,University of Rochester School of Medicine andDentistry, 885 S Ave, Rochester, NY 14620 (e-mail:[email protected]).

Mindful practitioners attend in a nonjudgmental way to their own physicaland mental processes during ordinary, everyday tasks. This critical self-reflection enables physicians to listen attentively to patients’ distress, rec-ognize their own errors, refine their technical skills, make evidence-baseddecisions, and clarify their values so that they can act with compassion, tech-nical competence, presence, and insight. Mindfulness informs all types ofprofessionally relevant knowledge, including propositional facts, personalexperiences, processes, and know-how, each of which may be tacit or ex-plicit. Explicit knowledge is readily taught, accessible to awareness, quan-tifiable and easily translated into evidence-based guidelines. Tacit knowl-edge is usually learned during observation and practice, includes priorexperiences, theories-in-action, and deeply held values, and is usually ap-plied more inductively. Mindful practitioners use a variety of means to en-hance their ability to engage in moment-to-moment self-monitoring, bringto consciousness their tacit personal knowledge and deeply held values, useperipheral vision and subsidiary awareness to become aware of new infor-mation and perspectives, and adopt curiosity in both ordinary and novel situ-ations. In contrast, mindlessness may account for some deviations from pro-fessionalism and errors in judgment and technique. Although mindfulnesscannot be taught explicitly, it can be modeled by mentors and cultivated inlearners. As a link between relationship-centered care and evidence-basedmedicine, mindfulness should be considered a characteristic of good clini-cal practice.JAMA. 1999;282:833-839 www.jama.com

See also pp 830 and 881.

©1999 American Medical Association. All rights reserved. JAMA, September 1, 1999—Vol 282, No. 9 833

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patient (Is she responding to this situ-ation in a way concordant with her pre-vious actions and values?) and myself(What values and biases affect the wayI frame this situation for myself and forthe patient?) to help us arrive at a mu-tual decision. These reflective activi-ties applied equally to the technical as-pects of medicine (How do I know I cantrust the interpretations of medicaltests?) and the affective domain (Howwell can I tolerate uncertainty andrisk?). An attitude of critical curios-ity,31 openness, and connection17,32,33 al-lowed us to defer the decision and re-consider testing once the immediatecrises had passed.

Explicit and Tacit KnowledgeClinical judgment is based on both ex-plicit and tacit knowledge.34-36 Medi-cal decision making, however, is oftenpresented only as the conscious appli-cation to the patient’s problem of ex-plicitly defined rules and objectivelyverifiable data.34,37,38 This form of ex-plicit knowledge can be quantified,modeled, readily communicated, andeasily translated into evidence-basedclinical practice guidelines.

Seasoned practitioners also apply totheir practice a large body of knowl-edge, skills, values, and experiences thatare not explicitly stated by or known tothem.34 This knowledge may constitutea different kind of evidence, which alsohas a strong influence on medical deci-sions. In everyday life, examples of tacitknowledge abound. Riding a bicycle in-volves judgments about speed, orienta-tion, and position that are rarely madeconscious except when something goesamiss. Similarly, an experienced neu-rologist can recognize Parkinson dis-

ease within moments of meeting a pa-tient, before processing the objective andsubjective data to support it. During thispreattentive processing,39 the brain rap-idly scans a wide array of perceptions, de-tects conspicuous features, and rel-egates some information to thebackground, all before the content of theperception is analyzed. Clinical skills,such as the depth of insertion of an oto-scope, the manipulation of the fetal headduring a delivery, and the realization thatthe patient has given sufficient informa-tion to diagnose major depression in-volve tacit knowledge and preattentiveprocessing.

While explicit elements of practiceare taught formally, tacit elements areusually learned during observation andpractice.40 Often, excellent clinicians areless able to articulate what they do thanothers who observe them. Nor do theyappreciate all of the biases in their ownreasoning processes.41 Subsidiary aware-ness35 is a term that describes how thepractitioner makes accessible the flowof unprocessed experience and tacitknowledge.

In the words of Anaïs Nin, “We don’tsee things as they are, we see things aswe are.”42 Evidence-based medicine of-fers a structure for analyzing medicaldecision making, but it is not suffi-cient to describe the more tacit pro-cess of expert clinical judgment.43 Alldata, regardless of their completenessor accuracy, are interpreted by the cli-nician to make sense of them and ap-ply them to clinical practice.44 Expertstake into account messy details, suchas context, cost, convenience, and thevalues of the patient.36,43,45,46 Physicianfactors such as emotions,47 bias,48 preju-dice,49 risk-aversion,50-53 tolerance foruncertainty,54,55 and personal knowl-edge of the patient also influence clini-cal judgment.50-55 Most of the pro-cesses described above remain relativelyunconscious to the practitioner.

Clinical judgment is a science and anart.36 Even those who are uncomfort-able with the notion of tacit knowl-edge recognize that it is impossible tomake explicit all aspects of profes-sional competence.43 Evidence-based

decision models are very powerful tools,but clinicians do not always use them,especially in complex situations.30,56 In-formation necessary to construct ex-plicit models is frequently incompleteor conflicting. Some important tacitknowledge about the patient, such aspersonality, simply does not fit into pre-defined categories. To clinicians, thesemodels may resemble computer-generated symphonies in the style ofMozart—correct but lifeless.

