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Mindful Medical Practice

Patricia Lynn Dobkin


Mindful Medical Practice

Clinical Narratives and Therapeutic Insights


Patricia Lynn Dobkin
Associate Professor
McGill University
Department of Medicine
Affiliated with McGill Programs in Whole Person Care
Montreal, Qubec

ISBN 978-3-319-15776-4 ISBN 978-3-319-15777-1 (eBook)

DOI 10.1007/978-3-319-15777-1
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In loving memory of my infant son, Nicolas


Before you know what kindness really is

you must lose things,
feel the future dissolve in a moment
like salt in a weakened broth.
What you held in your hand,
what you counted and carefully saved,
all this must go so you know
how desolate the landscape can be
between the regions of kindness.
How you ride and ride
thinking the bus will never stop,
the passengers eating maize and chicken
will stare out the window forever.
Before you learn the tender gravity of kindness,
you must travel where the Indian in a white poncho
lies dead by the side of the road.
You must see how this could be you,
how he too was someone
who journeyed through the night with plans
and the simple breath that kept him alive.
Before you know kindness as the deepest thing inside,
you must know sorrow as the other deepest thing.
You must wake up with sorrow.
You must speak to it till your voice
catches the thread of all sorrows
and you see the size of the cloth.
Then it is only kindness that makes sense anymore,
only kindness that ties your shoes
and sends you out into the day to mail letters and
purchase bread,
only kindness that raises its head
from the crowd of the world to say
it is I you have been looking for,
and then goes with you everywhere
like a shadow or a friend.
from The Words under the Words: Selected Poems by Naomi Shihab Nye
1995. Reprinted with the permission of Far Corner Books, Portland, Oregon.


I wish to extend my gratitude to people who have enabled me to conceive of and complete
this book. First, Dr. Tom Hutchinson, the Director of McGill Programs in Whole Person
Care, encouraged me to develop mindfulness programs at McGill University in the Faculty
of Medicine. He is an inspirational world-class leader of Whole Person Care. Second, my
brother, Dr. Dennis Dobkin, has always counseled me to abide by my inclinations even in
those heady hippy days when at 19 years old I trekked off to India and discovered Auroville, a
UNESCO recognized model city of peace. Aurobindo, the sage who founded the Pondicherry
Ashram, taught that work can be a spiritual practice. His vision led me to here, now. Dr. Paul
M. Jurkowski ignited my heart with loving kindness this was instrumental in transforming
my life.
My mindfulness teachers have been essential to my being able to teach MSBR and Mindful Medical Practice. They are: Dr. Jon Kabat-Zinn, Dr. Saki Santorelli, and Florence MeleoMeyer at the Center for Mindfulness in Medicine, Health Care, and Society; Dr. Gregory
Kramer, whose Insight Dialogue retreats have touched me deeply; Dr. Ronald Epstein and his
colleagues who are world leaders in Mindful Practice. Various instructors at the Insight Meditation Society in Barre, Massachusetts have been guides along the way as well. His Holiness
the Dala Lama has been a model of engaged social justice; his writings and visits to Canada
have been vital to my awakening.
Ms. Portia Wong at Springer Press has been helpful in transforming chapters into one coherent book. Ms. Angelica Todireanu at McGill Programs in Whole Person Care has provided
excellent technical support as well.
I dedicate this book to Mark S. Smith. I am grateful for his deep understanding me and this
work. He has offered me the inner and outer space to write in peace, dream in colour, and
share the joys of life together. His love is a precious jewel that adorns my heart.



Ronald M. Epstein, MD
University of Rochester Medical Center
A monk asked Zhaozhou to teach him.
Zhaozhou asked, Have you eaten your meal?
The monk replied, Yes, I have.
Then go wash your bowl, said Zhaozhou.
At that moment, the monk understood.
Wisdom, William James once said, is about a large acquaintance with particulars more than
overarching principles [1]. It is about finding our way in not just any situation, but this situation in which we encounter ourselves, right now. In medicine, these situations involve patients
and their families, with their sufferings and misfortunes. Overarching principles of clinical
practicethe teachingsprovide a beacon to help us know when we are off course, but the
wisdom of clinical practice lies beyond our general knowledge of diagnoses and treatments;
it has more to do with how we respond to the exigencies of the momentthe contexts, the
individual players and the range of outcomes that are possible for and desired by this patient.
Zhaozhous answer to the young monk seeking wisdom was to wash his bowlthe task that
the moment demands of us. In that way, each patient encounter is also in the present moment;
each encounter might be part of a long-range strategy informed by knowledge and evidence,
but is always a drama that is being written, enacted and interpreted in the moment.
This book is about being mindful in clinical practice. Importantly, mindfulness is emergentit manifests as a desired attitude of mind without having been willed into being. Like
love, empathy and many other things that are important in life, mindfulness is something that
we value and can make space for, but can never fully define nor evince because the act of overspecifying its shape, form, dynamism and trajectory limits it to something less than it isas
Laozi said some 2500 years ago, the Tao that can be named is not the real (or eternal) Tao. I
wont argue here what the Tao is, nor mindfulness, but those who have picked up this book
have some idea that mindful practice is an intentional attitude of mind that strives for clarity
and compassionby adding the qualifier medical it defines the context and the protagoniststhose who heal and those who seek healing.
The immediacy of clinical care is seen and enacted through stories that we tell ourselves
and others, stories that reveal our own perspectives. Reading stories about healers and patients
teaches us about the lenses through which theyand wesee the world. Stories are a vehicle
for wisdom. Narratives, as Rita Charon reminds us, serve to enlighten and to heal [2]. The
stories in this book have a particular focus and a particular purpose. They recount clinicians
experiences of being attentive and present in ways that are heartfelt, revelatory and insightful.
Yet, they do more. They invite the reader to think and construct narratives about their own
clinical lives with the purpose of deepening their self-understanding, become better listeners,
appreciate that stories unfold and almost never take the linear form that dominates medical
case histories. A good clinical story brings to light the dual purpose of the clinician-patient


relationshipbroadly defined, to interpret and categorize disease on the one hand and to interact with a suffering human being in a way that restores health on the other.
Thanks to the work of pioneers such as Jon Kabat-Zinn, mindfulness is a household word
in North America, enshrined on the cover of Time magazine, discussed in earnest in corporate
boardrooms and schools, infused into psychotherapy and engaged in practice by millions who
want to experience greater balance, health and wellbeing. Since 1999, when the Journal of the
American Medical Association first published Mindful Practice [3], the word mindful has
also entered the lexicon of mainstream medical practice. It has a positive valence, even for
those who doubt that it is possible to achieve. Starting in 2006, with colleagues at the University of Rochester, I have tried to answer the challenge of how to help clinicians become more
mindful. This is no small task. Building on the work of philosophers, reflective physicians
and cognitive scientists, I have also drawn on my own experienceas a student of Zen Buddhism (fortunately still a beginner after 42 years of practice), as a musician (my first attempt
at a career), as a chef (mindlessness manifests as burnt pine nuts) and as a healer. What has
emerged is that to cultivate mindfulness in action in clinical settingswhat I call mindful
practice and which Patricia Dobkin and colleagues now call mindful medical practice
requires preparation outside the workplace and enactment within it [49]. Usually, preparation
means some form of contemplative practice including but not limited to meditation, and the
enactment means some way to situate a practice of mindfulness in the context of healing.
Yet, meditationwith all its variations, power and allureis not enough. Moving from
mindfulness to mindful practice requires grounding in what the educator Donald Schn calls
the swampy lowlandsthe muddy amorphousness of everyday being in and with the world
[10]. Here is where stories come instories about, written by, told by, elicited from and listened to by clinicians about life experiences in health care contexts, full of their contradictions
and paradoxes, memory lapses, misapprehensions, emotional overlays and painfully poignant
turns of events; things that could never be captured in any other way. These stories are not
pretty and mindfulness does not flow from them like honeythese are pithy stories, infused
with grit and passion, foibles and humor, desperation and redemption.
This brings me to wonderwhat is a mindful story? Medical journals are filled with narrativesabout hope and loss, connection and unfulfilled promises, transformation and the
relentless unfolding of fate. All stories are meant to change how you look at the world. But,
do they all reveal mindfulness? I raise the question because I dont have the answer. Yet,
close reading sometimes provides clues. Does a mindful story have to involve transformation
in some way? Does it involve a revolutionary change in thinking or experienceor does it
simply uncover what has always been there but has remained unknown and unseen? Does the
protagonistwhen it is the patienthave to be, in Arthur Franks words, successfully ill,
and find meaning in his or her suffering? Does the healer have to be moved in some emotional
way? Can a mindful story be about placing a suture, reading an x-ray or responding to a medication alert on the computer screenthings that have little intrinsic emotional content? Does
the self-reflection implicit in the modern incarnations of the concept of mindfulness have to
be conscious, verbal and explicit? Or can it remain outside of everyday awareness, unspoken
and mysterious? Can mindfulness be humdrum? Does mindfulness have to be unexpected?
Can presence amid dissolution, destruction and disaster be mindful even though the outcome
is worse than anyone could possibly have imagined? Can mindfulness be giddy, silly, superficial, transient, fleeting? Does mindful intentionality have to involve forethought, or can our
intentions reveal themselves after the fact? Can you think youre being mindfully present and
be dead wrong, engaging in an elaborate self-deception? Do you really have to slow down to
be mindful? These questions are not necessarily issues to debate, but rather questions to hold
closely, to jiggle your thinking, to make sure youre not too sure of yourself.
Stories are important because they expand awareness. While general principles and ideals
can be monochromatic, good stories are always ambiguous. They always have several sides
to them. They never answer all the questions they raise. Is John Kearsleys Carmens Story




really just about Carmen? The way it is writtenand many others in this volumeit has multiple protagonistsclinicians, patients, family members, others. Is mindful practice about
any one of them, or is the emergent mindfulness the space that their interaction reveals as each
member of the quartet (or duo or trio) tacitly takes a new view of an evolving situation? Is
mindfulness contagious, as it seemed to be in The Opera of Medicine, Mick Krasners story
about his relationship with his father and the person whose presence brought them together in
unexpected ways? You see where I am going: asking reflective questions leads us deeper into
ourselves and opens up the possibility to see the ordinary with new eyes.
Stories require a teller and a listener. Today I read an article showing that electronic devices,
including the one that I am using right now, activate the same brain circuits as do addictions.
Ironically, I read the article on the screen. Thats okay for research articles, but when Im reading stories in a deeper way, I realize that reading on the screen requires a focus beyond my own
capacity, so I print them out. Reading them out loud demands another kind of attentionauditory information is qualitatively different from that which comes in just through the eyes. This
is to say that these stories are an invitation to read them mindfully, in whatever way you have
to in order to have them reveal themselves to you. These stories by health professionals, mostly
physicians, were written with the willing or unwitting help of patients and their families, and
in some cases, colleagues and trainees. As a reader, you are part of the community of listeners, witnesses and re-tellers of the stories, in whatever transformed or imperfect ways you can
As you read, when you think you have come up with an interpretation of whats going ona
label, a categoryperhaps stop for a moment and pay attention to the difference between the
words on the page and the evolving story in your mind. This is much the same activity as we
engage in with patients in order to hear them and help them disclose their suffering to us. In
that way, the mindful practice of reading can inform the mindful practice of doctoring. The
other day, I saw a patient who reported a funny sensation right here while walking up stairs,
gesturing to a large area of the anterior chest and upper abdomen, and yet when I was on the
phone to the emergency department (ED), I said that the patient was having chest pressure.
Only later did I recognize the unconscious distortion; the patient never used either of those
wordschest or pressureto describe her symptoms. It was too late. I didnt call the ED
back. I knew that the words chest pressure would paradoxically result in her getting better
care, even though they were not quite true to what the patient said. It makes me anxious to
think about trying to explain to a rushed humorless triage nurse about the funny sensation
right there; chest pressure is so much more convenient. A mindful moment, not shared with
those who mattered to the patient, so now you are the witnesses. In that way, we witness each
others foibles and inspirations. A good story records these kinds of events in a deep way, often
compassionate, sometimes funny, or just plain sad.
Perhaps mindful practice is just remembering who you are and focusing on what is important. Giving space for the telling of and listening to stories of mindful practice can transform
medicine by helping clinicians gain a deeper awareness of who they are, and by opening up
new possibilities of how they can offer what patients want and need. And, by creating a sense
of community, the telling of stories is the way that humans have always transformed their
individual visions into a shared enterprise.
1 James W. The Varieties of Religious Experience: A Study in Human Nature, reprint edition
1961. New York: W.W. Norton & Co.; 1902.
2 Charon R. Narrative medicine: form, function, and ethics. Ann Intern Med. 1/2/2001
3 Epstein RM. Mindful practice. Jama. 9/1/1999 1999;282(9):833839.
4 Epstein RM. Mindful practice in action (I): technical competence, evidence-based medicine
and relationship-centered care. Families Systems and Health. 2003 2003;21:110.
5 Epstein RM. Mindful practice in action (II): cultivating habits of mind. Families Systems
and Health. 2003 2003;21(1):1117.


6 Epstein RM, Siegel DJ, Silberman J. Self-monitoring in clinical practice: a challenge for
medical educators. J Contin.Educ Health Prof. 2008 2008;28(1):513.
7 Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary
care physicians. JAMA: The Journal of the American Medical Association. 9/23/2009
8 Epstein RM. Mindful Practice: A Key to Patient Safety. Focus on Patient Safety. 2011
9 Beckman HB, Wendland M, Mooney C, etal. The impact of a program in mindful communciationon primary care physicians. Academic Medicine. 6/2012 2012;87(6):15.
10 Schon DA. Educating the reflective practitioner. San Francisco: Jossey-Bass; 1987.



The idea for this book surfaced with the wail of a loon. She was swimming without a splash
across a lake that mirrored the evergreens bordering its shores. Summer is a matter of weeks
rather than months in Canadatradition has it that we, like birds, migrate to the countryside
where moose, grizzlies, herons, and if we are lucky, loons are found. While their cries evoke a
sense of loneliness, loons are loyal mates, protective of their chicks and thrive in a close-knit
The summer is a time when I allow my mind, heart and spirit to wander in the woods
and across the waters. An observer may presume that I am doing nothing, but truth be told,
I am being more than doing. Being human, that is. My meditation practice opens me to the
elementsthey are my teachers.
While listening to the loons, I wondered how I could gather other voicesthose of clinicians who exemplify whole person care. I have been teaching mindful medical practice, along
with my colleague Dr. Tom Hutchinsonthe director of McGill Programs for Whole Person
Carefor 8 years in various formats (8-week programs, half-day and full-day workshops and
weekend retreats). We published numerous papers (113) on the topic and presented our work
at conferencesthe conventional way of communicating the value of mindful medical practice
from our point of view. It occurred to me, that the 200 plus articulate and compassionate physicians and allied health care professionals we have encountered over the years have as much to
say about being present, bearing witness to pain and suffering and creating a space for healing
in their patients and themselves as we do. I realized that they often work in silos and seem
lonely, like the loons whose haunting cries permeate the lake I sat next to. Yet, I was aware that
there are many mindful practitioners who support one another. Similar to loons, they thrive in
groups. I thought by compiling their narratives they and you (the reader) would know that we
form a community. Shortly thereafter, I invited physicians and other clinicians working in various settings with different specialties to showcase how and why mindfulness matters.
Patients tales of illness and how it has altered their lives has become a genre in and of itself.
Less common are chronicles that emerge from the consciousness of their clinicians who treat
them. The narratives herein provide a window into their experiences1. The book is intended
for medical students and residents, physicians and other clinicians who aspire to bring mindfulness into their lives and work. It may also be of interest to patients, their families and the
general public given the broad interest in the relationship between mindfulness and wellbeing.
We are fortunate that the co-authors of this book were generous enough to share their insights
with us. Their narratives are inspiring and remind us that the tender gravity of kindness (14)
may guide our interventions.
Patricia Lynn Dobkin PhD
1 In all cases we have changed names and details to protect patient identities unless patients provided consent
to have their stories told.



Dobkin PL. Mindfulness-Based Stress Reduction: What processes are at work? Complement Ther Clin Pract.
Dobkin PL. Fostering healing through mindfulness in the context of medical practice [Guest Editorial]. Curr
Oncol. 2009;16(2):46.
Irving JA, Dobkin PL, Park J. Cultivating mindfulness in health care professionals: A review of empirical
studies of Mindfulness-Based Stress Reduction (MBSR). Complement Ther Clin Pract. 2009;15(2):6166.
Hutchinson TA, Dobkin PL. Mindful Medical Practice: Just another fad? Can Fam Phys. 2009;55(8):77879.
Dobkin PL, Hutchinson TA. Primary prevention for future doctors: promoting well-being in trainees. Med
Educ. 2010;44(3):22426.
Dobkin PL, Zhao Q. Increased mindfulness-the active component of the Mindfulness-Based Stress Reduction
program? Complement Ther Clin Pract. 2011;17(1):227.
Dobkin PL. Mindfulness and Whole Person Care. In: Hutchinson, TA. (ed.). Whole Person Care: A New Paradigm for the 21st Century. 1st ed. New York, NY: Springer; 2011. p.6982.
Dobkin PL, Irving JA, Amar S. For whom may participation in a Mindfulness-Based Stress Reduction program
be contraindicated? Mindfulness. 2011;3(1):4450.
Irving J, Park J, Fitzpatrick M, Dobkin PL, Chen, A, Hutchinson T. Experiences of Health Care Professionals Enrolled in Mindfulness-Based Medical Practice: A Grounded Theory Model. Mindfulness. 2012. doi:
Dobkin PL, Hutchinson T. Teaching mindfulness in medical school: Where are we now and where are we
going? Med Educ; 2013;47:76879.
Dobkin PL, Hickman S, Monshat K. Holding the heart of MBSR: Balancing fidelity and imagination when
adapting MBSR. Mindfulness. 2013. doi:10.1007/s12671-013-0225-7.
Garneau K, Hutchinson T, Zhao Q, Dobkin PL. Cultivating Person-Centered Medicine in Future Physicians.
Euro J Person-Centred Healthcare. 2013;1(2):46877.
Dobkin PL, Lalibert V. Being a mindful clinical teacher: Can mindfulness enhance education in a clinical setting? Med Teach. 2014;36(4):34752.
Nye NS. Kindness. In: The words under the words: Selected poems. 1995. The Eighth Mountain Press; 1st
edition. Accessed 27 Jun 2014



1 Introduction: Mindful Medical Practice 1

Patricia Lynn Dobkin
2 Mindful Rounds, Narrative Medicine, House Calls, and Other Stories 5
Maureen Rappaport
3 Lost Heart (Beat)/Broken (Body) 13
Patricia Lynn Dobkin
4 Working with Groups Mindfully 19
Craig Hassed
5 The Opera of Medicine 25
Michael S. Krasner
6 The Mindful Psychiatrist: Being Present with Suffering 29
Catherine L. Phillips
7 The Death of a Snowflake 37
Emmanuelle Baron
8 Carmens Story 41
John H. Kearsley
9 A Mindful Life in Medicine: One Pediatricians Reflections on Being Mindful 49
Michelle L. Bailey
10 Embodied Wisdom: Meeting Experience Through the Body 57
Sonia Osorio
11 Minding Baby Abigail 61
Andrea N. Frolic
12 Mindfulness in Oncology: Healing Through Relationship 71
Linda E. Carlson
13 Choosing to Survive: A Change inReproductive Plans 75
Kathy DeKoven


14 Mindfulness in the Realm of Hungry Ghosts 79

Ricardo J. M. Lucena
15 In the Heart of Cancer 85
Christian Boukaram
16 Hiking on the Eightfold Path 89
Ted Bober
17Strengthening the Therapeutic Alliance Through Mindfulness:
OneNephrologists Experiences 95
Corinne Isnard Bagnis
18 Richards Embers 99
Elisabeth Gold
19 M
 indful Decisions in Urogynecological Surgery: Paths
from Awareness to Action 105
Joyce Schachter
20 The Good Mother111
Kimberly Sogge
21 I Am My Brothers Keeper 119
Dennis L. Dobkin
22 The Mindful Shift 123
Tara Coles
23Lifeline 127
Carol Gonsalves
 edical Students Voices: Reflections on Mindfulness During
24 M
Clinical Encounters 131
Mark Smilovitch
25 Growth and Freedom in Five Chapters 139
Stephen Liben
26 A Wounded Healers Reflections on Healing 145
Cory Ingram
27 Mindfulness, Presence, and Whole Person Care 151
Tom A. Hutchinson
28 Mindful Attitudes Open Hearts in Clinical Practice 155
Patricia Lynn Dobkin
Index 161



Michelle L. Bailey Department of Pediatrics, Duke Health Center at Roxboro Street, Duke
University Medical Center, Durham, NC, USA
Emmanuelle Baron Department of Family Medicine and Emergency Medicine, Universit
de Sherbrooke, Saint-Lambert, QC, Canada
Ted Bober Physician Health Program, Ontario Medical Association, Toronto, ON, Canada
Christian Boukaram Maisonneuve-Rosemont Hospital, Universit de Montreal, Montreal,
QC, Canada
Linda E. Carlson Department of Oncology, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
Department of Psychosocial Oncology, Tom Baker Cancer Centre, Calgary, AB, Canada
Tara Coles University of Maryland, Baltimore, MD, USA
Medical Emergency Professionals, Rockville, MD, USA
Kathy DeKoven Department of Anesthesiology and Pain Clinic, Centre Hospitalier Universitaire Sainte-Justine, Universit de Montral, Montreal, QC, Canada
Dennis L. Dobkin Waterbury Hospital Health Center, Waterbury, CT, USA
Patricia Lynn Dobkin Department of Medicine, McGill Programs in Whole Person Care,
McGill University, Montreal, QC, Canada
Andrea N. Frolic Office of Clinical & Organizational Ethics, Hamilton Health Sciences,
McMaster University Medical Center, Hamilton, ON, Canada
Elisabeth Gold Family Medicine and Division of Medical Education, Dalhousie University,
Halifax, NS, Canada
Carol Gonsalves Department of Medicine, Division of Hematology, Ottawa Blood Disease
Centre, Ottawa Hospital, Ottawa, ON, Canada
Craig Hassed Department of General Practice, Monash University, Notting Hill, Victoria,



Tom A. Hutchinson McGill Programs in Whole Person Care, Faculty of Medicine, McGill
University, Montreal, QC, Canada
Cory Ingram Family and Palliative Medicine, Mayo Clinic, College of Medicine, Mankato,
Corinne Isnard Bagnis Service de Nphrologie, Institut dEducation Thrapeutique, Universit Pierre et Marie Curie, Hpital Piti-Salptrire, Paris, France
John H. Kearsley Department of Radiation Oncology, St. George Hospital, University of
New South Wales, Kogarah, NSW, Australia
Michael S. Krasner University of Rochester School of Medicine and Dentistry, Rochester,
Stephen Liben McGill Programs in Whole Person Care, Faculty of medicine, Paediatric Palliative Medicine, Montreal Childrens Hospital, McGill University, Montreal, QC, Canada
Ricardo J. M. Lucena Department of Internal Medicine, Centre of Medical Sciences, Universidade Federal da Paraba, Tamba, Joao Pessoa-PB, Brazil
Sonia Osorio Private Practice Outremont, QC, Canada
Catherine L. PhillipsDepartment of Psychiatry, University of Alberta, The Mindfulness, Edmonton, AB, Canada
Maureen Rappaport Department of Family Medicine, McGill University, Montreal West,
QC, Canada
Joyce Schachter Harmony Health, Ottawa Hospital, Ottawa, ON, Canada
Mark SmilovitchCardiology Division, Faculty of Medicine, McGill Programs in Whole
Person Care, McGill University, Montreal, QC, Canada
Kimberly Sogge University of Ottawa, Ottawa, ON, Canada


Introduction: Mindful Medical Practice

Patricia Lynn Dobkin

Mindfulness is a way of being in which an individual maintains attitudes such as, openness, curiosity, patience, and
acceptance, while focusing attention on a situation as it unfolds. Mindfulness is influenced by ones intention, for example, to act with kindness, and attention, i.e., being aware
of what is occurring in the present moment. It is an innate
universal human capacity that can be cultivated with specific
practices (e.g., meditation, journaling); it both fosters and is
fostered by insight, presence, and reflection.
Mindfulness in Medicine Clinicians need to be skilled in
listening fully to and being totally present to their patients/
clients to foster healing [1]. Even the most seasoned clinicians face ongoing challenges relative to shifting between the
automaticity demanded by fast-paced environments which
require multitasking and deliberate, focused attention necessary for monitoring and clinical decision making [2]. In order
to make mindfulness relevant to these specific concerns and
constraints, as well as to engage health-care professionals
more fully in the process, mindful medical practice programs
have been developed. For example, Krasner etal. [3] conducted an open trial of a modified mindfulness-based stress
reduction (MBSR) program that included aspects of appreciative inquiry [4] and narrative medicine [5] with primary
care physicians. One year following the 8-week program
with monthly follow-up classes, mindfulness, empathy, and
emotional stability were enhanced while physician burnout
decreased. Moreover, increases in mindfulness were significantly correlated with physician self-reports of improved
mood, perspective taking, and decreased burnout. McGill
Programs in Whole Person Care has offered mindfulnessbased medical practice since 2006. The program is closely
Department of Medicine, McGill Programs in Whole Person Care,
McGill University, Room: M/5, 3640 University Street,
Montreal, QC H3A 0C7, Canada

modeled after MBSR but includes role-plays, based on Satirs communication stances [6], other exercises emphasizing
communication skills and interpersonal mindfulness, based
on insight dialogue [7] and emphasizes self-care. It aims to
help clinicians integrate mindfulness into working relationships with patients and colleagues. In a sample of 110 healthcare professionals (half of whom were MDs), following the
8-week course, significant decreases were observed in participants perceived stress, depression, and burnout, as well
as significant increases in mindfulness, self-compassion,
and well-being. Hierarchical regression analyses showed
that decreases in stress predicted well-being; as did increases
in mindfulness and self-compassion [8, 9]. Moreover, 93%
reported increased awareness and continued meditation
practice following the program; 85% indicated that they had
a meaningful experience of lasting value [10]. Fortney etal.
[11] studied an abbreviated mindful intervention for 30 primary physicians who attended 18h of classes with access to
a web site that was designed to support their practice; they
reported similar improvements both immediately following
the intervention and 9 months later.
Mindfulness and the Therapeutic RelationshipTwo
decades ago, Stewart [12] published a review showing that
the quality of physicianpatient communication was linked
to better patient outcomes (e.g., emotional health, symptom resolution, pain control). Soon thereafter, physicians
began exploring how mindfulness could positively influence medical practice [13, 14]. Hick and Biens [15] edited
book highlights how mindfulness can enhance the therapeutic relationship by cultivating crucial therapeutic skills
such as unconditional positive regard, empathetic understanding, and improve different therapeutic interventions
(e.g., substance abuse, psychoanalytic psychotherapy). It is
hypothesized that positive patient outcomes are due to the
therapists own attention and affect regulation, acceptance,
trust, and nonjudgment of patient experiences, and their ability to tolerate patient emotional reactivity. Two qualitative
studies [8, 16] found that when physicians and clinicians

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_1,

Springer International Publishing Switzerland 2015

P. L. Dobkin

took a mindful medical practice course, they felt less isolated professionally. Moreover, they indicated that mindfulness improved their capacity to be attentive while listening
deeply to patient concerns. In the first study to examine if
practitioners mindfulness influenced the medical encounter,
Beach etal. conducted an observational study of 45 clinicians caring for patients infected with the HIV virus [17].
Medical visits were audiotaped and coded by raters blinded
to mindfulness scores; patients independently rated their perceptions following the visit. Clinicians who scored high on
mindfulness were more likely to engage in patient-centered
communication (e.g., they discussed psychosocial issues,
built rapport) and they displayed more positive emotional
tone with patients. Patients reported better communication
with the more mindful physicians and they were more satisfied with their care.
Escuriex and Labb [18] reviewed the relationship between clinicians mindfulness and treatment outcomes.
Much like the research cited herein, clinicians benefited
from mindfulness training personally and professionally.
They reported increased capacity for empathy and ability to
be present without becoming defensive or reactive. Nonetheless, in this review the link to patient outcomes was mixed.
While their interpretation indicated that there is not a simple
correlation between clinician mindfulness and mental health
outcomes, this may be because they assumed that the clinician is responsible for prompting patient improvements. In a
subtle way, this fails to recognize that patients have to take
responsibility for coping with illness in partnership with the
clinician (as shown in Fig.1.1).
Evidently, mindfulness allows for a trusting relationship
to develop between the clinician and the patient. This, is the
space in which healing can take place with the clinician
who accompanies the patient on the journey towards wholeness, even when no cure is possible. She/he invites the patient to approach the illness experience in a deeper way, exploring its meaning and opportunities. This is accomplished
through an analogic form of communication. In addition
to the words spoken, the clinicians genuine concern for the
patient is shown through his or her posture, gestures, facial
expression, voice inflection, sequence, rhythm, and cadence
in speech. Clinicians who intuit when to be silent, when to
allow time for integration of information, or when to use
touch reassure the patient that he/she is not abandoned to
his/her fate. Being present in this way provides a safety zone
in which the dark side of illness can be explored: the fears,
losses, and implications. To be able to be receptive to suffering, the clinician needs to be able to tolerate uncertainties,
strong emotions, and address existential issues. This is much
more than bedside manner; rather, it is true empathy in action. Herein lays the heart of medicine.








