Mindfulness,Inclusion,and Compassion in Austere Medicine

Introduction

The Wilderness Medical Society (WMS) recognizes the importance and benefits of a diverse and inclusive society. We are committed to fostering an environment of acceptance that is equitable to all. We recognize the rights of all individuals to mutual respect without bias based on differences of any kind. We value our individual and group differences. Our commitment to inclusiveness will be evident in our policies and procedures, as part of our strategic plan, and within our organizational goals. ¹

The following article is derived from discussions and consensus among members of the WMS JEDI (Justice, Equity, Diversity, and Inclusion) committee, which is composed of wilderness medical professionals who are specifically interested in developing a more inclusive community. In this article, we discuss the importance of inclusion. We define bias and its impact on the practice of austere medicine, specifically how it impacts teams as well as individuals. Additionally, we discuss how mindfulness and compassion can contribute to improvement in inclusion, to the benefit of patients, medical practitioners, and their teams.

Though it is written from the perspective of austere and prehospital medicine, this article can also serve as a framework for ongoing conversations around antiracism, justice, equity, diversity, and inclusion in the context of medical practice as a whole.

Importance of Inclusion

Inclusion may be defined as the act of creating a culture of belongingness, in which all participants of a group feel comfortable contributing, have equitable access to opportunities and resources, and know that their participation is valued. The WMS recognizes that advancement in any field is optimized when a diversity of perspectives is represented.^2–4 Those who practice medicine with people from different backgrounds feel more comfortable asking questions and learning about differences.^5–7 For our patients, diversity can also help them feel safe and represented.^8,9 Additionally, as we become more aware of the so-called “nature gap,” in which people of color and differently abled persons have less access to outdoor recreation, it is important that we contribute to inclusive solutions for equitable access to the health benefits of nature.^10–13 This is not only relevant to healthcare disparities but also to growing a diverse membership for wilderness teams.

Bias and Its Impact on the Practice of Medicine

Unconscious bias, also known as implicit bias, is a term that describes “the mental shortcuts that lead to snap judgments . . . about people's talents or character.” ¹⁴ Structural bias describes how unconscious bias contributes to the ways institutions and policies develop to benefit some groups more than others. ¹⁵ The WMS acknowledges that bias—explicit, implicit, and structural—can limit access to, and contributions from, underrepresented groups in wilderness medicine. These limitations directly undermine our potential as an academic society and have critical impacts on how wilderness medical knowledge is shared and implemented. ¹⁶ According to Harvard Business Review, the most resilient teams trust one another and feel safe. ¹⁷ Also known as psychological safety, this version of resilience occurs when teammates feel they can take interpersonal risks, such as making unusual or creative suggestions, without fear of being shut down or ridiculed. Failing to demonstrate inclusivity can result in communication breakdown, frustration, lack of trust, loss of members, and poor outcomes. ¹⁷

It is well documented that healthcare outcomes differ for racially and ethnically diverse populations. These disparities have myriad contributing factors, but emerging evidence suggests that implicit bias among providers can contribute to differences in clinical decision-making and, thereby, outcomes. ¹⁸ Patients also might be less likely to adhere to the plan or give a complete history if they feel they are not respected or heard by the provider treating them.^8,9 Individual healthcare workers can also be impacted by the biases of others, resulting in difficulty feeling valued or heard.

First Steps for Improvement: Organizations

At the organizational level, groups can evaluate biases and build internal awareness by tracking census demographics among leadership and participants and also by monitoring patterns in how awards or promotions are offered. Examples of how the WMS can become more inclusive are illustrated in the articles by Schlein et al ¹⁹ and Keyes et al ²⁰ in Wilderness & Environmental Medicine. There remains a lower percentage of women than men (about 30%) in the general membership of the WMS, which is also reflected in the gender split of conference presenters, award recipients, and those in leadership roles. ¹⁹ There is a significantly lower percentage of female authors, reviewers, and editorial board members in WEM, and while it has gradually increased between 2010 and 2019, it remains a concerning disparity. ²⁰ Binder et al announced the expansion and diversification of the WEM editorial board and reviewer panel in acknowledgment of the need for change. ²¹

Improvement: Individuals and Their Teams

Teams can build openness and inclusion by supporting their members to build awareness, by inviting diverse members to lead and share ideas and experiences, and by intentionally recruiting those of diverse backgrounds. We suggest making a habit of using inclusive language as a team. This might mean practicing introductions using our pronouns or relinquishing language and jokes that could be harmful to marginalized persons. These changes might seem small, but they make a big difference for those who are affected by them.

