No doubt about it: Doctors are stressed out. Surveys show that physician burnout is on the rise, with the percentage of physicians in the United States reporting symptoms of burnout rising from 45 percent in 2011 to 54 percent in 2014.
If you ask doctors why they’re so stressed, many mention heavy patient loads, endless patient charts to fill out, the looming possibility of litigation, and back-and-forth communication with health insurance companies. These constant distracters can lead to the erosion of patient-clinician interactions, miscommunication, clinical errors, or worse.
Now, two new books—Attending: Medicine, Mindfulness, and Humanity, by Dr. Ronald Epstein, and What Patients Say, What Doctors Hear, by Dr. Danielle Ofri—candidly unpack the factors that contribute to physician-patient communication breakdowns and medical errors. They reveal the challenges that doctors and patients face in communicating and provide optimistic insights on how to improve health care.
Four mindfulness skills for doctors
Epstein, a professor of medicine at Rochester University and a practicing physician, is a leader of the mindfulness movement in medicine. Drawing from his own groundbreaking paper, he explains how mindful self-reflection and self-regulation are key to masterful clinical care, enabling physicians to listen attentively, make good judgments, and act compassionately.
“Medicine and meditation, etymologically, come from the same root: to consider, advise, reflect, to take appropriate measures,” he writes, suggesting that the two are closely related. This explains why doctors should consider using mindfulness in their medical practice.
Using anecdotes, Zen Buddhist stories, and thoroughly cited research, Epstein explores how the four mindfulness skills of attention, curiosity, beginner’s mind, and presence mirror those physicians need to provide quality care:
- Attention. Because of everything they have on their minds, physicians may not be fully attentive in the exam room. Doctors often rely on automatic, fast thinking when interacting with patients. But practicing mindful attention can help them slow down enough to use deliberate, more conscious thinking when patients present signs of something serious.
- Curiosity. Developing a sense of curiosity can inspire physicians to ask more questions and dig deeper with patients, as well as foster empathy and understanding for patients’ unique needs, values, and circumstances. It also helps doctors recognize when something is off with a patient so they can then “tune in.” Epstein notes that while genetics partly contributes to curiosity, supportive environments can also foster it—particularly those that allow physicians to feel comfortable freely sharing their doubts, discoveries, and mishaps.
- Beginner’s mind. Inspired by a book written by Shunryu Suzuki, Epstein advises physicians to “hold expertise lightly” and be aware that their understanding of a patient’s case, while based on expertise, may be provisional and incomplete. He warns that self-confidence can get in the way of good care, if physicians don’t recognize that there are things they may not fully know. Luckily, beginner’s mind can be taught: At least one randomized controlled study found that practicing mindfulness meditation helped people to not be “blinded by experience” from novel or obvious solutions to problems.
- Presence. Listening deeply, without judgment, interruption, or preconceptions, can be tough for physicians who have a myriad of other things to worry about. However, a physician’s presence can help a patient feel understood and acknowledged, and decrease chances of miscommunication and error. To be present, one must “quiet the mind”—a skill that can be honed through reflective, contemplative practices.
Why doctors should train in mindfulness
Epstein makes a case that almost any physician can practice mindfulness to improve patient care, and the science supports that contention.
In a study of primary care physicians, Epstein found that a year-long mindfulness practice program increased their resilience (improved mood, lower burnout), quality of care (safer and more timely, accessible, effective, and patient-centered), and patient interactions (more empathetic, compassionate, and responsive). Patients of clinicians practicing mindfulness are more likely to disclose personal (and potentially critical) information and comply better with treatments.
Epstein highlights other important aspects of patient care that can benefit from mindfulness. Making good decisions involves becoming aware of one’s biases and engaging strategies to correct them, and mindfulness has been shown to support that. Also, being more mindful can help physicians be attuned to the suffering of their patients without becoming overwhelmed. While Epstein acknowledges that being with suffering can be draining, studies have found that training in compassion, self-compassion, or loving-kindness meditation can mitigate physicians’ emotional distress and increase their resilience.
How can mindfulness in medicine be sustained? It starts in medical school, where compassion and listening skills could be taught and emphasized as much as anatomy or biochemistry.
Support from colleagues and medical institutions is also important, writes Epstein. Doctors are held to high standards, and they are not inclined to share their mistakes with colleagues. However, sharing stories with each other can be very therapeutic, as can being in a place that encourages doctors to admit to difficulties they are experiencing.
Epstein cites the success of a “confessions” project led by colleague Dr. Suzanne Karan, to encourage doctors to share medical errors. Intended to identify causes and prevent future errors, the program also addresses clinicians’ psychological and educational needs. Initiatives like this can help the culture of medicine become more nurturing and supportive of its healers.
How physician-patient communication breaks down
Ofri, a professor of medicine at New York University and hospital internist, shares many of Epstein’s concerns about physician-patient interactions in her book What Patients Say, What Doctors Hear. But while Epstein focuses on the benefits of mindfulness, Ofri hones in on listening and communication skills as powerful tools for exceptional patient care.
There are many barriers to effective communication between physicians and patients, according to Ofri. Doctors may be distracted by millions of other things as they try to listen to patients. Sometimes, patients don’t know their true underlying problem or what to reveal to the doctor. Meaning and intent can get lost.
Although the healing professions seek to be nonjudgmental, Ofri points out that doctors’ implicit biases can prevent them from giving equal care to all patients. Studies have shown that doctors show less respect to patients with obesity, for example. African-American patients tend to get less patient-centered care, experience more verbal dominance from doctors, and receive fewer and less-aggressive treatments. (However, the flip side of implicit bias also exists; patients tend to feel more comfortable seeing doctors who are similar in race.)
The medicine of good communication
Ofri suggests that to improve communication, doctors should spend more time listening effectively during the appointment. On average, doctors interrupt patients within 12 seconds of them first speaking during primary care visits and throughout the appointment—often, before they have finished explaining an issue. One study shows that inattentive listening can distract the speaker from telling their own stories effectively, suggesting that speakers and listeners have a shared responsibility.
Doctors can help patients communicate their problems better and feel more understood by acknowledging what they’re saying and encouraging them to continue, and even removing physical barriers between the two of them (i.e., not talking from behind a computer).
Ofri also advises that doctors ask their patients, “Is there anything else?” She acknowledges that this can be daunting for doctors because it opens a Pandora’s box of dialogue that may cut into other patients’ appointment times.
However, understanding the patient as much as possible from the start can save a lot of time in subsequent visits. For example, Ofri once had a patient with a long history of trouble adhering to his numerous medication protocols (despite repeated efforts to explain them to him). It took a year of visits with her for the patient to reveal that he was illiterate and couldn’t read the bottles. She suggests that if she’d taken more care initially, she could have discovered this sooner.
Clear communication from doctors may have a healing effect. Studies on pain perception find that, similar to the placebo effect, thoughtfully walking a patient through a procedure that is being administered, or one that will occur in the future, can make them less anxious and more optimistic, leading to less pain.
Better communication can also lead to less litigation. Whereas patients may feel that doctors are indifferent toward medical errors, in reality those errors haunt doctors for years. Better understanding between parties—and a doctor’s willingness to admit to errors, show concern, and apologize—can help prevent patients from seeking retribution through lawsuits.
Amid the pressure and fast pace of medicine, doctors and other health care providers can still learn to slow down and cultivate better listening and understanding. Doing so gives patients a chance to communicate more effectively, which saves more time and more lives in the long run. Both of these books can help doctors and patients—and, really, anyone in any professional or personal partnership—to work together toward better communication and connection.