Fig. 1.1 A clinical encounter. Numerous factors influence the encounter when a person/patient seeks treatment for a disease or illness. There
are three intersecting foreground elements: the health-care professional,
the patient/person, and the disease. These are embedded in two overlapping contexts, i.e., the medical and social systems. In the left circle is
the doctor who arrives with her/his professional know-how and personal history. She/he meets the patient in A, encounters the patient and
disease together in B, and the disease itself in C. A is a place where healing may be fostered. B is the intersection of the clinician, patient, and
disease; this is where curing may occur. C contains the professionals
tool box containing medical knowledge, procedures, diagnostic tests,
surgery, and medications. The person, in the circle on the right, arrives
with his/her genetic loading, psychosocial characteristics, personal and
medical history, as well as health-related behaviors. These will impact
the disease in D (e.g., obesity, smoking with coronary heart disease).
Moreover, the patient/person brings to the disease or illness certain beliefs, expectations and hopes

Dr. Kearsley [19], a radiation oncologist, shows us his

heart in Wals story. His keen observation of the unshaven
Wal with good knees, who shuffles in; his fair skin makes
him look anemicwho wears old faded fawn shorts and old
green sandalswhose cheeky smile breaks across his ancient seafarer face; a toothless grin (p.2283) may give
the reader pause when it is revealed that Wal was an engineer in his younger days. The mind, if not open and able to
see the whole person in this human being, may have presumed that Wal originated from the underprivileged class,
especially given that, in addition to prostate cancer, he had
emphysema, diabetes, and bad circulation. A less mindful
oncologist may have hurried through the visit since he (the
doctor) thought the cancer was cured. His joining with the
patient is evident when he uses common language, How
are you, mate; whats new? Dr. Kearsley is unquestionably aware of himself (his thoughts and feelings), his patient

1 Introduction: Mindful Medical Practice

(his need to relate his stories), and the context (two hungry
medical students who seemed impatient and confused about
why the visit was taking so long). Significantly, Dr. Kearsley shares with us the truth of how exquisite presence can
provide a memorable and sublime silent encounter that
provided unexpected sustenance and meaning to the daily
routine (p.2283).
To approach all this from a mindful perspective, the clinician may open a dialogue with the patient that includes the
medical aspects of the presenting problem (e.g., fibromyalgia) and encourage patient coping strategies that may be useful to help her live as fully as possible with the disease or
illness. The clinician would listen with an open, clear mind
to the patients views and observe his/her own as well as the
patients reactions. The patient, in turn, would communicate
honestly with the clinician, understand her role, and engage
in self-care behaviors (e.g., pacing, adherence to exercise)
that impact her quality of life [20]. Mindfulness is the skill
set that facilitates these healing aspects of the clinicianpatient encounter.

Narratives and Therapeutic Insights

Narrative medicine [21, 22] provides a model for the development of empathy, reflection, and trust in clinical practice.
Charon [21] defined narrative competence as, the ability to acknowledge, absorb, interpret, and act on the stories
and plights of others (p.1897). In alignment with mindful medical practice, when faced with a story one needs to
pay attention; which according to Charon is, a combination
of mindfulness, contribution of the self, acute observation,
and attuned concentration [23 (p.1265)]. Reflective writing (one aspect of narrative medicine) affords the clinician
an opportunity to delve deeply into the meaning of patients
experiences as well as his own. The act of writing a narrative uncovers multiple layers of a clinical encounter; the
process invites the writer to discover what may have been
overlooked in the rush of seeing so many patients throughout
the day. It encourages presence; in both the writer and reader.
Moreover, narrative medicine cultivates affiliation; the clinician connects with the patient while paying full attention;
the writer connects with the reader by representing the clinical encounter in words. Consistent with Whole Person Care
[24], narrative medicine promotes caring for the patient as
much as curing diseases.
The subsequent chapters included in this book are narratives crafted by physicians and other clinicians who consciously apply mindfulness in their work with patients. While
some guidance was provided so that the chapters would have
similar structures, the freedom to write what emerged for
them when contemplating this invitation was extended to the
coauthors. This is consistent with key mindful attitudes such

as: being present to not knowing, being curious and open

minded while attending to ones own inner wisdom. The intention of this book was to showcase how mindfulness enriches both medical practice and clinicians lives. This book
was written from the larger context of McGill Programs in
Whole Person Care with our stated mission as:
To transform western medicine by synergizing the power of
modern biomedicine with the potential for healing of every
person who seeks the help of a healthcare practitioner. We plan
to achieve this objective by serving as champions for whole
person care at McGill [University] and in the wider community
through our teaching, research and translation of knowledge.

1. Dobkin PL. Fostering healing through mindfulness in the context
of medical practice. Curr Oncol. 2009;16(2):46.
2. Epstein RM, Seigel DJ, Silberman J. Self-monitoring in clinical
practice: a challenge for medical educators. J Contin Educ Health
Prof. 2008;28(1):513.
3. Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B,
Mooney CJ, etal. Association of an educational program in mindful communication with burnout, empathy, and attitudes among
primary care physicians. JAMA. 2009 Sep 23;302(12):128493.
4. Cooperrider D, Whitney D. Appreciative inquiry: a positive revolution in change. San Francisco: Berrett-Koehler; 2012.
5. Connelly JE. Narrative possibilities: using mindfulness in clinical
practice. Perspect Biol Med. 2005;48(1):8494.
6. Satir V. The new peoplemaking. Palo Alto: Science and Behaviour
Books Inc; 1988.
7. Kramer G. Insight dialogue: the interpersonal path to freedom.
Boston: Shambhala Publications; 2007.
8. Irving J, Park J, Fitzpatrick M, Dobkin PL, Chen A, Hutchinson T.
Experiences of health care professionals enrolled in mindfulnessbased medical practice: a grounded theory model. Mindfulness.
2014. doi:10.1007/s12671-012-0147-9.
9. Irving JA, Williams G, Chen A, Park J, Dobkin PL. Mindfulnessbased medical practice (MBMP): a mixed-methods study exploring benefits for physicians enrolled in an 8-week adapted MBSR
program. In: 2012 AMA-CMA-BMA International Conference on
Physician Health (ICPH); 2527 Oct 2012; Montreal, QC; 2012.
10. Irving JA, Dobkin PL, Park-Saltzman J, Fitzpatrick M, Hutchinson TA. Mindfulness-based medical practice: exploring the link
between self-compassion and wellness. Int J Whole Person Care.
2014;1(1). Accessed: 27 June 2014.
11. Fortney L, Luchterhand C, Zakletskaia L, Zgierska A, Rakel D.
Abbreviated mindfulness intervention for job satisfaction, quality
of life, and compassion in primary care clinicians: a pilot study.
Ann Fam Med. 2013 Sep;11(5):41220.
12. Stewart MA. Effective physician-patient communication and health
outcomes: a review. Can Med Assoc J. 1995;152(9):142333.
Epstein RM. Mindful practice. J Am Med Assoc.
14. Connelly J. Being in the present moment: developing the capacity
for mindfulness in medicine. Acad Med. 1999 Apr;74(4):4204.
15. Hick SF, Bien T, editors. Mindfulness and the therapeutic relationship. New York: Guilford Press; 2008.
16. Beckman HB, Wendland M, Mooney C, Krasner MS, Quill
TE, Suchman AL, etal. The impact of a program in mindful

communication on primary care physicians. Acad Med. 2012
17. Beach MC, Roter D, Korthuis PT, Epstein RM, Sharp V, Ratanawongsa N, etal. A multicenter study of physician mindfulness and
health care quality. Ann Fam Med. 2013 Sept;11(5):4218.
18. Escuriex BF, Labb EE. Health care providers mindfulness and
treatment outcomes: a critical review of the research literature.
Mindfulness. 2011;2(4):24253.
19. Kearsley JH. Wals story: reflections on presence. J Clin Oncol.
2012 June 20;30(18):22835.
20. Dobkin, PL. Mindfulness and whole person care. In: Hutchinson
TA, editor. Whole person care: a new paradigm for the 21st century. New York: Springer Science + Business Media, LLC; 2011.
21. Charon R. The patientphysician relationship. Narrative medicine:
a model for empathy, reflection, profession, and trust. J Am Med
Assoc. 2001 Oct 17;286(15):1897902.
22. Charon R. Narrative medicine: honoring the stories of illness. New
York: Oxford University Press; 2006.

P. L. Dobkin
23. Charon R. What to do with stories: the sciences of narrative medicine. Can Fam Physician. 2007;53(8):12657.
24. Hutchinson TA, Hutchinson N, Arnaert A. Whole person care: encompassing the two faces of medicine. CMAJ.
Patricia Lynn Dobkin PhD is a clinical psychologist specializing in
chronic illness and chronic pain. She is an associate professor in the
Department of Medicine at McGill University. As a certified mindfulness-based stress reduction (MBSR) instructor, she spearheaded the
mindfulness programs for patients, medical students, residents, physicians, and allied health-care professionals at McGill Programs in
Whole Person Care. Dr. Dobkin collaborates closely with Drs. Hutchinson, Liben, and Smilovitch to ensure the quality and integrity of the
mindfulness courses and workshops offered at McGill University and
other venues (e.g., conference workshops, weekend training retreats).

Mindful Rounds, Narrative Medicine,

House Calls, and Other Stories
Maureen Rappaport

Autobiography is only to be trusted if it reveals something shameful.

George Orwell

I started writing about my clinical encounters, including errors,

confusions, uncertainties, and hateful patients when I discovered the slim volume of William Carlos Williams Doctor
Stories [1] in McGills Osler Library. Williams, a physician,
was an early twentieth-century American poet. He is famous
for his modern poetry but I love his prose. In Doctor Stories,
he writes openly about negative feelings for his patients, his
sometimes unprofessional behaviour, his helplessness in the
face of medical limitations, extreme poverty, social misery,
and his shame, hate, joy, and love for these same patients.
Almost a 100 years lay between Dr. Williams and me,
yet for the first time I found the mentor I did not know I
was looking for, and heard another physician express taboo
thoughts and emotions that resonated with me. The doctor in
these stories reached out to me from the yellowing pages of
a book, and gave me permission to do the same.
I had written passionately in a journal since adolescence,
but in medical school the entries became sparse and disappeared as I matured into practice. Sitting under the shadowy
light of the librarys stained glass windows, I picked up a pen
and began writing. I have been writing since then, learning
about creative writing in general and narrative medicine in
particular, and leading writing workshops for medical students, residents, and staff for the past 20 years.
The method I use when writing, the one I teach medical
students and residents, is loosely based on creative writing
techniques I have learnt in writing workshops using prompts
I have learnt in medical humanities and narrative medicine
conferences. A huge influence on my writing practice is Nathalie Goldberg, American writer and writing teacher, who

explicitly compares writing practice to sitting practice in Zen

Buddhism, in her best-selling creative writing manuals,
Writing Down the Bones [2], and Wild Mind [3]. Goldberg studied formally with a Zen master for 6 years and wrote
that whenever she had trouble understanding something
about Buddhism, he would compare it to something she did
in writing. At one point, he suggested that writing practice
could replace her sitting practice, if she went deep enough.
The basic unit of writing practice is a timed exercise. The
instruction Goldberg gives to writers is like mindful practice.
You start at 10min and build up to an hour, and commit to
that time working with the following instructions:
1. Keep the hand moving (no rereading to try to get control
of what is being said)
2. Dont cross out (thats editing as you write. leave it for
3. Dont worry about spelling, punctuation, grammar or
staying on the lines
4. Lose control
5. Dont think; dont get logical
6. Be specificpay attention to details
7. Self-compassionits okay to write a bad first draft
8. Go for the jugular (energy in our personal hot spots)
The narratives and poems herein were written years ago,
using images and musing taken directly from my journals
of clinical practice. The stories are works of fiction, though,
with specific identifiers changed to protect patient confidentiality.

Department of Family Medicine, McGill University, 211 Ballantyne
Avenue North, Montreal West, QC H4X2C3, Canada
P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_2,
Springer International Publishing Switzerland 2015

M. Rappaport

A Litany of Discomforts
Mrs. H. was not physically attractive; she had a cushingoid,
fish-like face, and beady little eyes. Her lips looked like she
sucked on a lemon all day and now wanted to spit them in
my face. She was built like an overstuffed salami.
She was double-booked for a cough and I was running
2 hours late. I saw her scowling at me every time I rushed
through the waiting room to get another patient. When I finally called Mrs. H. in, she slowly collected her coat, hat,
and cane, which she carried like a weapon, and installed herself into a chair in my office as if she was ready to dig in
there for the entire winter.
A cough is usually a quickie. I need only ask a few
questions about fever, phlegm, shortness of breath, and then
listen to the lungs. I could do it in one shot, in less than 5
min, if only she would cooperate.
I wheebr ghunt chichi.
Were those words or wheezes? I could hear air struggling
to exit her constricted mucous filled bronchioles as the guttural grunts assaulted my tympanic membranes.
I have other, overweight, moustached old lady patients
who I love to hug, who even smell a bit of urge incontinence.
What is it about Mrs. H. that rubs me like fibrosed pus in
diseased pleura?
Is it her obnoxious son, Marcus, who at that moment
barged in the office, yelling into his cell phone? He is an
accountant who makes sure I balance his mothers litany of
complaints and neatly arrange them like the myriad of coloured pills in her dosette box.
Or is it because she never makes a proper appointment to
present me with glucose and creatinine levels, her sore back,
and obstructed lungs but is not fluent in any of the languages
I speak, and Marcus is a lousy interpreter (they spend half
the time arguing in Arabic)?
After I got through the ordeal of slipping my stethoscope
through a crack between her corpulent flesh and full body
girdle; when I was nose to thorax, skin to skin, I remembered
she had another son who was a paranoid schizophrenic, who
she still took care of, through his violent outbursts and despair.
She was a mother, like I was.
The air between us opened like a puff of ventolin to her
lungs. It did not last long but I took a few deep breathes in
the middle of a chaotic day.
William Carlos Williams unleashed my inhibitions towards writings about situations which, or patients who stir
up anger, shame, and what I perceive as unprofessional behaviour.
My writing practice includes my mistakes, the dark side
of my all too human nature, critical incidents [4] that are
given shape and form through prose and poetry. The practice consists of three phases: (1) the actual writing, (2) the
reflecting, in public, which can take many forms, such as

parallel chart sessions or small group responsive reading sessions, and (3) private redrafting of the story.
A Litany of Discomforts was written in response to the
trigger to write about someone you dislike so the first draft
consisted of my litany of complaints against Mrs. H., a fat,
ugly, difficult historian, with an aggressive family member.
The next exercise was to rewrite it in from the patients point
of view.
The draft reproduced here is a third draft, a story that
came out of my experiences of patients like her, in a similar
situation, where the metaphors of connection, in the last two
paragraphs healed the metaphor of congestion and inflammation. In the story with Mrs. H., it took physical touch, getting, nose to thorax, skin to skin to awaken the distracted
doctor to a memory of their humanity, to compassion from
one mother to another. The physical exam, facilitated a visceral conversation to occur where a verbal one was impossible, gently returning the doctor, as in meditation, back to
a present reality of non-judgement and awareness where
actions may occur more skilfully. It took me years to write
the way I did about Mrs. H., because it was hard to pierce
through my mask of professionalism to find repulsion in the
sacred doctorpatient relationship.

Stiff and Falling

Francine was booked at 9:00 a.m.. She is 40 years old, has
complicated neurological problems, and severe Parkinsons on
Comptan, and I can barely manage Sinnemetand now her
back hurts and her right leg is stiff, and, oh ya, she is falling.
Can I fill out her drivers license? NOW! she demands.
She has been tested already, or so she tells me, and I
vaguely remember this uneasy feeling I had a couple of years
ago when asked to renew her license. Francine can barely
walk; she is off balance and has choreatic movements. How
can she drive safely?
I told her to wait in the waiting room. In between other
patients, I put in a call to her neurologist. Dr. N. said physiotherapy might help the stiffness and pain (she cannot afford it), agrees she needs a proper driving evaluation, and
maybe she should take some time off work. As I tend to other
patients, I shakily place each brick of a therapeutic plan between Francine and me.
At 10:20 a.m., I call Francine back into my office thinking
I have the answers. I have the solution. Something about my
demeanour does something to hers. Wetness begins to seep
through her stony features. She is a humid wall with lips too
stiff to quiver. I have approximately 5min to spare.
Think family medicine. I need to F.I.F.E. her:
Feelings; theyre obvious, shes crying.
Ideas; what can I do to help you Francine?
Function; shes at work, as usual, but falling.
Expectations; she wants something I cant give her!

2 Mindful Rounds, Narrative Medicine, House Calls, and Other Stories

She proceeds to tell me the whole thing again, about the stiffness and numb back, the funny movements in her right leg,
the falling in the kitchen, and if she does not drive, she will
be worse because she will fall on the bus.
But, Francine I say, I also have to make sure youre a
safe driver and wont kill anyone else. Maybe you need some
time off work?
My pills are so expensive, over $400 a month! Are they
even doing me any good or are they slowly killing me? she
Its almost 11:00 a.m.
The skin around her eyes reddens and crumbles, as I stiffen more to keep from falling.
Robert Frost says we do not look to poetry for solutions
to problems but a pathway through. This is equally true in
clinical narratives, and mindful practice.
Dr. Charon is an internist as well as a literary theorist. She
has coined the term Narrative Medicine and legitimized
something ephemeral in an evidence-based medical education world by using the precision, structure, and validity
found within literary theory. This allows for a certain objectivity, distance, or nonattachment of the self in an exercise of
self-reflection, self-awareness, and awareness of the other.
I see Charons treatment of the parallel chart [5] much as
I see the mindful approach to our thoughts. She asks us to
focus on the text, to honour the text not to focus initially
on the clinical situation or arising emotions. It is a work of
fiction, and Charon first comments on genre, temporality,
metaphors, narrative situation, and structure. She then asks
her students to listen for the writers voice, and invites them
to respond to the text, in their own individual way.
Stiff and falling is a first-person clinical narrative, written in the doctors voice, but the voice in this story is very
different than the first. It is written in an almost clinically,
detached way, a forty year old, complicated neurological
problemParkinsons, on Comptan. A specialist is consulted, and a family medicine guideline, feelings, ideas, functions, and expectations (FIFE) [6] is used, all to no avail. The
time is reported three times. Metaphor and image are used
only twice, both in reference to Parkinsons.
Wetness begins to seep through her stony features. Shes
a humid wall with lips.
The skin around her eyes redden and crumble, as I stiffen
My response to this story is that the doctor is uneasy with
the patients request for a drivers license, yet does not want
to be perceived as the bad guy, so she tries different stalling
techniques all morning, and takes on a stony face persona, to
become an emotional wall, mirroring the emotionally Parkinson stiffness, to do what she must.
In reflective practice, Bolton [7] states that this type of
writing is more than confession, and more than examination
of personal experience. Writing becomes a method of inqui-

ry, not just a way to tell, but a way of knowing. It will not
directly answer the question, What should I have done?,
but allow one to stay present with the realities of uncertainty,
difficult, and painful issues.
There is no easy solution, or answer, to some clinical
situations, but perhaps allowing herself to feel and act on
her unease with authenticity, would have allowed the doctor
to show more empathy towards her patient and soften their
Parkinsons disease is so visual and visceral for me perhaps because my father struggled with this disease for many
years. I have written many narratives about this disease.

Bessie Pulse or Parkinsons

She shuffles slowly to my examining room, stick legs
in polyester barely lifting off the floor. Even the walkers
wheels do not roll, but stutter and squeak. Twiggy bones, I
hope she does not fall, support an ancient stone, her head.
Blistered lips quiver.
Im getting along just fine Doctor.
Dirty nails shake. How will she ever thread the button
through the hole?
I undress her, help rigid limbs slip through an armpit
stained shirt. I wrap the vinyl, blue blood pressure cuff around
her left arm, and hold on, one hand placing my stethoscope
over the bend in her elbow, the place I should hear the steady
knock of her pulse, with the other I inflate the cuff.
Bessie has Parkinsons disease, her arm cannot be stilled.
Despite closing my eyes and holding my breath, I cannot
hear her heartbeat because of interference. The noise of her
illness sounds like sandpaper rubbing against stone.
I am clutching this shaking arm, and feel the turbulent
beat of Parkinsons pulsate through me.
My stethoscope cannot separate us now.
Bessies pulse, like stiff and falling, is a first-person
narrative told from the doctors point of view about a patient with Parkinsons. In this story, as well, there is countertransference of the patients main symptom unto the doctor, this time tremor, instead of stiffness. Although there is a
literal connection with her stethoscope, she holds her breath
and is able to feel the turbulent beat of Parkinsons pulsate
through me. I am uncertain whether this doctor is being any
more effective than in the previous story.
These stories are simply a way of knowing. I try to remember to keep breathing calmly, during clinical encounters.
Writing narratively about a patient forces the clinician to
dwell in that patients presence. In describing a clinical encounter with a patient, I have to sit silently with my memory
of having been with her. The descriptions of the patient and
of the self usually include very powerful interior dimensions;
the biological interior of the patients body, the emotional in-

M. Rappaport

terior of the patient, and my own emotional interior. Finally

there is the interior of the two of us [5].
I love being a family doctor, in general, and making house
calls, in particular because it is a very special moment when
patients open the door to us, their family doctors, and gift us
with a part of their essence. A doctor has little control over
things in a patients home. Aside from a nostalgic connection
to a remote past of the revered and beloved family doctor, it
brings one into the patients world faster and closer. Their
stories are not only in their eyes as in a usual clinical encounter, but in the family portraits, plants, shabby furniture, piles
of beloved junk, and chipped tea cups.

July 1999
Mrs. W. was an 88-year-old woman, with diabetes, among
other things. I had never met her before. It was a beautiful
summer day when I visited, to assess a foot ulcer. I am wearing sandals and I remove my footwear before entering her
house. Mrs. W. can hardly move, and it takes all her energy
to finally plop her weight down on an easy chair.
She wants to show me something under her left heel. She
lifts her leg as I try to support her calf. I squat on her living
room carpet (baby blue broadloom), holding an old ladys
leg, trying to position the heel, my eyes, and the light source
strategically. I cannot see. She shifts, I change angles, and
another lamp is lit.
Sitting crossed legged on the blue broadloom, I hold her
foot, assess the callous and surrounding red skin. I press
here and there (it hurt a bit), wondering if I should lance the
wound. It looks and feels okay. I pack up, say my farewells,
and leave.
Back at the clinic, writing my note I feel like a dummy.
With all the shifting, holding, and manoeuvring of lights, I
forgot the foot I was holding was a diabetic one. I did not
test for sensation, or feel for a pulse. I blame it on the blue
broadloom, the feel of it on my naked toes.
And then I remembered the warmth of her foot in my
I will apply the drill Charon uses (frame, form, time,
plot, and desire) with her students in parallel chart sessions,
more to enhance and illustrate a mindful process, than to
offer an explanation of the texts. Recognizing that without a
group of astute readers to help me, the self-awareness, selfreflective, and mindful aspects of writing are compromised
because writers need readers who can reveal what the writer
himself or herself cannot see [5].
So I ask you, attentive readers, to let yourselves respond
to the text independently of my offerings and to continually
ask these questions, in addition to the drill.
What do you see? What do you hear? What do you want
to learn more about? [5].

In the opening story with Mrs. W., the narrator starts out
being very busy and focused on trying to see something that
ultimately remains hidden for all sorts of reasons. I cant
see. I shift, change angles, and another lamp is lit.
The doctors desire of perfect physical exam, perfect
note, and harsh self-judgment, I feel like a dummy, probably sounds familiar to many clinicians. Then through the
unconscious use of metaphor, she was literally taken back
to her senses, to feel the lush broadloom on naked toes. This
feeling, this way of being, brought her to another way of
seeing her patients body. And then I remembered the
warmth of her foot in my hand. The metaphor of a patients
warm foot likely refers to more than the presence of a pulse,
but the ability of a patients innate humanity to heal the doctor, to help the author of this short piece let go of her imperfections as a doctor, and still be whole.
When I first sat down to write this story, I had no idea it
would come out this way. The writing process, then reading
it with some distance, using Charons framework achieved
mindfulness of body sensation, awareness of self-denigration, to transcendence through human connection.

Doctor, I never imagined me, who has always been so
strong, to be so weak and slow. Dont get old. Ninety-six,
ech who needs it?
What, I ask, Do you want me to die young?
Mollys lips, chapped but still generous, press together as
she paused for a second.
Doctor, I love you like a friend, God forbid you should
die young. Thats it, lifes a mystery and its a terrible thing
when God takes a young person and leaves someone old
like me! A friend of mine, much younger than me, a second
cousin, died suddenly. I was at the funeral yesterday. She
was only 74!
Mollys muzzle was whitened. She wore badly fitted
dentures stained with bits of lipstick. I could imagine her
face and body rounded out in health in her prime. Today she
looked frailer than usual, old and skinny. She shuffled to
greet me at the door of her room schlepping her sunken jowls
and droopy eyes along with her walker and old beige purse.
That old wrinkled bag looked exactly like the one my bubby
had, the one she would let me rummage through in search of
candy. Mollys Yiddish flavoured diction, the lipstick smear,
the clean, yet simple red woollen jersey over nylon black
pants were all familiar.
I dont think Ill survive till Rosh Hashanah, she says,
making sure to stress that the pain in her left ankle is particularly bad. The Jewish New Year is 3 days away and Molly
is over 95.

2 Mindful Rounds, Narrative Medicine, House Calls, and Other Stories

I measure blood pressure, auscultate her heart and lungs,

fiddle with her ankles, but I think the hugs and sincere wishes of happiness and health in the New Year we exchange, are
just as important.
The following poem is poetic musing on Mollys words to
me. Poetry, in skilled hands, primarily makes the reader feel
something, rather than understand something, using form,
rhythm, image, metaphor, etc. One of the aims of mindful
meditation is to get out of our ruminations and be aware of
our emotions, or feelings. I am not a skilled poet, but I love
writing poetry because it frees me to let images percolate
into connections I never saw before. Like how a patients
cataract reflects light instead of allowing it to penetrate to
the retina.
old woman
waiting alone
dragged down by
osteoporosis and time.
Your glorious white crown
bowed over the shiny new walker.
Little old lady, who would recognize you?
Dont get old, you always whisper.
As I look into your shimmering eye
the light of my scope reflects
off your cataract,
a wall of

When I first wrote the poem, I was not aware of how much
I identified with Molly, and all my geriatric patients in general. I saw my past, my wonderful grandparents; my present,
the reflection off the cataract; and my future, my little old
lady self.

Girls, girls, everybody in.
I was in the elevator at Mollys residence, angry at the
speaker calling a group of four or five white haired, ladies
with walkers and granny purses, girls. The speaker was the
last one in; she had a dowager hump, crowned with a white
pouf. Oh, its okay then, I thought. A 30-something Russian companion, thin, tight tee shirt, Capri pants, well-heeled
sandals, sexy polished toes, lots of young tanned skin, also
Wheres Nathan? asked one of the white perms.
I killed himchuckled the Russian. She looked around.
No one was noticing her despite the cropped metallic red
I said I killed Nathan!
Its kind of funny and I smile, feeling less like a foreigner
in a land of octogenarians.
What, says a little lady, not on the Sabbath, I hope!

Trench humour at the residence.

This would be funny if it wasnt so tragic, a sour voice
next me pipes in.
It is funny!
No tragedy here.
It would be tragic, though, if Molly jumped out the window as she told me several times she would like to if she
could, but vows she would never because it would not be
nice for her grandchildren, or great children, or the residence.
She once asked me for pills to overdose on but quickly whispered, Never mind, I couldnt do that to you, yet if I had a
knife Id stick it in my heart.
I did not believe her as only the week before, when I treated her pneumonia with antibiotics, she called me a life saver,
as she pinched then kissed my cheek.
Some days Molly clings to life with the same determined
grip she has on her walker. Other days she is resigned to just
sit there, impatiently, gleaming walker and all, like an eager
bride, waiting for death.
It would be nice if she died in her sleep.