Professional Knowledgeand Self-awarenessEraut57,58 defines 4 types of profession-ally relevant knowledge, each of whichcan be tacit or explicit (TABLE 1). Themost familiar is propositional knowl-edge, or what most people call fact:theories, concepts, and principles, usu-ally acquired from books, electronic me-dia, or instructors. Self-awareness ofwhat one does not know and the ap-preciation for the transient nature offacts can direct ongoing learning.

Knowledge acquired through experi-ence, or personal knowledge, is a col-lection of information, intuitions, and in-terpretations that guides professionalpractice.35 Consider the following ex-ample. Returning from vacation, I sawone of my patients who was infected withhuman immunodeficiency virus and saidto the resident caring for him, “MrCharles looks worse. Looks like he mighthave adrenal insufficiency.” The per-sonal knowledge exemplified in this sce-nario differs from an anecdote becauseit is contextualized. I can say that MrCharles looks worse because I know himas a person, not just because I knowabout him, and because I recognize a pat-tern of disease (weakness and skin colorchange). This knowledge enters into mymind in an inductive, impressionisticway, providing the gestalt or feel of aclinical situation inaddition to thepropo-sitional facts.29 However, confusion be-tween personal knowledge and anec-dotal information results in both beingneglected and discounted during medi-cal training. An example of the uncriti-cal application of a decontextualized an-ecdote is when a physician who after

Table 1. Professionally Relevant Awarenessand Knowledge

Levels of Awareness

Tacit (subsidiary awareness)Explicit (focal awareness)

Types of Knowledge

PropositionalPersonalProcess (including metaprocessing)Know-how

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834 JAMA, September 1, 1999—Vol 282, No. 9 ©1999 American Medical Association. All rights reserved.


missing a diagnosis of colon cancer, sub-sequently overtests all of his patients. Incontrast, if he had raised tacit personalknowledge to awareness, it could havebeen subjected to critical reflection.

Process knowledge is knowing howto accomplish a task,59 such as gather-ing information, performing proce-dures, making decisions, and plan-ning for the future.58 Process knowledgealso includes metaprocessing, or theprocess of reflection on one’s own men-tal processes. This is particularly im-portant in practice, because “we do notobserve nature as much as we observenature exposed to our method of ques-tioning.”60 Metaprocessing might becalled thinking about thinking or feel-ing about feelings. It is both a con-crete action (such as the modificationin a trajectory of light in a mirror) andan act of self-observation in which themind attends to its own actions (in-cluding the subject who is performingthose actions). Metaprocessing allowsthe physician to uncover areas of un-conscious incompetence,61 the blindspots wherein a physician might notknow his or her deficiencies. Fortu-nately, clinicians can often readily iden-tify these blind spots and gain insightinto the influence of the observer, forexample, when they review their ownvideotaped patient visits.62,63

Eraut’s fourth type of professionallyrelevant knowledge, know-how, isknowing how to get things done. A resi-dent working in a new setting may knowthat a diagnostic test is important, butmay not know that the test will happensooner with a friendly call to the radi-ologist. Learning the steps necessary forgetting something done is important inprofessional development of physi-cians, but it is often relegated to the in-formal64 or hidden24,26 curriculum.

Mindful PracticeMindfulness is a logical extension of theconcept of reflective practice.4,12,14 Themindful practitioner is present in every-day experience, in all of its manifesta-tions, including actions, thoughts, sen-sations, images, interpretations, andemotions.12,13,65 Mindfulness “leads the

mind back from theories, attitudes andabstractions . . . to the situation of ex-perience itself,”11 which prevents us from“falling prey to our own prejudices, opin-ions, projections, expectations” and en-ables us to free ourselves from the“straightjacket of unconsciousness.”66

Mindfulness is attending to the ordi-nary, the obvious, and the present. Jo-hann Sebastian Bach is reported to havesaid, when asked how he found melo-dies: “The problem is not finding them,it’s—when getting up in the morning andout of bed—not stepping on them.”67

Although mindfulness is a practice thatderives from a philosophical-religioustradition,12,14,15 the underlying philoso-phy is fundamentally pragmatic13 and isbased on the interdependence of ac-tion, cognition, memory, and emotion.These connections represent a rela-tively new idea in neuroscience re-search.28,68 Western approaches to theunderstanding of mental processes havehistorically separated mental activityfrom action in the world, and the schismbetween behavioral and psychody-namic psychology has reinforced someof this separation. However, in theEast.11,14 and in phenomenological tra-ditions in the West,27 philosophy haslinked cognition to emotion, memory,and action in the world.

The goals of mindful practice are tobecome more aware of one’s own men-tal processes, listen more attentively, be-come flexible, and recognize bias andjudgments, and thereby act with prin-ciples and compassion (TABLE 2). Mind-ful practice involves a sense of “unfin-ishedness,”31 curiosity about theunknown and humility in having an im-perfect understanding of another’s suf-fering. Mindfulness is the opposite ofmultitasking. Mindfulness is a quality ofthe physician as person, without bound-aries between technical, cognitive, emo-tional, and spiritual aspects of practice.

