The Tao of Medicine

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When “The Tao of Pooh” was published in 1982, author Benjamin Hoff likely didn’t realize that his westernizing of Taoism would seep into the halls of medicine. But “mindfulness” is being preached as a way to not only reduce stress on medical practitioners, but also to reduce medical errors.

Unlike the “over-thinking” characters in A.A. Milne’s classic “Winnie-the-Pooh,” Pooh exemplifies effortless doing, being fully present without judgment in the moment. Translating that concept to medicine can be challenging, but not impossible and worth the effort, says David N. Korones, MD, an oncologist and palliative care physician at the University of Rochester Medical Center in Rochester, N.Y.

Korones recounts being asked to teach a mindfulness course to medical students and being baffled why he was chosen (J Clin Oncol 2010;28:4778-4779). Later, he realized it was because he was stressed, and this was “my own obtuse way of reaching out for help.”

In Korones’ preparatory course on mindfulness, the physician-instructor sat “cross-legged, barefoot, in jeans, ringing a gentle-sounding, high-pitched gong to get our attention.” Though he initially wanted to leave due to the unique methodology, Korones since has embraced and taught the art of mindfulness.  

The three most important lessons he has learned from the practice involve: focus (being fully present with patients), time (no longer a clock-watcher) and getting away (when he’s physically away from the hospital, he’s mentally away as well).

Practicing mindfulness could be a way to reduce medical errors that stem from cognitive biases, write Erica M.S. Sibinga, MD, from the Center for Child and Community Health Research, and Albert W. Wu, MD, from the department of health policy and management, both at Johns Hopkins School of Medicine in Baltimore (JAMA 2010;304[22]:2532-2533). They note that others have proposed “debiasing strategies” to prevent these types of errors and that prominent among these strategies is metacognition, or “an individual’s knowledge of his or her own thinking process,” a concept aligned with mindfulness.

Some cognitive biases, for example, can lead physicians to blame the illness on the patient, selectively search for information to confirm a diagnosis but not for information to refute the diagnosis, and confer a judgment that something is more likely if it easily comes to mind. The mindfulness approaches to overcome these biases include employing beginner’s mind (openness), trust, nonjudgment, acceptance and letting go. Of course, this terminology could immediately sour some people to this concept.

Even Korones says that mindfulness can still be challenging for someone like him, who is “forever mired in the stage of concrete operations.” But he has accepted it as a “way of being present for my patients and for myself” and as a discipline that requires training and ongoing practice.

In a study of 70 primary care physicians who underwent an intensive CME program that focused on mindfulness, Krasner et al found a reduction in qualities associated with burnout and an increase in qualities associated with patient-centered care (JAMA 2009:302[12]:1284-1293). “Furthermore,” they write, “these patient-centered behaviors have been associated with improved patient trust, appropriate prescribing, reduction in healthcare disparities and lower heathcare costs.”

Interestingly, the practice of mindfulness might actually be good for your heart. Joan Fox, PhD, and Thomas Morledge, MD, from the Center for Integrative Medicine at the Cleveland Clinic, found that individuals practicing mindfulness had a significantly greater decrease in inflammatory markers compared with a control group that practiced a conventional stress-reduction program.   

"When you wake up in the morning, Pooh," said Piglet at last, "what's the first thing you say to yourself?"
"What's for breakfast?” said Pooh. "What do you say, Piglet?"
"I say, I wonder what's going to happen exciting today," said Piglet.
Pooh nodded thoughtfully.
"It's the same thing," he said.