Attending: Medicine, Mindfulness, and Humanity by Ronald Epstein, MD
I started reading Attending: Medicine, Mindfulness, and Humanity after completing a 16-hour training in electronic health records. The timing was coincidental but fortunate, as despair was only a checkbox away.
Author Ronald Epstein ’84—family physician, palliative care consultant, meditator, harpsichordist—has given mindfulness a great deal of thought, especially in a medical era of “demoralizing metrics that measure what can be counted and not what really counts.” Medicine and meditation, he points out, derive from the same etymologic root: “to consider, advise, reflect.” (I’m compelled to note that electronic health record has no similar derivation.)
Most of us want to recognize and address suffering: to consider, advise, and reflect. Current medical training, Epstein argues, claims an interest in all this but “largely ignores the development of these capacities.” In spite of that, empathic master clinicians roam among us, recognizable by the kind of care they give. These doctors use analytic and imaginative thinking in tandem in order to “cultivate … informed intuition” and “transform … discomfort into curiosity.”
For instance, up to a third of patient symptoms ultimately defy diagnosis (blowing the “minds” of EMR programs, which don’t permit notes to be signed without billable International Classification of Diseases codes). Curiosity trumps what Epstein calls “the tyranny of categories,” and attentiveness trumps the kind of obedient enervation that leads to burnout. He describes a chart he once read with checks in all the required boxes: smoking habits, alcohol use, risky sexual behavior. The patient was a six-month-old baby.
We know the benefits of treating haste and stress in our patients—prescribing mindfulness programs has become almost pro forma—but we remain less rigorous about treating them in ourselves. Still, possibilities exist. Along with a colleague, Epstein developed a yearlong mindful practice program for primary care physicians. Another colleague of his started a “confessions” project for anesthesiology residents: In typed, Times New Roman font, the residents anonymously submit stories of personal disasters (and, occasionally, disasters averted) and then read them aloud to one another. Instead of the traditional haze of blame, disclosure creates community. A third colleague, bowing to the inevitable, reoriented her computer so that she and her patients could view its screen together.
What does Epstein do with his own haste and stress?
“Elapsed time might be out of a doctor’s control to some degree,” he writes, “but perceived time can always be created.” Before entering each patient’s room, he pauses. His screen saver rotates through a series of poems.
He meditates, of course, and encourages what the Zen masters call “beginner’s mind” in his thinking. Sometimes, when he could be modifying billing codes, he instead walks a patient in pain to and from the reception area. They don’t suffer alone.
Beginning with his book’s title, Epstein’s point is crystal clear. But to make it even clearer, he enlists the writings of other master clinicians: a Zen roshi, Niels Bohr, Bach, John Dewey, Rumi. They are thoughtful company in times when we’ve never needed thoughtful company more.
Elissa Ely ’87 is a Massachusetts-based psychiatrist.
Image: Rick Groleau