Home Journal Issues Journal Index Blog Search Contact Us Help

Volume 2, Issue 4
Winter 2006:

Inward Bound

Linda Welsh, Ed.D.

Cell 2 Soul. 2006 Winter; 2(4):a13

Based on presentation at Cell 2 Soul Conference
November 11, 2006

Healers have the power to diminish suffering by striving to understand their patients as individuals. The humane physician must be analytical, maintain perspective and cultivate self-reflection. Such physicians have developed an awareness of their own attitudes, values and biases in the context of patient care.

Today I encourage you as healers to choose once again what you chose before — re-establish touch with that mysterious thing inside you that drove you to be a doctor. How can you go about doing this?

By cultivating mindfulness.

We struggle to remain present during our interactions with patients. One of the biggest challenges we face is to be completely available and open to the patient — that human being before us who asks for our help, our expertise, our compassion. To help us return to these roots, I will explore three questions:

  1. Why cultivate mindfulness?
  2. Why strive to know who you are?
  3. How does the doctor-patient relationship evolve?

MINDFULNESS

  1. Attentive observation of the patient, ourselves, and the patient's problem.
  2. Courage to see our own weakness in a situation.
  3. Looking with a fresh and accepting eye for contradictions.
  4. Presence — undistracted attention with compassion and connection.

The patient asks: "Understand me and embrace my broader concerns." That's a tall order for the healer. The patient wants to be heard; and, despite the pressures of time, the doctor needs to listen.

What can you do in fourteen minutes with a patient? With an open heart, you can experience vulnerability — his and yours. The traumas you live with can close your heart, as can threats of malpractice and performance anxiety; if you close your heart, you put yourself at risk for increased stress and alienation.

Enter mindfulness. First, establish contact with yourself — stop, breathe, ask "How am I?" Then establish eye contact with the patient. Listen to him rather than concentrating on how to manage his illness. Although we can not save each patient, we may not abandon them. We might shrink the tumor, but we also want to return the person to wholeness. Learn to use the patient's story like Judo — as the patient's own energy contributes to his healing, his stories become antibodies against his pain. Life has meaning only through struggle. Triumph or defeat is in the hand of God, so let us celebrate the struggle. Busy-ness makes us numb; mindfulness brings us out of isolation and back to the world.

A man is walking through the desert with a towel around his neck, a surfboard under his arm and zinc oxide on his nose. A car pulls up, and the driver asks, "Are you okay?" The man answers, "Sure; I'm headed for the ocean." "But," the driver says, "the ocean is 500 miles away." "Yes, I know," says the man, "but look at this beautiful beach!" Those who get it right notice the details: they find richness and beauty and help their patients find it as well.

While driving to Pittsburgh, anxious to see my children, anticipating the four-and-a-half hour trip with dread, I realized that, if I would keep my eyes and mind focused on the few feet of roadway ahead of me, I would make it through the long journey, safely and intact. Medical students, overwhelmed by long years of training ahead of them, must learn to focus on the immediate tasks at hand to get through the process.

Respecting the patient means listening without interruption. Recent surveys show that on average a doctor interrupts the patient's narrative after only 32 seconds. How many of us tune out the narrative and only focus on the symptoms so we can diagnose, prescribe or test? We need to retrain ourselves to hear every word.

Often the doctor knows how to treat the illness, but not the patient. The doctor must throw away his judgmental baggage to see the whole patient. Everything in your life is grist for the mill in your relationship with your patients — your own pain, losses and love. Watch out for your rational mind — that mind that has been attended to vehemently all through school. Calm down, get quiet; breathe and listen. Train yourself to hear your small inner voice and that of your patient.

Mindfulness offers recognition. It's easy to look at a child or a kitten with tenderness. The conscious mind blocks this recognition — this conscious mind that we've learned to use effectively as physicians, to get our taxes done, fill our cars with gas, to dictate medical records. It's hard to look at yourself with the same sense of awe with which you regard an infant, but practice helps. Once you look at yourself with friendly compassion, you see others with respect. You don't drop kick a puppy every time it piddles on the floor. You just keep bringing it back to the newspaper. So keep gently bringing back your mind to what is there to be seen with a kind of reverence, a sense of awe.

