Attending: Medicine, Mindfulness, and Humanity
I read this deeply informed and compassionate book imagining myself to be a patient, or family member, not as a doctor immersed in healthcare for so many years. I wondered what it would be like to be cared for by the type of doctor the author aspires his students and colleagues (doctors and nurses) to be.
There is a Yiddish word to describe the (patient) experience this book seeks to achieve: a mitzvah, a beneficent and charitable act performed by another on your behalf—and it applies to all of life, not just in medicine. While I know that mitzvahs happen a lot in doctors' offices, clinics, and hospitals it is far from common, less so today in the U.S. world of corporate, insurance-driven, and litigious medicine. Can humanity be better and more consistently inserted into the privileged encounter between a patient and a caregiver?
Dr. Ronald Epstein is Professor of Family Medicine, Psychiatry and Oncology at the University of Rochester Medical Center in upstate New York, and board-certified in Family Medicine and Hospice and Palliative Medicine. He believes we can raise the level of caring (and competence) in medical care, and this book is his exegesis as to how that can (and needs to be) done. As a patient or family member this is very welcome.
A year short of this millennium he published a seminal and groundbreaking article in The Journal of The American Medical Association (JAMA). Titled "Mindful Practice," Dr. Epstein offers a view of what it takes to be a good doctor. Good training and lots of experience are necessary but not sufficient. Doctors, he proposed, need an "inner operating system"—an awareness of their own minds and hearts if they are going to be treasured by their patients, likely to make fewer errors, and far less apt to burnout from what can be overly repetitive and emotionally draining clinical care, the ". . . erosion of the soul."
This is his first book, and takes its title from the wonderful denotation of what it means to be the attending physician, the senior doctor responsible for a patient's care. Dr. Epstein recognizes the hallowed role an attending assumes and tells us that it is a "moral imperative" to do right by our patients. And he shows why and how, not by exhortation but by teaching the reader about social, cognitive and neurosciences, psychology, Zen and other eastern meditative practices, poetry, and good old common sense.
Take, for example, not seeing something a patient exhibits, clearly presented or not. He quotes the legendary (Canadian born) British physician, Sir William Osler, who remarked "We miss more by not seeing than by not knowing." On this side of the Atlantic, also of the same early 20th century era, we had Dr. Francis W. Peabody lecture to Harvard medical students “For the secret of the care of the patient is in caring for the patient.” Dr. Epstein tracks closely to both their therapeutic footsteps.
Doctors, all of us in fact, are prone to miss essential information because of so-called "fast thinking," the immediate, automatic thoughts that our ingrained neural circuits generate. As useful as is fast thinking, it keeps the brain from recognizing the atypical and the unexpected. To "see" the 20% of complexity or exceptional that can automatically elude our minds we need "slow thinking," the capacity to be more deliberative—a trainable skill.
By way of further illustration from Attending, take, for example, compassion. Dr. Epstein stresses this is different from empathy (a skill that most medical schools aim to instruct). He believes that empathy is typically "cool and detached . . ." in which the patient's feeling state is observed, even fed back in the clinical moment. But it lacks actual resonance with the patient's distress. Compassion means the caregiver also feels the pain.
Paradoxically, instead of emotionally draining the doctor, feeling the pain (within limits) can nourish the healer: It releases endogenous opioids (natural substances that have us feel good) as well as dopamine, the reward neurotransmitter, and oxytocin, the caring and affiliative hormone. Not only sounds good for the patient, it sounds really good for an enervated, irritated, and rushed doctor.
Take, for example, "interpersonal mindfulness," a state of shared mind instead of going through the motions. Or being present instead of distant or withdrawn. Or eclipsing cynicism and hopelessness with a mental battery of positive thinking. And welcoming change (also within limits!) rather than dreading and bucking it. All these concepts are amply explained, especially through his continuous provision of clinical, contemplative practice (e.g., meditation and mindfulness), collegial and personal stories. You can feel in his writing what he means to happen in his and every other doctor's office.
What is also so heartening about Dr. Epstein's proposal to humanize (or is it to re-humanize?) medicine is that the tools needed are not innate: They can be taught. Attention can be improved by daily meditation in a week or more. Active listening is readily learned. Compassion is an evanescent and "fragile" state readily pirated away by authority (recall Stanley Milgram's experiments where students were led to behave cruelly) yet Dr. Epstein is sanguine here too, offering the "ingredients" of compassion and how they can be acquired.
If the U.S. military has already adopted meditation practices to foster stress resilience why not medicine? he asks. Studies demonstrate that recovery from stress is hastened and heart rate, blood pressure and stress hormones (like cortisol) more rapidly return to normal. In turn, that permits emotional intelligence to bloom in both military and medical personnel.
Admirable as well is Dr. Epstein's chapter titled "Imagining a Mindful Health Care System." Organizational mindfulness is spreading through businesses to improve their performance and reduce stress among employees (since that produces absenteeism, mental and substance use disorders, and expensive unemployment and disability payments). Why not American medicine? he gently challenges. In medicine, mindfulness can improve quality and safety as well as make for more grateful patients; it aids doctors in lasting longer in their profession because they have rediscovered the energizing power of meaning and purpose. He notes a "cord of three strands—individual, collective, and institutional {mindfulness and humanity} is not quickly broken." As a patient or family member, Dr. Epstein’s prescription for change could fundamentally alter and improve my experience of American medicine from what too often it is today.
The book would be better if Dr. Epstein refrained from his profusion of chapter notes. Their presence either pulls the reader from the narrative or results in their generally being ignored. A book for an educated, lay audience does not need them, and many a doctor reader would welcome their substitution, from time to time, with a few more sentences on the same page with relevant material.
I had to ask myself at the end of this cogent book whether I was meeting his standards and creating the conditions for them in the large mental health care system where I am the Chief Medical Officer. I thank Dr. Epstein for pointing the way, with great clarity and kindness, for me to do better.