Mindful practitioners have an abil-ity to observe the observed while ob-serving the observer in the consultingroom. This process, not often dis-cussed in medical practice, is consid-ered essential to musicians, whose taskis to perform and listen at the same time,

attending simultaneously to the tech-nical challenges, emotional expres-sion, and overall theoretical structureof the music.69 The accomplished mu-sician performs midcourse correc-tions of finger movements, comparesthe sound produced with the imag-ined sound, and, at the same time,brings expressive spontaneity to theperformance. However, if the musi-cian were to attempt to control each fin-ger movement while simultaneouslyanalyzing the harmonic structures,rhythms, and silences that constituteexpressive playing, playing would be-come impossible. Thus, focal aware-ness on the music is accompanied bysubsidiary awareness35 of technique andanalysis—a mix of peripheral vision andsemiautomatic action that is high-lighted only when the unexpected ordifficult occurs.

In medicine, consider what a resi-dent in a busy pediatric emergencydepartment might do when he is unableto determine whether an ear examina-tion is normal or abnormal and theattending physician is not immediatelyavailable. The resident has severaloptions, consideration of which couldbe conscious or unconscious. The resi-dent weighs the consequences of mis-diagnosis for the patient, the humilia-tion of having to call an otolaryngologyresident out of the clinic, the loss of self-esteem by having to admit incompe-tence, and the pride in being strongenough to admit his need to learn. Anunmindful practitioner who is con-scious of the dilemma might judge orblame himself or others. He might base

Table 2. Characteristics of Mindful Practice

Active observation of oneself, the patient, andthe problem

Peripheral visionPreattentive processingCritical curiosityCourage to see the world as it is rather than as

one would have it beWillingness to examine and set aside categories

and prejudicesAdoption of a beginner’s mindHumility to tolerate awareness of one’s areas

of incompetenceConnection between the knower and the knownCompassion based on insightPresence

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his course of action on an external stan-dard of correctness or on expedience.However, little would be learned, and hewould be no better prepared for the nextsituation.Amindful consciousapproachwould be to cultivate awareness not onlyof the correct course of action but alsoof the factors that cloud the decision-making process. The mindful practi-tioner is mentally and technically bet-ter prepared for the next situation.

The object of mindfulness can applyto any aspect of medical practice andwithin any domain of tacit or explicitknowledge. Intrapersonal self-aw-areness helps the physician be con-scious of his or her strengths, limita-tions, and sources of professionalsatisfaction. It helps the individual avoidblind spots, such as a physician who,because his or her parent was an alco-holic, avoids discussions of alcohol withpatients. It may clarify deeply held val-ues and motivations for becoming a phy-sician. Interpersonal self-awareness, orsocial intelligence,70,71 allows physi-cians to see themselves as they are seenby others and helps to establish satisfac-tory interpersonal relationshipswithcol-leagues, patients, and students. Aware-nessofmetaprocessingallowsphysiciansto be aware of their own clinical reason-ing, including the necessary connec-tions between cognition, memory, andemotional processing.28 Self-awarenessof learning needs allows physicians torecognize areas of unconscious incom-petenceandtodevelopameanstoachiev-ing their learning goals.61 Ethical self-awareness is the moment-to-momentcognizance of values that are shapingmedical encounters. Technical self-awareness is necessary for self-correc-tionduringproceduressuchas thephysi-cal examination, surgery, computeroperations, and communication.

Often reflection is prompted by a criti-cal incident involving an error, a diffi-cult situation, or an unexpected resultof one’s actions.25,72,73 At other times, re-flection is prompted by the maturing ofan idea rather than by a discrete exter-nal event. However, many of these eventsgo unnoticed by all but the most cre-ative thinkers. The discoveries of peni-

cillin, radiation, and the benzene ringwere not accidents, but rather the re-sult of someone making what had beenconsidered an outlier (a tainted Petridish) into data (a useful medication).

Mindfulness enables the practitionerto use a wider set of perceptual re-sources. The fluidity of mind that canmaintain some constant subthresholdawareness of preattentive and subsid-iary processes has been described as a“beginner’s mind.”12 A beginner’s mindis open and allows for new diagnosticand therapeutic possibilities, as may hap-pen when a patient meets a new physi-cian. By contrast, the expert’s mind nar-rows possibilities, using prior experienceto delimit and confine observations.Langer13 describes mindfulness as a stateof “could be,” welcoming uncertaintyrather than trying to avoid it. Difficultpatients might then become interest-ing patients; unsolvable problems mightbecome avenues for research. Critical cu-riosity shows the limits of categories andhelps create more meaningful ones. Forexample, the recognition of panic dis-order as a common cause of chest painmight help physicians recategorize thesepatients from symptom amplifiers74 topatients with a serious and treatable ill-ness. Expertise is often well served bybeginner’s mind, especially in new, un-familiar, or stressful situations.

Mindfulness implies examining the re-lationship between the knower and theknown as suggested in the “I-Thou” re-lationship of Martin Buber75 or the “con-nected knowing” of ideas, people orthings, suggested by Belenky and col-leagues.33 Knowledge, then, does not ex-ist independently but rather in relation-ship to the one observing and using it.Theories are seen as fragile approxima-tions rather than reality itself.76 Such-man and Matthews17 have described thisas the connexional dimension of medi-cal practice, in which there is a tacit bondbetween patient and physician that tran-scends professional roles.

Mindlessness: Gaps BetweenKnowledge, Values, and ActionsPhysicians make moment-to-momentvalue-laden decisions that entail cog-

nitive and emotional factors. They de-cide how much effort to expend in pur-suit of knowledge, how much painmedication to prescribe, how muchtime to spend with each patient, andwhen to return patients’ telephone calls.These rapid decisions, usually based onpersonal knowledge, level of skill, ef-ficiency, and values, ultimately resultin actions. Thus, objectives for the prac-tice of medicine calling on physiciansshould include the ability to performor knowledge about important aspectsof medical care77 as well as the require-ment to actually use those practices indaily work.