Jeannie is a 60-year-old schizophrenic. I am making this
house call more for her elderly mother, Beryl, also my patient, who cares for her. It is too cold, icy, and challenging,
for mom to bring Jeannie to see me. I have seen Jeannie only
a few times through the years, though I know a great deal
about her from the stories Beryl has told me.
A brown slime oozes out of Jeannies broken teeth. Her
wrinkles contain crumbs, bits of toast or old boiled egg. Her
clothes that are way too big for her shrinking frame of bones,
smell like cabbage and wet blanket. She has lost over 30lb
in the past few months.
It is clear to me she must have a tumour somewhere. Her
sister who lives on the other side of town told me to leave it
alone. Do not investigate, do not treat.
When mom dies shes going in a home, anyways. I cant
take care of her like she does. Her life is awful. Shed be
better off dead.
Mama Beryl, with her orange hair, is still a spitfire at 86.
She wears pearls and lipstick for every one of my visits but
the state of things at home are pointing to Beryls difficulty
What do we need those tests for Doctor? Jeannies got
no pain? Going up to hospital for her treatments is hard
Jeannies been getting electroconvulsive therapy (ECT)
monthly for years now. The family insists on my secrecy
with Jeannie. Her understanding and grasp of things are at a
juvenile level and she reassures me she wants her mother to
decide on everything.

M. Rappaport


I speak to her psychiatrist who is also concerned about the

weight loss but concurs that scans, scopes, and operations
would bring on a relapse, so why torture poor Jean?
What would Jeannie want, what is best for her? Though
her well-being permeates through everyones perspectives,
we each have our own personal agendas.
These narratives are about patients on the doorstep of
death, one waiting for death to come, like an eager bride,
the latter, Jeannie, hints of a deadly illness brewing, kept in
the dark, in accordance with her guardians wishes, do not
investigate, do not treat. Shed be better off dead.
With Molly, the writer can allow herself to remain passive. She starts out being a distant narrator, a foreigner in
the elevator, but a true foreigner, the Russian, dressed differently in this land of octogenarians sexy polished toes,
young tanned skin unites them all with tragic humour.
And Mollys plea for assisted suicide is ironic, it wouldnt
be nice, and she does not want to get the doctor in trouble.
The doctor is able to stay in the background, although the
wish is there for her to be able to remain passive in this matter hoping that Molly dies in her sleep.
In Jeannies story, the writer thinks she may have the
control of life and death in her hands and is in a dilemma.
Scans, scopes, and operations, is what the doctor needs to
put order in this chaos of not knowing what is wrong with
the patient, although she is unsure of how to get informed
consent. The messy world of mental illness and severe disability are juxtaposed on medical logic. Her clothes that
are way too big for her shrinking frame of bones, smell like
cabbage and wet blanket. She must have lost thirty pounds.
There is no reaction to the slime on the teeth, only to the
weight loss.
What is best for her? in the context of her severe mental
illness, the reality of her dependency on an aging mother, is
a taboo question for this writer and remains hidden like the
inevitable cancer.
The doctor in Jeannies story cannot remain consciously
passive. She cannot contemplate a doctor surrendering control, cannot see herself perhaps overcompensating in a world
where all the forms are not filled, old ladies misbehave, and
mental illness challenges our concepts of equality.

November 21, 2000

Molly was a Jewish refugee from Russia. She came before
World War II, alone, and penniless, and survived by cleaning houses. Today, her only child, a son Marty, who lives in
Boston, gives his mom everything he can to make her life
easier. She now needs a hospital bed moved into the suite of
the fancy residence. Her gnarled fingers do not have to clean
other peoples houses any more. Other people now look after
all her needs.

Her little white-haired body is lost among the white crisp

sheets. Those caved in wrinkled lips reach out to kiss me.
She is surrounded by women; a doctor, a nurse, the residence
manager, the companion. She begged me not to send her
to the hospital ever again, that she was not afraid of dying,
that she was tired already. On his last visit, Marty agreed on
comfort care, to Do everything to ensure his mother died
peacefully was of the utmost importance to all concerned.

November 25, 2000

Molly was breathing rapidly. Her pulse was fast. With chronic lung disease and heart disease, her lungs always sounded
wheezy and rattley so that did not help much. She was unresponsive.
The nurse was around from 9 a.m. to 5 p.m. so she could
give furosemide, nitro, and morphine subcutaneously during
working hours. What would happen at 10 p.m.? This could
be pneumonia, a heart attack, anything? They already had
the oxygen on her. My little oximeter read an oxygen saturation of 60%. Very bad.
I spoke to Marty long distance and got my orders not
to transfer to hospital. The only humane thing was to use
a syringe driver loaded with morphine, scopolamine, and
midazolam. In plain language, I managed to get a community palliative care pharmacy to quickly mix what I guessed
would be enough of a cocktail to keep Molly and her caregivers peaceful. A tiny needle inserted unobtrusively in her
skin would deliver symptom relief for 24h. The geriatric
mantra of going low and slow no longer applied. I probably
administered a form of terminal sedation to ensure Molly
went gently into that night.
It would have been much easier to call 911. Some of my
colleagues may disagree with my actions.

December 5, 2000
Jeannie spent another month at home with her mom before
her bowel ruptured. It was a clean, hidden rupture that walled
itself up, so though bedridden, hospitalized, and terminal,
Jeannie was still able to eat a bit. I found myself visiting her
bedside in hospital, guilt ridden over an outcome that was
inevitable. We were alone, and I heard myself asking Jeannie
if she knew she was dying?
Jeannie looked at me, bewildered.
Oh, what have I just done? I searched through my mind
for a way to fix things, because in my mind I had erred in my
care for this patient in so many ways.
Are you afraid? I asked, trying to see if she understood
Oh, not so much, but I just want to get the dying part
over with.

2 Mindful Rounds, Narrative Medicine, House Calls, and Other Stories

A Medical Intervention
She is a body between
White sheets labouring
Like all the rest on the
Oncology ward. Comfort
Measures only. Nothing
More to do. The grey tubes
Of my stethoscope, lie
Limp round my neck.
I notice her staring
At her food tray.
The cool steel of a
Teaspoon connects us.
Peaches in syrup slip
Between parched lips.
Nourishment in this sea
Of bowel disease.

Using poetry in my writing practice is something that

emerged in my process. It was not a conscious decision, nor
used as a specific literary device. Turning to my mentor, William Carlos Williams, I quote:
You cannot get the news from poems
Yet many die miserably from lack
of what is found there. [8]

Writing and reading my own poems evokes something profound in me, something I cannot explain in words, but similar
to what a poetry lover experiences when reading a favourite
poet. I am totally present and in the moment, while writing
and rereading my poems. My professional and personal egos
are of no concern.
Poetic form does not have to follow narrative or cognitive
logic, line breaks can defy grammatical rules, the interpretations can vary, yet we can learn how certain words and images trigger certain thoughts and emotions [9].
The doctor could not let Jeannie go without doing some
sort of medical intervention, so she asked her if, she knew
she was dying. It did not take long for the doctor to recognize her error and that it was time to focus on the patient
and the patients needs, which came in the form of peaches
in syrup.


The cool steel of a teaspoon connects us, peaches in

syrup slip between parched lips, nourishment in a sea of
bowel disease. Each time the sound of those words slip
off my tongue, I feel deeply satisfied, and nourished as if the
poem itself, becomes a medical act of feeding a patient.
Medicine is a calling in which our hearts are exercised as
much as our heads, to paraphrase Sir William Osler. Practising medicine mindfully with a strong heart is to practice with
an awake openness and tenderness to both my patients and
myself. Writing has always been a way for me to stop and
nurture moments. Writing about my medical practice gives
clinical moments a new beginning, a new way of seeing,
hearing, touching, and connecting [10].

1. Williams WC. The doctor stories. Compiled by Robert Coles. New
York: New Directions; 1984.
2. Goldberg N. Writing down the bones. Boston: Shambhala; 1986.
3. Goldberg N. Wind mind: ling the writers life. New York: Bantam;
4. Epstein RM. Mindful practice. JAMA. 1999;282(9):83339.
5. Charon R. Narrative medicine: honoring the stories of illness. New
York: Oxford University Press; 2006.
6. Weston WW, Brown JB, Stewart MA. Patient centered interviewing Part I: understanding patients experiences. Can Fam Physician. 1989;35:14751.
7. Bolton G. Reflective practice. London: Paul Chapman; 2001.
8. Williams WC. Asphodel, that greeny flower (excerpt). New York:
New Directions; 1962.
9. Connelly J. Being in the present moment: developing the capacity
for mindfulness in medicine. Acad Med. 1999;74(4):4204.
10. Kabat-Zinn J. Wherever you go there you are. New York: Hyperion; 2005.
Maureen Rappaport MD, FCCFPhas been a community family
physician for more than 25 years. Although she has a soft spot for the
elderly, her practice encompasses prenatal and newborns up to end-oflife care. She is an associate professor of medicine at McGill University
where she teaches clinically at both the undergraduate and graduate
levels, and shares her love of creative writing. She is also a wife, and a
mother of two young adults.

Lost Heart (Beat)/Broken (Body)

Patricia Lynn Dobkin

The Uses of Sorrow

(In my sleep I dreamed this poem)
Someone I loved once gave me
a box full of darkness.
It took me years to understand
that this too, was a gift.
Mary Oliver [1]

Epstein [2] adapted the core aspect of mindfulness to clinical practice and described the four habits of mind of the
mindful practitioner. First, she engages in attentive observation of the self, the patient, and the problem. This awareness
includes ones own perceptual biases and filtering processes
such as when the therapists residual developmental issues
influence how she/he interprets a patients words or behaviours [3]. The second habit is curiosity. For example, the clinician may wonder why certain facts do not add up. The
third habit has been referred to as the beginners mind, i.e.
the ability to see things as if for the first time. The fourth
habit is termed presence; by being fully with the patient,
ones work can be guided by insight and compassion.
In the first part of this narrative, I will highlight how
these habits of mind were instrumental in my work with
Monique. In the second part, Monique will reveal her
perceptions of what transpired within her as she faced her
issues in therapy.
Keeping Mary Olivers poem in mind while reading this
narrative, one may ponder what gift (if any) was lurking in
the box full of darkness she opened during our psychotherapy sessions.
Following a flurry of back and forth e-mail correspondences, a mutual decision was made for Monique to start
individual psychotherapy rather than belatedly join my
mindfulness-based stress reduction (MBSR) program for
P.L. Dobkin()
Department of Medicine, McGill Programs in Whole Person Care,
McGill University, Strathcona Dentistry and Anatomy Building,
Room: M/5, 3640 University Street, Montreal, QC H3A 0C7, Canada

p atients with chronic health problems. As it turned out, this

was a better choice, given Moniques situation.

Attentive Observation
I noticed myself listening intently to Moniques expos of
the weighty problems she was experiencing with an open
mind. As she described how distraught she felt when the
technician called in the doctor once the ultrasound test indicated that her 13-week-old foetus no longer had a heartbeat,
I was thrown back to the moment when an oblivious resident
turned to me 22 years earlier. I was then 7 months pregnant
following 6 years of infertility treatment when he bluntly
stated, This is the worst stress test I have ever seen. I can
still see his face, one that expressed no emotion whatsoever.
I too had been alone, like Monique; our respective husbands
not there to help us bear the brunt of these words.
When Monique related how hard it was for her to cope
with a miscarriage that occurred the year before, I recalled
being equally disheartened following two miscarriages prior
to and yet another one following my infant son Nicolas
death. Being keenly aware of these phantom memories, I
made a mental note to accept them, but not permit them to
intrude. I wondered if my own heavy history would help me
relate better to Monique or if it would trigger counter-transference. I chose not to give voice to my past in the context
of our sessions because self-disclosure would not have been
appropriate or helpful. Nonetheless, I recognized that what I
lived through would influence how I listened and related to
Monique. Some of the parallels were uncanny.
During the session, my thoughts returned to the time
when, like Monique, I was focused on my career, while my
biological alarm clock signalled that procreation time was
running out. She being 35 years old now, I, 36 thencommitted to reaching academic milestones at a respected medical
school. In retrospect, I realize that I too sometimes worked

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_3,

Springer International Publishing Switzerland 2015


P. L. Dobkin


rather than experience unpleasant emotions. Determined to

have it allcareer, family, and financial security, typical
of the baby boomer cohort I belong toI dove headfirst into
life with scant awareness. Over the past two decades, my
mindfulness practice has been instrumental in revealing and
changing this pattern. During our sessions, I could feel yet
not react to my part of this unfolding story.

Monique entered my office with a sense of urgency the first
time we met. A tall woman dressed in dark colours accented
by bright scarves and an impressive handbagshe sported
pitch-black hair cropped close to her skull showing off her
chiselled facial features. As a professional, Monique gives
the distinct impression that she has a way with words, yet
her speech in French and Englishwhich she switched from
one to the other without hesitationwas pressured (more so
in her mother tongue, French).
From sessions to session, scarves became attractive
necklaces and various handbags were set down behind her
Im a big shopper, she admitted in passing.
I admired her taste in accessories. They suggested that her
appearance mattered, yet she was not ostentatious or affected
in her manner. The dark sweaters and trousers hinted that
something was concealed underneath it all.

Presenting Problem(s)
Monique has a history of various anxiety disorders (e.g.
phobias; obsessions and compulsions); she reported that her
mind races (e.g. during meditation, she experienced her mind
as a river rushing forward) and that she harbours distressing thoughts that clutter her mind (e.g. my body is broken)
and envisions terrible things happening.
Four years earlier, she gave birth to a son who has autism. Several sessions that focused on her feelings regarding him revealed a mlange of hot emotions: guilt, rage (in
the face of others reactions to him), along with harsh judgments of herself as a mother compounded by worry for his
Monique had had a miscarriage a year earlier and her
fourth pregnancy ended therapeutically when the babys
heartbeat was lost a few weeks prior to our first session. She
experienced continual bleeding that required yet another
medical procedure. These multiple medical problems convinced her that her body was broken.

I was curious about what Monique was not talking about:
How she managed to work full time in a demanding job, while
raising a special needs child; what her work meant to her; if
religion or a philosophy helped her make sense of her multiple
losses. Little to nothing was mentioned about her husband
other than the fact that they had sought counselling following
their sons diagnosis to assist them in making the decision to
have another baby. Moreover, I wondered what it was like to
be the oldest of a large family and how this influenced her
ardent desire to be a mother. Did she help raise her siblings?
I knew she was close to two of her sisters, a physicist and a
painter, but what of the others? No mention was made of them.
Nor did I get a sense of her having friends or a social network.
Was she isolated by having a child unlike the others? Did having a special needs child drive her desire have a normal
one? Could Monique accept to have only one, this one?

Beginners Mind
Each patient who crosses the threshold into my office affords
me the opportunity to meet a new person; one I know absolutely nothing about. I rarely read a medical chart before the
first session, as I want the person to reveal to me what I need
to know, from her perspective. Thus, as I usually do, I opened
the session with the question, What brings you here now? I
was ready for the not knowing to slowly evolve into knowing.

Siegel [3] defines presence as, how we are fully open to
what is emerging within and between us, a state of receptivity to what arises as it is happening. He continues by explaining that it enables us to focus our attention on the internal experience of another persona process called attunement; we honour differences and promote compassionate
linksintegrative acts. Interpersonal attunement may give
way to resonance, i.e. whereby the other feels felt by us
deepening our connection, arousing trust, and encouraging
social engagement. This process is crucial to psychotherapy.
It is likely that our ability to be at ease together was related to our earlier, respective experiences in relationships in
which we could be open and honest. Also, my role as Dr.
Dobkinher psychotherapistprovided a context and safe
space for her to explore her innermost experiences.
As our relationship deepened and we became comfortable with one another, I began to feel un-at-ease with her use
of my title Dr. Dobkin. It was as if there was a glass wall
between us, transparent but obstructing the space that invites
healing. Moreover, my own use of the word patient rather

3 Lost Heart (Beat)/Broken (Body)

than human being (Dr. Paul Jurkowski, personal communication, July 23, 2006) clouded the glass with a mist contributing to the illusion of separation. Having worked as a
psychologist amongst physicians for 25 years, I had long ago
adopted this jargon as a means of gaining acceptance into the
exclusive club of medicine. My research and publications
were aimed at demonstrating empirically that psychosocial
factors were crucial to patients mental and physical health.
But now, with integrative medicine gaining ground in the
finest of medical faculties, is this still necessary, I wonder.
More importantly, could I drop it in the context of Moniques
therapy? Was it not more professional to maintain my role
as her doctor? Could I shift midstream from Dr. Dobkin to
Patricia? Would this invite Monique to meet the whole person that she is; the one who is complete just as she is? While
these reflections were not voiced, they became my homework, in between our sessions. I decided to keep the title.
I also paid more attention to the use of self-disclosures
of any kind. As is typical of an MBSR instructor, sometimes
one shares insights from ones own practice. For example, I
have practiced yoga for the past 18 years, and I mentioned
how it helped me to see the direct relationship between body
pain and emotional suffering. I spoke of how it helped me to
stay with rather than avoid not only body sensations but
also lifes challenges. As Epstein made clear in his book, The
Trauma of Everyday Life [4], all experiences are recorded in
our bodies, and we can learn to work with them. Nonetheless, before speaking of me or my experiences, I asked myself three questions: (1) What is my intention? (2) What may
be the impact? (3) Is it appropriate?

Monique needed to probe the disconcerting experiences
lurking in her consciousness. Much like snow melting in
springtime, they filled rivers with wet emotions once she
took the plunge.
Outside of our sessions, she began a meditation course
with a well-respected French-speaking meditation teacher.
Her sister, who has been meditating for 10 years, accompanied her, and she found this support helpful. Given her
attendance to these classes, I chose not to teach her, as I do
with some patients, how to meditate. Monique found these
classes worthwhile yet she had some difficulty not judging
her practice since her mind, like most minds, wandered endlessly during the sitting-meditation practices.
Even though Monique did not take my MBSR course, I
introduced elements of it when they were called for. I gave
her compact discs (CDs) for home practice of the body scan
and hatha yoga. Most patients, including Monique, find
the diagram depicting the triangle of awareness (Fig.3.1)
helpful in understanding how mindfulness can elucidate
the mindbody connection. For example, when Monique


Fig. 3.1 Triangle of awareness

was undergoing a medical procedure, she observed that her

thoughts contributed to her body tension as well as how
anxiety contributed to her suffering. Once she appreciated
these links, she was better equipped to respond to the situation rather than react.
STOP, while seemingly very simple, is another tool
for patients caught up in unhealthy patterns. S=stop or slow
down; T=take a breath; O=observe (e.g. use the triangle of
awareness to gain insight into dysfunctional patterns); and
finally, P=proceed, based on ones knowing/understanding
what is occurring and choosing the best response for a given
situation in the present moment.
Exhausted from the hormonal changes due to her pregnancy and its termination, Monique found that the body scan
helped her sleep. She had avoided her emotions regarding
the end of yet another hopeful period and its implications by
immersing herself into her work the holiday weekend right
after receiving the devastating news. Given Moniques racing mind it is not surprising that hatha yoga was more accessible to her than sitting meditation. She found this practice
especially helpful as she used to work out at the gym and
needed a physical way of healing her body and spirit. During
the sixth session, Monique told me about a situation in which
she wanted to pick a fight; she noticed this urge in time
and withdrew to practice yoga rather than act out her anger.
She was pleased with herself afterwards. I made a point of
noting this positive change as she was beginning to heal both
physically and emotionally [5].
Based on Garrison et al.s [6] work with medical students,
who were being trained to use narrative therapy with psychiatric inpatients, I recommended that Monique (in the fourth


session) start a journal by responding to the following questions:

What are the top problems that you had to face in your
What is the biggest problem you are facing right now?
If your problem were solved, how would your life be different?
Ten days later, Monique stated, I was like a crazed teenager
writing and writing, as the words spilled out in an incoherent manner. In fact, she had written more about topics we
had explored thus far in previous sessions. She had been instructed to write by hand, rather than with a computer, as the
process is different and may engage the creative, right brain.
Two other questions were proposed (in the fifth session) as
probes for writing:
What are some of the ways that you have succeeded
against your problems in the past?
Do you think it is possible that your problem exists for a
During our sixth session, I invited Monique to participate in
the cocreation of this narrative. Given the ethical issues that
could arise with this proposal, I was careful to state clearly
that if at any point she preferred not to do this I was OK with
that. We agreed that for her part of the narrative she would
focus on what was healing for her in our sessions together
as well as the mediation practices she was engaging in with
a French group and with the yoga CD I gave her from my
MBSR program.
After the holidays (during the seventh session), Monique
no longer perceived her body as broken. She found writing
in her journal provocative; it helped her to take the time to
reflect on her life. She was not as easily hijacked by obsessions; she witnessed thoughts with some space around them
and therefore was less distressed by them.
Some of the questions she explored through writing were
an extension of our sessions. Others were those I had assigned to her. For example, when she tried to address the
What have you done in your life that you are most proud
Monique felt stumped. She noticed the imposter phenomena. Here, we have a professional woman who was just
offered a new position in at work (despite having taken 3
months leave for health issues), and she had little to write
about. Appearances can be deceptive; Monique had struggled since adolescence to become socially skilled and accepted; she longed to belong.
Obsessions, compulsions, perfectionismall stemming
from the roots of anxiety permeated her bodymind states.

P. L. Dobkin

She was beginning to have some clarity about this by identifying less with her thoughts. Monique questioned whether her
thoughts were based in truth. While she called this detachment in psychology, we refer to this process as decentring.
Given Moniques proclivity for words several months
into her work with me, when we were seeing each other less
often (as she recovered and returned to work full time), I
read to her the poem by Rumi, The Guest House [7]. Something occurred that reminded me never to assume you know
anothers mindheart. While I supposed that the uninvited
guests that arrived at her door were her pregnancy losses
and her sons autistic condition, this was not what came up
for her. Instead, Monique spoke of anxious and sometimes
threatening thoughts that were most disconcerting. She expressed love for her son and related that her relationship
with him had improved over the past 3 months. Once more, I
needed to examine if and how my losses were loitering in the
room with us. I reminded myself that one cannot know what
lurks in the heartmind of another person. Not knowing is
another important attitude that mindfulness encourages. By
not being the expert, one can listen better and learn from the
other person.
Excerpts from Moniques journal (her identity is masked;
this is reproduced with her written consent):
December 9th, 2013the events that brought Monique to
the edge and to psychotherapy
On October 11, pregnant 13 weeks, I went for an ultrasound,
the one that screens for Downs syndrome, a routine test, a
detail almost, and then there was no heartbeat. And as much as
I always enter ultrasound rooms with the conviction that things
will end badly, I can now confirm that it still feels terrible when
they do. Right then and there, watching the technicians Adams
apple go up and down in her neck, the way you swallow just
before you have to deliver bad news, I knew even before she said
it, I knew in the way some things come to you almost through
your skin, skipping the brain altogether, that something had gone
wrong. And at that moment I felt like everything was caving in,
all the previous months of craziness at work, of tension over the
pregnancy with Martin, of feeling sick, not nauseous per se but
just overall tired and queasy and heavy and bloated and generally very much not myself, and the idea that this would stop in
the second trimester, that people would soon see that I had been
pregnant for three months, would praise me for having worked
so hard while in the first trimester, would take care of me, all
of it came to a brutal halt and I felt as if I had hit a wall. Over
the last three years I have had cancera benign one mind you,
not the kind you die ofthen an autism diagnosis for my only
son. Then I had a miscarriage at 11 weeks, after a difficult first
trimester of tension between my husband and me, over the next
kid being autistic as well. Finally, this second miscarriage at 13
weeks, this time after having been at the first ultrasound, and
having seen the heart beat. So this is where I hit a wall: on
the morning of October 11, 2013, in the dark and warm hospital
room with the technician being polite, passing me the box of
Kleenexes that I realized are not only useful to wipe off the blue
gel they use for ultrasounds.

December 17, 2013Monique faces her past and forgives

herself; healing has begun

3 Lost Heart (Beat)/Broken (Body)

I only realized a couple days later, while driving, that this dream
was probably my brains way of making her [an unborn lost
child] come true, and she was smiling in the dream, so maybe
somewhere out there forgave me? Or that I am ready to forgive
myself? And what does it say of me that the only thing I could
think of was physical appearance? I had not realized how much
pain was still there, how much hollowness, how much shame,
how much conviction that with that act I had sealed my fate as
a bad person. That sentence that Pascal Auclair [a meditation
teacher] said, in that video of him I watched online, that sentence
that says It could not have been otherwise. That is what helped
most I think, the realization that the me from all those years ago
did what she could, the shifting in my thoughts from judging her
to protecting, nurturing, consoling her, that helped.

December 20th, 2013Monique begins to listen to her inner

Do I think things happen for a reason? [a prompt given to her in
one of our sessions]
Yes, or at least I did before I began that whole journey through
consciousness and meditation. It is an odd duality, knowing
intellectually that there is (probably?) no such thing as Karma
or retaliation of the universe for your bad deeds, yet being emotionally intimately convinced that there is, that if I had not stolen
money from my parents when I was younger, been a sullen and
difficult teenager, drank so much, had an abortion, thought only
of guys, flirted so much, spent all my money on trivial things
and cosmetics and gifts, then my life would have been better.
That if I did not spend time watching TV, buying clothes, focusing on food and social interactions, then I would be a wiser,
deeper, better human being. I think this voice is always there,
but now I have learned to watch it, to listen to it being there, and
wait. And I think of the person who did all these things and I
feel like hugging her, like telling her it will be all right, we will
be all right.

January 14th, 2014Monique is better equipped to face her

fears and she does
Yesterday afternoon I mentioned at work that I was interested in
this new position they have proposed for me. I said yes in part
because they asked me, a kind of automatic response to someone
telling you would be good at something, like a boy who say he
loves you and you are not so sure but the fact that he is so categorical in declaring his love makes you feel like surely he saw
something in you, he is right and your hesitation is not.
But I took it also out of a sense, somewhere deep inside of me,
that this is a good thing for me professionally, that it will shape
me up, make me more alert, force me to pay attention and learn
new things, that I need this at this point in my life, the challenge, the change of perspective. Dr. Dobkin said to just sit with
the decision, and I did. Surprisingly, it feels sometimes like the
answer is there and all you have to do is let it come up, and just
sitting in silence is an excellent way of achieving this.
The things I fear most about this new position is the potential
of ridicule, of not knowing, of being made to look foolish, but I
figure as long as I work as hard as I can on this Ill have given
it an honest try. I know also, from the meditation practice and
from working with Dr. Dobkin, that that fear, those paralyzing
dreams, are based on anxiety over the future, and that what I
really need to focus on is the present, now. So here goes. I turned
35 this year, aged (it feels like) a decade at least inside (and, I
often think looking into the mirror, outside as well), hit a wall
with the way I have been managing my like so far, so this is the
next step.

I have to be careful not to see it as a huge departure from what I
have been doing, like a new life, because that is a lot of expectations. What I take from all of this process since the fall is
really take it one day at a time and see what comes out of it. The
observing, the seeing that comes out of it, is really the part of
the MBSR program that resonates the most with me, as it is an
approach (the curious, observing, scientific-like approach) that
I value in my life in general, so the idea of turning it on myself
and using it to curiously observe myself and my thoughts and
my feelings feels like a comfortable, reassuring, and interesting
path. Combine this with the yoga that lets you appreciate, every
time you do it, the various aches or stiffness in your body, and
you have a succession of scenes of you own life, snapshots of
every single mood and moment, very revealing when you start
really paying attention.

January 21st, 2014Monique is finding meaning and identifying her values

But today it dawned on me that there are things that I value (I
know it sounds odd that I would not have realized it before, I
think I just had a hard time articulating it), and they include
being with my family and friends and meeting new people, getting a glimpse of the world through them.

February 23rd, 2014Monique learned that the baby she

lost in the fall would have been a girl with Downs syndrome. She stayed with her mixed emotions without needing
to turn away.
This makes me feel relieved, on the surface, relieved to not have
had to take the decision. And yet somehow it also makes me feel
a profound malaise, like I am somehow broken, producing sick
children, like this will be something that people will hush over,
as if it was shameful. I wish people would talk to me about it, to
remove the shame element, I wish they would let me know that
its OK, everything will be fine, I will have another child one
day if I want to. But the energy I feel from them, the unspoken
response, is as if I had told them I have cancer, or perhaps worse,
genital herpes or AIDS, something tinged with guilt, with my
own wrongdoing, my fault.
Maybe this is in part because I do not know what to think of
it myself, do not know if I should be happy (I dodged a bulletdid not have to decide toagainkill a child), or deeply
sad because everything I touch is under the cartoonish little rain
cloud they have following characters in comic strips, like I am
jinxed, or plagued, or impure, or dark, or getting punished for
All of this makes me feel: slightly nauseous, angry, sad like I
want to keep on moving or doing things to avoid thinking about
it. Writing helps.

March 6th, 2014Monique responds to Rumis poem The

Guest House [7] with depth and insight
Uninvited guests
Maybe I never really thought of them this way, as uninvited
guests, as visitorsthe latest one is this news about the miscarriage last fall being due to Downs syndrome.
This made me feel physically ill and I noticed, amongst other
things, the strong urge to have a glass of wine, as if to dull the
feeling, to drown it, to have a moment of pleasure, of forgetfulnesswriting is what helped most, in the end, more than a glass
of wine, more than introspection or silence, writing was what I
needed it looks like.