Though awareness on its own might not change behaviors, it is essential in order to move toward tangible change. ¹⁴ An excellent place to start is the Harvard Implicit Associations Test, which is easily found online and takes a few minutes per section. ²² Once the process of building awareness is underway, individuals can take steps to manage their bias. For example, they can acknowledge a biased thought and then decide if they actually believe it. They can also seek counterpoints to their biases, bringing nuance and disrupting preexisting mental shortcuts. This process will hopefully give way to changing behaviors, which could be as simple as making space for a previously marginalized teammate to speak. ¹⁴

Importance of Reflection, Self-Care, and Mindfulness in the Field

We, the authors, argue that mindfulness, in combination with compassion for self and others, is a skillful way to maintain awareness of and manage one's implicit biases.^23,24 Mindfulness can be defined as a state of being conscious or aware of the present moment. A mindfulness practice may or may not include modalities such as meditation or breathwork. Studies suggest that a stressed person is more likely to rely on biases unless otherwise trained. ²⁵ Other studies have shown that mindfulness practice can help with stress.^26,27 This goes beyond the (valid) survival axiom of the positive mental attitude and asks us to practice creating space for the spontaneous environments in which we work. Because psychologically safe and resilient teams perform better together, we recommend a mindfulness practice alongside inclusivity training. This will reinforce attention to language and the compassionate treatment of others.^17,18,28

Box Breathing: A Simple Practice

Box breathing, also referred to as combat breathing, is a very simple self-care practice: inhale for 4 s, hold for 4 s, exhale for 4 s, hold for 4 s, repeat. Because of its simplicity, it can be used before, during, or after an event. ²⁹ A recent scientific study supports “brief structured respiration practices,” such as box breathing, to “enhance mood and reduce physiological arousal.” ³⁰ Stress activates the autonomic nervous system, which is responsible for arousal states such as fight, flight, or freeze. Elevated resting heart rate can persist after an acute stress event. ³¹ Breathing techniques can activate the parasympathetic nervous system, which is responsible for “rest and digest” mode, and can help to give the “all clear” signal to the brain. This return to the present moment (also known as mindfulness) can contribute to an improved sense of well-being and help us connect more readily with our teammates, our patients, and our families. ²⁹

The Mindful Rescuer

As discussed previously, certain practices can be implemented to be more inclusive as teammates and rescuers. We believe the addition of a mindfulness practice that centers on the breath is a helpful device to augment these practices of inclusion. For a team using our care model, we suggest that, prior to initiating rescue activities, participants introduce themselves with their pronouns and consider box breathing or similar. Then, as part of debriefing, we suggest that postrescue activities include a mindfulness element (together or separately). Even if the team is not implementing such strategies yet, an individual can include their mindfulness practice as they join their team, set off on their assignment, and arrive on the scene.

One opportunity for inclusion is upon introducing oneself and the team to the patient, using one's pronouns and asking if they have preferred pronouns. Another opportunity is during physical assessment, asking permission to touch or inviting the patient to participate in palpation for tenderness, for example. Consider using a sheet for privacy and to sequester bystanders. In addition to using breath to calm oneself, an additional application of mindfulness is to invite the patient to take deep breaths to help reduce anxiety or pain. If the patient is obtunded, we suggest continuing to use respectful and inclusive language as much as possible, but otherwise, care would continue as usual in a critical scenario. This can be important for multiple reasons—family may be nearby, or perhaps the patient can still hear you.

Though the example and suggested modifications are based on a search-and-rescue framework, they can easily be applied to any scenario that involves a patient and a caregiver. The main concepts are that a mindful care team will be more attentive to the recipient's needs in a culturally humble and inclusive manner, and the patient will be more comfortable and cooperative if they feel like they are included and have autonomy in their own care.

Discussion: Putting It All Together

We ask that individuals start this process with introspection. Though awareness alone may not be enough for change, it is necessary for change to begin. Consider taking an implicit bias test. Consider initiating a mindfulness practice, such as meditation, or a breathing practice, such as box breathing. Take time to mentally prepare for and recover from wilderness events. Practice using inclusive language at home and in everyday life.

Once in the field, practice connecting with your intention to serve, with how your mind and body are feeling, with your teammates, and with those you are assisting. Empower and engage the patient with as much care and detail as possible and consider their background and preferences. Ask them how they would like to be treated, and use joint decision-making when possible. Leaders can encourage this as part of their team culture via group training and by modeling these behaviors. ³² As with many of our essential skills, unconscious competence is the goal: if an altruistic attitude of inclusion and cultural humility is habitual, it will be natural during times of high stress as well. ²⁷

Conclusion

The WMS recognizes the value and need for an inclusive and diverse society. Patient care can be challenging to standardize in austere settings, among the varied and multidisciplinary teams. This can be an advantage of sorts—with flexibility in such a dynamic setting, there is also room to individualize care to the particular patient.

The authors recognize a number of limitations with this review: our individual experiences as healthcare professionals, our personal lenses and biases, as well as the complex cultural context in which we work.

We acknowledge there are areas for improvement in our organization and in the system of medicine, which include the tendency to focus on the needs of the patient, potentially to the detriment of the caregiver. We hope that, by including self-care in our recommendations, this aspect of our culture of helping professions can change. More work is needed in the areas of preventative mental health as well as psychological first aid for caregivers. We also recognize the need for more organized resources for the diverse medical workforce. We hope that future efforts in the global diversity, equity, and inclusion community can make strides toward a more inclusive and compassionate wilderness.