I was especially struck by this article from the New England Journal of Medicine, and offer it with a note of thanks to my patients and all that you teach me. – Jackie
I was a harried, green resident busily readying an elderly patient — call her Margaret — for hospital discharge when her face unexpectedly began glowing with pleasure. Looking me intently in the eye, she exclaimed, “I do hope you know Dr. Edgecomb!” But before I could respond, she continued, “Do you know what he told me when I left his office last time? `Now you just be sure to notice the crocuses by the doorway on your way out, Margaret; they’re lovely this year.’ That’s just the kind of person he is . . . and he was so right about the crocuses.”
“Isn’t that nice!” I replied, discreetly rolling my eyes and continuing to write prescriptions. How quaint it seemed: the elderly doctor, possibly taught by Osler’s students, trying to do as little harm as possible with his hoary knowledge; his elderly patient, evidently delighted to receive crocus-based medicine. Though I didn’t know Dr. Edgecomb (also a pseudonym) personally, I had seen him striding through the hospital hallways. Tall and trim, well past middle age, kindly, bow-tied, tortoise-rimmed, seer-suckered, and thoroughly Harvard, he belonged to a then-vanishing breed of Boston Brahmin physicians, a species now seemingly extinct. As Margaret cheerfully waved goodbye to me, I had to face up to the obvious: she really loved her doctor, and I — the cynical novice — envied him. I hoped my patients might one day think as fondly of me, but I was only beginning to learn how doctors inspired gratitude. Dr. Edgecomb had brought delight to his patient, and I couldn’t help wondering: Are doctors supposed to do that? And if so, are there alternatives to pointing out flowering bulbs?
Of course “bringing delight” doesn’t precisely capture what Dr. Edgecomb did. He helped Margaret notice her surroundings, and that, in turn, brought her delight — delight at the familiar beauty of a harbinger of spring, but also delight that her doctor cared enough to make her aware of that beauty. A gesture toward something easily overlooked brought Margaret an instant sense of well-being and strengthened the connection to her doctor. Could what Dr. Edgecomb did be considered “promoting mindfulness”? This now-trendy formulation suggests non–evidence-based New Age philosophy, derived in part from Eastern religions, that could easily alienate a confirmed Western allopath like Dr. Edgecomb (as it would many contemporary U.S. physicians). But in his own way, perhaps he was indeed practicing mindfulness, which has been defined as “paying attention in a particular way: on purpose, in the present moment, and non-judgmentally.”Such activity seems consistent with a physician’s goal of noticing any significant sign, symptom, or circumstance — and could thus help us to avoid missing information that could prove helpful to patients.
Dr. Edgecomb would have had a good chuckle over his gin and tonic at my making such a fuss about his offhand remark. He would correctly say he was just being human, possibly adding that — in the words of a song from his youth — he was accentuating the positive. True enough; and in an era when many physicians and patients alike bemoan the lack of time in health care for “being human,” should doctors voluntarily add to their responsibilities the task of promoting mindfulness in themselves and their patients?
Francis Peabody, another Boston Brahmin physician, may have given us a way to think about this question when he famously said that the secret of the care of the patient is in caring for the patient — an old saw, but also a basic truth of doctoring. Once a doctor can really care about the patient, everything else follows; the hard part is allowing oneself to care, especially in the face of the often-frenzied pace of medicine today. One might similarly say that the way to achieve mindfulness lies in also caring for the moment — which is, of course, easier said than done. But if one can cultivate and foster a mindset in which nothing is too trivial to pay attention to, heightened awareness follows naturally. Ralph Waldo Emerson (yet another Brahmin) described a similar process as “embracing the common.” I’d suggest that caring for the present moment, or allowing ourselves to be more mindful, is underrated as a technique for both improving care and increasing professional satisfaction.
Clinical work provides endless opportunities to engage in that effort, and we can often avail ourselves of them by saying something as simple as some variation on “I noticed that . . .” in tones as benevolent and nonjudgmental as we can muster. What we take note of is not crocuses but body language, train of thought, or other nonverbal signals: “I couldn’t help noticing that when you were talking about how worried you are about your cancer treatment, you looked angry for a moment” or “You know, it seemed that when I raised the fact that your sugars have been high you were quick to change the subject.” Though such comments have long been standard fare for psychiatry, there’s no reason why they couldn’t have a much wider application. Making such observations, I sometimes feel like a coach reviewing a game video with a player and asking “Can you see what I see?” We collaborate on understanding what’s happening in the moment. Doing so can enhance my alliance with the patient, who is often surprised — and grateful — that a doctor can recognize and diagnose what may be on the brink of awareness, and do so in a nonshaming way. Alternatively, I may try to help patients maintain perspective by noticing, as Dr. Edgecomb might, the nonpathologic aspects of their lives that are easy to lose sight of amidst illness and suffering.
Proficiency at promoting mindfulness will never be evaluated on the objective structured clinical examination, but I believe it has always been and should remain part of a doctor’s clinical toolkit. Dr. Edgecomb knew that useful information can be found in the quotidian — and knew that sharing such information with his patient would comfort her. In a sense, he was exercising his ancient priestly prerogative as guru–healer — further confirmation of his Brahmin status, even if technically of the Back Bay, rather than Bombay, variety. Maybe his Yankee inheritance had also taught him the value of the seemingly insignificant — the “common,” as Emerson put it. It took me years to become fully aware of all this, but I’d like to think that the lesson could be conveyed to other trainees as simultaneously ignorant and all-knowing as I was.
In fact, I think Margaret was unwittingly teaching me that very lesson. Why did she bother mentioning her little epiphany to me? She wanted to share a happy moment and her good fortune in knowing Dr. Edgecomb, but did she realize she was also helping me, her distracted doctor, to eventually become more mindful? She inoculated me with an idea that developed over time, ultimately making me a better clinician — a good example of the value, and infectiousness, of mindfulness.
From the Beth Israel Deaconess Medical Center and Harvard Medical School — both in Boston.