P. L. Dobkin

So maybe this is what I need to do with these guests: invite them
in, sit them down, talk to them, learn more about them, get to
know where they come from, their story, their purpose, their
But I need to sit down with them, to let them in, to welcome them
almost, because otherwise they leave me with a terrible feeling,
a bad taste in my mouth, that lingering ominous dreadful feeling
of the kind that comes back to you just after you wake up, right
after the moment where everything is new, that same feeling I
imagine you would have if you had killed someone, you would
wake up in the morning and have a brief respite before reality
sank in, before the truth came back and dragged you down.
So these guests, standing on the other side of the door, I need
to know them, need to understand them, to digest them almost,
lest their standing on the other side of the closed door makes
me sick.
Spring is coming, and with it light and with it renewal and hopefully reconciliation, and calm.
I long for calm, for peace, for unison.

Monique and I were gifted with a deep sense of connection
during our work together. We are simply two women who
have turned toward multiples losses (the box full of darkness) rather than avoid or deny them. This being with and
acceptance of what is welcomes us into the human family.

1. Oliver M. The uses of sorrow. Thirst. Boston: Beacon; 2006. p.52.
2. Epstein RM. Mindful practice in action (I): technical competence,
evidence-based medicine, and relationship-centered care. Fam Sys
Health. 2003;21(1):19.
3. Siegel DJ. Therapeutic presence: mindful awareness and the person of the therapist. In: Siegel DJ, Solomon M, editors. Healing
moments in psychotherapy. New York: W. W. Norton & Company;
2013. p.24370.
4. Epstein M. The trauma of everyday life. New York: Penguin; 2013.
5. Wesselmann D. Healing trauma and creating secure attachments
through EDMR. In: Siegel DJ, Solomon M, editors. Healing
moments in psychotherapy. New York: W. W. Norton & Company;
2013. p.11528.
6. Garrison D, Lyness JM, Frank JB, Epstein RM. Qualitative analysis
of medical student impressions of a narrative exercise in the thirdyear psychiatry clerkship. Acad Med. 2011;86(1):859.
7. Rumi J. (Translated by Colman Barks). The guest house. The
essential rumi. San Francisco: Harper; 2004. p.9.
Patricia Lynn Dobkin PhD is a clinical psychologist specializing in
chronic illness and chronic pain. She is an associate professor in the
Department of Medicine at McGill University. As a certified mindfulness-based stress reduction (MBSR) instructor, she spearheaded the
mindfulness programs for patients, medical students, residents, physicians, and allied health-care professionals at McGill programs in
Whole Person Care. Dr. Dobkin collaborates closely with Drs. Hutchinson, Liben, and Smilovitch to ensure the quality and integrity of the
mindfulness courses and workshops offered at McGill University and
other venues (e.g. conference workshops, weekend training retreats).
Addendum: Monique gave birth to a healthy baby girl one year later.

Working with Groups Mindfully

Craig Hassed

The Back Story to Becoming a Mindfulness

The most important formative experience in developing my
interest in mindfulness arose when I was a teenager at medical school. In response to the stresses and disillusionment
that came with being an adolescent and a medical student, I,
for some reason, intuitively decided that meditation would
be useful. Having had no instruction on how to meditate, and
not having read any books on the subject, I decided that the
simpler I kept it the better it would be. The simplest thing I
could think of was to sit in a chair, be still, and just watch
what took place in body and mind with interest but without
involvement. There was no attempt to change anything because I did not want to prejudice the process with expectations about what it should be, so I just had an open mind as
the moment-to-moment experience unfolded. Nevertheless,
after some time, when I got out of the chair, my perspective had changed entirely. I noticed that it was self-evidently
true that I was not my thoughts, feelings, and sensations; I
was the observer of them. Neither was I defined nor limited by my life and what happened in it. None of this was
me but they were just experiences happening within a state
of awareness that had nothing to do with (the essential) me.
From that moment I had an insight that underneath the surface experiences of life there was a level of being that was
ever present, nonattached, unafraid, and totally at peace with
itself and the world. It has been an ongoing pole star, as it
were, that has guided life ever since.
That experience, along with other moments of insight,
set the compass for my personal and professional life. In the
years that followed my interest in the worlds great wisdom
traditions led to a deeper appreciation of the direction that
had been set by my meditation experience. They spoke in
Department of General Practice, Monash University, Building 1, 270
Ferntree Gully Road, Notting Hill, Victoria 3168, Australia

depth about something of which I had merely had a taste.

Meditation was both the simplest path to fulfillment and a
profoundly healing practice for body and mind.
I eventually became a general practitioner and later started teaching at Monash University in 1989 with the intention
of finding a way to introduce these practices to medical education and practice. When, in 1991, I originally wrote and
piloted the stress release program [1], a mindfulness-based
stress management program for use in general practice, it
was framed in such a way as to be applicable for individuals
and groups. It was modified and adapted for use in training
medical students and has been part of core curriculum on a
limited scale since 1992 and on a larger scale since 2002,
when the Health Enhancement Program commenced in the
Monash medical curriculum [2, 3]. Since 2002, all medical
students at Monash have had a 6-week mindfulness program
as the core curriculum and the principles and science of
mindfulness is an examinable topic like any other part of the
Over the years, with increasing time demands at Monash
University and outside, my work as a clinician has increasingly moved in the direction of running groups rather than
one-on-one counseling. Therefore, this chapter will explore
how mindfulness is not only helpful for the people who
come to group-based mindfulness programs but also for oneself as the facilitator. I will discuss some of the key principles of teaching mindfulness drawn from my experience
and illustrate them with dialogues from interactions within
the groups.

Experience as a Foundation for Teaching

Why am I writing about the back story? Because the first key
point to make is that the best, and indeed only, firm foundation upon which to teach mindfulness is the personal experience of it. I believe we cannot recognize it in others if we
have not seen it for ourselves. We cannot help a person to

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_4,

Springer International Publishing Switzerland 2015



find a place that we have never been to. The risk is that if we
teach what we think is mindfulness, but without understanding it from within, then we could be teaching the opposite of
what we think we are teaching.
We can all improve in our capacity to apply mindfulness
in our lives, but if a practitioner says they teach it but do not
practice it themselves then it is likely that they have not understood it. The more we understand it the more we will be
disposed to practice it.
We can apply mindfulness formally (e.g., mindfulness
meditation) and informally (e.g., being mindful in our dayto-day life). We may or may not practice 40min of mindfulness meditation every day, but at very least if we are making
sincere efforts to be mindful in our day-to-day life then we
are on the right path. Especially for those who are ambivalent to mindfulness, objectively exploring the impact of unmindfulness is just as useful.
This was the 2nd week of the 6-week mindfulness program
for the medical students. The previous week, the students
had been introduced to mindfulness meditation and were invited to punctuate their day with it for 5min twice a day
(full stops) and at other times for seconds to a minute or two
(commas). They were also invited to notice where their attention was as they went about their day-to-day life whether
studying, eating, speaking, playing sports, or doing anything
else. At the start of the class, we practiced a minute of mindfulness meditation to put a little space between their last
class and this one.
Good, I said, now let your eyes gently open. After a
couple of moments I asked, Now lets take the opportunity
to hear how you got on with the practices from the week; the
formal and informal practice of mindfulness. What have you
You never know what will happen next and I have long
ago given up making assumptions or having expectations
about what will come forward from the group. Before long a
student, Peter, pipes up.
I didnt practice the meditation at all. I dont get the
point of it, Peter says in a half-confrontational way as if he
is testing how you are going to respond and whether there
is any reason to be spending curriculum time on something
soft like this.
It is very important, especially when all the students are
thrown into a mindfulness program as a core part of their
training, that they do not feel like they are having it forced on
them. Sensing the resistance in the voice, one also senses that
the resistance could be reinforced by opposing it. I internally
remind myself, as passionate as I might be about promoting
mindfulness, that this is an invitation to practice it, not an
obligation. In myself I notice a ripple of disappointment that
this is the first offering from the group and an oppositional
attitude to Peters input, which I let pass. I remind myself to
welcome whatever comes up in the moment.

C. Hassed

Thats fine, Peter, you dont have to practice anything

you dont feel disposed to practice. Its your choice. Well
hear from some of the other students shortly, but, if youre
happy to share, can I ask, did you notice anything about the
informal practice of mindfulness? Being mindful is not just
the meditation practice; its also what we do in the whole of
our lives. For example, did you notice yourself being attentive or inattentive, being present or not present, in your daily
Yeh, I did notice a few times that I wasnt paying attention in lectures and tutorials.
Did you also notice yourself being distracted at other
times, like speaking with friends, eating or when studying?
Well, in these unmindful moments what did it show you,
Peter? For example, what was the effect of not listening in
the lecture or tutorial? Did it mean you didnt understand
what was being taught?
It was like the guy at the front had been trying to explain
something and I had forgotten what subject it was let alone
the finer points of what he was talking about.
Thats interesting. And what about when you were not
paying attention to your friends, or the food you were eating?
Did being unmindful have an effect of reducing the connection in the conversation or enjoying the taste of your food?
I guess so.
When you were not aware of where your attention was
when you were studying did you find that it wasted time and
led to frustration?
Well, I had to keep rereading things. There were a few
times this week I gave up in disgust.
And were there times when you were not paying attention to what you were doing that you noticed what your mind
had gone to instead. Did you find that in those unmindful
times you were worrying about things like, Im not getting
anywhere, or, How am I going to get through all of this
work, or, Everyone in the medical course is smart except
me. How did they let me in?
Peter grinned and nodded, as did others in the tutorial
group. They all recognize internal conversations such as
Well Peter, I said, whether or not you have practiced
mindfulness meditation, you have made some very useful
discoveries about the cost of unmindfulness this week which
is great. You have noticed that being unmindful impedes
learning, reduces enjoyment, gets in the way of connecting
with people, wastes time, and leaves us vulnerable to frustration and worry. If being unmindful works for us then we
should practice it but if unmindfulness isnt so useful then
perhaps we might want to cultivate mindfulness instead.
Thanks Peter for being brave and sharing that. I dare say that
others in the group recognized what you were talking about
and I value that you said exactly how it was for you. I en-

4 Working with Groups Mindfully

courage you and the whole class to just say it as it is and not
to just say what you think I want to hear. Now, would anyone
else like to share something from the week?
There are many participants in mindfulness programs who
practice very little mindfulness meditation particularly when
they did not choose to participate in the program to begin
with or are doing it because they were urged to by someone
else. If there is too much emphasis on having to practice the
meditation, and not enough emphasis on the role of mindfulness in daily life, then there is a possibility of alienating
many participants who might otherwise have gained a lot
from a mindfulness program.
Personal experience helps us to empathize with others
and relate to where they are on their own personal journey.
It helps us to be aware of what is going on within ourselves
in the process of teaching mindfulness. It is very easy, when
unmindful, to try and convince others or to oppose something that does not fit in with what we want or expect. It is
far better to inquire and help people to convince themselves
of what works or does not work. Opposition comes from our
own attachments and only creates a division between the
teacher and the student, patient, or client. Being open and
accepting does not mean never questioning or challenging,
but the attitude with which we question or challenge makes
all the difference. A large part of teaching mindfulness is the
modelling of it. Wherever possible we try to be an example
of mindfulness, and if we are inadvertently unmindful then
we can be a warning.
Our personal experiences are sometimes very useful from
a teaching perspective. A teacher of mindfulness instructs
much more by the way they are with the group (or individual) than by what they say. It is in the responses, attention,
openness, and interest that we demonstrate mindfulness in
action. Living mindfully reveals more than any amount of
theory could ever communicate.

A Dialectic Approach to Mindful Inquiry

For me, if I am teaching mindfulness well, then the atmosphere in the group is very much alive and immediate. We
are all, teacher and students alike, actively involved in a collective inquiry whether that is into the cause of stress, our
relationship to thoughts and emotions, our ability to function
well, the nature of happiness, or any other topic of importance. Although there might be a central topic or practice for
the week, the group largely sets the agenda by the individual experiences, insights and questions brought along to the
class. The role as the facilitator is to lead the inquiry and to
help the group to learn from experience.
For the inquiry to be fresh and alive then it is very important not just to go through the motions of asking a set series
of well-rehearsed questions. Mindful inquiry is not formula-


ic. The questions arise in the moment directly from what the
person just said, whether that be in words or body language,
in response to the previous question. We do not quite know
where the conversation will lead but it takes attention and
mental flexibility to follow and not to force the conversation
where we think it should go. Although they could appear superficially similar, no two moments are the same, nor are two
conversations the same.
I have always found that questioning is far more useful
than trying to explain what mindfulness is about. A group
may have been given a mindfulness meditation practice to
practice, have been invited to be mindful in day-to-day life,
and have been given a mindfulness-based cognitive topic to
explore for the week (such as letting go, acceptance, or being
in the present moment), but it is what the individuals bring
back to the group the following week that really matters. Participants relate their experiences and then we see what the
experience teaches us. It does not matter whether the person
thinks it was a good or bad experience, whether they think
they are getting mindfulness right or wrong. The only thing
that matters is learning from that experience. Even our outwardly most negative experiences have the greatest potential
to teach us the most profound lessons if we are open to explore them mindfully. That provides the kind of alchemy that
turns lead into gold.
Sally was attending a mindfulness course for people with issues around anxiety. She was a capable, intelligent, and outgoing young woman. Her main problem was that for the last
few years she had experienced increasing levels of anxiety
and sometimes panic attacks came out of the blue, particularly in social situations. She was in a relationship with a
young man but he did not understand why she could not just
get over it. He was frustrated because these episodes prevented them from doing many things they would otherwise
do together. The pressure of trying to get over it as soon
as possible had led to Sally seeking out a range of therapies
but all to no avail. In fact, it made the problem worse. The
harder she tried, the worse the anxiety got. Sally felt increasingly bad about herself and was afraid that the relationship
might come to an end as a result. She came to a mindfulness
program. In the first couple of weeks, among other things,
we had learned a mindfulness meditation exercise and had
opened up an inquiry into the cognitive aspect of acceptance.
Well, how did we go last week?; What did we practice?;
What did we experience?; What did we discover? I inquired
of the group.
A few members of the group shared experiences and insights. Sally sat back and seemed to be listening but looked
as though she was shrinking back when further offerings
were invited from the group. Noticing this, I decided to
specifically invite Sally if there was anything she wanted to
share because this kind of body language generally means
that someone is sitting on something important, something


close to home, and from which there could be some valuable

Sally, what about you. You seem to be sitting quietly
over there. If youre happy to, would you like to tell us how
you got on this week?
I havent got anything useful to say, said Sally.
Why not? I asked.
Because I wasnt at all successful in doing what we were
meant to be doing.
Lets not be too judgmental about whether or not we
think we were getting mindfulness right, but just have a look
at what happened and see what we can learn from it.
Yes, but I was hopeless at the mindfulness practices.
What happened when you practiced?
I tried to practice the mindfulness exercises and be more
accepting but I couldnt get it right.
What do you mean by couldnt get it right?
I accepted it but couldnt make the anxiety go away.
What happened instead?
Well, take the other night. I was feeling anxious and was
worried about having a panic attack while at a dinner with
my boyfriend and some friends. I tried to be mindful of it but
it was getting worse so I had to leave. When my boyfriend
and I talked about it he got really frustrated.
Perhaps he has a bit to learn about the challenges you are
facing in dealing with anxiety. Thats another story but, for
now, lets stay with what went on for you. I dont think learning to deal with anxiety is easy, but did you beat yourself up
over what you thought was a failure?
Yes, I sure did. I felt terrible about myself and could
barely get out the door the next day.
Do you practice beating yourself up over things like
that? If so, where does it get you?"
It makes me feel worse.
Does it entrench the very things you are trying to free
yourself of?
Yes, I guess it does.
Does it fixate your attention on the very thoughts and
feelings you are trying to get rid of?
I notice the self-criticism under the surface for Sally.
Helping to ease tension for a member of the group when it
arises often helps the inquiry to proceed a lot more fruitfully. I sense that it may be helpful to briefly open up to the
whole group for confirmation and acknowledgment because
we often feel like we have these problems to ourselves. This
can be very isolating. Realizing that we all have experiences
such as these helps to normalize them and also helps us to
stand back and be objective about them. It loosens the personal grip such experiences can have.
I therefore asked, Does anyone else recognize what Sally
is speaking about? A sea of hands went up. We may have
all done the same experiment that Sally is talking about;

C. Hassed

being very hard on ourselves? So, what is the lesson in that?

I asked, Is being hard on ourselves a helpful strategy?
Not really, said one of the other members of the group,
It saps a lot of time and energy and makes me feel terrible.
Ive been more aware of that habit since I started practicing
mindfulness and have tried to give it up.
What effect has that had for you, Margaret?
Im a lot gentler on myself and things dont seem to stick
for anywhere near as long.
Thats interesting to notice that: not fighting with what
we dont like helps it to pass a lot more easily by itself. So
Sally, it seems that youre not alone. Perhaps if we can gain
some insights from your experience it might be useful for everyone. You said the anxiety arose and you tried to be mindful of it and accept it.
But you also said that you were being accepting of it in
order to make it go away.
Yes, but isnt that the point of practicing mindfulness
to make the anxiety go away.
Not necessarily. When the anxiety arose and you were
practicing being mindful what was your attention on? Was
it on the sensation of the breath, the sounds of the conversation, or some other sensory experience, or was the attention
on something else?
I was trying to pay attention to the sounds but I dont remember too much about what everyone was talking about.
If you werent listening to the conversation then were
you listening to something else, like a commentary running
in your mind?
It seemed like it might be useful to verbalize the kind of
internal commentary that a person is likely to have been having at such a time. It may help Sally and others to stand back
from it and have a look at it from the perspective of the observer of it. So I put the following possibility to Sally.
Sally, I said, dont agree if this isnt right, but was the
commentary running along the lines of, Whats wrong with
me, I cant stop the anxiety, the mindfulness isnt working,
what if it gets worse, whats everyone going to think, whats
my boyfriend going to think, will I ever get this right?
Yes, how did you know?
That kind of internal dialogue is probably familiar to a
number of people in the room, but did that mean that you
were listening to what was going on in your mind rather than
the conversation going on around you?
Yes, I guess so.
Then although you thought you were being mindful,
were you actually unmindful at the time?
I suppose so.
You remember last week we discussed the so-called default mental activity. It can take many forms such as daydreaming, recalling the past, worrying about the future and

4 Working with Groups Mindfully

talking to ourselves. Its the thing that distracts us from the

I remember we talked about it but Im not very good at
recognizing it.
That will come with time, and we all need practice mindfulness to help us to be able to see it. But there was one other
thing I wanted to explore. You also said that you were trying
to accept the anxiety. Why?
I wanted it to go away.
Is wanting something to go away actually acceptance, or
is it non-acceptance masquerading as acceptance?
I guess its not really acceptance if youre trying to make
it go away.
I suspect you are right. Non-acceptance makes it worse.
It seems to.
So, can we be thinking we are practicing acceptance
when we are in reality practicing non-acceptance?
Yes, were probably doing it all the time.
Acceptance is exactly what is says; acceptance. If something is there its there. Were just practicing being at peace
with whatever is there, even if its anxiety. It may change but
from a mindfulness perspective, we are just watching without trying to do something to make it change.
I keep falling into the same habits.
Youre not alone. Were all a work in progress. Outwardly it may seem to the group that I am reminding her
to be patient with her progress, but inwardly, I am reminding myself that what we are talking about applies to me as
much as it does to the other members of the group. I find it
is a good remedy to the false idea that I, the teacher, knows
whereas the group participants do not. Wisdom resides in us
all. Being conscious of using inclusive language also helps. I
continue, So, although with the best will in the world, perhaps we are often unconsciously and habitually practicing
unmindfulness in the sense that our attention is not connected
to the senses and what is happening around us. Maybe that
is what was happening to you. Further, perhaps we are often
unconsciously adopting a non-accepting attitude to what is
going on even when we think we are practicing acceptance.
Now that I look at it that way, I can see what was happening. I guess I have proved to myself again that not accepting feelings that I dont like doesnt work. It just accentuates
Well, if you have seen that for yourself you will be better able to recognize it next time it occurs, if it occurs. Your
experience wasnt a failure, not from a mindfulness point of
view. We are only interested in looking at what is going on
and learning from it and, from that perspective, your experience has illustrated some really useful insights about attention and acceptance that we have all learned from. Thank
you for being brave enough to share it.
When a question is responded to, without preconceived ideas
prejudicing the inquiry, there is the possibility for discovery.


If the instructor can adopt that attitude then it makes it easier

for the group to adopt that attitude. The insight will be in the
persons own answers. This gives the insight far more depth
than if the person had been told what to think by the instructor. There is nothing more satisfying that seeing the light go
on for a person when they make discoveries for themselves.
The thing is, when a person comes to a conclusion for themselves then they have ownership over it.
This Socratic approach to inquiry is based on the educative principle. Education comes from a Latin word, educare,
meaning to draw out. Education, in the mindful sense, is not
the stuffing in of ideas by the teacher; it is the drawing out
of wisdom. The whole approach rests on the assumption that
we have wisdom latent within us and all it needs is for it to
be drawn out. What covers it? The clutter in our minds made
up of habitual thoughts, unquestioned assumptions, the stories we tell ourselves, imaginings taken to be real, and all
the rest.
The feeling in oneself and the group when mindful inquiry
is in full swing is intensely but calmly alive. It is awakening
and enlightening not only in terms of everyone being wiser
but also in being lighter at the end of the inquiry because we
let go of a lot of baggage in the process. For this process to
work well I find that it is vital to have, as a reference point,
the desire to learn. If I, as a teacher, think I have learned all
that there is to be known about mindfulness then the inquiry
is lifeless and limited. It is important not to push or prejudice
the inquiry with our own preconceived ideas in as much as
we are able to see them. When it is going well I am as likely
as anyone else in the room to discover something important
or to see things in a new light.
To get better at asking questions we have to practice it,
resisting the temptation to tell people how it is rather than
inquiring into how it is. This means that we have to be
aware moment by moment. Telling people how it is, no matter how good the explanation, may be tempting but if it is
not supported by actual discovery, it will be more akin to
mere information, not real insight. That is indoctrination, not
education. Group participants come to groups understanding things but not knowing that insight is there until they
have heard it come out of their own mouths. For the group,
insights have a lot more authority when they come out of the
mouths of other group members rather than the instructors.

For the abovementioned process to go well it all revolves
around listening, not to the clutter of ones own thoughts, but
to the person speaking. It is interesting to notice that we may
think we are listening to someone speaking but in actual fact
are hearing little of what they say because the attention is
on an internal dialogue. That internal dialogue may be about

C. Hassed


what question to ask next, where to take the conversation,

how to wrap up the consultation, or how long until lunch.
It is often so subtle and habitual that we do not even notice
that it is there.
Listening mindfully means listening with a clear and open
mind. The curious thing is that I find myself a lot more insightful and intuitive when the mind is clear not when it is
full. Of all the thoughts that go through our heads in a day,
very few are relevant or useful compared to which are not.
One has to be mindful in order to discern the difference between which is which.
It was the first follow-up session of a mindfulness course for
psychologists. The group had been invited to practice being
mindful in their day-to-day life and to come back to share
their experiences. I invited the group to offer something of
what they had discovered. Kathryn offered the following example.
Last week I really came to the conclusion that I am paying attention a lot less than I thought I did, Kathryn said
with a sense of amusement. Curiosity, surprise, and amusement are three indications that something mindful has taken
Youve had a very good week then Kathryn. Can you
give an example to illustrate why youre not as mindful as
you thought you were?
Well, Ive been consulting for nearly twenty years now
and I thought I was a pretty good listener. Ive discovered
Im not as good as I thought I was.
Ive noticed that when I ask a question and a client is
speaking in response, more often than not I am not listening to what theyre saying. Im thinking about what three
questions to ask next, where to take the consultation, or what
therapeutic approach Ill use at the end of the consultation.
What effect does that have on you or the consultation?
It means that I am often pressured, dont remember stuff,
or dont feel so connected to the client.
That doesnt sound very helpful. What happens when
you have a mindful moment?
I feel calmer and more connected. Its a lot more satisfying. Im also a lot more intuitive in my responses to people
but by thinking less rather than more.
Sounds useful.
Absolutely. I dont know how I could have not noticed
that ever before.
Who knows what else we might discover?
Often leaving a conversation with a sense of openness and
ongoing inquiry is very useful. Even when there is no sense
of resolution to a question it is better to leave it open for further inquiry. Nearly always the group will give you insights
at some stage in the future.

Impartiality to Results
One of the greatest barriers to teaching mindfulness is being
partial to results. If I, even inwardly, am OK when people
have pleasant experiences, but not OK with the opposite, then
I am modelling the opposite of mindful acceptance. I am not
adept at teaching the class about impartiality or acceptance
of lifes ups and downs, pleasures and pains, successes and
failures, if I am implicitly communicating the opposite. To
speak of acceptance when we are inwardly looking for one
kind of outcome and rejecting another is, at best, frustrating
and ineffectual and, at worst, demoralizing, hypocritical and
Acceptance is what it says: acceptance. It is not nonacceptance with a veneer of acceptance. Our own attitude of
preferring one kind of experience for the group over another,
as well intentioned as it may seem, will reveal itself in the
sound of our voice, the openness and lightness with which
we respond, and the directness and interest with which we
engage in mindful inquiry. I try to remind myself to be as interested when someone says something like, It didnt work
for me, as when they say, It was wonderful.

The Blessing of Teaching Mindfulness

I find that in teaching mindfulness I am constantly being
reminded of it myself as well as always learning from the
group participants. It could appear that the teacher sits at the
front of the group while the group learnsbut it may actually be the other way around. That is a real blessing.

1. Hassed RC. Know thyself: the stress release program. 1sted. Melbourne: Michelle Anderson; 2002.
2. Hassed C, de Lisle S, Sullivan G, Pier C. Enhancing the health of
medical students: outcomes of an integrated mindfulness and lifestyle program. Adv Health Sci Educ Theory Pract. 2009;14:38798.
3. Hassed C, Sierpina VS, Kreitzer MJ. The health enhancement program at Monash University medical school. Explore (NY). 2008
NovDec;4(6):3947. doi:10.1016/j.explore.2008.09.008.
Craig Hassedis a general practitioner and senior lecturer at the
Monash University Department of General Practice in Victoria, Australia. His teaching, research, and clinical interests include mindfulness,
mindbody medicine, health promotion, integrative medicine, and
medical ethics. He was the founding president of the Australian Teachers of Meditation Association and is a regular media commentator. He
has published seven books: New Frontiers in Medicine (Volumes 1
and 2); Know Thyself; The Essence of Health; a textbook coauthored
with Kerryn Phelps, General Practice: the Integrative Approach; with
Stephen McKenzie, Mindfulness for Life; and with Richard Chambers,
Mindful Learning.