Self-knowledge is essential to the ex-pression of core values in medicine, suchas empathy, compassion, and altruism.To be empathic, I must witness and un-derstand the patient’s suffering and myreactions to the patient’s suffering to dis-tinguish the patient’s experience frommy own. Then I can communicate myunderstanding and be compassionate, touse my presence to relieve suffering andto put the patient’s interests first. Per-haps lack of self-awareness is why phy-sicians more often espouse these val-ues than demonstrate them78-81 and whythey tend to be less patient-centered82

and confuse their own perspectives withthose of the patient1,80 in situations thatinvolve conflict and strong emotions.

Curiosity is central both to caringabout the patient and to solving prob-lems.83 Fitzgerald16 describes a traineewho reported a patient as having hada history of “BKA” (below-the-knee am-putation) without noting that the pa-tient, in fact, had both feet. A transcrip-tionist had mistranscribed DKA(diabetic ketoacidosis) and the asser-tion went unchallenged. The stu-dent’s lack of curiosity, or overcon-creteness, led to mistaking the chart forthe patient. Similarly, caring requiresan interest in the patient as a personrather than as an abstraction of dis-ease.84,85 For example, Stetten18 de-scribed how his physicians were unin-terested in his adaptation to blindnesswhile they attempted to treat his macu-lar degeneration; they saw the diseasebut not the person.

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Mindlessness accounts for many de-viations from professionalism, whichseem to occur more often in emotion-ally charged situations, during situa-tions of uncertainty, and under pres-sure to resolve problems. For example,many medical students and residents,and presumably practitioners as well, re-port findings that were not observed anddo not seek correction for errors.20 Ac-tions diverge from professional knowl-edge and values because of attempts tobe efficient, a desire to please supervi-sors, feelings of embarrassment, and asense of being overwhelmed.2,19,21,82,86,87

Practitioners may not think to applyknowledge gained in a classroom con-text (such as an ethics course) in a stress-ful clinical environment. Deviations of-ten involve avoidance of difficult issues,rationalization, externalization, or frankdenial rather than the healthy process-ing of emotional feelings toward pa-tients.88,89

Levels of Mindful PracticeTo guide physicians’ professional de-velopment, I would like to propose 5levels of mindfulness, each of whichsubsumes the previous level and issubject to verification in future obser-vational studies (TABLE 3). At the ex-treme of mindless practice, the practi-tioner’s response is denial (level 0). Bymaking the problem “out there,” thepractitioner may avoid responsibilityand reflection or describe the situa-tion (or the patient) in ways that arecontrary to the evidence.

Level 1 describes practitioners whodo not necessarily use reflection buttake some responsibility for the situa-tion and solve it by conforming to anexternal standard of behavior. For ex-ample, a practitioner might deal withhis attraction to a patient by reciting arule, such as “sexual intimacy with pa-tients is wrong,” but may not seek un-derstanding of the factors that put phy-sicians at risk for misconduct.86

Level 2 describes medical decisionanalysis based on the assumption thatexplicit cognitive models guide physi-cian behavior and the key to change isthe transfer of information. While cu-

riosity and reflection are required togenerate hypotheses and importantquestions, physicians at this level ig-nore personal knowledge, tacit knowl-edge, and emotions. Level 3 includescuriosity about feelings, thoughts, andbehaviors without attempting to sup-press or label them as good or bad. Byincluding emotions and personalknowledge, the clinician has more toolsavailable to promote patient care. Level4, insight, has 3 facets: understandingthe nature of the problem, understand-ing how one attempts to solve it, andunderstanding the interconnected-ness between the practitioner and theknowledge that he or she possesses.15

Insight facilitates the calibration of men-tal processes, in addition to correctionof the external problem. Finally, prac-titioners at level 5 can use their in-sight to generalize, overcome similarchallenges in the future, incorporatenew behaviors and attitudes, expresscompassion, and be present.

Becoming MindfulRecent articles1,5,90 have described a va-riety of ways for becoming more self-aware. Individually, practitioners mightkeep a journal, practice meditation, re-view videotapes of sessions with their pa-tients, and use learning contracts. Inmedical education, self-evaluation formsfor students and residents have been im-portant adjuncts to the evaluation pro-cess. Learners can compare their per-ceptions with those of a teacher ormentor. Peer evaluations have been use-ful in bringing awareness to aspects ofprofessionalism and social skills for stu-dents, residents, and practicing physi-cians.91,92 Critical incident reports writ-ten by practitioners about mistakes,20,93

impairment,94 ethical dilemmas,95 anddifficult situations can be discussed insmall group settings and raise aware-ness about common situations and one’sreactions to them. Sharing of family in-formation and cultural background, us-ing genograms or illness narratives, canhelp practitioners learn about the ex-pectations, biases, strengths, and ten-dencies that influence clinical care.96-99

These approaches, historically focused

on the emotional aspects of medicalpractice and the patient-physician rela-tionship, usually consist of exercisesseparated in space and time from ac-tual clinical practice. Mindfulness train-ing goes one step further. It applies toall aspects of practice, from looking upreferences to performing physical ex-aminations, from tying sutures to giv-ing bad news.

