Abstract
A reasonable question for the medical profession is how enthusiastic we should be about incorporating the increasingly popular modality of mindfulness/meditation into our daily lives. As the medical school curriculum is an extraordinarily demanding zero sum game which demands that any addition to the existing corpus be strongly justified, the specter of adding a thread of mindfulness/meditation in the third year course of the Art and Practice of Medicine at the Cleveland Clinic Lerner College of Medicine has given me pause to answer the question of whether doing so may just lead to the students (and faculty) to reap some serious benefits. The topic of mindfulness itself—which loosely refers to a process of bringing one’s nonjudgmental attention to experiences occurring in the present moment, and which can be developed through the practice of meditation and other types of training—is both popular and controversial. Starting in the East as a method of cultivating mental and spiritual health to feed the soul and find enlightenment 2500 years ago, mindfulness has now come to the West and is touted as a way of destressing, enhancing memory and concentration, and generally improving well-being. Perhaps unsettlingly, mindfulness/meditation has been co-opted by such diverse groups as Goldman Sachs and the US Army in an effort to create more successful investors and better warriors. To me, the migration of meditation from the temples of the East to the boardrooms of New York and the battlefields of the world represents what I refer to as a “natural sign of danger.”
Robert Wright, in his recent book “Why Buddhism Is True,” points out 2 types of contemporary blowback over mindfulness/meditation. In the West, there are those who say that the unequivocal rewards of the activity (lowered stress, increased mental alacrity, and focus) are not specific to the practice and that many of us reap similar rewards from exercising, playing a musical instrument, or merely enjoying nature. From the East, there are practitioners of a life practice of mindfulness/meditation who are challenged not to lose their equanimity of their “nonself” at the notion of Time Out magazine listing the best places and spas to meditate in New York. Considering the dialectic of these arguments, I believe the Buddha was indeed correct in advocating the middle path for all.
For those of us in the health-care profession, and specifically physicians, I believe there are several lines of reasoning supporting incorporating mindfulness/meditation into our training programs and our lives. First, I suggest that there are strong arguments to be made supporting the concept that mindfulness/meditation enhances our care for our patients. The rewards of a calmer physician, capable of focusing on the moment’s work, are transparently beneficial for critical decision-making. Recognizing that we all do our best work when we are not over- or underexcited in the domains of our raw energy and/or hedonic tone, mindfulness/meditation has proven benefits in its capacity to put us in the optimal zone. Studies have demonstrated that mindfulness/meditation can affect several aspects of quality including patient-centered communications and patient satisfaction (1), but there is an urgent need to further demonstrate that mindfulness can be translated into patient safety and quality of care (2).
While the evidence supporting mindfulness/meditation capacity to enhance the quality of patient care is modest, there are ample evidence for its capacity to reduce emotional exhaustion, job dissatisfaction, and burnout (3,4). There are few skeptics to the assertion that medicine today is on a worrisome trajectory where providers are increasingly demanded to work harder, faster, and also be nicer to ensure enhanced patient satisfaction scores. The solution to this problem remains elusive, but remedies directed at both the individual and the institutions where they work have both been suggested (4). Unfortunately, none of the remedies are quick or easy. Here too there are growing evidence, based on carefully conducted trials, that mindfulness/meditation can play a role in soothing the burned out or threatened provider (4 -6). If better care of the patient in terms of reducing medical errors and making providers happier is not enough, then I will also assert that mindfulness/meditation also provides for better caring. In this area, I suggest that there are the strongest data to support that training in mindfulness and meditation has the capacity to enhance both empathy and compassion. Studies of mindful practice have demonstrated an enhanced capacity to build relationships, gather perspectives, and actually act in a compassionate way to relieve suffering (7 -10). Furthermore, behavioral changes in this direction have been observed with as little as 3 weeks of training (8).
So let me return again to the question of why—if mindfulness/meditation is indeed a path for better care and caring—aren’t we all doing it? The answer seems superficially easy, namely in that the practice of mindfulness/meditation is hard. In fact, few studies of mindfulness/meditation are analyzed on rigorous grounds such as via intent to treat as we use in clinical drug trials. Critics suggest that meditation shines only when analyzed on an “as-treated” basis. Meaning which, mindfulness/meditation works only if one does it. If this reality is not sobering enough, we also are limited in our understanding of which type of mindfulness/mediation technique to advocate for. The National Institutes of Health lists over 20 different techniques that are considered mindfulness based. Furthermore, if we are successful at traversing these obstacles, then targeting an optimum “dose” of mediation is also less clear. Recognize that the most impressive data demonstrating the benefits of mindfulness/mediation come from studies utilizing mind–body stress reduction (MBSR), a demanding practice which requires an all-day introduction, regular weekly gatherings, daily meditation of 45 minutes, and a day of silence over 8 weeks. This is a hard balm to sell to stressed out and overworked physicians struggling to balance work and life to begin with.
This brings us to some newer options that deserve serious consideration and investigation. A benefit of the current era of interest in mindfulness/meditation has been the proliferation of lower dose, online, guided meditation programs for mobile devices that are both high touch in design and readily accessible. When I first was introduced to these several years ago, my natural inclination was to consider these merely inferior versions or “meditation-lite” versions of the venerable and time-honored (as well as demanding) standard bearer MBSR, which is time intensive and intimidating to many. In fact, as it turns out one of the most provocative studies demonstrating the effectiveness of mindfulness/meditation on generating compassionate behavior utilized one of the most successful online programs in the field: Headspace, which was cofounded by the mellifluous Andy Puddicombe (8). From a personal perspective, prior to my introduction to low-dose online mindfulness/meditation programs, I was a meditation loser, a failure, and a dropout. Over time, utilizing several online programs for mindfulness/meditation, I achieved success which for me was elusive with more formal and demanding programs. I now use these online programs on a regular basis and feel somewhat transformed. While this personal anecdote has greatly influenced my enthusiasm for introducing this stream of mindfulness training in our third-year curriculum, overall efforts such as this (ie, one class at a time) are inadequate to influence the profession on any grand scale. Similar to the synthesis of data on interventions to prevent and reduce physician burnout, which advocate both individual focused and organizational or structural strategies for optimum success (3), so too these principles may equally apply to the incorporation of mindfulness/mediation in the health-care setting as well. Previous studies from our institution (11) examining the effectiveness of web-based mindfulness interventions in non-health-related workplaces have suggested that minimizing time required out of the workplace for practice and social or group support enhances both participation and results. Thus, health-care institutions have the capacity to enhance engagement in mindfulness programs by supporting some work time participation, if they have the will to do so.
So why are we dedicating time and making the introduction of mindfulness/meditation in our third-year curriculum at the Cleveland Clinic Lerner College of Medicine mandatory and not optional? My defense is based on a clear analysis of risks and benefits outlined above. I truly believe that health-care institutions including medical schools, postgraduate medical education programs, and medical centers should be exposing as many people as possible to as many techniques of mindfulness/meditation as possible to increase the uptake among healers. Mindfulness/meditation is a “no brainer” (no pun intended) in that no matter why you do it (to relax, unwind, find joy, make money, or bring love and compassion to the world) you win. I have read that Chade-Meng Tan, the creator of Google’s popular Search Inside Yourself course, compares meditation to exercise. He was described as saying that even if you start going to the gym to work out just to impress the boss, you still get a workout and you still will get training effect. Mindfulness/meditation, in my opinion, works the same way. I close by asking you to just try it. It’s a path to compassion, the cure for burnout, and a cool hobby.