One night during my training, long after all the other doctors had fled the hospital, I found a senior surgeon still on the wards working on a patient note. He was a surgeon with extraordinary skill, a doctor of few words whose folksy quips had become the stuff of department legend. “I’m sorry you’re still stuck here,” I said, walking up to him.
I had just reviewed the next day’s operating room schedule and knew he had a full day of cases. I began to contradict him, but he held his hand up to stop me.
“Time in the O.R.,” he said with a broad grin, “is not work; it’s play.”
For several years my peers and I relished anecdotes like this one because we believed we knew exactly what our mentor had meant. All of us had had the experience of “disappearing” into the meditative world of a procedure and re-emerging not exhausted, but refreshed. The ritual ablutions by the scrub sink washed away the bacteria clinging to our skin and the endless paperwork threatening to choke our enthusiasm. A single rhythmic cardiac monitor replaced the relentless calls of our beepers; and nothing would matter during the long operations except the patient under our knife.
We had entered “the zone.” We were focused on nothing else but our patients and that moment.
But my more recent conversations with surgical colleagues and physicians from other specialties have had a distinctly different timbre. While we continue to deal with many of the same pressures that my mentor dealt with — decreasing autonomy, increasing administrative requirements, less control over our practice environment — the demands on our attention have gone, well, viral.
Extreme multitasking has invaded the patient-doctor relationship.
Now, along with the piles of forms to fill and blinking lights of phone calls on hold, are threads of text messages, columns of e-mails and lists of electronic medical record alerts to attend to. In this ever-widening sea of distractions, all that once gave meaning to our work and allowed us to enter the zone — the operations, the diagnostic saves, the lifetime relationships — have turned quaintly insufficient.
As one surgical colleague confided, “I still like operating, but it’s not enough. There are so many hassles it’s hardly worth practicing.”
Or as another doctor said to me recently while simultaneously typing an electronic medical record note, checking e-mail and holding a phone to his ear, “It used to never bother me to put in extra time at work. But I cannot do that anymore.”
The time pressures and demands that drive this endless multitasking and loss of focus on patients have contributed to high rates of burnout among physicians. Depending on the study, anywhere from one out of every three to more than half of all doctors is suffering from burnout, with potentially devastating clinical implications. Doctors who are burned out are more likely to depersonalize their patients and treat them as objects rather than as individuals suffering from disease. They are less professional, exhibit less empathy and are more prone to making errors. And these physicians are also more likely to become depressed, commit suicide and leave a profession that is already facing severe shortages in specialties like primary care.
As with most other occupations and aspects of our lives, it is probably impossible to hold back the rising tide of demands on our attention. But within the clinics, the wards and the operating rooms, is there a way for physicians to do all their work and maintain their focus on the patient in front of them, without accelerating the rate of burnout?
It turns out that working and living in the zone, not just getting into it on occasion, may be one solution.
Last month, The Journal of the American Medical Association published the results of a study examining the effects of a year-long course for primary care physicians on mindfulness, that ability to be in the zone and present in the moment purposefully and without judgment. Seventy physicians enrolled and participated in the four components of the course — mindfulness meditation; writing sessions; discussions; and lectures on topics like managing conflict, setting boundaries and self-care.
The effects of the sessions were dramatic. The participating doctors became more mindful, less burned out and less emotionally exhausted. But two additional findings surprised the investigators. Several of the improvements persisted even after the yearlong course ended. And, those changes correlated with a significant increase in attributes that contribute to patient-centered care, such as empathy and valuing the psychosocial factors that might affect a patient’s illness experience.
I asked Dr. Michael S. Krasner, lead author of the study and an associate professor of clinical medicine at the University of Rochester, about mindfulness and its effects on physician burnout and the patient-doctor relationship.
“We all use mindfulness at some point,” Dr. Krasner said. “It’s not something that you go out and get, but it’s something you can cultivate.” Some examples of mindfulness in everyday life include nursing a baby, attending to a young child in distress or, for surgeons, being engrossed in an operation. “Mindfulness allows us to be in a whole host of situations with a sense of equanimity. We don’t get sucked into how charged an experience is but are simply having that experience.
While many physicians try to be present for their patients, “there are so many other distractions and traps that pull us away,” Dr. Krasner observed. Those distractions can make practicing mindfulness particularly difficult. “It’s one thing to sit and be comfortable with oneself. But trying to be mindful in a busy clinical practice can be really challenging.”
Over time, the persistent distractions of such a practice can lead to burnout. For many of the study participants, “they barely recognized certain experiences as either powerful or challenging before they moved to the next experience,” Dr. Krasner noted. The word “silo” came up again and again during the course, and the physicians recounted how they “kept their nose to the grindstone” and rarely reflected on their work. “It becomes easy to look at our patients as objects,” Dr. Krasner said, “rather than appreciating the meaning and joy of an experience, even if that experience is difficult. But lack of meaning goes hand in hand with ineffectiveness and a lack of well-being as a physician.”
Acquiring the ability to be mindful in the most challenging circumstances can do more than improve a physician’s well-being; it can also sharpen clinical skills. “If something goes wrong and you fail to notice,” said Dr. Krasner, “you end up going down one path in your care. But if you fully accept these challenges — not resign yourself to them but fully accept them — you can see more clearly and proceed down a path where you have a better chance of success.”
Dr. Krasner acknowledges that courses like his may not be helpful for every doctor. “There are people who aren’t going to be interested because it may seem different, even a little frightening, to get together with colleagues and be silent for a while, then talk about these things with one another.” Instead, he proposes offering physicians in the future a “menu of options” to choose from to help prevent burnout. “But I think mindfulness should be among the menu of educational interventions that are evidence-based.”
“Patients know when their doctors are or are not present,” Dr. Krasner said. “As a practitioner, I know when I’m really there for my patients and when other things are pulling me away and I’m not.” It seems fitting then that physicians, who are constantly asking their patients to be mindful — asking them to talk about how they feel — should also be able to do so themselves.
“One of the most wonderful things about practicing medicine,” Dr. Krasner said, “is that you have the opportunity to be in the middle of challenging events. Reflecting on those events while also holding them in your thoughts has to do with not only physician well-being but also patient healing.”
“If we can be mindful in the midst of those challenging circumstances,” Dr. Krasner reflected, “we can derive a greater sense of meaning from even the most demanding situations.”
Join the discussion on the Well blog, “For Doctor Burnout, Meditation and Mindfulness.”
The Guest-House
Michael S. Krasner, MD; Ronald M. Epstein, MD; Howard Beckman, MD; Anthony L. Suchman, MD, MA; Benjamin Chapman, PhD; Christopher J. Mooney, MA; Timothy E. Quill, MD
Our next formal 8-week Mindfulness-Based Stress Reduction Program will be held for health care practitioners. located at the Schofield Barracks Army Health Clinic, Honolulu, Hawaii.