The Opera of Medicine

Michael S. Krasner

I grew up listening to opera. Actually that is not entirely

true. More accurately, my parents loved opera and I grew
up listening to operatic arias sung mostly by my father on
long family car trips, leisurely weekend afternoons, and most
commonly heard reverberating out of bathrooms while my
father was in the shower. The youngest of seven brothers, he
grew up listening to the operatic arias that his siblings sang,
and even recorded. The great dramatic tragedies of Aida and
Turandot and Tosca were part of my familys mythos. And
when in 1967 my parents bought our first stereo console, the
sounds of operatic superstars spun off the turntable, filling
our home. Mario Lanza, Enrico Caruso, Maria Callas, Beverly Sills to name a few.
I, the youngest boy of five serial brothers, and my younger sister had different musical and dramatic preferences than
Puccini or Verdi or Mozart. Ours were the Beatles, the Who,
Led Zeppelin, the Eagles. Yet like the embedded associations
of fragrant foods with powerful personal events and even epochs, the melodies and marches and sad confessions about
love and death of the opera have incorporated themselves
into my psyche in ways that I do not quite understand. Yet
when I hear E lucevan le stelle or Nessun dorma, I am transported right into the very heart of what feels like my genetic
endowment, complete with the tenor voice of Dad and his
not-bad booming vibrato.
It is with this in mind that I share this story, still incomplete, of friendship, love, loss, and griefin short, opera.
This story has its beginnings while I was a resident physician,
and connects me to my family, my patients, and the power of
relationship in medicine. During my intern year, my father
and mother retired from their work lives as university professor and community organizer, respectively, and because I
entered residency training several thousand miles from their
home, they looked for opportunities to visit. They discovered
University of Rochester School of Medicine and Dentistry, 42 Lilac
Drive #8, Rochester, NY 14620, USA

by my second year in training that one of the local colleges

in my new community offered an Elder Hostel in which participants could spend a week studying Verdis great operas.
So the plan was executed, and they spent a wonderful seven
days, living in the dormitories of the college campus, engaging in lively lecture and discussion of the works, watching
video productions, and, when I was free, taking me out to
dinners at places I either could not afford or had little free
time to explore, find, and try out. The elder hostel course
director music professor, a Sister of the Daughters of Mercy,
was engaging, humorous, and as so often happened with my
parents when meeting new people it seemed they became
fast friends, enjoying hearing each others mutual interests
and backgrounds and life experiences. In short, they bonded
closely to Sister Josepha, and I spent many a dinner listening to more about Sister Josepha than sharing the trials and
tribulations of my life as a medical resident. This was OK
with me, for I felt the break from how I was spending the
vast majority of my waking hours and much of my sleeping
hours necessary and energizing.
The very next spring, they returned for another week with
Sister Josepha, studying Puccini this time. They seemed even
more excited and engaged, and I knew this was good. I had no
idea about what I subsequently discovered regarding how they
almost did not attend, and how that discovery for me became a
source of healing. More on that later. One of my clearer memories of that visit was my mother breaking her fifth metatarsal while walking on the college grounds early that week, and
how I felt so useful and effective finding her efficient orthopedic care. It was an event where they could turn toward me
for right action, trusting in my judgment and counsel. Perhaps
I remember that so clearly because during that period, I also
recall working doggedly in the intensive care unit, experiencing feelings of futility and hopelessness caring for critically ill
patients with mutiorgan failure, offering what seemed at the
time to be so little to the patients and their families.
All in all, it was an enjoyable and well-spent week for
them. I managed to break away from the hospital at least
a few times, sharing food and conversation with them. As

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_5,

Springer International Publishing Switzerland 2015



before, I heard all about Sister Josepha and even had the
pleasure of meeting her one afternoon when I picked them
up. Of all things, I distinctly recall her clear voice and good
diction, perhaps projecting onto her my notions of the effects of a life-honing vocal skills, steeped in the history and
pomp of classical music, and the grandeur of the opera. I did
not know much then about opera, and still know very little,
only the familiar melodies that were part of my childhood. I
recall, however, in my brief conversation with Sister Josepha
learning of the folk roots of the opera, and how it was not a
reified art but part of the community aesthetic of the common people. And from that I could make sense of the connection my parents had with it. That the stories told the epic
tragedies depicted in the opera were somehow connected to
the broader human experience of suffering. It seemed to involve the placing of ones own personal dramas of birth, illness, aging, and death into the operatic storyline, connecting
these experiences with the universal human experience, and
in so doing healing through association, recognition, camaraderie, connection, and engaging the senses.
About 13 years later, I met Sister Josepha for the second
time. A lot had transpired in the intervening years, including
the death of my father about 7 years earlier from pancreatic
cancer. By this time, my increasingly busy medical practice
had already created within me the nascent seeds of burnout,
and I wondered how the coming years would unfold for me.
I explored ways to combat my emotional exhaustion through
physical activities, book groups, cultivating friendships,
while focusing on my home life with two of three children
already born. Reflecting on my fathers final 2 years, I was
struck by his relative health for over seventy-five percent
of the time he lived with his diagnosis. He had taken up a
sincere practice of mindfulness meditation, attending workshops, and retreats up until the last few months of his life.
Toward the end of his life, I also began to explore this myself
more deeply, and by the time I renewed my acquaintance
with Sister Josepha, I was facilitating groups of patients in
a meditation-based stress reduction activity called mindfulness-based stress reduction (MBSR). And that is exactly how
we met again.
Upon entering the waiting room in my office one Wednesday evening for the first gathering of a new MBSR class, I
gazed upon the 20 or so individuals sitting in the blue-cushioned chairs, nervously waiting for something to happen.
That is all except two women who appeared to be in their
mid-to-late sixties, whose eyes lit up as I went around the
room greeting participants before officially beginning class.
It was clear these two were confidant, curious, and engaged,
and at the time I could only assume they attended for reasons
that may be mysterious even to them. Although I introduced
myself, and repeated their names upon greeting, Sister Josepha and Norma, I did not at the time recall who she was, or

M. S. Krasner

that I had met her years previously. The class began with the
participants sharing what motivated them to take this program, and although I also do not recall the details, I know
that both Sister Josepha and Norma shared something about
the challenges of retiring. Both were college professors and
both were questioning how to find meaning and a sense of
engagement after their professional careers no longer defined their identities. I recall asking a question to them and
to the entire group about how do we truly know and define
ourselves, not through giving the group any answer to that
question, but inviting all of us, including myself, to consider
living with that question through the 8 weeks that we would
be spending together.
It was not until week three of the course that I realized
who Sister Josepha was, and as I came to that realization
I felt a longing for my father, knowing the connection she
had with him and with my mother. I approached her before
class and apologized for not remembering, and as I told her
this she lit up, beaming and smiling, acknowledging her own
recollection of my parents. I felt comforted by her compassion as I told her of my fathers death, and saw an authentic sadness in her as well. In that moment, I felt bonded to
her and Norma, who engaged in this conversation as well.
I realized that the two of them were best of friends. They
were colleagues and confidants, and in a very real way, life
partners. As I thought of this, I realized and contemplated
upon the many manifestations of love and relationship, and
felt opened up to seeing a broader expression of this than my
own narrow ideas of what relationship should look like. So
Norma, in this way, also became connected to my parents,
even though they had never met.
The following week before class, Sister Josepha had
something to show me. She took out a letter, typewritten by
my father in 1989, addressed to her. I trembled as I touched
the slightly faded paper that he had typed upon with the mechanical typewriter that he used in the home office where
I recall him spending long hours reading papers and planning classes and compiling data from his career in teaching
and qualitative research. As I read the letter, I laughed and
cried. It was a letter of persuasion, asking Sister Josepha
to consider making accommodations that would allow my
mother and father into the second Elder Hostel program on
Puccini. It seems that they were late enrolling, registration
was closed, and the program was full. In his very recognizable and undeniable style, with just the right show of respect
and ample use of his unique sense of humor and praise, while
also taking ownership of the responsibility for not registering on time, like a college student asking the professor for
special dispensation with good reason, he was able to convince Sister Josepha to let him and my mother into the program. Reading this letter so rich with his personality was like
having his voice speaking to me in that very moment. My

5 The Opera of Medicine

gratitude was evident and this cemented the bond between

the three of usSister Josepha, Norma, and me.
At the end of the 8 week course, I received a request to
become the primary care physician for both Sister Josepha
and Norma, a request I gladly accommodated. And so we
continued to establish our relationship in a professional manner, from teacher now to physician. About 5 years later, Sister Josepha began to have memory difficulties, and was diagnosed with a rare type of dementia. Eventually, she moved
from her apartment in the Mother House to the memory unit,
still within the Mother House. And I began to make nearly
weekly visits to her, each time finding Norma always at her
bedside, always attending to Sisters personal, emotional,
and spiritual needs. I would sometimes just sit with the
two of them, holding conversations about music, speaking
of composers and vocal artists, and learning much more of
Sisters own musical performance career. I brought to her
recorded talks of a contemplative nature for her and Norma
to enjoy, and during my visits I listened to old recordings of
Sister Josepha singing in choral groups and solo some of the
very arias I had grown up listening to.
As her condition worsened, Norma became more vigilant, and as her vigilance increased, her anxiety levels increased as well. I would find her fatigued, not having slept
well, spending overnights in Sister Josephas room. Many a
visit I encountered her bleary eyed, yet very present with the
latest updates on Sisters condition, armed with a series of
questions regarding what seemed like small details of care.
I was struck by her attention to detail, with meticulous accounting of all that transpired including detailed recounting
of nurse and unit manager conversations, inputs and outputs
of bodily fluids, vital signs, and certainly changes in levels
of consciousness, agitation, and sleep. Sister Josephas condition progressed as expected, and when she was no longer
able to take in food and fluids, she received respectful and
compassionate palliative care. The care she received in the
Mother House was exemplary, a hybrid between being cared
for by close and loving family, with the nursing and medical
expertise of a skilled long-term care facility. Her passing was
relatively smooth, and I was fortunate to attend the Mass for
her funeral.
Unfortunately, Norma fell into a deep depression as a result of this loss. I came to fully recognize this as no different
than the loss of a spouse, with all the attendant health risks
of the surviving partner. And despite attempts at pharmacotherapy and psychotherapy, her grief was resistant to treatment. She lost weight, became somatically fixated, and as
a result we engaged in a series of detailed and seemingly
endless medical investigations, finding no new explanations
for her multiple and challenging complaints. Eventually,
after several years, her condition stabilized, and continued
at a plateau level of symptoms that could be best described


as melancholy. Outside of attending daily Mass and visiting the Mother House nearly every day, her social contacts
Over the ensuing months and following year, she began
to find it difficult to remain living on her own in an apartment. Her memory began to slip, and she began to share a
concern that someone living in her apartment building had
been attempting to steal from her. Initially, her concerns
sounded plausible, and the thefts described involved documents that would allow this perpetrator access to personal
documents such as retirement account statements and securities she held. Over time, it became increasingly clear that her
concerns reflected a growing paranoia. She shared of how at
night, while she slept, the neighbor snuck into her apartment
and lifted documents, and as proof she described papers and
mundane items in the apartment slightly out of place.
Her growing anxiety and agitation over this led her to
move into an independent senior living facility, and prompted
me to further investigate her deepening cognitive and behavioral decline. It appears she has developed a vascular dementia which has been very challenging to treat. The medication
management has been complicated by her deep conviction
that any medication she is given will be contaminated by the
malevolent perpetrator who has the ability to gain access to
her current living facility. And despite moving into a caring
community that has been willing to assist her in locking up
her medications and personal documents for safekeeping, she
still believes that these are not safe and they are easily violated. Yet she has been making some progress. She has befriended one of the residents dwelling in the facility who looks
after her, regularly testing her reality and accompanying her
to medical appointments. She has restarted her medications,
both older ones for the management of her heart disease and
newer ones to assist in lessening her paranoid delusions. I am
finding she laughs and smiles more at appointments.
Although we do not agree on the veracity of her claims
of being poisoned and stolen from, she is willing to discuss
it with me. And she continues to light up when we speak of
Sister Josepha, sharing with me clear and untainted memories of their life together, in which I hear of events and experiences that are often new to me. Her memory also remains
clear on the class in which we first met over a decade ago,
and on the circumstances of my parents connection with
Sister Josepha. For me, Norma continues to be a connection
with a part of my life that at times seems to be fading away,
until I see her. And I hope for her that she finds comfort and
confidence in the medical care I continue to offer. But in
the end, it is more than simply medical care and connections
with the past. It is the continued unfolding of birth, aging, illness, and death that draw us together, within which the lines
between healer and patient blur slightly, at times merging
into simple human connection and kindness.

Michael S. Krasner, MD, FACP is a professor of clinical medicine
at the University of Rochester School of Medicine and Dentistry; he
practices primary care internal medicine in Rochester, New York, USA.
Dr. Krasner has been facilitating mindfulness-based interventions for
patients, medical students, and health professionals for more than 14
years, involving nearly 1800 participants, including more than 600

M. S. Krasner
health professionals. He has shared his work in peer-reviewed publications, scientific assemblies, workshops, visiting professorships, and
intensives throughout the world, focusing primarily on the roots of Hippocratic medicine through the cultivation of attention, awareness, and
reflection of the health professionalhealing relationship.

The Mindful Psychiatrist: Being Present

with Suffering
Catherine L. Phillips

I first met Charlene while I was covering for her own psychiatrist. As I called her name in the waiting room, a tall thin
womanaround age 30, I estimatedseated in the corner of
the filled room lifted her gaze from her lap. Her eyeswide
as saucerscommunicated her pain and fear as they met
mine. Moving toward her, I held out my hand. Hi Charlene,
Im Catherine Phillips.
Early in my practice, I had pondered the ongoing question of how to introduce myself to my patients. I chose to
meet my patients not just as a physician to whom one turns
for relief from suffering but also as a fellow human being.
In each introduction, I intentionally dropped the use of my
title. By and large over the years, patients have chosen to call
me Dr. Phillips or have appreciatively nicknamed me their
own personal version of Dr. Phil. Aware of the issue of
potential boundary crossing, I have found I can always sensitively redirect my patient and clarify our roles if needed.
As I greeted her, Charlene closed her eyes. Placing her
hand on her left leg, she looked down and winced with pain
as she leveraged herself into a standing position using a cane
for support. She shifted her cane from her right hand to her
left, before reaching out to shake my hand. Hi Dr. Phillips,
she said; her hand was cold and dry. We walked slowly together down the hallway. Once in my office, her many sources of stress and suffering came pouring out. The pain in her
right leg, secondary to an injury in a motor vehicle accident
some years ago, overshadowed all else. She spoke of the unbearable physical pain that she endured night and day and
the significant limitations this placed on all areas of her life,
especially her interactions with her children. She spoke of
her anxiety and her fear related to the accident, including her
intense fear of driving, of riding as a passenger, and her fear
the pain would never end. She shared her emotional pain,

Department of Psychiatry, University of Alberta, The Mindfulness, 14032 23 Avenue NW, Suite 282, Edmonton,
AB T6R 3L6, Canada

especially regarding how her symptoms affected her relationship with her family; she could no longer do activities
she had previously taken for granted such as playing with
her children, and she feared her husband might not tolerate
her emotional and physical limitations much longer. As her
distress escalated, the tone of her voice grew louder, more
forceful, and the rate of her speech accelerated. Her intermittent plea I need help Dr. Phillips! reverberated with a
sense of desperation. With wide watery eyes, she explained
that she had been diagnosed with a particularly severe and
nasty chronic pain disordera progressive condition which
might wax and wane in severity, and for which there was no
cure. She urgently wanted help and wanted to believe that
she could be helped, but she knew that I had no magic wand.
We had only an houra luxury, I thought, compared with
the likely time restrictions of her family doctor. Yet, an hour
barely gave us time to scratch the surface of the stressors in
her life and the dilemmas she faced. These poured out in a
disjointed torrent, allowing her perhaps some temporary relief
through venting, but leaving me feeling mildly overwhelmed
by the nature and severity of her stressors and suffering. I was
reminded of the comic strip in which a patient enters a psychiatrists office with a black cloud over her head, and when the
patient leaves it is the psychiatrist who now carries the cloud.
In addition to my awareness of both Charlenes sense of
helplessness and my own feeling of being overwhelmed by
the complexity of her stressors, I felt a sense of relief; in our
few sessions, I would listen empathically, review and adjust
her psychotropic medications if needed, and then her own psychiatrist would return, and Charlene would return to his care.
Several months later, however, I again found Charlene
booked in my schedule. I was again covering for my colleague, this time for a period of 6 weeks. When we had parted, Charlene had thanked me, told me I had a kind heart
and ended our appointment with a handshake and a God
bless you, Dr. Phillips. Beneath her suffering, I had had a
glimpse of a compassionate human being who cared deeply
about her children, her husband, and her connection with others. I had liked this woman. Yet, her presence on my schedule

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_6,

Springer International Publishing Switzerland 2015



triggered feelings of anxiety in me. Her neediness was tangible; I imagined that if she presented to others as she did to
me, their natural response might be to distance themselves
from her. She had made little progress under the care of her
previous health-care providers, who, like me, had probably
felt overwhelmed by her pressure of speech, tangentiality,
emotional liability, the magnitude of her losses and stressors
in all areas of her life, as well as her despair and desperation
to alleviate her palpable suffering. Given the degree of her
traumatization, my traditional tool kit of psychotherapeutic
interventions had significant limitations; although I wanted
to help, I doubted I had anything to offer. I also feared that if
she were to make a therapeutic connection with me over the
next 6 weeks, I might find myself feeling a sense of responsibility to continue working with her, in spite of just being the
covering physician. Yet, amidst my apprehension, I was filled
with compassion for this woman, for her caregivers, and for
myself. I paused; for a brief moment, I felt less helpless.
As human beings, we are united by many things, including by our own human suffering. As a psychiatrist and psychotherapist, I have chosen to work with this particular experience professionally as I help my patients explore the nature
of their suffering and how their own internal conditionings
can potentially contribute to this suffering. Over the years,
the fruits of my meditation practicebegun as a personal
practice over 30 years agohave directly and indirectly
found their way into my professional work. My perception
and understanding of the positive effects of my meditation
practice on my therapeutic skills have been affirmed by research findings over the past 15 years, which demonstrate
that the therapists mindfulness practice benefits therapeutic
outcomes [1, 2]. My practice of mindfulness inside and outside the therapy hour has enhanced my capacity for compassionate, nonjudgmental attunement to my own inner world,
to that of my patients and to our shared experience, as well
as my ability to stay present with the suffering of my patients
as we journey together in the safety of my office.
In my attunement to myself, I am acutely aware of my
own personal suffering and limitations, and the need to first
care for myself in order to be able to extend myself to others.
When Charlene appeared on my schedule, my life was already very full; I had a fairly heavy patient loadseveral of
whom had a combination of physical, mental health and pain
conditions. I considered, too, my desire to be more available emotionally to my own family. I did not wish to run
the risk of tipping this at times delicate balance. Would I be
able to walk the razor-fine edge with Charlene of being empathically present to her suffering while accepting my own
limitations and inability to offer her the cure for which she
yearned? Given that I was simply covering for my colleague,
these reflections and questions were perhaps premature, yet
I was very aware of them arising in reaction to seeing Charlenes name on my schedule.

C. L. Phillips

Hunched over her cane in the waiting room, Charlene

appeared sad and withdrawn. When I spoke her name, she
looked up at me with expressive eyes. Hi Dr. Phillips; I
sensed in her a twinge of pleasure at seeing me.
Once in my office, Charlenes voice began to escalate
with anger. While I had spent our two earlier sessions continually redirecting her in an attempt to glean fragments of
her history, she now opened up, venting her frustration regarding her treatment to date. She had been prescribed various medications and treatments to which she had reacted
with distressing side effectsleading either to her discontinuing the treatment on her own, or to low-dose medication
being trialed without effect. She was frustrated when nobody
seemed to understand that she did not have the stamina to
participate in the treatment programs to which she had been
referred, and where in some instances her emotional distress
had been retriggered. While sharing her frustration, she grew
so emotionally activated that she became almost incoherent;
the simple recollection of her interactions with caregivers
appeared to trigger such intense emotional discharge from
her limbic system that her thoughts came to an abrupt halt.
Sentence after sentence rose with the same crescendo of intensity and was cutoff abruptly.
In four 1-h appointments during her psychiatrists absence, I became familiar with Charlenes history and began
to piece together an understanding of her life and why she
presented in the manner that she did. Then the unexpected
occurredher psychiatrists leave was extended. Given my
knowledge of Charlene, I felt responsible for continuing to
work with her.
Charlenes words spoken in our very first appointment
I need helpstood out in my mind. I was very aware that
I, too, would need help, in order to help Charlene. Alone,
I would be useless, as I would likely feel as overwhelmed
and helpless as she herself did. The complexity of Charlenes
problems required a team approachspecialists who could
each lend their expertise to address her multiple problems,
simultaneously supporting each other and preventing any
one team member from feeling overburdened, or from succumbing to the helplessness inherent in working with the
magnitude of such suffering.
I referred Charlene to Dr. Martini, a psychologist who had
experience in working with both trauma and chronic pain,
and with whom I consulted regularly with Charlenes permission. Given Charlenes severe trauma, compounded by
her very real physical pain and significant life stressors, we
agreed that the primary goals of the treatment were threefold:
1. To build a therapeutic alliance with the work of psychotherapy being largely supportive in nature at this time (the
therapy being Dr. Martinis role).
2. To find a combination of psychotropic medications that
Charlene could tolerate and that would provide some relief of her symptoms of trauma and depression (my role).

6 The Mindful Psychiatrist: Being Present with Suffering

3. To mobilize a team, including a referral to a chronic pain

specialist, as it was our opinion that her chronic pain condition required management before her trauma could be
addressed in psychotherapyand we agreed the treatment of her chronic pain was beyond our expertise.
As her psychologist and I discussed how to proceed, I
breathed a sigh of relief. I no longer felt helpless or immobilized by what had felt like the burden of dealing with Charlenes complex issues and suffering on my own. I phoned her
family doctor who agreed to refer Charlene to a pain specialist. The specialist, who prescribed gabapentin, was now in
charge of this area that had overshadowed Charlenes mental
health and ability to cope with life. A team appeared to be
taking shape.
One morning, several weeks later, Charlene unexpectedly
showed up in my office, beside herself with distress. She had
been a passenger in a motor vehicle accident that morning,
re-traumatizing her and reinforcing her fear of being reinjured while driving.
Fortunately, I had had a cancellation that morning. Charlene had never shown up without an appointment beforeshe
knew my schedule was generally full, and we had outlined
the steps she should take and who to contact if she required
emergency assistance. Nevertheless, she was here, and I was
available, so I brought her into my office. I started by clarifying time limitations, concerned that if I did not immediately
clarify this boundary, in her current distress, my afternoon
could easily disappear. I had other patients, booked hourly,
who needed my attention.
It took me an hour with Charlene, including a telephone
conversation in her presence with her family doctor, to begin
to understand what had happened following the accident
that morning. According to Charlene, while waiting to see
the on-call physician at her family doctors office, she had
asked the clinic staff for a Tylenol. Experiencing excruciating pain, and re-traumatized by her motor vehicle accident,
she assumed the staff, who knew her well, would grant what
seemed to her to be a small request. She had been surprised
when a clinic nurse told her she would first have to see the
doctor. No doubt, I reflected to myself, this had reinforced
her feelings of isolation and her sense that nobody understood the magnitude of her suffering; what was more, it may
have felt as though nobody cared. I imagined that perhaps to
the clinic nurse, Charlenes request may have felt like one
too many demands on her time and energy that morning;
perhaps she had felt a need to say no (No! Not one more
thing!!) to regain some semblance of control over what may
have seemed an overwhelmingly busy clinic that day.
According to her family doctor, Charlene had raised her
voice, her anger inappropriately pouring out in the waiting
room as she yelled at the reception staff, and at the on-call
physician, who, not surprisingly, had been unwilling to allow
his staff to be yelled at that morningor to take it himself.


To all outward appearances, Charlene had abruptly switched

from being pleasant, passive and even subdued, to verbally
aggressive and threatening. My guess was that in the wellmeaning, efficient, and highly busy clinic, no one had been
aware of, or considered Charlenes internal sufferingtheir
minds were likely preoccupied with the several emergencies
with which they were no doubt already dealing. Likely, no
one had been aware of the multitude of stressors piled high
within Charlene, stressors which were very real, and most of
which she could do nothing about, except approach with as
positive an attitude as possible. Given the clinic staffs surprise at Charlenes outburst, it seemed no one but Dr. Martini
and I was aware that her inner state was like that of a tinderbox waiting for a match. The staff had heard her expressions
of pain many times over the course of her visits to the clinic,
and perhaps her words no longer held the same meaning,
nor elicited the same reaction from them as 6 months earlier.
Perhaps they had become conditioned with learned helplessness, immune to the impulse to respond in a helping manner,
as nothing they had done in the past seemed to make any
I could relate to the staffs response to Charlene that
morning. Early in my career, I had encountered another patient with severe chronic pain, and had had no clear idea really, exactly what he had meant when he had used the word
pain. When this man had sat in front of me years before,
in hindsight, I had been too caught up in my own discomfort
in his presence to have genuine curiosity or compassion for
the experience of his pain that he shared with me. I had noted
attitudes of anger and irritability, particularly when this man
alluded to the medical system; this included me, and I had
appreciated neither his generalization nor his attitude! His
history of a limited capacity for emotional and behavioral
regulation had suggested features of borderline personality disordera term which in common English frequently
equates to a difficult and challenging personality. I could
not judge how severe this mans physical pain had been in
reality, but I had known that given his hostility, apparent
even in our first encounter, he was not someone with whom
I thought I could work well.
Perhaps Charlenes other care providers felt the same way
with Charlene. She was so needybut neediness, I knew,
sprang from unmet needs. She was so distraught that communication was, at best, fragmented and frustrating, and I
suspected that few people took the time to familiarize themselves with Charlenes internal world. While her distraught
ramblings served as an attempt to reach out and communicate her experience in order to feel heard and supported, they
unfortunately further alienated those around her. I wondered
by whom, in Charlenes life, she was understoodwho responded to her distress and her need in a manner that affirmed and supported her. Certainly not her husband, who
needed his wife back and could not understand why she


could not get better, not the insurance company, who was
convinced that she needed an intensive pain rehab program,
and not her primary care health team, who after this morning, now perceived her to be angry, hostile, and demanding.
How can a human being accurately convey the depths
of their suffering to others who have not suffered in such
a way? How can one truly understand anothers suffering
without having had (or daring to take) a glimpse into the
internal world of the other? What can a health-care provider
offer when faced with such suffering? These questions and
others passed through my awareness as I listened to Charlene and her physicians account of the incident that morning. Nothing I could recall being taught in medical school, in
the toolbox of various clinical tests, medications, or medical
procedures had prepared me to meet this magnitude of suffering.
In my experience, even good bedside manner frequently
falls short of what is called for in such situationsthe word
manner reflecting an outward presentation, and not necessarily the genuine internal intention, attitudes, or presence
of the clinician. To be truly supportive of another requires
empathy, which in part stems from an emotional understanding of anothers inner world and the nature of their suffering,
including knowledge of the person and the past experiences
that have shaped who they are. It also requires the capacity
and willingness to be present with anothers suffering as well
as with ones ownrather than turning away from feelings
of discomfort or helplessness. In spite of the good intentions
of the people by whom she was surrounded, Charlene did not
appear to feel understood or supported.
I knew both the on-call physician and her family doctor
well, having shared several mutual patients over the years;
I had great respect for them both. As we spoke, her family physician expressed understandable exasperation about
Charlenes behavior and demands that morning. Once in the
on-call doctors office, Charlenes distress over her accident
and injuries had apparently escalated in a crescendo. She had
insisted she needed home care as well as a motorized wheelchair in order to keep up with her children as she walked
them to the park. The on-call doctor had emphasized to her
that she needed to become more mobile, not relegate herself
to a wheelchair for the rest of her life.
This was, of course, true; she did need to stay mobile.
Her psychologist and I, however, were convinced that she
did not intend to become wheelchair-bound; she had told us
about her walks to the park and the supermarket, stopping to
rest every 100ft or so along the way. But we were not pain
specialists. We were not physiotherapists or occupational
therapists, or even her primary care providerswe were her
mental health consultants. Interestingly, Dr. Martinis and
my experience with Charlenes primary health-care team
had begun to mirror Charlenes experience. Just as Charlene
felt isolated and unheard by her primary care providers, Dr.