Mindfulness can link evidence-based and relationship-centered care andhelp to overcome the limitations of bothapproaches.37,43,100 The success of evi-dence-based approaches depends on theability of the practitioner to decide whichissues require further investigation andhow to frame a question. These, in turn,require that the practitioner identify hisor her own biases and the influences ofthe patient-physician relationship onframing of the question to investigate.This personal knowledge should also beconsidered a form of evidence and couldbe integrateded into decision making toincorporate patients’ preferences. Evi-dence-based data that are not specific toone patient-physician relationship wouldthen be applied in a more mindful way.

Seminars about difficult topics suchas HIV management, delivery of badnews, medical mistakes, professional-ism, and adherence to treatment canfoster reflection and raise practition-ers’ awareness of their own emotionsand biases, while, at the same time, at-tending to the practicalities of the pa-tient’s problem.101,102 However, the abil-ity to reflect in a classroom environmentis not equivalent to reflection in a stress-ful clinical environment. For ex-ample, ethics courses might increasestudents’ knowledge base and im-prove their ability to solve difficultproblems, but ethics courses do not nec-essarily produce physicians whose be-

Table 3. Levels of Mindfulness

Levels Characteristics

0 Denial and externalization1 Imitation: behavioral modeling2 Curiosity: cognitive understanding3 Curiosity: emotions and attitudes4 Insight5 Generalization, incorporation, and

presence

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havior is more ethical than it would beotherwise. Clinician-mentors can helpstudents put ideas into action by mod-eling a moment-to-moment aware-ness of their own knowledge and emo-tions that inform their decisions whenvalues are on the line. Professionals canlearn to articulate their personal knowl-edge by observing their own actions(How do I respond to uncertainty? Howdo I present risks? How do I self-correct when doing a difficult techni-cal procedure?) Professional knowl-edge is defined, then, not by its validity,but by how it is used.23

There is an inherentparadox in teach-ing or writing about mindfulness. Theteacher’s task is to invokeastateofmind-fulness in the learner, and, thus, theteacher can only act as a guide, not atransmitterofknowledge. Inarecentex-ample of a resident about to face adreadedfollow-upvisitwithanangrypa-tient who thought that earlier treatmentof his hepatitis C might have preventedhisend-stagecirrhosis, thementor’s rolewas complex. He had to help the resi-dent identify his feelings of guilt and de-fensiveness that might interfere withcommunicating effectively with the pa-tient, determine the risks and benefitsof liver transplantation, and explore thepatient’s wishes regarding end-of-lifecare.Thementor’s approachwas tohelptheresident identifyhowhepsychologi-cally prepares for each visit with a pa-tient,a“centering”process thathadbeenpreviously tacit,whichusually isnotex-plicit for most practitioners, and to useit more effectively. The mentor helpedthe resident observe himself, effectinga transition from unconscious incom-petence to critical reflection and allow-ing him to come to a satisfactory deci-sion with the patient based on both ob-jectiveevidenceandpersonalknowledge.

Barriers tomindfulness arenumerousinmedicaltraining,eveninreformedcur-ricula. Fatigue, dogmatism, and an em-phasis on behavior (rather than on con-sciousness)103 closethemindtoideasandfeelings.Unexaminednegativeemotionsleadtoemotionaldistanceandarrogance.McWhinney identified 3 additional bar-riers:unexaminednegativeemotions,fail-

ureofimagination,andliteral-mindedness(I.R.McWhinney,MD,oralpresentation,London,Ontario,October6,1995).Fail-ureofimaginationlimitsthecuriositythatis the first step in any process of inquiry.Concrete literal mindedness may servesimplediagnosticprocesseswell,but im-pedes creative problem solving and lim-itsthephysician’sviewofthepatient.Lackof opportunities to learn how to becomemindfulinpracticeandthelackofforumstodealwithfearsandanxietiescreate fur-therbarriers.Finally,somecliniciansmayfear that mindfulness is the same as ex-cessive self-absorption that would delaynecessary clinical actions. They wouldneed to be educated that navel-gazing isantitheticaltomindfulpractice,whichhasasitsgoalclarityandattentiontothetasksat hand.

ConclusionsMindfulness, critical reflection, learn-ing, and patient care all “begin with theself as the first, but not the only, ob-ject of knowledge.”104 Mindful prac-tice extends beyond examining the af-fective domains and involves criticalreflection on action, tacit personalknowledge, and values in all realms ofclinical practice, teaching, and re-search. Mindfulness is a discipline andan attitude of mind. It requires criticalinformed curiosity and courage to seethe world as it is rather than how onewould have it be. Mindful practition-ers tolerate making conscious their pre-viously unconscious actions and er-rors. The goal of mindfulness iscompassionate informed action in theworld, to use a wide array of data, makecorrect decisions, understand the pa-tient, and relieve suffering.

Mindful practice requires mentor-ing and guidance. Recognition of one’slimitations and areas of incompetencecan be emotionally difficult and can in-vite avoidance in even highly moti-vated practitioners. Although mindful-ness is an individual and subjectiveprocess, each of us can identify prac-titioners who embody these at-tributes, learn from them, and iden-tify unique ways of being self-aware.Educators can take on the task of help-

ing trainees become more mindful byexplicitly modeling their means for cul-tivating awareness.