Share with your students that awe you had when you recognized the beauty of life and the sanctity of death and the opportunity to glimpse into the human body, just as a child points out a scruffy dog or red sky.

KNOW WHO YOU ARE

In an old Mel Brooks routine the psychiatrist tells his patient: "Listen to your broccoli, and your broccoli will tell you how to eat it." Things get lost in translation. You need to translate your medical school dreams into the day-to-day practice of medicine.

Before we grapple with what it means to be a doctor or what it means to be a patient, let's talk about what it means to be human. Mindfulness puts us in touch with our humanity. You must know who you are before you can hope to know your children, your loved ones, or your patients. I am a mother, a widow, a cancer survivor, a teacher and — my greatest aspiration — a healer to my patients, children, friends and self. I also have to find out who they are. Sometimes I find the humanity in them. How thrilled I am when my kids show me who they are; how honored when my friends let me see both their good and bad sides; how respected when my students show me their mistakes; and how touched when my patients reveal their wounds.

Our society values performance — the old lie that says when we perform sufficiently, we are okay. So we work harder; we pretend to know more than we do. We earn more money and appear to be okay. Are we then comfortable in our own skin? A terminally ill woman said to her daughter: "All my life I have felt something's wrong with me — what a waste!" How must patients feel when they bring that "something-is-wrong-with-me" agenda to us?

Dan is a friend of mine: a father, a husband, and a quadriplegic. In the hospital bed after his life-altering accident, wrestling with his demons, Dan lost the fundamental things that he thought made him human. He overhears his physician ask about the "quad in 301." Yesterday, he was Dan — a doctor, a daddy; today he's the quad in 301. Enter the nurse who asks Dan for help, a chance to share her problems with him after her shift. Enter the resident who sits by Dan's bed and listens to his story with eye contact. Enter compassion, restoration of dignity and identity. Why is compassion so restorative? Because, as Dan says, the hunger to be known is even greater than the hunger to be loved. We possess a fundamental need to be a part of a larger community, accepted and understood. Often I can not change the horror in my patients' lives, but I can offer to know and understand them. My husband suffered with end-stage renal disease for 15 years, had two transplants, and died 10 years ago. He often said he hated being out of the game more than anything. Dan was hit by the tire that went through his windshield; I was hit by cancer; most of us in this room have been hit by something.

What opens your heart is generosity toward yourself; what closes it is shame, alienation, insecurity and pretense — often those very elements found in medical school culture. That culture is dangerous and inhumane. What does it teach us? If there is no time to show compassion to patients, your ability to empathize will shrivel up. There are two vulnerable people in the hospital room — one in the bed in the gown and one in the chair in the white coat. Schweitzer said: "Inside every patient there's a doctor," and Gottlieb said: "Inside every doctor there is a patient. And, if the four of us can come together, even for a moment, then genuine healing is possible."

When you know who you are, you can cure better, parent better, couple better. Patients can offer you the opportunity to do this. Have you ever been in a hurry to get to work in the morning and had a two-year-old to drop off at daycare along the way? The child will stop, pick up a leaf, notice the ant carrying a crumb. And yet, the gifts she offers through her eyes are immeasurable.

A doctor's biggest challenge is to focus on one patient at a time. This is where mindfulness brings you into focus. It's through the patient that you receive self-esteem, not through your MD degree. His narrative can offer you solace, illumination and direction. Mindfulness slows you down, allows you to focus, opens your heart to the details. Then you can see the big picture and be awed by it. Doctoring involves helping people to find some meaning in their suffering. But you can't do that if you're not respectful. If you look at people and see them as just a diagnosis — "the quad in 301" — you're going to get it wrong. Your job is to see people as they really are. To do this you have to know who you are in the most compassionate sense — a simple concept, but not easy to do. Why know yourself? Because sometimes you will run into a patient or family member, and regardless of age, sex, or socioeconomic level, a place inside of you will know and will resonate with recognition; and therein will come the relationship. If you don't have compassion first, you can't have recognition.

HOW DOES THE DOCTOR- PATIENT RELATIONSHIP EVOLVE?