C. L. Phillips

Martini and I likewise felt isolated and unheard. The primary

care team seemed convinced that the primary diagnosis was
a mental health issue. While her mental health issues were
very real, Dr. Martini, her pain specialist, and I were convinced that her physical pain was also very real, had a medical basis, and needed to be managed before she could begin
to process her trauma.
There are many forms of suffering. Charlenes, I mused,
was one of the most malignant. Through an event over which
she had had no control (her motor vehicle accident), she had
been hurtled into a lifetime of physical pain and, in tandem
with this, the reliving of the experience: her terror, helplessness and ensuing anxiety, fear, avoidance, irritability, and
other potentially life-destroying symptoms of traumatization. Compounding this suffering were her lossesof her
physical and mental health, mobility, friends, and former life.
Charlenes feelings of being overwhelmed and helpless
felt contagiousher apparent inability to tolerate or benefit
from her treatment appeared to have left her clinicians at a
loss for what to do, and each dealt with this in his or her own
unique way. Dr. Martini had expressed helplessness, worrying that her appointments with Charlene were not of any
benefit. I understood, as I had certainly had my doubts about
the value of my own time spent with Charlene. The pain specialist continued to follow Charlene every few months, but
made no further changes to the gabapentin dosage. Several
members of the team, to whom she had turned with phone
calls in an attempt to mobilize resources for herself, perceived her to have a behavioral problem. The nature of Charlenes suffering posed a challenge to each of her caregivers
sense of agency and competency; as a result, her caregivers
gave the impression of being stuck, while her treatment
appeared to remain at a standstill.
In our attempts to understand, process, and positively
contribute to Charlenes treatment and to her team as best
we could, Dr. Martini and I explored the potential challenges
faced by health-care providers in dealing with such patients.
We discussed how easy it can be to perceive a patient as difficult or unhelpable in defense against ones own painful
feelings of helplessness triggered by such patients. We also
knew from our own experience as therapists how easy it can
be to unconsciously shut out, or turn away from suffering for
which there is no cure.
We all have preconceived notionswell-conditioned
patterns of thought, emotion, and reactionas well as the
human need for a sense of security. Many of us are threatened by ideas that in some way endanger this sense of security. In clinical practice, however, when our own ideas and
attachments prevent us from being fully open and present
to hearing what a patient is attempting to communicate, or
prevent us from sincerely attempting to empathically attune
to and deeply understand the patient, this may hinder our
ability as a clinician to form a therapeutic relationship or to

6 The Mindful Psychiatrist: Being Present with Suffering

meet our patient with what is called for in the therapy hour.
Thus, the foundation of therapythe clinicianpatient relationshipas well as the work required in the therapy may
be jeopardized: by the clinician who is partially unavailable
due to his or her inability to be present with what the patient
brings into the office, by the patients conscious or unconscious reaction to this, and by the interplay between these
dual internal reactions.
In my experience, a strong therapeutic alliance requires
the clinician to accompany the patient on her journey through
suffering with an empathic presence, and with an awareness
and openness to ones own helplessness and fears as well as
to those of the patient. The thirteenth-century scholar and
mystic Rumi describes this aspect of the healing process
in these words: Dont turn your head. Keep looking at the
bandaged place. Thats where the Light enters you [3]. In
therapy, as in life, attunement to ones own and anothers
suffering requires patience and compassion for oneself and
the other.
While exploring the challenges faced by Charlenes treatment team, Dr. Martini and I confronted our own experiences triggered by Charlene and were able to mobilize our
own strengths to work with these challenges. We were both
seasoned therapists who had worked with difficult patientspeople who have often experienced trauma either in
childhood or later in their lives. Such patients, like Charlene,
frequently have heightened reactivity as well as weakened
capacity to hold, contain and work with traumas and feelings by which they likely felt overwhelmed at the time of
the traumatic event, and which continue to overwhelm them.
As psychotherapists, Dr. Martini and I had spent thousands
of hours of practicing mindful attunementto all of our patients in the present moment, to our own internal world, and
to the interaction and felt sense between the two.
I consider the therapeutic work I do with patients to be
an informal mindfulness practice; much like formal mindfulness meditation, which is practiced in a time specifically set
aside for it each day, this work requires that I meet each moment in the therapy hour as best I can with sensitivity, attunement, and with my full presence (or, at least, as best I can
be present on any given day). To use an analogy sometimes
used in Mindfulness-Based Stress Reduction (MBSR) programs, I have learned to use my awareness like a flashlight,
at times shining the high beam on the patient, at times on
what is arising within me, and at times on the dynamic between us both, holding this awareness along with my knowledge and training.
Figure 6.1 illustrates the application of mindful awareness
in therapeutic communication. My patients verbalization
enhances my understanding of her patterns of thought, emotion, and interpersonal interaction. As I empathically attune
to her issues, dynamics and internal states, while serving the


Fig. 6.1 Mindful awareness in therapeutic communication: This diagram illustrates how sensitive attunement to ones patient, ones own
internal world, and the interpersonal dynamic can enhance the therapy process through fostering awareness and enhancing ones ability to communicate the patients repetitive conditionings patterns
of thoughts, feelings, attitudes, and behaviours. Such communication
has potential to assist patients in becoming unstuck from conditionings that do not serve them well, allowing them to live life with greater
awareness, creativity, and internal freedom.

functions of holding, soothing, accepting, and modeling, I

can attempt to offer sensitive clarification, interpretation,
and, when necessary, confrontation. Through attunement to
my own internal world, the verbal and nonverbal communications of my patient, and the dynamic between us, I can
attempt to foster my patients enhanced awareness of repetitive patterns of thought, feeling, attitudes, and behavior
patterns which may not be helpful and in which the patient
may be stuck.
Herein lies the art of medicine: in compassionate attunement to oneself as a wounded healer, to the patient who
seeks relief from suffering, and to the interaction between
oneself and ones patient, while holding in awareness all
one has learned about the practice of medicine. Honing this
compassionate attunementsuch as through a practice of
daily meditationis particularly useful when working with
complex patients presenting with multiple layers of suffering
such as Charlene.
Not feeling heard or understood by her primary care team,
Charlene continued to repeat her tale of woe, asking for reassurance through questions such as, Do you understand, Dr.
Phillips? Unfortunately, the greater her need, the greater the
reactivity of others and the greater her sense of isolation and
frustration; it was a vicious cycle.
Over time, however, I observed a subtle shift emerge in
my appointments with Charlene. To all outward appearances, her presentation with cane, limp, pain, pressure of speech
and readily invoked agitation appeared unchanged. But


within the hours she spent with Dr. Martini and me, small
changes began to emerge. Charlene became able to allow
space within her appointments in which to listen.
Very early on in working with her, I had introduced Charlene to a 3-min mindfulness exercise focusing on awareness
of breath. Even with my patient guidance, she had interrupted the exercise several times, giving the impression of
being disinterested and unable to concentrate for more than
a few seconds. I had not pursued the exercise. However, one
day as her volume and pressure of speech began to escalate,
I had the impulse to interject. As I frequently do with patients struggling with self-regulation, I suggested we pause
for a moment. What are you noticing inside yourself, right
now, Charlene? I asked. As youre talking, what are you
noticing in your body? She looked perplexed, and then her
left leg stopped tapping. She sighed, and sank visibly into
the chair. She was getting it. Yes, you were starting to get
worked up, I affirmed. What are you noticing about your
state of mind right now? Silence. What emotions are you
aware of? Charlenes tired, faded appearance dissipated, as
her eyes became unexpectedly animated. She sat up straight
and leaned forward; I am so angry, Dr. Phillips! For a moment, she looked like an apoplectic figure from a Dickens
novel, eyes ready to pop out of her head. Why did this happen, Dr. Phillips? Im a good person. I didnt do anything
to deserve this. It isnt fair. My family is suffering. I sat,
fully present, fully attuned, and taking in what she was sayingher helplessness, her disappointment, her physical and
emotional pain at her enormous losses, and her anger. There
were no consolations I could offer. I could only be as present as possible, there with her and for her. My face sombre, I nodded. I know. You are a good person, Charlene.
With this affirmation, Charlene jumped in again, her voice
becoming louder, faster. I intervened. Charlene, lets pause
again. What do you notice about your breath right now?
She abruptly halted, again looking puzzled, as if trying to
figure out what I was referring to. I was taken aback by her
response: Oh, the breath exercise you taught me. I didnt
forget it, Dr. Phillips. I sometimes do it. I was stunned; I
had no idea she had absorbed anything I had said that day,
some months earlier, when I had attempted to introduce her
to awareness of breath as a tool for self-regulation. Are you
willing to try it now? I asked. She nodded. Perhaps sit back
in your chair, and bring your awareness to your breath, just
as it is. Notice the quality of your breathwhether fast or
slow, narrow or broad, deep or shallow, following the breath
one moment at a time, one breath at a time. Lets follow just
one breathand another breathbringing awareness to
each moment of the breath. All the way in, and all the way
outand lets pause to tune in to whats going on in your
inner state. Tune in to the state of your body and notice

C. L. Phillips

what is present, without trying to change a thing. Tune in

to the state of your mind, whatever this is like right now.
Tune in to any emotions present, while continuing to follow
the breath. Charlenes face softened; she appeared more
relaxed than I had ever seen her. I assigned this exercise as
homework. And she practicedfor brief moments when she
noticed her frustrations increasing along with the myriad of
symptoms we had identified. Over a period of a few months,
both Dr. Martini and I observed Charlene becoming more
able to collect herself, refocus her attention and energy, and
temporarily let go of upset that had been triggered.
Roughly 8 months after Dr. Martini and I had begun our
work with her, Charlene shared with me an unexpected acknowledgement. You hear me Dr. Phillips, she said one
day. I want you to know I really appreciate that. I trust you.
You and Dr. Martini are doing your best. I know that. Thank
you, Dr. Phillips. I heard, and this affirmed my experience.
She came across not as a demanding, entitled woman whose
caregivers would never be able to do enough to satisfy her.
In that moment, she came across as a woman who was aware
of our limitations, and appreciative of our presence and patience. A woman whose suffering was simply so great that
she often could not contain itand it scared many people
Other indications of Charlenes progress also began to
emerge. In spite of her unremitting pain and very real stressors, she appeared less wrapped up in these, more often able
to calm herself and to communicate in a coherent and positive manner. This incremental improvement was occurring
in spite of miniscule doses of medication and an inability to
tolerate or complete pain treatment programs to which she
had been referred.
What was happening? I believe that the answer lies in
Charlenes acknowledgement to me that she felt heard,
and in the evidence that her self-regulation skillsoften
problematic in traumatized individualswere incrementally
improving. The repetition of bringing Charlenes wandering
mind back to our point of discussion again and again served
a parallel function to mindfulness meditation, in which one
repeatedly directs ones mind back to the present moment
often initially focusing on the breath as an anchor. Charlene
was also practicing brief mindfulness exercises throughout
the day in the form of noticing the state of her body, mind,
and emotions, and focusing on the breath to re-anchor herself in her body and in the present moment. Although this did
not change her circumstances, it appeared to somewhat lighten her load and to have some calming effect. While setting
clear boundaries, Dr. Martini and I had empathically listened
with acceptance, nonjudgment, and compassion. Rather than
reacting to her disjointed train of thought and at times wildeyed and angry presentation, we understood and accepted

6 The Mindful Psychiatrist: Being Present with Suffering

the suffering beneath this. We had caught a glimpse of the

person underlying the talk and behavior, and had responded
with compassion by remaining present with her through her
suffering rather than recoiling or withdrawing from her.
Perhaps the only thing worse than being in pain, either
physical or emotional, is being in pain alonefeeling that
nobody hears, understands or cares. This had been Charlenes plight prior to entering treatment with Dr. Martini and
me. When medications and other treatments had failed, we
had faced our own helplessness as we dared to remain present to Charlenes and our own suffering with acceptance and
compassion. Within the holding environment of therapy, the
degree of her suffering began to shift, and Charlene began to
mobilize her own internal resources. Her self-regulation improving, she began to be able to calm herself and redirect her
ramblings as she interacted with others and faced her new
future. As Charlene acknowledged her appreciation for the
little I felt I had done, I felt the depth of her gratitude, and
in this moment it felt like a gift not just to my patient, but to
methis being present with suffering.


1. Grepmair L, Mitterlehner F, Loew T, Bacheler E, Rother W, Nickel
M. Promoting mindfulness in psychotherapists in training influences the treatment results of their patients: a randomized, doubleblind, controlled study. Psychother Psychosom. 2007;76:3328.
2. Grepmair L, Mitterlehner F, Loew T, Nickel M. Promotion of
mindfulness in psychotherapists in training: preliminary study. Eur
Psychiatry. 2007;22:4859.
3. Rumi J, Barks, C. Delicious laughter: rambunctious teaching stories from the Mathnawi of Jelaluddin Rumi. Athens: Maypop;
1990. p.97.
Catherine L. Phillips MD, FRCP(C)is an Assistant Clinical
rofessor in the Department of Psychiatry at the University of Alberta,
where she is a psychotherapy supervisor and offers seminars and an
elective on mindfulness to psychiatry residents. Dr. Phillips has integrated mindfulness into psychiatric practice and psychodynamically
oriented psychotherapy for more than 25 years. A certified Mindfulness-Based Stress Reduction (MBSR) instructor, she has led the MBSR
program in Edmonton, Alberta, since 2006, and offers mindfulnessbased programs modeled on MBSR to health-care professionals and in
her role as psychiatric consultant to the Canadian Armed Forces

The Death of a Snowflake

Emmanuelle Baron

I remember my first encounter with death

I was 8 years old. A young girl at my school had died after
being hit by a truck while she was riding her bicycle. All of
it seemed so surreal. I went through this experience with an
egocentric view: I did not want the same thing to happen to
My life, like hers, was just startingI could not imagine
never coming back. The grown-ups at school were saying
that the young girl had departed for a new journey. For me,
this was a one-way trip she traveled alone. The feelings I was
left with were fear and anxiety. Those feelings passed, as my
daily school life and play continued.
Death revisited me a few times during my adolescence.
My grandparents died, as did my cousin, at the age of 17.
Death was easier to accept at the end of a long life than at
the start of one young one. I could consider death as part of
life when it happened in the elderly, especially following an
But that fear and anxiety returned when my cousin died
suddenly in a car accident. I was trying to grasp the incomprehensible. Accepting what happened was not easy. I was
using reason to grapple with something we cannot control. I
wanted to find a meaning to his death and to make sense of
what I saw as a grave injustice. Why had he been robbed of
his young life? How could he start a new journey if he had
just begun the first one? After a few months of turning and
twisting these questions in my mind and not finding an answer, I cast them aside and continued my typical teenage life
without being unsettled by frequent thoughts about death.
Clearly, the career I chose necessitated my exposure to
the subject again. The first time I became reacquainted with
death was as a clerk on my first rotation in internal medicine.
I remember this experience vividly. It was the first time that I
was on call and I was asked to confirm the death of a patient
Department of Family Medicine and Emergency Medicine, Universit
de Sherbrooke, GMF de lUMF Charles-LeMoyne, 299 boulevard SirWilfrid-Laurier, Suite 201, Saint-Lambert, QC J4R 2L1, Canada

late at night. I arrived in a room where numerous members

of a large family were grieving. Some were crying, others
The deceased patient was around 50 years old. Her eyes
and mouth were opened. She was covered in sweat. In the
hallway, just before entering the room, I had reviewed the
steps I had to perform to write her death certificate. A medical resident had shown me how to do it a few days before.
The completion of death certificates was one of the tasks a
clerk had to do while on call. Nobody liked doing this, me
I arrived in the room emotionally unprepared. I felt completely out of place and powerless. Some of the family members did not want me to touch the corpse. I tried to explain
that I had to do it to write her death certificate. That it was
part of the protocol. I informed them that I would close her
eyes because it would probably be more difficult if we waited too long. I remember feeling repulsed by having to touch
the sticky, cold and wet body. Was death not supposed to be a
peaceful process? Some family members seemed angry and
asked me to leave. I did my work rapidly, with little to no eye
contact and then exited feeling incompetent and helpless.
Shortly after that event, I contemplated death frequently
as if thinking about it would provide some control over it.
Instead, these thoughts elicited more feelings of anxiety and
distress. Over years, I encountered death with various patients. Usually, they were patients I did not know well and
with whom I had not had long therapeutic relationship. With
time, I acquired skills to announce bad news and to support
mourning families, but this simply helped me to manage situations in which I had less emotional engagement. What was
most valuable for me was meditation; it enabled me to cope
with the notion of my own death and, consequently, that of
others. This is how I was able to live mindfully through another experience that was much more significant for me.
When I first met her, I was beginning my practice in family medicine. Having completed treatment and gone into
remission, her oncologist recommended that she should be
followed by a family doctor to accompany her in her newly

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_7,

Springer International Publishing Switzerland 2015



found health. A woman in her late 40s, she was calm and
seemed relatively at peace with what had happened. Her
hair was short and gray like many other cancer patients. In
good health, even a bit overweight, she was well enough to
start work and was happy about that. She was polite, wellspoken, and listened to my advice. I was excited and curious
about becoming her family doctor as I had never followed a
long-term cancer patient. I had an open mind and I wanted to
know her better. Without knowing it, I was experiencing one
of the attitudes of mindfulness: a beginners mind.
For a few years, I was happy to be an active support during the scary time when the possibility of a relapse loomed
large. At that time, I saw her every 6 months and then became
her husbands and two daughters family doctor as well. I
was there for one of her daughters through her pregnancies
and looked after the health of this growing family. I had the
joy of celebrating the end of her tamoxifen medication, an
important step that meant that she was slowly moving out
of the dangerous relapse zone. We had gradually developed
a mutual respect and appreciation. I was impressed by her
courage and positive attitude throughout that uncertain period and she appreciated my support and willingness to insure the wellness of her whole family. We had established a
positive therapeutic relationship.
Unfortunately, without warning, events took an unwelcomed turn. I discovered and had to announce that the cancer had returned. The dreaded moment every cancer survivor
wishes not to meet, the moment when they realize they will
have to fight again to remain a survivor, had arrived. But she
never had a chance to defeat this disease. Additional tests
revealed metastases, reducing the chances of another remission with current treatments. I had been there in times of
hope; then we had to face despair and the need to accept
what lay ahead.
I had not yet started practicing mindfulness mediation
when this happened but I was more experienced, could cope
better, and had the maturity to share this bad news in the best
way possible. Yet, I was feeling anxious and unsettled. How
would she react? How would I react if she was my mother, or
this was me? I wanted to be as empathetic as possible. I cannot remember if she came alone to that visit. This fact makes
me think that I was probably more preoccupied with my own
thoughts and feelings that I would have wanted to be.
I had discovered the metastases on a routine ultrasound
her surgeon requested every year. Without showing any
signs of anger, she remained calm and seemed sad. She
asked me what would happen next and I described the steps
ahead. There were a few moments of silence and I felt uneasy. Because I wanted to do and say the right things I filled
the silence with information, including the tests that needed
to be run, the next appointments she had to schedule, and the
leave of absence she needed to take from her work. I probably talked too much and did not give her enough time to

E. Baron

receive the bad news. I remember that she did not talk much
and as usual, she seemed to make an effort to listen carefully
to what I was saying and agreed with the plan. I offered my
support and tried to be empathic. She left in silence. I felt
somewhat satisfied about how the encounter had gone but I
did not really know how she was feeling. I wanted things to
be different for her.
After that day, I saw her less because she started a series
of treatments to contain the disease. Each time we met, similar to past visits, she remained calm, pleasant, and smiling.
At every appointment, I was supportive and answered her
questions and health concerns in an empathetic way.
Naturally, she expressed her fears about the future and her
difficulty accepting her fate, but afterward, she seemed resilient and able to enjoy the present moment. She was doing
everything in her power to control the disease and to appreciate her life.
But I knew her life was reaching its final stages and that
the aim of treatment needed to be oriented toward making
her final moments painless and hopefully, peaceful. In February of that year, I organized her transfer to a palliative care
home. Shortly thereafter, her husband called me and asked if
I would come and visit her in her own home, before she took
the last step in her journey. It was her wish to see me. Time
was against us.
It was a few years ago, nonetheless, the memory is so
clear in my mind that this could have happened yesterday.
I recall that day. That snow. Now, every time I see snow
falling in the same way, with big flurries looking like bunny
tails, it takes me back to that moment.
At that point, I had been practicing meditation for some
time and I wanted to use the tools I had acquired to fully
immerse myself in that meeting. I was a bit apprehensive,
but my mindfulness practice allowed me to move forward
toward her, toward death, with an open heart in a direction
that I would have avoided out of fear.
I cleared my schedule and made space for that moment
the next day. When I sat down in my office, I focused on my
breath and allowed my thoughts to float away like the flurries falling from the sky. Then I went on my way.
The practice of mindfulness has transformed my view of
death. I no longer feel the need to think of it as frequently,
and when I do, I no longer experience fear and anxiety. I see
with clarity the impermanence of all things, including life.
The practice of many of the attitudes of mindful meditation helped me in that process. Cultivating patience helped
me understand and accept that things have their own time for
unfolding. No need to force things, they will happen at their
own pace.
I also learned to trust myself more. I discovered that I am
my best guide. When I will be faced with my own death, I will
trust my own wisdom. The practice of non-striving, simply
being and not doing, strengthened my faith in my own wisdom.

7 The Death of a Snowflake

I discovered the concept of acceptance and letting go.

Death is beyond my control, it is part of life. Acceptance allows me to cease struggling to change things that are beyond
my control. By simply letting my experience be what it is,
accepting things as they are without judging, and realizing
the constantly changing nature of all experiences, I can remain calm. Birth and death are a part of the multitude of life
Finally, the cultivation of gratitude helped me appreciate
and be ever thankful for the present moment.
I was determined to be mindful of what was going to
occur next. Driving to her home, I started noticing. I started
being present. I watched the flurries floating in the air, each
of them different, countless white objects, looking alike,
until I took the time to appreciate, to really look, to feel, to
understand. My being present in that moment helped me to
see not only the unique nature of each snowflake but also the
uniqueness of each moment, each encounter, and each life
touching mine.
She lived on a street near a building where I frequently
traveled. Despite my regular visits to that neighborhood,
I had never noticed her street before. It was beautiful and
I rang the doorbell. Her husband opened the door while
she was waiting for me in a chair in her living room. She
had difficulty keeping her head up to look at me; it seemed
so heavy. Her hair was the same as when I had initially met
her, short and gray. She had not lost much weight but seemed
tired. Nonetheless, she was still smiling when she saw me.
Her husband tactfully stepped out of the room and left us
alone to talk. She wanted to thank me. She did it simply and
I wanted to tell her how I admired her courage and willingness to fight this terrible illness. I wanted to be a reassuring presence and be present for her in that specific moment. She looked at me and I looked back at her in complete
silence. It was a comfortable silence. Time stood still. I felt
peaceful, appreciating each moment of this simple and powerful encounter. My body was released of tension and my
heart was free of discomfort. I felt in harmony, despite the


gravity of the situation, while attending to her needs and to

The silence lasted a while until we both knew the time
had come to say good-bye. Despite physical pain, she insisted on walking me back to the front door. She had trouble
moving even with the aid of her walker; her head was tilted
to one side. I saw in this gesture her courage and dignity.
I admired her. Once arrived at the door, she said good-bye
with a tear forming in the corner of her eye.
I told her that I would be seeing her again
Despite the nature of the situation, I left light hearted. I
had just lived a deep magical moment as a doctor and as a
I am still in awe with what happened that day. I hold onto
the fact that the simplest of things like taking a breath, taking
time, and making space for the unknown to arise can bring
long-lasting memories and valuable lessons.
I was able to fully live this unique moment by being
mindful. Mindfulness opened the door to a realm of possibilities I could not imagine before. By being first present to
my breath, my body, my feelings, and my thoughts and then
to my surroundings, including the features of the flurries and
the streets on which I drove, I was able to provide exquisite presence and experience the joy of a powerful, albeit
simple, human relationship. Healing by its very nature is a
personal, emotional, and conscious process; it is more than
just a medical act.
She died 2 days later. I am convinced that I played a part
in helping her to feel healed and complete in some way. I
feel privileged to have acquired tools that allow me to nurture and appreciate the core of my work: the patientdoctor
relationship. An experience such as this one helped me realize and define the foundation on which healing relationships
are built.
Emmanuelle Baron MD/CCFPis an associate professor in the
Department of Family Medicine and Emergency Medicine at the Universit de Sherbrooke. She teaches and does clinical work at the Family
Medicine Unit at Charles-LeMoyne Hospital in St-Lambert, Quebec,
and at the Sports Medicine Clinic of Universit de Montral in Montreal, Quebec, Canada

Carmens Story
John H. Kearsley

The Clinical Context

Ms. Carmen S is a previously fit and healthy 55-year-old
lady who presented to the Cancer Care Center for an opinion regarding the role of radiotherapy following a right-sided
lumpectomy and sentinel lymph node biopsy for early-stage
breast cancer. Carmens breast cancer was diagnosed as a result of screening mammography. Following her surgery, the
histopathology report documented the presence of a grade 1,
7-mm-diameter invasive ductal carcinoma without spread to
the axillary lymph nodes. The primary malignancy was estrogen/progesterone receptor positive and human epidermal
growth factor receptor (HER)-2 negative. Complete surgical
resection had been achieved.
Carmen is retired, and lives alone. Her time is divided
between Sydney, where her son lives close by, and South
Australia where her partner lives. She is completely independent and she feels well supported by her son and partner.
Carmen exercises regularly and she also travels, particularly
to Europe (Croatia).
The recommendation for Carmen is that she undergo a
5-week course of daily radiotherapy to the remainder of her
right breast in order to reduce the likelihood of her breast
cancer recurring. Given the small size of her cancer, the absence of spread of cancer to her armpit, the complete resection of her malignancy, and the absence of aggressive features, Carmens prospect for cure should exceed 90%.

The Doctors Reflection

They were already waiting for me, as I walked into my clinic room that afternoon: two third-year medical students
Katherine and Callum. Third yeara difficult year for most
Department of Radiation Oncology, St. George Hospital, University
of New South Wales, 40/501 Glebe Point Rd, Glebe, Kogarah, NSW
2037, Australia

students, especially during their oncology and palliative care

rotations; a time when empathy is at risk of being eroded by
the pressure of undergraduate medical study, the hidden curriculum, and the depersonalization which can occur in some
situations in modern hospitals [1, 2]. Hardly any wonder that
there is an increasing sense of cynicism, and of detachment,
in dealing with people who are ill [2].
Away overseas for the previous 2 weeks, I was involved
in only one student tutorial for this particular rotation, a tutorial a few days ago on communication skills. I wondered how
Katherine and Callum were doing; I wondered whether, like
most of their peers, they were still experiencing initial dread
of confronting this rotation. As I made friendly chatter with
Katherine and Callum, I was aware that my recent paper on
transformative learning among third-year medical students
during this rotation was just about to be published. My coauthor and I had demonstrated the many personal transformations that may take place in the lives of students during this
oncology and palliative care rotation [3]. I wondered what
Katherine and Callum had learnt during their rotation over
the past few weeks. Had they any worthwhile experiences
to tell me? Were they, like many others, still feeling overwhelmed by their perceived sense of inadequacy?
Little did I realize that, for these two students, today
would be special.
The first patient of the afternoon was to be Katherines.
We looked at the referral note, inscribed with the barest fragment of information, and then the patients registration detailsMs. Carmen S, a 55-year-old woman, born in Romania, her son the next of kin. Not much to go on, I thought. We
carefully reviewed Carmens pathology report; I was content
that a curable cancer had been described, and I suspected that
the consultation should proceed in a fairly routine fashion
for someone whose cancer was eminently curable.
I had asked Katherine to glean as much information about
Carmen as she could in the 40s it would take her to find
Carmen in the waiting room, introduce herself, and lead her
to the consultation room where I would be waiting with Callum. As I sat in silence with Callum, becoming ever more

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_8,

Springer International Publishing Switzerland 2015



present to myself and the room, I felt a sense of anticipation, almost excitement, at the prospect of meeting a totally
unknown person, and the prospect of making a difference
in whatever opportunities presented themselves. I enjoy the
not knowing about who the next person might be.
The door opened, and Carmen slipped through quickly
as if escaping from a threatening outside world. Katherine
promptly followed. Apart from a brief glance during introductions, Carmen avoided eye contact. She had a gentle
eastern European accent. Carmen looked at me fleetingly,
but then preferred to gaze at the grey linoleum on the consulting room floor. She quickly sat down, a little huddled on
the dark pink vinyl chair at the side of the imitation timber
desk where Katherine was about to commence taking Carmens history. Carmen was slender, attractive, and almost
elegant with wavy brown shoulder-length hair in large soft
curls and a prominent black choker around her neck. She
dressed well, but, she looked drawn; there were no smiles
nor was she wearing lipstick or makeup, and she appeared
hypervigilant and agitated. As she sat down, Carmen began
anxiously to massage her fingers in small, repetitive, writhing movements.
Katherine began the interview by staring awkwardly at
Carmen who said nothing, merely awaiting the first interchange of real words. Katherine half spoke, then seemed to
withdraw her words in mid-sentence. I am not sure what she
said, but Katherine seemed nervous and alone, not unlike an
actor on an empty stage. Well, then, Carmen, how are you?
Carmen averted her eyes to the grey linoleum floor again, I
am very depressed. She then began to weep. Carmen reached
for a small tissue from her sleeve to gently dry her nose and
eyelids, but the weeping did not cease. Great, I thought, a
perfect opportunity for Katherine to demonstrate how to deal
with an emotional patient. Katherine sat motionless.
Good, I reflected. I think that Katherine is letting Carmen compose herself before she proceeds.
But the crying continued. Katherine appeared frozen in
action; only a few days before, we had discussed in some
detail an approach to the patient who may become emotional
and teary in front of you. Yet, Katherine appeared catatonic;
her left forearm jerked forward only a few inches towards
Carmen, but then her arm froze, motionless. What to do?
Katherines eyes were wide open, her smile frozen, her lips
apart, her body leaning forward, but immobile. She looked
stunned as Carmens weeping turned to sobbing. Wrinkles,
lined with pain, appeared on Katherines forehead and
around her eyes. My fear was that Katherine would now become totally overwhelmed and might herself become tearful;
I needed a circuit breaker before the interaction imploded
I cannot recall planning exactly what I should do. Instinctively, however, I placed my two hands on the sides of my
chair and gently moved both myself and my chair forward,

J. H. Kearsley

very close to Carmen, our knees almost touching, in full

view of the two students. I sensed that Carmen required a
closer presence; I saw Carmen as a shattered piece of pottery
[4], with each jagged piece somehow cleaving to its neighbor in fragile repose; maybe, I thought, the next teardrop or
sob would be enough to cause total disintegration of her fractured self. I did not look forward to the prospect of having a
thousand shattered pieces of pottery break all over me. Carmen needed a connection; she and her fractured self needed
to be held together somehow.
I do not usually sit quite as close to my patients as I did
with Carmen. But this time, it was different. I sat directly in
front of Carmen, knee to knee as I clasped all ten fingers of
both her hands, gently but firmly. But what was I doing by
clasping all her fingers and both her hands in mine? I think
I was trying to hold her together; please do not disintegrate
over me. Maybe I was trying to give her a direct infusion
of courage, and humanity, the reassurance that all would be
well. During this intense experience of presence, I was also
keenly aware of how I was feeling. My pervasive feeling was
that of uncertaintywhere is this going? What will Carmen
say next? What might I say? Will I say the right thing? Will
I just need to sit in silence with her? And yet, over the years,
I recall that I have borne this feeling frequently. It happens
every time when circumstances, such as Carmens arise. But
it does not destroy me. I sometimes ask myself, How do I
endure this uncertainty when I would rather just run away?
Certainly, running away would be an easier option. But, in
bearing uncertainty and staying present, I am continually
mindful of attempting to make a difference despite the unfamiliar seaways of uncertainty through which I navigate.
The words of Balfour Mount, written almost 20 years ago,
provide sustenance for me to stay presentYou make a difference when you take the time to sit down and listen, when
you stay there in the face of unanswerable questions [5].
That challenge gives me strength and reassurance in situations like Carmens, every time. It means that I also have to
believe in mystery, and to develop a sense of nonattachment to outcomes over which I have little or no control; on
most occasions, I have no idea as to what type of difference
I make.
Carmen, I said, it sounds like you have had a rough
There is certainly a very private dynamic, I think, around
the use of empathic statements in the clinical setting, whether
the statements used are empathic statements of understanding, respect, or support [6]. I find these statements to be immensely powerful, particularly as circuit breakers in the
midst of those swirling emotions, both spoken and unspoken, that can sometimes cause disorientation in the clinical
encounter. I use empathic statements to seek out a place of
peace and shelter in the midst of the eye of a tornado; when
delivered with care and sensitivity, there will often follow a

8 Carmens Story

silence which can be profound, deep, and longing, moistened

with silent tears.
When I said, Carmen, it sounds like you have had a rough
time, or Carmen you are the only one that matters at this
moment; we are here totally for you, despite the ensuing
silence, there is still a conversation going on; it is just that it
takes place in another silent, contemplative space where only
the two of us can be, each bringing our wounds to heal, or to
be healed. I find it is often a mistake to speak too soon; if any
words are said, they arise from deep and hidden places. This
is my concept of exquisite presence. According to Buber,
exquisite presence represents searing, fragmentary episodes
of direct spiritual union between two people during which
nothing exists, neither time nor distance nor place, apart from
us, in dyadic union [7]. According to Rohr, exquisite presence is experienced as a moment of deep inner connection,
and it always pulls you, intensely satisfied, into the naked
and undefended now, which can involve both profound joy
and profound sadness. At that point, you either want to write
poetry, pray, or be utterly silent [8]. I suspect that many of
us who work with ill people experience episodes of exquisite
presence more often than we realize, as we enter involuntarily into these healing spaces. As I sat with Carmen, in the
midst of my uncertainty, I experienced feelings similar to
those expressed in one of my published poems:
That time when we sat naked, unfolded and laid bare
The truth of our existence was all we had to wear.
Washed clean by every silence, in the realm of our between,
We walked along the Narrow Ridge, then returned to where
wed been [9].