Funding/Support: DrEpstein receivedsupport fromtheRobert Wood Johnson Foundation Generalist PhysicianFacultyScholarsProgramand theFulbrightFoundation.Acknowledgment: The ideas in this article were gen-erated during a seminar at the Institute for Health Stud-ies, Barcelona, Spain, and also borrows generously fromconversations with Jeffrey Draisin, MD, Pieter Le-Roux, PhD, Larry Mauksch, CSW, Maria Nolla, MD,Dennis Novack, MD. I would like to thank Arthur Frank,PhD, Cindy Haq, MD, and Ian McWhinney, MD, fortheir comments on early drafts of this article, and tothe JAMA reviewers whose suggestions were extraor-dinarily thoughtful and helpful.

REFERENCES

1. Novack DH, Suchman AL, Clark W, Epstein RM,Najberg E, Kaplan C. Calibrating the physician. JAMA.1997;278:502-509.2. Balint M. The Doctor, His Patient and the Illness.London, England: Pitman; 1964.3. Brock CD, Stock RD. A survey of Balint group ac-tivities in US family practice residency programs. FamMed. 1990;22:33-37.4. Hewson MGA. Reflection in clinical teaching: ananalysis of reflection-on-action and its implications forstaffing residents. Med Teach. 1991;13:227.5. Novack DH, Kaplan C, Epstein RM, et al. Personalawareness and professional growth: a proposed cur-riculum. Med Encounter. 1997;13:2-7.6. Novack DH, Volk G, Drossman DA, Lipkin M Jr.Medical interviewing and interpersonal skills teach-ing in US medical schools: progress, problems, andpromise. JAMA. 1993;269:2101-2105.7. Novack DH, Dube C, Goldstein MG. Teaching medi-cal interviewing. Arch Intern Med. 1992;152:1814-1820.8. Makoul G, Curry RH, Novack DH. The future ofmedical school courses in professional skills and per-spectives. Acad Med. 1998;73:48-51.9. McPhee SJ. The practice of presence. Presented at:Alpha Omega Alpha Honor Society Spring Lecture;April 17, 1981; Piscataway, NJ.10. Westberg J, Jason H, Fostering reflection and self-assessment. Fam Med. 1994:26;278-282.11. Varela FJ, Thompson E, Rosch E. The EmbodiedMind: Cognitive Science and Human Experience. Cam-bridge, Mass: Massachusetts Institute of TechnologyPress; 1991.12. Suzuki S. Zen Mind, Beginner’s Mind. New York,NY: Weatherhill; 1980.13. Langer EJ. Mindfulness. Reading, Mass: Addison-Wesley Publishing Co Inc; 1989.14. Streng FJ. Emptiness: A Study in Religious Mean-ing. Nashville, Tenn: Abingdon Press; 1967.15. Nhat Hahn T. Peace Is Every Step: The Path ofMindfulness in Everyday Life. New York, NY: Ban-tam Books; 1992.16. Fitzgerald FT. Curiosity. Ann Intern Med. 1999;130:70-72.17. Suchman AL, Matthews DA. What makes the pa-tient-doctor relationship therapeutic? [published cor-rection appears in Ann Intern Med. 1988;109:173].Ann Intern Med. 1988;108:125-130.18. Stetten D Jr. Coping with blindness. N Engl J Med.1981;305:458- 460.19. Christakis DA, Feudtner C. Ethics in a short whitecoat. Acad Med. 1993;68:249-254.20. Christensen JF, Levinson W, Dunn PM. The heartof darkness. J Gen Intern Med. 1992;7:424-431.21. Dimsdale JE. Delays and slips in medical diagno-sis. Perspect Biol Med. 1984;27:213-220.22. Coles C. Approaching professional develop-

