The Mindful physiciaNtm

Mindfulness in Medicine


The Mindful RX

with Scott Rogers

One of the challenges in the practice of medicine is the difficult patient interaction.  It can be disconcerting to have the very person you are charged with helping and wish to help with the best of intentions, be the source of agitation and frustration.  As we’ll explore in this article, with greater mindful awareness of these challenging interactions, you can become a more effective physician, enhance your relationship with patients, and feel more at ease during challenging moments.  To better understand this, we’ll elaborate on what is a difficult patient, discuss mindful awareness, and learn a mindfulness exercise that you can use when you next find yourself dealing with challenging patients.

The Challenging Patient

Challenging patients present themselves in numerous ways.  They can be discourteous, disagreeable, doubtful, and disrespectful.  They can fail to disclose crucial information, fail to adhere to treatment, and fail to show up. They can be excessively nosy, nervy, and needy.  And they can become angry, agitated, annoying and acrimonious.

Despite the myriad qualities of the challenging patient, they all have one thing in common – they do not act the way you would like them to.  They also have something else in common – often they are sick, they are scared, and they have placed their faith in you to help them feel better and heal.

Mindful Awareness

Mindfulness is the practice of paying attention on purpose to what is taking place in the present moment.  Often the mind wanders into the past, where it can get lost in doubt and regret, and into the future, where it can experience worry and fear.  This mental time travel is common and can be a source of distress as well as an impediment to your effective performance.  Combine the tendency of the mind to wander into doubtful and worrisome places with the demands placed on you by the difficult patient, and your ability to listen deeply, communicate effectively, and make wise decisions can become impaired. Even more, because of these consequences, you can find yourself overly stressed, increasingly prone to doubt and worry (often unaware that you are picking up on your patient’s distress), and dissatisfied.  Mindfulness is a practice that tones down the mental time travel, catches the mind and body as it moves into agitation, and offers tools for what to do during these times to enhance performance and well-being.

When things don’t go the way we want them we can become agitated.  In an effort to reduce the agitation we may turn to problem solving or any of a variety of less constructive way of soothing ourselves.  As physicians, when confronted with a medical problem, quite often the problem solving path is taken, and often effectively.  But when the challenge is an interpersonal conflict caused by another person’s undesirable conduct, the physician’s keen intellect does not always generate an optimal solution.  Moreover, in the doctor-patient context where the physician has the lion’s share of the power, it can be easy to avoid directly confronting the problem, or reacting in a way that weakens the doctor-patient connection, leaving the patient feeling neglected or invisible and the physician feeling badly about the way he or she treated the patient. This is where mindfulness comes in.   

Application of Mindfulness

When the patient does not act the way you would like them to, resistance surfaces.  It is a natural tension between the way things are and the way you would like them to be.  If only everyone would understand your good intentions, appreciate the stress you’re under, and be patient with you as you do your job.  But they don’t.  One of the key insights of mindfulness practices is of the benefits that flow when we recognize and approach resistance.  This seemingly counterintuitive invitation asks you to turn into the discomfort, as opposed to turning away from it, or trying to eliminate it.  In the context of the difficult patient, it means taking a few moments – either during the interaction or afterward – and deliberately turning inward to observe thoughts, feelings, and bodily sensations that are arising out of the tension.

Mindfulness Exercise

The mind is quick to jump to judgment. When a patient says or does something that agitates you, a natural reaction is to defend against the agitation. This happens in an instant and can take the form of defending your position, trying to change a patient’s mind, or distancing yourself from the patient. It can also surface at a later time when you displace some of the lingering agitation onto someone else.

While it is certainly the case that you are charged with responding to the patient’s expressed needs, often when caught in the moment of agitation, quick reactions are overreactions, unnecessary or poorly executed. Mindfulness offers the great insight that whenever we find ourselves agitated, there is something to be learned.  And through that learning, there is relief to be found.  As such, we can learn a great deal about ourselves during social interactions, and indeed, it is often said that the people we find most challenging are our greatest teachers. 

This insight forms the basis for this exercise.  While many mindfulness exercises and practices take place when one is in a quiet setting, removed from the rigmarole of everyday life –this exercise is intended to be practiced in the heat of the moment.  As such, it can be especially challenging because there is more going on that can agitate and distract. At the same time, it is during these challenging moments that some of the greatest insights and benefits may be realized.

This exercise is one that you can practice in the span of a few seconds while interacting with a patient.  Because it is short, you will find that doing so need not detract from your ability to pay attention, listen to the patient, or communicate clearly.  In fact, when practiced regularly, and indeed it can be practiced with all patients – you may find that it not only improves your mood and demeanor, but enhances your ability to pay attention, listen deeply, and communicate effectively.

Because this exercise is intended to be practiced as a part of your day, and, strictly speaking, is not intended as a guided exercise, I will first describe it to you.  Then, I will guide you through it, as we simulate an interaction with a patient.

The exercise consists of four short phrases you will want to memorize, and I suggest you write them down.  After reciting them a handful of times, you should have no problem committing them to memory.

These four phrases are:

May you be safe.

May you be happy.

May you be healthy.

May you live with ease of heart.

These four simple lines form the foundation of a longstanding mindfulness practice known Lovingkindness or Metta, and both a millennia of personal accounts as well as more modern scientific research is finding its recitation to be strong metta-sin.

As an exercise – or, of you prefer, a “private practice” -- it is regarded as a way of enhancing feelings of empathy and compassion. It enlivens a connective fiber joining us with others. Richie Davidson, a neuroscientist at University of Madison Wisconsin has peered into the interior of the brains of longtime practitioners who have immersed themselves in practicing what is known as non-referential compassion, where such regard is felt for all beings.  He reports off-the-charts findings of leftward shifts of cortical brain activity that has been associated with feelings of happiness and engagement, and also of spikes in gamma waves, the high-oscillating brain activity that has been associated with neural integration.  While the few moments you may practice this exercise are a far cry from the countless hours spent by the adepts in Davidson’s lab, I believe you’ll find practicing it to make a real difference in your daily life. 

Exercise Instructions

The exercise begins with you bringing sensory awareness to you hands, sensing where they are making contact with another object – for example, a pencil or pen, a chart, your pockets, or the patient.

This quick sensory check will help anchor you more deeply in the moment.  Then, look at your patient -- in the eyes if possible – soften your gaze and silently wish for him or her the following:

May you be safe

May you be happy

May you be healthy

May you live with ease of heart.

After you silently offer your patient these four kindnesses, you remind yourself that they

are doing the best they can and simply wish not to suffer. 

You can practice this exercise when at home with a family member or with a friend.  This can serve as a powerful end in itself, but also you’ll find that when you’re with a patient, recalling it will come a little more easily.  You may also want to wish these kindnesses for yourself when things become overwhelming or stressed.

You will find that practicing this simple exercise offers surprising and positive benefits both in your personal life and in the practice of medicine.

(Click here to listen to a version of this exercise that appears on the newly released CD, Attending: A Physician’s Introduction to Mindfulness.)

*The “Patients are a Virtue” series offers mindfulness insights and exercises to physicians, using the medical context to teach traditional mindfulness practices.  Each article addresses a challenge that arises in the doctor-patient relationship, recognizing the irony that it is the patient who serves as the cue to move into a state of greater mindful awareness, benefiting both patient and physician.

Click here to read a previously published The Mindful Rx column -- The Real Heart to Heart.

Patients are a Virtue:

The Challenging Patient