Can you tell me a little bit about yourself? I asked. What

do you like to do? Do you cook?
Yes, fortunately, Carmen loved to cook. In between sobs,
her broken voice told me that she liked to cook goulash,
Hungarian goulash (goulash to the rescue, I hoped).
And I see you were born in Romania. Do you often
travel to Romania? Tell me what its like.
Carmen indicated that she returns occasionally to her
homeland. She loves to travel, and for 6 months of every
year, travels to a little house which she owns in a small Croatian town. Her weeping had ceased, at least temporarily. Although her voice was still breaking in mid-sentence, I sensed
her mood might have lifted for a bare moment of respite.
And tell me Carmen, what does the word cancer mean to
you? There was something very odd, I thought, in Carmens
situation. She had undergone surgery for a highly curable
small breast cancer, and yet her reaction to the diagnosis appeared extreme. I recalled Eric Cassells work on the importance of defining the meaning which patients apportion to
their diagnoses; we humans are inveterate meaning makers
It means the end, doctor, it means the end for me. We
then explored why the word cancer meant the end for


Carmen. It transpired she had only recently lost two close

friends, shortly after both had apparently been reassured they
would survive their cancers. It had been a big shock. Carmens wounds were still raw.
I spoke softly, slowly but firmly, as I continued to hold
her hands in mine, our knees still touching.
Carmen I said, I want to tell you that you have had
a very small cancer removed from your breast, it has been
completely removed and it is not an aggressive cancer. I
think the most likely outcome by far is that you will be totally cured.
She started to weep again, sobbing, as she continued to
dry her eyes and wipe her nose.
You will be in big trouble, doctor, if you are wrong, she
Dont worry Carmen I wont be wrong; I will even make
a bet with you, I said. I had not planned to say this; there
was no planning, the words just came. It was an infusion of
If I am wrong and you are not cured, then you can come
back to haunt me, every day. If I am right, and you are cured,
which will happen, you will need to cook me Hungarian goulash every month for one year.
At this prospect, Carmen gave a half laugh. OK doctor,
its a deal, she said. Carmen started weeping again, her eyes
averted, and she regressed once again into herself.
I would not have been able to make any such bet with
Carmen had her cancer been large, or aggressive, nor had it
spread to the lymph nodes within her armpit. I counted myself lucky that her cancer was small and curable. I thought
that I, myself, might now even survive this consultation. It
was a bet, unlike many others, that I might just win.
Once Carmens emotions had resolved somewhat, I asked
Katherine to continue taking Carmens medical history. But
I noticed that during my interlude with Carmen, that something had happened to Katherine. She seemed much less
anxious and more confident to engage with Carmen.
Katherine demonstrated empathic listening and good use
of silence, allowing Carmen to talk freely. Katherines beautiful full face, and engaging smiles, reflected something that
had happened deeply within her over the preceding few minutes. At one point, Carmen said to Katherine, I am so lucky
that I got to speak to you today. Katherine seemed relieved,
almost speechless at this compliment, and she maintained
her soft composure throughout the remainder of the interview with Carmen.
Callum continued to look on, a keen observer of the dynamics. I knew that he would be seeing and feeling something quite different to what Katherine and I were seeing and
Apart from finding out more about Carmens past medical
history, her few medications, lack of allergies, social history,
and daily activities, Katherine was able to explore with calm

J. H. Kearsley


repose why Carmen thought she had developed breast cancer, and how the cancer diagnosis had been so severely influencing Carmens lifestyle since the diagnosis had been made
a week or two ago. Carmen indicated that she felt very guilty
about being the cause of her own breast cancer. I took hormone replacement therapy, doctor, for too long. I was only
supposed to take it for a few months, but I didnt understand
what the specialist said, and I took it for several years. Thats
why I think I have got the cancer. Its my fault.
At this point, Carmen began sobbing again. I held back
to see how Katherine might handle the situation, given that
she had developed an increasing degree of rapport with
Carmen. Katherine drew closer to Carmen, but then froze
again. I sensed that a new wave of brokenness had overcome
Carmen. What would Katherine do? To offer Carmen a hug
seemed appropriate. Sometimes, a hug is all that we may
have to offer.
I said to Katherine Katherine do you feel like giving Carmen a hugwould you please show me how you hug? I
had been taking careful note of both Carmens and Katherines emotions during the interview, and sensed that Carmen
needed further physical comfort, and that Katherine might
know what to do. But something was stopping her. I had no
doubt that Katherine was a tender young woman with lots
of empathy. But, how would she express her empathy? Fortunately, Katherine responded, albeit with a small reluctant
smile; Carmen was happy to be hugged. Katherines need for
empathic connection had been liberated at last.
While I recognised the reality of Carmens guilt, I also
recognized it was not my job to fix her guilt. When guilt
results in suffering, it is my view that no amount of cognitive-based reasoning with a patient will achieve anything to
relieve that suffering. There is little point in telling someone
not to feel guilty. It just does not work. A hug in silence
can often penetrate where words cannot go. As Katherine
bent forward, her hug appeared a little stiff and uncertain;
she was unsure how much hugging was appropriate. Momentarily, as she reached out to Carmen, her blouse rose up
slowly over her back to reveal unblemished and tanned flesh.
Katherine was vulnerable and exposed.
At the time of our parting, Carmen said farewell to Katherine by giving her a deep and sustaining hug. This hug was
different from the first hug Katherine had initiated; rather
than a slightly stiff embrace on Katherines part, Katherine
was much more natural in her response this second time. It
seemed to me that Katherine and Carmen had connected at
some deep level. They did not speak.
Carmen and I agreed that I would arrange her radiotherapy appointment promptly. Apart from some minor details
regarding the logistics of radiotherapy, I sensed that Carmen
did not need to know many technical details. All she needed
to know was that radiotherapy was highly likely to cure her,
that she would not be harmed and that she would be cared

for. I realized, however, that I would need to continue to hold

her together loosely during the 5-week radiotherapy course,
as Carmen would attempt to put together her broken pieces
in a new configuration.
As she walked out the door, Carmen looked back at us
over her right shoulder. She was smiling; she looked optimistic. Carmen gave us a quick wave with her left hand
and began bobbing along the corridor towards the exit, as I
closed the door.
Nothing needed to be said. It had been an experience in
which we had gone beyond good clinical care to an experience which epitomized the essence of whole person care.
The three of us just stood in stillKatherine, silent and
beaming; Callum silent with amazement; and me, silent and

Katherines Reflection
There really is not anything that can prepare you for the first
time that a patient is truly distressed and cries in front of you.
It was not that I had never been exposed to emotional,
distressed, or even crying patients, but they had never been
under my care. I had comforted friends before, so surely, I
thought, it would be the same? What I did not realize was
just how true this really was.
Carmens answer to my simple How are you? was not
at all what I expected. While I had felt her anxiousness initially, I was not prepared for the bluntness of her honesty in
replying, Im very depressed. When I asked if she wanted
to explain it further, the way she began to cry knocked me
over. I just felt so unprepared and overwhelmed by her distress. I could feel my mind going blank.
Thinking back to it, I realize now that I had been unsure
as to how I should act professionally. While professionalism
is a very important aspect of being a doctor, I cannot help
thinking, why was I so conscious of this? And did I fixate
on this rather than just act as a human being? At the time, I
would instinctively feel my hand move out to touch her, but
I would catch myself. I felt too unsure. I did not know how
to rub her shoulder, or how to give her knee a squeeze. I did
not know how to be appropriate in the situation.
This need to be appropriate is something that I feel can
create a challenge for many students, such as me. I feel that
we are often caught in this pattern of erring on the side of
caution, and not allowing ourselves to be truly compassionate humans. By holding back, we lose the ability to fully empathize. How can we offer our patients care, and true caring,
to the best of our ability, if we hold ourselves back?
One of the things I felt I really learned from this experience was that it is okay to sit close to a patient. It is okay to
give their shoulders a squeeze, or even a hug, just as you
would a friend. Professor Kearsley encouraged me to give

8 Carmens Story

Carmen a hug. He helped me to feel more natural and to feel

as though I was comforting a friend.
As I watched him pull his chair right up to Carmen and
give her knees a squeeze, I could feel Carmen relaxing and
feeling understood. The touch was just natural. It was as if
she was relieved that, as her doctor, Professor Kearsley not
only cared but could also show that he cared for her. Her distress was meaningful to him, and this made her meaningful,
as a person, not just a patient.
Using the setting, perception, invitation, knowledge, empathizing and exploring, strategy, and summary (SPIKES)
technique [6], Professor Kearsley was able to elicit why Carmen was so distressed. Her perception of cancer was that it
is the end. It did not matter that she had been told her cancer
had not been a bad one, or that it could be cured. Her personal beliefs clouded her thoughts, and as she said, she just
could not stop the thoughts in her head. I felt that this was
a very clear example of being able to demonstrate empathy.
Professor Kearsley was not just able to elicit that Carmen
was upset, but explore why she was upset. Carmen revealed
that her sense of hopelessness was influenced by her experience of having two friends pass away from cancer.
The turning point in the interaction was probably when
Professor Kearsley was able to make Carmen feel more like
herself again. He was able to comfort her and make her laugh
by making a playful bet. He was able to form a friendship
with her, even as her doctor. This calmed and stabilized the
situation, established rapport, and showed that he would be
supportive throughout her treatment.
As he said afterwards, many patients, especially cancer
patients, will come in pieces, with their person shattered.
What they need is a connection. Someone to be able to understand the way they feel and comfort them in their distress.
Someone needs to remind them that they are still themselves,
and not their illness; that it is normal to feel overwhelmed
and upset, and that in some way, it will be okay.
Observing and participating in this, I saw the way all the
little things, such as leaning forward, nodding, paraphrasing, touching, and making empathetic statements shaped a
sense of empathy. Professor Kearsley was so focused and
completely present in the moment. During his interaction
with Carmen, I felt a real connection was being made. And
as she left, she said she felt so changed from the way she had
come in. The second hug I received from Carmen felt full of
gratitude and relief.
So often, patients will become upset and as students, or
doctors, we feel that we have upset them. Yet, as Professor
Kearsley pointed out, a multitude of things causes their distress, and we are almost always not the cause. Often patients
need someone to be there for them, perhaps to talk to. Yet
when they start crying or when they are distressed, we give
them space. We would not leave a friend crying, so why
would we leave a patient crying?


I feel this experience has really given me the confidence

to put myself out there for future patients. I feel that I really
do now know that it is okay to comfort a patient as I would a
friend. And that holding back not only feels unnatural but is
unnatural. To be completely present for a patient is to really
be there for them, whether or not they have bad news, are
distressed, or overwhelmed. Empathy cannot be halfhearted.
After Carmen left, Professor Kearsley reminded me to
clear my mind for the next patient. We would be entirely
present for him too.

Callums Reflection
My name is Callum Barnes and I am a medical student with
the University of New South Wales. On Thursday, 7 November 2013, another student and I were fortunate enough to be
scheduled to a radiation oncology clinic with Professor J H
Before we saw our first patient, Professor Kearsley sat
us down and spoke to us about what he would like us to do.
We reviewed the patients history and pathology and spoke
about her prognosis and the treatment options available to
her. The patient, Ms. Carmen S, was a woman in her mid-50s
of Romanian descent. She had been diagnosed with breast
cancer following a screening mammogram and which had
been completely excised during a lumpectomy procedure. I
do not recall the grade/stage of her tumor, but I understand
it was minimally invasive with no nodal spread and that we
could be relatively assured that her prognosis was good.
Unfortunately, as we found out, she had not been told such
information. Professor Kearsley and I stayed in his room,
while my colleague went to the waiting room to find Carmen
to bring her in. When she entered the room, we could see that
this woman was suffering, both emotionally and physically.
My fellow student began the consultation by asking
Carmen how she had been doing since her procedure (the
lumpectomy), and it transpired that things had not been
going very well. The patient noted that she felt depressed
and found no pleasure in things she had previously enjoyed.
She had also stopped eating well and exercising regularly.
As we delved deeper into these emotions, Carmen began to
break down into tears.
I cannot speak for my colleague, but this was definitely
the first time I had been so exposed to the internal torment
of another person (whom I did not previously know), and as
such I was taken a little aback. I believe she was able to open
up to us so readily because of the caring atmosphere of the
room and the nature of the consultation.
Fortunately for Carmen, Professor Kearsley was no
stranger to seeing this side of peopleand as such he could
read the situation perfectly, knowing exactly how to react.
Professor Kearsley had been sitting approximately 1.5m


away from the patient, but as this happened he moved right

in close to her, resting one hand on her back and taking her
hand with his other. I could see a woman who was terrified about what was going to happen to her, crying out for
a shoulder to lean on; this close contact was something Carmen clearly needed.
For several minutes we sat there, mindful of the silence
and just letting Carmen talk. She spoke of two friends
who had been diagnosed with cancer (one of breast, one
of colorectal), who had both passed away in the last 12
months. It was this personal history that affected Carmen;
she thought a diagnosis of cancer meant only one thingthe
end. This experience showed me how important it is to talk
to patients about results of their tests/procedures and explain
what the results mean for their future. In one sense (for our
learning purposes alone), it was fortunate she had not been
told about her prognosis. Professor Kearsley was able to talk
to her about what her results meant (that it was most definitely not the end) and about the kinds of extra therapy he
could offer her.
What happened next, however, was what stunned me
more than the initial scene of this patient in such emotional
agony. Through Professor Kearsleys bedside manner,
mindfulness of the situation and explanation of her problem,
he was able to bring a smile to this ladys face. I still cannot quite remember how he did it so effortlessly. Professor
Kearsley really just spoke to her in a way she needed to be
spoken to, used appropriate jokes and gentle humor with her
and asked her to tell him more about herself. He was able to
assure her of his confidence in her prognosis, reinforcing this
was not the end.
Carmen walked into the hospital clinic with a heart full of
pain, ready to give up. I truly believe that she left the hospital
clinic with a smile on her face and some hope for the future.
This entire encounter was a very valuable learning experience for me. A session like that taught me things I could
never learn in a lecture or from a textbook. It showed me the
importance of being present: being there with the patients
concerns, being there with the patients emotions, and being
there as a hand to hold. I will use this experience to build on
my personal skills, in the hope that I can one day be such a
good practitioner.

Carmens Reflection
When I came to see you, I had so many mixed emotions. All
the negative thoughts I could think of all came pounding into
my mind.
First, I would like to say that I am a believer of the saying
you are what you eat. For years I have been following a
healthy diet. I would stay away from unhealthy foods which
might give toxicity into my body, which could then eventually lead to some diseases.

J. H. Kearsley

Naturally, when I was diagnosed with breast cancer and

was told about it, I was beyond shock. I could not believe
what I heard. The word cancer made my heart to stop beating
for a moment.
It was not until I arrived back home that day that the
weight and the seriousness of that negative report had begun
to sink into my system. At this time, all my hopes for a long
life were clouded with my tears of uncertainty. In my head,
I saw my life come tumbling down to the ground, shattered.
Sitting in the waiting room, I was scared. My mind was
bombarded with so many bad thoughts. I was sitting there
not knowing what was going to happen next. I felt so devastated. My life is ending, I thought to myself. Then seeing
those young medical students approaching me, my uncertainties were being magnified. I was saying to myself, What
do these young, inexperienced people know? Admittedly,
my level of stress went up high.
My greatest worry during the consultation was that you,
Professor Kearsley, who has the knowledge and the expertise
in this field, would confirm to me my chance of surviving
cancer was slim. That death was on the agenda.
When I walked into the consultation room, my worries
were heavy in my heart. I could not pretend I was alright nor
could I hide my fears. I remember walking beside those two
medical students and imagining my best friend, whom I lost
to cancer 2 years ago, must have done exactly like what I was
doing now. She probably would have been so scared thinking about her ordeal. As I sat down with the three of you, I
felt I was being surrounded by some strangers, I felt being
exposed. Having this feeling of exposure added a degree of
unease on my part. But surprisingly later during the consultation, my burdens started to lighten up. I was beginning to
trust you. Your kind manner as well as that of those medical
students helped me to see the brighter side of my condition.
The words of encouragement which you gave me were like
drink to my dying spirit. The positive attitude and gesture of
reassurance which I received during the entire consultation
have somehow changed my emotions and my perspectives.
The overwhelming display of concern and support has given
me a sense of victory over my battle. These positive aspects
brought into my heart a new seed of hope. My smile was
restored. It was like a new door has been opened for me.
At the end of the consultation, my views were altered
from being negative to positive. It felt like I could see a light
on the other side of my journey.
I would like to thank you and those two medical students
for the professional yet kind and down-to-earth manner
which in every way has given me the hope that I will make it
through. The hugs which at times seem to be just a standard
way to greet friends and people have impacted me. It brought
a sense of belongingness in me. I felt I was not just one of
your cancer patients, but a member of your family.
As of now, my emotions are still changing, feeling up one
day and down the next. I am trying to keep a good spirit. The

8 Carmens Story

future might still be uncertain as far as my breast cancer is

the issue, but the good thing is, I am still alive today.
I repeat, thank you very much.

Michelangelo, it is said, carved in order to liberate the person imprisoned within his block of marble; I saw the angel
in the marble, he wrote, and carved until I set him free
[11]. Several of his slaves remain unfinished sculptures
on purpose. Maybe what we are doing in the field of whole
person care is to replicate the work of Michelangelo with
human subjects. People find themselves again; and, as we
chip away, perhaps we may even see ourselves in a new
light; complete, though unfinished; whole, though imperfect.
Acknowledgments I am indebted to Ms. Carmen Simon for her resilience in allowing herself to be the subject of this story. I also acknowledge the bravery of Ms. Katherine Nguyen and Mr. Callum Barnes for
making themselves vulnerable enough to contribute to Carmens story.
I thank Ms. Sue OReilly for helpful editorial comments, and Judy
Cush for her secretarial expertise.

1. Hojat M, Vergare M, Maxwell K, etal. The devil is in the third year:
a longitudinal study of erosion of empathy in medical school. Acad
Med. 2009;84(9):118291.
2. Coulehan J. Todays professionalism: engaging the mind but not
the heart. Acad Med. 2005;80(10):8928.

3. Kearsley J, Lobb EA. It Is not a disease we treat, but a person:
reflections of medical students from their first rotation to an oncology and palliative care unit. Pall Care. 2013;29(4):2315.
4. The Holy Bible, Psalm 31. New Testament Version. International
Bible Society: East Brunswick; 1978.
5. Hamilton J. Dr. Balfour Mount and the cruel irony of our care for
the dying. Can Med Assoc J. 1995;153(3):3346.
6. Buckman RA. Breaking bad news: the S-P-I-K-E-S strategy.
Comm Oncol. 2005;(2):13842.
7. Buber M. I and thou. New York: Simon & Schuster; 1996.
8. Rohr R. The naked now. New York: Crossroad Publishing Company; 2009.
9. Kearsley JH. An exquisite presence (after Buber). Pall Supp Care.
10. Cassell EJ. The nature of suffering and the goals of medicine. 2nd
ed. New York: Oxford University Press; 2004.
11. Kearsley JH. Rembrandt, Michelangelo, and stories of healing. J
Pain Symptom Manag. 2011;42(5):7837.
John H. Kearsley MD, PhD is a professor of medicine at the University of NSW, Sydney, Australia, and director of the Department of
Radiation Oncology at St. George Hospital, Kogarah, NSW. He is an
accredited physician in medical oncology, and has a doctorate degree
in pathology. His major interests in oncology include psycho-spiritual
aspects of patient care and medical student teaching. He is the founder
of the Prostate Cancer Institute at St. George Hospital, and Whole Person Care Australia.

A Mindful Life in Medicine: One Pediatricians Reflections on Being Mindful

Michelle L. Bailey

Lisa sat on the examination table with her head hanging low.
She did not look up when I entered the room. This was her
fourth visit in the childhood obesity clinic; third visit with
me and second visit with our licensed clinical social worker,
Meryl. At first glance, Lisa looked like any other sullen teenager that had been dragged to the doctors office by a parent.
And yet after spending just a little time with her at that first
visit 3 months ago, I had a feeling that there was a story she
wanted to tell.
At the age of 15, Lisa was still wetting the bed. She was
referred to our program by the pediatric urology team to address her weight and associated comorbidities. I met with her
alone during our first visit to learn more about her daily habits. She was not hungry in the morning and skipped breakfast
most days. She usually skipped lunch too; she did not like
the food. She had a long history of disrupted sleep, often falling asleep early in the evening after school and waking up in
the middle of the night. She is not sure why it is so hard to
fall asleep and stay asleep. She did not want to talk about her
bedwetting or stool accidents. I do not think she made eye
contact with me once during the 30min we spent together.
A high school sophomore, Lisa seemed to be somewhat
isolated reporting no real friends or social activities. She
walks the school track during lunch so she will not have to be
with the other teens in the cafeteria. This is in stark contrast to
her very outgoing and gregarious younger sister. She mostly
keeps to herself, even at home, eating dinner alone in her
room. She reports a lot of tension between her and her mother,
and she is not very fond of her stepfather. She longs to spend
more time with her father who recently relocated to the area.
Lisa was numb. Her affect was flat and everything about
her seemed to scream sadness. I wondered what her life was
like. I imagined how she may have used food to ease the discomfort and pain she felt inside. How the weight may have
Department of Pediatrics, Duke Childrens Healthy Lifestyles,
Duke University Medical Center, PO Box 3675, Durham,
NC 27707, USA

been seen as a way to insulate her from the internal distress

she was experiencing. If only she could talk about it. I was
hopeful when she accepted an invitation to meet with Meryl.
Hi Lisa. How was your session with Meryl today?
Okay. She did not look up at all. Her voice was so soft
I strained to hear her. I rolled my stool a bit closer to the
examination table.
She mentioned that you had something you wanted to
share with me.
Lisa hung her head a little lower. There was a long period
of silence filled with tension so thick you could slice through
it. We waited for what felt like hours. In these moments of
silence, I became aware of how loudly my heart was pounding. I wondered if she could hear it. I found my breath and allowed my attention to follow the natural rhythm of my body
breathing. I knew I did not need to do anything in this moment. I simply needed to give her time and space. I felt my
body relax as I joined her right where she was. I no longer
felt the need to bite my tongue to avoid breaking the silence.
Just then she spoke.
Her voice was barely perceptible as she whispered to me
her thoughts of suicide just a few months prior. She has had
more thoughts of hurting herself since that time, cutting on
her wrist just a few days ago. She talked about her thoughts
of her own death as if she were talking about the weather. It was devoid of any emotion. I thanked her for sharing
these very difficult emotions with me. I reassured her that
she could feel better once her depression was addressed. We
spoke briefly about a plan to manage both the symptoms of
the depression and identify conditions in her life that may
have led to how she was feeling. She agreed to accept our
help and undergo a full evaluation at a local outpatient mental health center. I asked her to go wait with Meryl while I
updated her mother.
Her mother was appropriately concerned when I told her
about Lisas recent suicidal thoughts resulting from severe
depression. She understood the need for urgent evaluation in
the outpatient clinic within the next 24hours; we would arrange the appointment. She was instructed to secure any and

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_9,

Springer International Publishing Switzerland 2015


M. L. Bailey


all weapons at home until further notice. We were interrupted

by Meryl who said she needed to speak to me for a moment. I
excused myself from the room telling mom I would be right
back. Once outside the room, Meryl shared that Lisa was
now actively suicidal and could not contract for safety overnight. I knew immediately the plan needed to change. Lisa
would need to go directly to the emergency department for
urgent evaluation. She would almost certainly be admitted.
My heart sank as I thought about how I would share this latest development with mom.

Being with Uncertainty

As I stepped back inside the room, I told mom that Lisa had
shared some additional information with Meryl. I motioned
for mom to stand up and I indicated that this news had heightened our concern about her safety tonight. I let her know that
we needed to change the plan. I escorted her down the hall
so we could continue the conversation. I invited mom into
Meryls consultation room. It was a small square windowless room that was now very crowded as mom and I entered.
There were five of us in total, Lisa, her mother, a nurse practitioner student on rotation with us, Meryl, and myself.
I thought it was interesting that mom chose the seat furthest away from her daughter. As Meryl and I alternated
sharing information about adolescent depression and risk
of suicide, I took a mindful breath. Feeling the sensations
of my breathpaying attention to the natural rhythm of my
breathingbringing my attention to what was happening
right now. Inhalepause to notice thoughts and emotions
exhaleobserve what is happening in the room. Mom looks
like she is listening but she is not really here. She sat stiffly
on the edge of her seat, never once looking at her daughter.
I wished she would reach out to provide some comfort to
her daughter. Inhalerecognizing the presence of a judging
mindexhalefeeling compassion for momthis must be
so hard for her.
I glanced over to look at Lisa. Just above her was the white
board where she had written one of her lyrical poems. She
told Meryl she had created the prose to capture the difficult
emotions that had been churning inside of her for such a long
time. It was the most hauntingly eloquent suicide note I had
ever read. Writing poetry helped her to deal with the pain she
was feeling. She had other written works posted all over the
walls of her bedroom. She sat in the chair motionless, staring
off into space. Inhalewondering how mom will respond to
the changing situationwondering how Lisa will handle all
of this and if she is regretting her choice to be so honest with
us todaywondering what is running through the mind of
her younger sister in the waiting room, completely unaware

of all that is happening in this momentexhalesending

out wishes for comfort, peace, and safety for all of us in the
room and her sister.
Mom verbalized her understanding that she needed to
take Lisa to the emergency room tonight. She was very calm
under the circumstances. I wondered how long it would take
her to fully process what was happening. I wondered how
many thoughts were currently racing through her mind, distracting her from hearing and processing the information
shared. I applauded Lisa for the courage she demonstrated
by asking for help, acknowledging the uncertainty she must
be feeling and maybe even some doubt about sharing her
thoughts and feelings with us. I called ahead to give report to
the emergency room physician and completed my documentation. Then I sank down into the chair in the workroom and
turned to face the team.
What a challenging situation. The entire encounter was
riddled with uncertainty at every turn. We were called to stay
fluid with a dynamic situation as it unfolded. We were called
to demonstrate a willingness to be open to the challenges
we were facing and accept the reality of how things were;
not clinging to how we wished it was. In doing so, we got
to respond from a more authentic place, having a broader
perspective on the events as they developed.
We shared with one another our individual reflections on
the moments that had just transpired and our deep appreciation for having each others support. We were in awe of the
way we had skillfully navigated this situation, honoring everyone involved. We both recognized the importance of hitting the pause button so that our nurse practitioner student
had time and space to process what she had just witnessed.
This was a teachable moment, not just from a medical education perspective but also from a personal and professional
development perspective. This was a valuable lesson in presence.