MINDFUL PRACTICE



ment. J Contin Educ Health Prof. 1996;16:152-158.23. Eraut M. Developing Professional Knowledge andCompetence. London, England: Falmer Press; 1994.24. Hafferty FW, Franks R. The hidden curriculum,ethics teaching, and the structure of medical educa-tion. Acad Med. 1994;69:861-871.25. Schon DA. The Reflective Practitioner. New York,NY: Basic Books; 1983.26. Wear D. Professional development of medical stu-dents: problems and promises. Acad Med. 1997;72:1056-1062.27. Baron RJ. An introduction to medical phenom-enology. Ann Intern Med. 1985;103:606-611.28. Damasio AR. Descartes’ Error: Emotion, Reason,and the Human Brain. New York, NY: GP Putnam’sSons; 1994.29. Peters RM. The role of intuitive thinking in thediagnostic process. Arch Fam Med. 1995;4:939-941.30. Wartofsky M. Clinical judgment, expert pro-grams, and cognitive style: a counter-essay in the logicof diagnoses. J Med Philosophy. 1986;11:81-82.31. Friere P. Pedagogy of Freedom. New York, NY:Rowman & Littlefield; 1998.32. Matthews DA, Suchman AL, Branch WT Jr. Mak-ing“connexions.”AnnInternMed.1993;118:973-977.33. Belenky MF, Clinchy McVicker B, Goldberger NR,Tarule JM. Women’s Ways of Knowing: The Devel-opment of Self, Voice, and Mind. New York, NY: Ba-sic Books; 1997.34. Goldman GM. The tacit dimension of clinical judg-ment. Yale J Biol Med. 1990;63:47-61.35. Polanyi M. Personal Knowledge: Towards a Post-Critical Philosophy. Chicago, Ill: University of Chi-cago Press; 1974.36. Feinstein AR. “Clinical Judgment” revisited: thedistraction of quantitative models. Ann Intern Med.1994;120:799-805.37. Sackett DL. Evidence-Based Medicine: How toPractice and Teach EBM. New York, NY: Churchill Liv-ingstone; 1997.38. Pauker SG, Kassirer JP. Decision analysis. N EnglJ Med. 1987;316:250-258.39. Austin JH. Zen and the Brain: Toward an Under-standing of Meditation and Consciousness. Cam-bridge, Mass: Massachusetts Institute of TechnologyPress; 1998.40. Epstein RM, Cole DR, Gawinski BA, Piotrowski-Lee S, Ruddy NB. How students learn from community-based preceptors. Arch Fam Med. 1998;7:149-154.41. Nisbett RE, Wilson TD. Telling more than we canknow: verbal reports on mental processes. Psychol Rev.1977;84:231-259.42. Nin A. The Diary of Anais Nin, 1939-1944. NewYork, NY: Harcourt Brace & World; 1969.43. Tonelli MR. The philosophical limits of evidence-based medicine. Acad Med. 1998;73:1234-1240.44. Tanenbaum SJ. What physicians know. N Engl JMed. 1993;329:1268-1271.45. Benner P. From Novice to Expert. Menlo Park,Calif: Addison-Wesley; 1984.46. Malterud K. The legitimacy of clinical knowl-edge: towards a medical epistemology embracing theart of medicine. Theor Med. 1995;16:183-198.47. Greenberg DB, Eisenthal S, Stoeckle JD. Affectiveaspects of clinical reasoning. Psychol Rep. 1984;55.48. Franks P, Culpepper L, Dickinson J. Psychosocialbias in the diagnosis of obesity. J Fam Pract. 1982;14:745-750.49. Todd KH, Samaroo N, Hoffman JR. Ethnicity as arisk factor for inadequate emergency department an-algesia. JAMA. 1993;269:1537-1539.50. Holtgrave DR, Lawler F, Spann SJ. Physicians’ riskattitudes, laboratory usage, and referral decisions: thecase of an academic family practice center. MedDecis Making. 1991;11:125-30.51. Bertakis KD, Callahan EJ. A comparison of initial andestablished patient encounters using the Davis Obser-vation Code. Fam Med. 1992;24:307-311.

52. Nightingale SD. Risk preference and laboratorytest selection. J Gen Intern Med. 1987;2:25-28.53. Pearson SD, Goldman L, Orav EJ, Guadagnoli E,Garcia TB, Johnson PA. Triage decisions for emer-gency department patients with chest pain. J Gen In-tern Med. 1995;10:557-564.54. Kassirer JP. Our stubborn quest for diagnostic cer-tainty: a cause of excessive testing. N Engl J Med. 1989;320:1489-1491.55. Quill TE, Suchman AL. Uncertainty and control:learning to live with medicine’s limitations. HumaneMed. 1993;9:109-120.56. Detsky AS, Redelmeier D, Abrams HB. What’swrong with decision analysis? can the left brain in-fluence the right? J Chronic Dis. 1987;40:831-838.57. Eraut M. The context for professional educationand development. In: Eraut M, ed. Developing Pro-fessional Knowledge and Competence. London, En-gland: Falmer Press; 1994:1-18.58. Eraut M. Learning professional processes: publicknowledge and personal experience. In: Eraut M, ed.Developing Professional Knowledge and Compe-tence. London, England: Falmer Press; 1994:100-122.59. Ryle G. The Concept of Mind. New York, NY: Bar-nes & Noble; 1949.60. Heisenberg W. Physics and Philosophy. New York,NY: Harper & Brothers; 1958:58.61. Westberg J, Jason H. Collaborative Clinical Edu-cation: The Foundation of Effective Patient Care. NewYork, NY: Springer Publishing Co; 1993.62. Epstein RM, Morse DS, Frankel RM, Frarey L,Anderson K, Beckman HB. Awkward moments in pa-tient-physician communication about HIV risk. AnnIntern Med. 1998;128:435-442.63. Westberg J. Teaching Creatively With Video: Fos-tering Reflection, Communication, and Other Clini-cal Skills. New York, NY: Springer Publishing Co; 1994.64. Hundert EM, Hafferty F, Christakis D. Character-istics of the informal curriculum and trainees’ ethicalchoices. Acad Med. 1996;71:624-642.65. McWhinney, I. R. Fifty years on: the legacy of Mi-chael Balint. Br J Gen Pract. 1999;49:418-419.66. Kabat-Zinn J. Wherever You Go, There You Are:Mindfulness Meditation in Everyday Life. New York,NY: Hyperion; 1994.67. Goldberg P. The Intuitive Edge: Understandingand Developing Intuition. Los Angeles, Calif: JPTarcher; 1983.68. LeDoux JE. Emotion, memory and the brain. SciAm. 1994;270:50-57.69. Bernstein S. With Your Own Two Hands. NewYork, NY: Schirmer Books; 1981:215-217.70. Goleman D. Emotional Intelligence. New York,NY: Bantam Books; 1995.71. Gardner H. Multiple Intelligences: The Theory inPractice. New York, NY: Basic Books; 1993.72. Schon DA. Educating the reflective practitioner.San Francisco, Calif: Jossey-Bass Publishers; 1987.73. Argyris C, Schon DA. Theory in Practice: Increas-ing Professional Effectiveness. San Francisco, Calif: Jos-sey-Bass Publishers; 1974.74. Barsky AJ III. Patients who amplify bodily sensa-tions. Ann Intern Med. 1979;91:63-70.75. Buber M. I and Thou. New York, NY: Scribner; 1970.76. James W. Pragmatism. Cambridge, Mass: Har-vard University Press; 1975.77. Association of American Medical Colleges. Re-port I: Learning Objectives for Medical Student Edu-cation: Guidelines for Medical Schools. Chicago, Ill:Association of American Medical Colleges; 1998.78. Stern DT. Practicing what we preach? an analy-sis of the curriculum of values in medical education.Am J Med. 1998;104:569-575.79. Suchman AL, Markakis K, Beckman HB, FrankelR. A model of empathic communication in the medi-cal interview. JAMA. 1997;277:678-682.80. Crawshaw R. Greed. BMJ. 1996;313:1596-1597.81. Epstein RM, Belle Brown J, Anderson K, Frarey L,