Hospitals are installing national computer systems to avoid human error in transcriptions, but they won't be used unless doctors are taught one-by-one how to use them. Similarly, mindfulness will be a waste of human resources unless doctors are taught to recognize their own humanity one-by-one, through experience and narrative, not by didactic lectures.

An 80-year-old woman in my practice suffered enormous pain when a transcription error denied her pain medication for the day. When she asked the nurse for relief, she was chastised and told that the orders had to be followed. The family, recognizing her distress, climbed the chain of command to get assistance, but to no avail. She suffered needlessly. At Johns Hopkins a rapid response team has been set up solely for the purpose of listening to family members, those who are often the first to recognize trouble.

In a poem by Rumi, God's joy moves from unmarked box to unmarked box as diagnosis moves from cell to cell, as rain water tickles down into flower beds, as roses push up from the ground — it hides within these until one day it cracks them open. There's ecstasy in paying attention. Look closely, you will notice. Are the ripples on the water generated by silver salmon below different from those caused by a breeze? Every patient feels different because they are different. A Tibetan nun sings a mantra of compassion over and over and finds difference in each chant. That kind of attention is a prize — a powerful antidote for the rational mind.

A favorite writer tells of her tonsillectomy. The pain is intense for a week after surgery. She calls her physician requesting more painkillers. The nurse advises: "Buy gum, chew it vigorously. When we have a wound in our body, the muscles around it cramp to protect it from further violation or infection. These muscles must relax. The first chew brings ripping hurt, but then the pain eases." The same thing happens with our psychic muscles. They cramp around our pain — wounds from childhood, disappointments in our adult lives, humiliation in medical school. We strive toward perfection to keep from getting hurt again, but the wound has no chance to heal. This self-demand limits us from life, people, loved ones and patients. What to do? Keep ourselves compassionate company.

What do fourth year medical students fear most? They fear losing empathetic capacity — losing their core professional and personal identity. They fear losing joy in patient care due to pressures in training and practice. What if we could sustain and develop the gratitude and wonder they looked forward to in medicine? This is not simply patient-centered medicine: it's relationship-centered medicine. Empathy, curiosity and openness bring self-awareness. This is more than teaching humanism and ethics. The next step is to experience and understand the doctor-patient relationship through the emotional work of self-awareness and mindful practice — both are healing and attainable. Notice the mutuality. The patient has gifts — be open to receiving them.

Relationship-centered care orients us to the importance of self-awareness, which enriches us beyond our clinical practice. I ask my students: what did you receive from your patient, and how did you take it into your life? A dying patient once told my friend, "If you teach me how to live, I will teach you how to die." We are not empty-handed when we walk into the room. We carry our culture, beliefs, conscious and unconscious assumptions, needs, emotions, expectations, skills, and most of all, level of presence, undistracted in that moment.

Where will this take medicine? Look at Johns Hopkins. They implemented the rapid response team to address family concerns in the wake of the unnecessary death of a small child after the family pleaded for attention as they saw her slipping away. Look at the medical college of Georgia. Families are now invited into the OR and the ICU and have caught critical medical errors through the knowledge of their children's condition. Hospital rooms have been designed to allow both parents to sleep with their child, and they no longer hear the echoes of "let me take him home to die." In the adult ward, the wife of a stroke patient moves in and sleeps with her husband — she can hear and walk and talk and offer a second pair of eyes. Patients are designing rooms with color schemes, children are on advisory boards, and patients and their families are interviewing staff for the neurosurgical center. Are providers threatened by this family-centered care? Not at the Medical College of Georgia — it's a lifesaver. 1. They have reduced medical errors significantly. 2. They have reduced mortality rates significantly. 3. They have reduced the turnover of nurses and support staff, who now have a voice. 4. They have reduced patient dissatisfaction. They are now rated as one of the leading hospitals in the country. The task will be to pull the disciplines together, include the families and patients, and make this great change away from the vertical style of medical decision making.

Henry James was asked by his nephew to name the three most important things in life. He responded: "To be kind; to be kind; to be kind." Let those three words guide you as you open the door to each patient. To be mindful — to be nowhere else but in that room with that human asking for your help — is to be kind, to be kind, to be kind.

Return To Top