Michael Krasner M.D. on “Physician Resilience and Mindfulness”

More and more I have come to admire resilience.
Not the simple resistance of a pillow, whose foam returns over and
over to the same shape, but the sinuous tenacity of a tree: finding the
light newly blocked on one side,
it turns in another.
A blind intelligence, true.
But out of such persistence arose turtles, rivers, mitochondria, figs—
all this resinous, unretractable earth.

Optimism  by Jane Hirshfield, from Given Sugar, Given Salt. © Harper Collins, 2002.

A malpractice action is among the most stressful challenges that a physician can face, personally and professionally. One analogy is being asked to weave a parachute only moments before being pushed out of the airplane door. Unprepared and unexpected, the wind created in that fall hits one like a brick wall, distorting an entire sense of self, self-image, self-worth, and self-reliance. And yet, we humans are alive in large part as a result of our capacity to not only “handle” such life-threatening stresses, but to grow, adapt, and even find meaning from such experiences. It is in our DNA, and this capacity is also responsible, the poem tells us, for the diversity found in the natural world itself.

Even so, there exists an inherent ability within us to enhance this capacity for resilience. By cultivating this capacity we can begin to weave the parachute long before it may ever be necessary to jump, so that if we do jump or are pushed out that door, it may hold us and soften our fall. Yes, and even allow us to look at the landscape below, and in part direct the landing itself. Paradoxically, this capacity requires us to not turn away, dodge, or avoid adversity, but to move close in, even if it is painful, to experience how things really are, in this moment, and by doing so, influence in very real ways the unfolding of the moments to come.

Mindfulness is this capacity, and has been defined operationally as the awareness that arises by paying attention in a very specific way: on purpose, in the present moment, and without judgment. We could call it awareness itself- an awareness that can hold judgments, likes and dislikes, pleasant and unpleasant thoughts, feelings, and sensations, without being caught by the constant flow of the content of these phenomena, especially the thought stream. This thought stream during these most stressful experiences often contains more than its share of self-directed thoughts, usually of a negative and critical nature, that further impede our ability to think clearly, and act wisely. What are some of these thoughts? Not being good enough, not being smart enough, not being worthy enough are only a few. They also include an ample dose of shame and humiliation. With mindfulness, these thoughts can be held in awareness as simply thoughts, not necessarily inherently accurate (and quite often just the opposite), and just held in this way, in awareness, without being “attached” to them, but with compassion. Part of the challenge therefore is developing the capacity and the courage (openheartedness- root of courage is the Norman French word couer- heart) to move in close enough to recognize and accept these thoughts as merely being part of our experience, but only a part.

Mindfulness training with physicians has been demonstrated to significantly improve burnout, physical and mental well-being, and enhance patient-centered qualities of empathy and psychosocial orientation (JAMA 2009; 302(12): 1284-93). There is a growing body of research that connects burnout with patient safety, quality of care, and quality of caring. Mindful practice has the capacity, through its salutary effects on burnout and well-being, to enhance resilience, and improve both quality of care including patient safety, and quality of caring, compassion and empathy. Practicing medicine with this kind of non-judgmental awareness that allows for greater discernment and wisdom may not only be a preventive practice for potential malpractice actions, but may also preserve a sense of self-worth, self-compassion, and clear thoughts and actions when faced with the challenges of a medical liability case. Resilience is a capacity that can be grown, and mindful practice is one way in which physicians can build resilience, improve quality of care and caring, and perhaps develop deeper meaning and connection with their work and with the patients they serve.

Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.

Victor Frankl

For information about Mindful Practice, please visit www.mindfulpractice.urmc.edu.

About the Author:

Mick Krasner, MD, FACP, is a Professor of Clinical Medicine at the University of Rochester School of Medicine and Dentistry. A teacher of Mindfulness-Based Stress Reduction, Dr. Krasner is very interested in the connection between health care professional well-being and the effectiveness of the healing relationship. He is engaged in a variety of research projects including the investigation of the effects of mindfulness practices on the immune system in the elderly and on medical student stress and well-being as well as the effects on health care professionals' well-being.

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