A thoughtful colleague pointed out that over the past 50 years we have experimented with many different ways to humanize medicine. Recently, a few of our attempts have included explicitly promoting empathy,1 inculcating cultural competence,2 and offering courses on narrative medicine.3 This is not to say that any of these approaches have failed, but we are still searching—and recent evidence suggests that medicine retains powerful dehumanizing characteristics.4 The continuation of the problem might reflect the challenge that ongoing expansion of medical capabilities5 and demand poses to humane care, but it might also reflect an important omission in the humanizing initiatives—an explicit focus on self-care of practitioners’ own humanity. The increasing awareness of burnout and stress among physicians6 and how physician well-being affects patient care7 might explain the developing interest in mindfulness, one of the few self-care practices for which there is empirical evidence of benefit.8 A PubMed search of the terms mindfulness and mindful revealed the following trend: 10 articles published between 1969 and 1978; 22 articles published between 1979 and 1988; 93 articles published between 1989 and 1998; and 300 articles published between 1999 and 2008 (including 80 in 2008). In addition, we found that 16 medical schools in North America, including Harvard, Duke, and McGill, offer courses on mindfulness to medical students and health care practitioners. Our purpose here is to point out some features of mindfulness that could threaten its long-term viability in medicine, while clarifying its potential role in improving medical practice.
Mindfulness
First of all, what is mindfulness? Jon Kabat-Zinn9 at the University of Massachusetts Medical School in Worcester, drawing on his long experience and many studies, described it as the practice of moment-to-moment, open-hearted awareness, focused in the present moment. To get a sense of what is meant, recall when you were at the top of your game in an activity you enjoyed, when you lost yourself and your sense of time in listening to someone’s story, or when you were absorbed in an activity that you love. Mindful practice and meditation aim to foster this capacity to let go of our preoccupations and be fully alive and present in the moment. Put like that it is hard to argue against the value of mindfulness in medicine or any other field. So why might mindfulness become a passing fad?
Mindfulness a passing fashion?
We can think of 2 main reasons. The first relates to a radical difference between mindfulness and some of the other approaches to humanizing medicine that we as a discipline have tried. In preparing this article we read many of those 300 papers on mindfulness published in the past 10 years. We found that writing (and reading) about mindfulness can rapidly turn into a sterile scholastic exercise. The difficulty in comprehending mindfulness by reading about it arises because mindfulness, in a distinction proposed by philosopher Jacob Needleman,10 is an idea not a concept. Ideas, according to Needleman, have an experiential component that must be effectively transmitted in order to reach their full effect. Concepts, on the other hand, only need the right words to be effectively communicated. We are concerned that if mindfulness is discussed at a conceptual level, rather than practised experientially, it will become a passing fashion.
There is a second problem. Mindfulness does not appear to have a clear medical goal or purpose. Being more alive and aware sounds laudable, but will it fix a fractured hip or get you a grant? We believe that mindfulness has 2 distinct but intimately related goals that are at the heart of good medical practice: the promotion of well-being among health care workers and the facilitation of healing in patients. Healing is a complex individual process,11 and the physician’s task is further complicated because he or she has 2 divergent jobs to perform simultaneously12: curing disease and fostering healing in patients. Nevertheless, without attempting to summarize the recent literature on healing in medicine, we would point out that healing is an ancient part of the health care mandate that involves patients moving from suffering to a sense of integrity and wholeness, whether or not their disease is cured or even improving.13 Clinical experience suggests that health care practitioners facilitate healing by being open, accepting, and focused in the present moment.14 Mindfulness meditation training helps us practise this way of being so that we can be effective facilitators of healing for ourselves and our patients.
Mindful medical practice
How do you foster a practice that is aimed at improving the well-being of practitioners and the quality of the medicine that they practise? We have begun to teach this approach in the Faculty of Medicine at McGill University in Montreal, Que, where we combine training in mindfulness with communication exercises and role playing. Participants (physicians, nurses, psychologists, and other health care practitioners) practise being mindful in reality-based clinical interactions with patients and colleagues. Preliminary analyses of the pilot data from an 8-week mindfulness-based medical practice course with 27 health care professionals showed that participants had enhanced awareness of and ability to disengage from ruminative thoughts, and they reported increases in self-care practices and psychological well-being after the course.15 We realize that our experience with small numbers of volunteer health care practitioners does not prove the benefits of mindfulness. We are, however, encouraged by empirical evidence of benefit (with health care practitioners, nursing students, and medical students) shown in other centres.8 Future work needs to address whether mindfulness can be taught to all health care practitioners or only to those who volunteer. We also need to determine how the changes in those who practise mindfulness within the medical setting affect patient care and outcomes.
Even if (or when) these data become available, we are not suggesting that mindfulness should replace the teaching of empathy, cultural awareness, narrative competence, or other humanizing approaches, all of which will continue to contribute to the practice of better medicine. Nor do we wish to ignore the important structural elements of how medicine is organized that might truncate the relationship of patient and caregiver in ways that lead to demoralization and dehumanization.5 Nevertheless, rehumanization probably needs to take place within some institutional constraints,5 and mindfulness might contribute to this process by relieving the stress9 that distracts from optimal care.7 This stress relief might allow physicians to be more fully present with their patients and, at the same time, improve their own health and well-being. Or, as the Canadian Medical Association policy states, “to manage professional and personal stress to maintain their own health and well-being and to maximize their ability to provide quality health care to their patients.”6
But there is a last catch. In order to be effective, mindfulness requires regular practice.9 This requirement for regular, formal practice is what distinguishes mindfulness from other humanizing initiatives and will be both a challenge for busy health care practitioners and a part of the unique potential of mindfulness to transform the lives of those practitioners and the medicine that they practise. Is mindfulness just another medical fad? We hope not!
Footnotes
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Competing interests
None declared
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The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
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This article has been peer reviewed.
- Copyright© the College of Family Physicians of Canada