Meredith L, Stewart M. Physician ineffectiveness in dis-cussionsofemotionallychargedtopics. In:ProgramsandAbstracts of the 3rd International Conference on Com-munication in Medicine; July 22, 1999; Chicago, Ill.82. Mengel M. Physician ineffectiveness due to fam-ily of origin issues. Fam Syst Med. 1987;5:176-190.83. Peabody F. The care of the patient. JAMA. 1927;88:877-882.84. McWhinney IR. Illness, suffering, and healing. In:McWhinney IR,ed.ATextbookofFamilyMedicine.2nded.NewYork,NY:OxfordUniversityPress;1997:83-103.85. McWhinney IR. William Pickles Lecture 1996: theimportance of being different. Br J Gen Pract. 1996;46:433-436.86. Frankel RM, Williams S. Sexuality and profession-alism. In: Feldman M, Christensen T, eds. BehavioralMedicine: A Primary Care Handbook. Stamford, Conn:Appleton & Lange; 1997:30-39.87. Feudtner C, Christakis DA, Christakis NA. Do clini-cal clerks suffer ethical erosion: students’ perceptionsof their ethical environment and personal develop-ment. Acad Med. 1994;69:670-679.88. Hahn SR, Thompson KS, Wills TA, Stern V, Bud-ner NS. The difficult doctor-patient relationship: so-matization, personality and psychopathology. J ClinEpidemiol. 1994;47:647-657.89. Groves JE. Taking care of the hateful patient.N Engl J Med. 1978;298:883-887.90. Novack DH, Esptein RM, Paulsen RH. Toward cre-ating physician healers: personal awareness, growthand well-being in medical training. Acad Med. 1999;74:516-520.91. Asch E, Saltzberg D, Kaiser S. Reinforcement ofself-directed learning and the development of pro-fess ional att i tudes through peer- and self-assessment. Acad Med. 1998;73:575.92. Ramsey PG, Wenrich MD, Carline JD, Inui TS, Lar-son EB, LoGerfo JP. Use of peer ratings to evaluate phy-sician performance. JAMA. 1993;269:1655-1660.93. Wu AW, Cavanaugh TA, McPhee SJ, Lo B, MiccoGP. To tell the truth: ethical and practical issues in dis-closing medical mistakes to patients. J Gen Intern Med.1997;12:770-775.94. LaCombe MA. Problems of professionalism: phy-sician impairment. Am J Med. 1996;5:654-656.95. Fleetwood J, Novack DH, Feldman D, Farber N.MedEthEx: Standardized Patient Exercises in Medi-cal Ethics and Communication Skills. Philadelphia, Pa:Allegheny University of the Health Sciences; 1997.96. McDaniel SH, Landau-Stanton J. Family-of-origin work and family therapy skills training: both-and. Fam Process. 1991;30:459-471.97. Crouch M. Working with one’s own family: an-other path for professional development. Fam Med.1986;18:93-98.98. Epstein R. Is there a doctor in the family? Inter-nal Medicine News. April 1997:13.99. Epstein R. Physician know thy family: looking atone’s family-of-origin as a method of physician self-awareness. Med Encounter. 1991;8:9-9.100. Tresolini C, and the Pew-Fetzer Task Force.Health Professions Education and Relationship-Centered Care: Report of the Pew-Fetzer Task Forceon Advancing Psychosocial Health Education. SanFrancisco, Calif: Pew Health Communications; 1994.101. Hensel WA, Dickey NW. Teaching profession-alism: passing the torch. Acad Med. 1998;73:865-870.102. EpsteinRM,ChristieML.HIVasachronicdisease:teaching using simulated clinical encounters. In: Pro-grams and abstracts of the 29th annual meeting of theSociety of Teachers of Family Medicine Annual Meet-ing Workshop; April 30 1996; San Francisco, Calif.103. Searle JR. The Rediscovery of the Mind. Cam-bridge, Mass: Massachusetts Institute of TechnologyPress; 1992.104. Aronowitz S. Introduction. In: Friere P, ed. Peda-gogy of Freedom: Ethics, Democracy, and Civic Cour-age. New York, NY: Rowman & Littlefield; 1998:1-27.

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Mindful practice. ronald epstein[1]

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Transcript of Mindful practice. ronald epstein[1]