Practicing Presence
I was first introduced to mindfulness in 2005 during my integrative medicine fellowship. I was intrigued learning about
the connection between mind and body and how it could help
reduce stress. I had no idea how disconnected I was from my
body. When teaching medical students and residents about
mindfulness, I relay a story from my primary care practice
that illustrates this point.
Johnny came into the office to see me for his 3-year wellchild check. He was a very charming boy who enjoyed his
visits to the doctor. I appreciated his inquisitiveness and was
happy to see his name on my schedule. We were close to
wrapping up the visit and I was providing some anticipatory

9 A Mindful Life in Medicine: One Pediatricians Reflections on Being Mindful

guidance for his mother on achieving dry nights. Johnny was

tugging on my pants leg to get my attention.
Hold on Johnny, Im talking to mommy right now. He
went off to a corner to play for a few moments then came
back around and gave another tug on my pants.
Be patient Johnny. Were almost done. His mother and
I talked for another 23min. I then turned to Johnny and
applauded him on being patient while his mother and I were
finishing our conversation.
Johnny looked up at me with his big blue eyes and said,
Dr. Bailey, do you have to pee?
I must admit, I was not expecting that question. His mother blushed and lowered her head. I thought for a moment
and realized I did have to go to the bathroom. As I checked
in with my body I noticed that I was standing with my legs
tightly crossed. Come to think of it, I may have been rocking
just a bit to keep things at bay. Johnny recognized the I-needto-go-to-the-bathroom-now dance that I was doing.
I laughed as I leaned down to whisper to him, Yes Johnny. I do. He smiled as he waved good bye. And I hurried
down the hall to the restroom.
How was it that I did not know I had to urinate? My mind
was busy with all of the things that I needed to attend to; it
was anywhere but the present moment. This was a powerful
lesson that taught me what it is like to be disconnected from
the body. In the mindfulness-based stress reduction (MBSR)
course, I learned how to cultivate mindfulnessmoment-tomoment awareness without judgment.
As I paid attention, I noticed just how often my mind was
somewhere other than the present moment. Sitting in the
examination room with a mother who was sharing her concerns about her childs health, my mind raced with thoughts
of the past (I forgot to give that last mother the toilet training handout I promised) and the future (I meant to tell the
nurse to collect a urine specimen from the 4 p.m. patient with
a complaint of painful urination). I was physically present
in the room and yet I was not truly present with her. Over
time, I developed strategies to help me return my attention
to the present moment while at work. Instead of knocking
on the examination room door and entering the room immediately, I knocked then allowed my hand to rest on the
metal handle of the door. Sensing the coolness of the metal
and the pressure of my hand against the handle gave me a
temporary pause on all the other mental activity and allowed
me to focus my attention on the patient in this room. I also
used hand washing as another opportunity to return my attention to the present; feeling the temperature of the water,
the movement of my soapy hands as they glided back and
forth in a rhythmic flow.
In the MBSR course, I achieved such a wonderful state of
relaxation. It was a welcome relief to the tension and stress
that dominated my busy work day. I came to look forward to


my daily practice so I could return to this place of calm. Initially, I approached my new mindfulness practice as an intellectual exercise. My goal was to become more aware of both
my internal and external environment at work and at home.
I started to identify habit patterns I had been unaware
of. For example, my body held onto stress in my neck and
shoulder areas. I soon realized that my shoulders would rise
in response to stress, like a turtle retreating into its shell.
This became a signal to me; when I noticed my shoulders
up around my ears, I paused to pay attention to thoughts and
feelings that may be contributing to stress. Asking questions
with an attitude of curiosity allows you to gently peel back
the layers of busyness to clearly see what is inside.
We deal with uncertainty in medicine all the time. While
it might be easier to live in a world that is black and white,
the reality is that much of what we do falls in a gray zone.
There are times when we have a well-defined path to follow.
At other times, we rely on our experience to guide situations
where the way is less clear. This is the real art in medicine. In
the encounter with Lisa and her mother, there were a variety
of factors that created great uncertainty from the mothers
response to information disclosed... to the patients trust of
the health-care team.
In cases such as these, it is important to be aware of the
moment-to-moment unfolding so that an informed response
can be chosen, rather than unknowingly reacting to difficult
thoughts and emotions. As I observed Lisa in the consultation room, I could see and appreciate the tough situation she
found herself in. Putting myself in her shoes allowed me to
imagine the flood of emotions she may be feeling. Without
that awareness, I may have missed an opportunity to validate
her experience and acknowledge the bravery of her act in
telling her truth. It was due to this cultivation of awareness
that I was also able to sense the confusion, disbelief, and
utter helplessness experienced by our nurse practitioner student. This led to an invitation to talk about a medical encounter that she is not likely to forget during her career.

Tolerating Emotional Reactivity

Being able to attend to your own emotions is a key skill
in managing difficult situations. Sometimes it is your own
emotions; at other times it is the emotion of patients and family members or even other members of the health-care team.
As a pediatrician in practice for over 15 years, I frequently
manage conversations between children and their adult caretakers. This can sometimes be a delicate dance, akin to walking a tight rope at times. I have found it valuable to be able
to quickly measure the emotional temperature in the room.
It is not uncommon for this to change abruptly depending
on the nature of the conversation and the resulting emotions
that arise.

M. L. Bailey


This was the case with Josefina. Although this was my

first meeting with Josefina, she has been followed in the
childhood obesity clinic for a very long time. She was with
her grandmother and older brother today. Upon entering the
room, I introduced myself to the family via our Spanish interpreter, Silvia. It was clear that Josefina did not want to
be there. According to her, she did not have a problem. In
fact, she did not have to do anything that anyone told her,
including me and her grandmother. She and her brother fed
off of one another, proudly boasting how they run things. I
noticed my irritation rising. I turned my questions to Josefinas grandmother to get a better sense of her lifestyle habits.
We were frequently interrupted by Josefina and her brother
contradicting whatever grandma said. Their comments and
behavior became increasingly disrespectful.
As I checked in with my internal emotional state, I recognized how thin my patience was growing. After all, I was
raised in a household where this type of disrespect was not
tolerated. How could they treat their grandmother this way?
I took a breath. How would I feel if I had been abandoned
by my mother who still lives locally? Perhaps I would be
angry too. I made space for both my irritation for their blatant disrespect of their grandmother with any accompanying
judgmental thoughts and my appreciation for the childhood
trauma they have experienced through abandonment. It was
from this place that I could respond to the developing chaos
in the room with fierce compassion.
I have heard Sharon Salzberg, well-known meditation
teacher and author of The Force of Kindness, speak on fierce
compassion, describing it as a powerful quality of kindness
rather than a secondary virtue or some form of weakness.
When used with an intention of love, this quality has the
capacity to transform our worldview from one of fear and
isolation to one rooted in clarity, courage, and compassion.
It was this force that allowed for an opportunity to open
minds and hearts in the room that had been closed for quite
some time. This force allowed me to speak the truth of what
I saw as a fundamental problem in the dynamic between this
grandmother and her grandchildren.
I named the elephants in the roomthe sacrifices that this
grandmother was voluntarily making to care for her grandchildren that had gone unrecognized and unappreciatedthe
pain and anguish that these children felt but did not have
words to articulate that resulted in escalating disrespect and
poor choicesthe absence of a mother who no one dared to
speak about because it was too excruciating to think about
how she could lead her own life without understanding why
the situation was the way it was. What followed was a positive shifting of energy in the room centered on the ability to
recognize, acknowledge, and accept the reality of the pain
they were all experiencing. We honored both the tremendous
pain and abundance of love present in the room and made
space to hold all of it. The kids hearts softened; grandmoth-

ers frustration eased. And in that moment, there was a new

place to begin.
There were lots of emotions at play here including,
grandmothers feelings of frustration, anger, and helplessness; Josefinas feelings of anger, sadness, and ambivalence
in making lifestyle changes; and, my feelings of irritation,
impatience, and openheartedness, just to name a few. When
emotions arise causing some level of discomfort or distress,
it is common to react out of fear. Being aware of these changing internal emotional states can help you to ride out these
emotional waves without automatically moving into fightflight-freeze.
Emotions are like the weather; they are temporary. Here
in North Carolina during the winter months, it is not uncommon to move from a high of 50 one day to a high of 80 the
next. Temperatures fluctuate and storms come and go. Our
emotions are very similar. It is helpful to remember that in
any given situation you are dealing with it is one moment in
time, not the rest of your life. Emotions enrich our lives and
make it anything but boring. If not kept in perspective, our
emotions can serve to distract us and pull our attention back
into the past or push it quickly into the future. Mindfulness
has helped me learn how to recognize when emotions have
hijacked my attention and gently return my attention back to
the present moment. Daily practice hones this skill so that
the time between noticing that my attention has drifted and
bringing it back to this moment has gradually declined. In
my opinion, this is a key factor in skillfully traveling through
the sometimes choppy waters and emotional waves of medical practice.

Holding Space
The skills described above are very useful in the clinic setting. When I work with medical students, I often emphasize
the importance of not making assumptions. This is hard to
do at times, however, and I have seen it backfire when we
assume a patient will not have a negative reaction to news
shared and then they do. You never know when intense emotions may appear in the room. It can really catch you off
There is a recent situation that illustrates this point and
stands out in my mind. My last patient of the day was a Hispanic family with two school age children. The children were
well known in our primary care clinic located downstairs;
however, this was my first meeting with them. Mom appeared
to be very distant answering even open-ended questions with
short one- or two-word answers. I was working with one of
our very skilled Spanish interpreters, Genris aka Henry who
knew the family well. He had warned me that this was a difficult mom who did not seem to understand the importance
of making changes to improve the health of her kids.

9 A Mindful Life in Medicine: One Pediatricians Reflections on Being Mindful

One of my strengths is in engaging kids and adults fairly

quickly. I was very proud of this skill; however, it was being
tested to the limits today. I was unsuccessful in eliciting an
intrinsic motivation for mom and the kids to make the yearlong commitment in our program. I decided to move on to
more routine questions and circle back to the motivation
later. I had just finished asking about past medical history
and turned to family history.
Are there any medical conditions that run on either side
of the family, like diabetes, heart disease, or high blood pressure?
Mom shook her head no. I decided to take a different approach. I asked about the health history of mom and dad and
the last time they each had a preventive visit with the doctor.
Mom indicated that both she and dad were healthy.
Lets talk about grandparents. Are both your parents living?
I never would have expected the response I witnessed.
Both the interpreter and I knew immediately we had opened
a can of worms as mom started visibly shaking. I reached out
for her hand. As I rolled my stool closer her tears started to
flow freely.
Its okay. Whats making you so upset right now?
The interpreter leaned in to hear. Moms voice was barely
audible as she kept repeating something in Spanish that I did
not understand. I looked up at the interpreter. He said she
keeps saying I never told them. Mom says something different this time. She is talking louder and at a rapid pace. She
breaks down even more. I looked over at the kids who are
now crying uncontrollably. The interpreter looks at me with
disbelief as he shares moms story.
Her mother is living. Her father died 2 years ago. The kids
were very close to him. They kept asking for him and mom
told them he was sleeping. He was tired. He could not come
to the phone. They are now hearing for the first time that
their grandfather is dead.
Wow. I took a moment to let the information sink in. I
imagined how much this mom had been keeping bottled up
inside. Without looking at each other the interpreter and I
moved in close simultaneously, forming a tight circle with
the family. We sat in silence as they cried. Although we did
not say a word, it was known that they had permission to feel
what they were feeling. It was safe to allow the emotions to
bubble up to the surface. We sat like this for what felt like
a really long time. In actuality, it was probably less than 5
minutes. Mom then spoke of her fathers illness and his rapid
death. She shared her sorrow in not attending his funeral services in Mexico. And she talked about what it was like for
her to keep such a big secret from the kids for the past 2
years. At the end of this, mom seemed both exhausted and
relieved at the same time. She looked like a different person.
Her facial expression had softened and her body posture was
more open and relaxed.


Mom suddenly seemed more alive. She told me how sick

her dad had been and how she did not want her kids to suffer
from illness as he had. She thought it was okay for them to
eat whatever they wanted to eat because they were kids. She
believed you did not have to worry about being healthy until
you were much older. She was now engaged and in touch
with her motivation for participating in the program. The
kids were also on board, wanting to learn how to be strong
and healthy. They wanted to run and play and keep up with
their friends.
Mom thanked me at the end of the visit, giving me a tight
hug. She promised to bring the kids back in 1 month for
follow-up as suggested and to work on the goal they had
set today. Henry and I sat in the workroom exhausted and
exhilarated. What a ride we had just been on. He shared with
me the range of emotions he experienced as he listened to
moms story, began to process it for himself as he prepared
to translate for me. We marveled at how in tune we all were
when things changed so suddenly.
I call it holding space. That is what we did for this family.
We created a safe environment to allow an unfolding of emotions that was a key process in shifting things for this family.
And we all felt a little better for having had the experience.
Holding space is a gift we give to our patients and families.
This is where the healing is possible. We are not so much
fixers as we are facilitators. Like a parent setting up invisible
yet firm boundaries to keep a roving toddler safe; we help
keep them safe while they explore unchartered territory.

Mindfulness in Action
People have asked me how long I practice mindfulness each
day. This is a hard question to answer because the practice
does not end when I leave the mat. The longer I practice the
easier it is for me to see how my informal practice is woven
throughout my day. There are many ways to practice mindfulness in the midst of the day. One of the most useful has
been in becoming aware of when I am not operating at my
best and need to make changes. I call this course correction.
This becomes most difficult for me when my energy is low
(i.e., I am tired) and/or when I am stressed. The story below
is a good example of how course correction can benefit both
patients and providers.
I was nearing the end of a very busy day and was eagerly awaiting the clock to strike five. I had one more patient
to see. My 4:00 p.m. overbook was an 8-year-old Hispanic
male scheduled for follow-up. In reviewing his record, I was
struck by the long list of comorbidities for such a young
child. I had been working with the pediatric weight management center for 5 years and seen many kids and teens with
severe obesitybut he was so young. I typed a quick summary into my template note to help guide the visitbody


mass index (BMI)>99th percentile (for age and gender),

lipid abnormalities, history of insulin resistance with most
recent HbA1c>6.5%, severe elevations in transaminases
status post liver biopsy, and hypertension managed with oral
antihypertensive medication prescribed at recent visit with
cardiology, and proteinuria.
I was glad when the status changed to arrive. I had a plan
for the visit; follow-up on prior goals and assess any lifestyle
changes since the last visit. But when I entered the room with
the interpreter and sat down to speak with mom; it was clear
that the agenda needed to change. Mom was not sure why
they were here. She explained to the interpreter that she had
just taken her son to a doctors appointment last week and
he has another one scheduled for the next week. She had
brought him to our clinic just last month. Why so many appointments, she wanted to know.
It was clear to me that mom had no idea how sick her son
was. She did not understand the necessity of the close medical follow-up with multiple specialists. In that moment, I
became aware of a more important task; to help mom understand her sons health issues and the impact they may have
on his life. I acknowledged how tired I was and how ready I
was for the day to end. I was gentle with myself, extending
as much kindness to myself as I could while also extending kindness to mom and her little boy. We spent the next
25min discussing his comorbidities one by one, answering
questions, etc. I do not know that she understood what it all
meant by the end of the visit but I felt a sense of satisfaction
that she knew someone cared enough to answer her questions and help her try to have a better understanding of her
sons health status.
For some, it would have been easy to just stick to the
script. In acknowledging both my readiness for the clinical
work day to end (at least the direct patient care portion) and
my desire to help this mother see the bigger picture, I was
able to change direction and move to a higher agenda.

The Art of Mindful Listening

Natasha set a goal to be more active. At 11 years of age,
she was frustrated that her weight did not allow her to wear
the kinds of clothes that she could before. Mom was very
pleased. As we spent time exploring how she could be physically active for at least 1 hour a day, we hit a wall.
Well, I cant go outside because its already dark by the
time I get home from school. And, mama says I cant go
out on the weekends because its too cold and itll make my
asthma worse.
Natasha, what activities can you think of that are fun
ways to move your body inside the house?

M. L. Bailey

With this question, I was hoping to help her see that there
are many different ways to be physically active. Next, we
would address the myth that exercise is not good for kids
with asthma.
Umm There was silence. After some time, I asked
her mother if she could think of any ways that Natasha could
exercise indoors. Moms response was a bit surprising to me.
She rattled off a long list of why Natasha and her younger
brother could not exercise inside. The bottom line for many
of the excuses given was a fear of the kids breaking valuables inside the house. She also mentioned that they could
not afford a gym membership at the fitness club. Mom had
already investigated that option last month; it was too expensive. There was an increasing frustration in her voice as she
continued to talk.
I paused for a moment to decide where the conversation
should go from here. There was certainly a lot of resistance
coming up. Both mom and Natasha wanted to see her move
her body more to be healthier and yet they kept running up
against barriers. This is hard for them. They want it to be
different and there are so many variables that they feel are
working against them. What a difficult place to be, I thought.
Like being trapped between the proverbial rock and a hard
I spent some time summarizing what I had heard both of
them say. Natasha was really motivated to find fun ways to
move her body. Mom was ready to support Natasha in being
more active. Neither of them could think of how to make it
happen without risking an asthma flare or spending a lot of
money. I applauded mom for researching community options
for indoor exercise. Her action demonstrated that this is important to her. She smiled.
Is this a good time for me to suggest some strategies that
have worked for other families in a similar situation?
They both nodded.
Ive found that yoga has been a positive solution for
many families. I explained the concept of the mindbody
connection and how yoga was an effective way to help girls
learn to be more aware of their bodies. Body awareness was
a great way to check in with the body to pick up on hunger
cues and satiety cues, teaching kids to eat guided by internal signals rather than external factors (i.e., the clean plate
club). As I went on to describe the benefits of yoga, I sensed
a problem. Moms smile was gone and she had taken on a
completely defensive posture. She was sitting up straight
with her back pressed so hard against the chair, I feared it
might topple over. Her arms were folded tightly high across
her chest and her legs were now crossed.
What had just happened? I was assaulted with a series
of thoughts thrown at me in rapid fire succession. Did I say
or do something wrong? Did I miss something that had occurred between her and her daughter? Was there a secret I

9 A Mindful Life in Medicine: One Pediatricians Reflections on Being Mindful

did not know about? As these thoughts swirled all around

me, I kept talking. I could have finished my conversation and
ended the visit and moved onto the next patient, but something was bothering me. I was aware of my own internal distress in that moment. The communication had not ceased; it
had simply switched to one without words and there was a
lot being said.
I finally decided to just name what I was sensing. I
stopped mid-sentence and took a breath.
Im not sure what happened but Im sensing some discomfort in the room. Do you feel it too?
Mom maintained her defensive posture and without looking up nodded her head.
I would like to talk about it before we end the visit today.
Id like to understand what happened.
Mom agreed. She asked if we could talk alone. I nodded and invited her to step out into the hall with me while
the kids played in the room. Once outside the room, mom
seemed less angry. Her body language had softened and yet
there was still discomfort there; a kind of nervous energy.
She struggled to find the words to describe what she was
feeling internally. I could tell she was providing me with
hints, hoping I would figure it out and she would not have to
say what seemed so difficult for her to say. I reached out and
took her hand in a gesture of support.
I can see this is difficult for you. Its okay. You can say
whatever you need to say without worrying about how it
sounds. Itll give us a place to start and we can figure it out
as we go along.
This seemed to give her permission to speak from the
Her voice was lowered to a whisper now. The yoga I
dont know were Christians do you understand?
Now I did understand. Mom was worried that the yoga
was a form of religion that would teach her child something
different from their Christian faith. She was torn, wanting a
solution to help Natasha exercise while not going against her
religious beliefs. Mom later expressed it was hard for her to
tell me because she did not want to hurt my feelings. I spoke
about yoga as a mindbody practice that focuses on awareness of the breath and the body. I suggested that mom and
dad watch a few of the yoga videos that I recommended for
kids to see what they think. Once they reviewed the videos, I
offered to answer any questions they had by phone or email.
Mom thanked me for my kindness and understanding.
She said they would watch the videos and follow-up with me
before the next visit. I received an email message from mom
about 10 days later. She spoke to a few of the parents at her
church and learned that a few of the mothers practiced yoga
in the community. Hearing about their experiences helped
mom better understand how the practice was beneficial without going against her beliefs. They were in discussions about


holding a yoga class through the church for mothers and

daughters. The yoga teacher had agreed to volunteer some of
her time on Sunday afternoons.
This experience taught me many lessons but the one that
stands out as most valuable: it is important to pay attention
not only to what is said but also to what is not said. This lesson has served me well in many patient encounters where the
unspoken language in the room was the loudest and served
as a key to the root of the problem that was keeping people

Renewing the Passion in Medicine

Developing strategies to be more mindful in medicine extends beyond patients. It often improves how you are in relationship with your team members (including difficult colleagues), loved ones, and friends. It is challenging for even
the most seasoned clinician to stay focused in the midst of
a harried day. We show up with many hats onclinician,
parent, partner, etc. We not only manage the activities of the
work day, we are also responsible for personal and family
obligations. The list is long and at times feels never-ending.
For many, the list includes drop-off and pick up of children
to and from school and/or before and after school programs,
preparing meals for the family, negotiating unpredictable
commutes, helping to care for aging parents (sometimes at
a distance), and assisting adult family members who may be
struggling financially or with poorly managed health conditions including substance use.
In Esphyr Slobodkinas childrens book, Caps for Sale,
we are like the peddler, wearing all of our caps stacked high
and neatly on top of our heads. Often not discussed, many of
us are feeling overwhelmed and challenged in finding practical ways to maintain some sense of balance in our life. When
was the last time you stopped to ask, Who am I when I take
off all the caps? Unfortunately, the majority of clinicians
have not paused long enough to ask this question. Sadly, the
response for many who do ask the question is I dont know.
An unexpected gift that my mindfulness practice has given
me is the awareness that I do not do as good a job taking care
of myself as I do in taking care of others. Before I deepened
my commitment to my daily practice, I approached mindfulness as more of an intellectual endeavor. It was something to
check off the to-do list and when life became busy, the time
dedicated to practice would shrink and sometimes disappear
altogether. Unfortunately, this was the time when I needed to
lean on my practice even more.
I had the opportunity to develop and teach a self-care curriculum to residents. The year-long Integrative Self-Care for
physicians program, generously funded by the Arthur Vining
Davis foundation, highlighted the hypocrisy of not prioritizing


my own self-care as I worked on curricular materials late into

the night, sacrificing sleep and time with family. This continued as I worked as course director with medical students in
developing healthy coping skills and self-care habits to serve
them throughout their medical career. The turning point for me
was in working with other practicing physicians and healthcare professionals. Along with my colleagues Dr. Jeffrey
Brantley and Dr. Karen Kingsolver, I developed and co-led the
Refuge program, a Mindfulness-Based Stress Management
service for physicians at Duke. This weekly offering provided
an opportunity for me to get to know physicians and other
health professionals across the organization, many of whom I
may not have otherwise come into contact with. We gathered
to learn the principles of mindfulness and how they could be
applied to our work and home life to better manage stress.
The lessons learned from this work are many. First, physicians are seeking a sense of belonging. The sessions allowed
physicians to come together in a safe space to talk about
the challenges of living a life in medicine. Hearing others
talk about the challenges common to practicing in todays
changing environment normalized what others were feeling
and reduced the sense of isolation so pervasive among many
health-care providers today. Second, I was surprised by the
immense power of connection and community. Building this
sense of community led to shifts in perspectives and provided valuable experiences that helped to break down walls and
opens minds and hearts. This translated into positive changes
among health-care team members, office staff, and medical
learners. Many physicians also found that this carried over to
their home environment too.
This experience has helped me to recognize the very real
need to provide an ongoing forum for physicians to gather to
support one another in a positive waycommunity without
competition. I have committed to my own self-care, wanting to serve as a positive role model for how we cannot just
survive, but thrive in a medical life. This work has inspired
me to start a coaching practice to help physicians and other
health professionals create personalized strategies for balancing life using the principles of self-care, self-compassion,
and mindfulness. I am hopeful that I can walk the talk and
give permission for others to do the same.

Take Away Pearls

Mindfulness has been a life saver for me. I now have a better
understanding of how I can show up fully for my patients
and my team. I can really be there for my family and friends.

M. L. Bailey

I can show up for my life. The benefits of mindfulness practice are too numerous to list here. I hope the reflections
above have helped to give you a glimmer of what is possible
with a commitment to a daily practice. Here are my parting
thoughts on the top points to take away:
Learn how to be with uncertainty, yours and your patients.
It will pay off big time.
Be curious about the unfolding; you never know where it
may lead.
Do not be afraid to open your mind and your heart. There
are unexpected gifts waiting for you.
Do not beat up on yourself when you fall short. You are
human. Remember your patients are too.
Extend kindness whenever and wherever you can. A
caring word, a generous thought, a simple smileyou
never know whose day you will change. This is an act of
strength, demonstrate it every day and encourage those
around you to do the same.
My personal mindfulness practice has helped me to stay in
medicine. It has highlighted the importance of self-care and
compassion in everyday life, both at work and at home. It has
led me to show up and be more present for my patients, my
loved ones, and myself. I am now experiencing the moments
of my life and I get to share moments with those in the world
around me. We are all on a journey towards remembering our
wholeness. We are not broken, nor are our patients. We simply forget. Mindful moments help us to return to ourselves
and feel whole again. With mindfulness, we are human beings rather than human doings. And when we focus on the
present moment, our being can inform our doing. Here is to
being mindful.
Acknowledgment The author would like to kindly acknowledge the
following individuals and groups for their generosity of time, wisdom,
spirit and funding that informed the development of this chapter: The
Arthur-Vining-Davis Foundation, Jeffrey Brantley, MD, the Duke Childrens Healthy Lifestyles team, Duke Integrative Medicine faculty and
staff, Meryl Kanfer, LCSW, Karen Kingsolver, PhD, John and Christy
Mack, Javier Rodriguez, Genris Rumaldo, Silvia Valencia, the University of Arizona Fellowship in Integrative Medicine Program with special thanks to Tieraona Low Dog, MD and Victoria Maizes, MD, and
the patients and families that have allowed me to participate in their
care and taught me many valuable lessons over the years.
Michelle L. Bailey MDis a pediatrician and educator in the Duke
Childrens Healthy Lifestyles Program and Duke University School of
Medicine Durham, North Carolina, USA. She serves on the Executive
Committee for the American Academy of Pediatrics Section on Integrative Medicine.

Embodied Wisdom: Meeting

Experience Through the Body


Sonia Osorio

What Matters Right Now

He arrives late, once again; this is the latest he has been yet.
I am frustrated, conscious of my time, my next patient after
him, the afternoon booked back to back with other clients. I
know that I cannot give him extra time, once again, despite
his lateness. He is flustered, apologetic, words spilling uselessly around him. I continue to be aware of my time, as
the words pile up between us. We need to get startedand
I need to refocus, I tell myself. Then, as I know well how to
do, I become aware of my body, my breath, my hands, my
thoughtsall of which will soon be moving into the experience of touching him.
I follow my breath; follow my exhaleonce, twice, a few
more times. I notice the sensations in my body, my feelings
and thoughts. I do this from years of training, in minutesor
is it seconds? I allow tension to fall away with every exhalation, and this steadies my body and my voice before responding.
Well, youre here nowthats all that matters, so lets
begin, I say, still noting an edge of frustration, still conscious of the time, but telling myself I am more present.
There is no response from him. Is he more confused today
than other days, I wonder, as he glances around the room,
turning away from my words?
After more than 5 years working together, I know his
history and how his mind has been deteriorating almost in
pace with his body. I know this. I open to this. I open to
my own frustration, sadness, and a heart-felt connection, as
I recall him telling me once, tears welling in his clear blue
eyes as the words flowed out with them: I wish I had found
this [massage] years ago. If only Id known what it is to be
touched like this.
He glances back at me then, drawing me out of my memories of him. His eyes snap into mine, sharp, without confuS.Osorio()
5492 Hutchison, Private Practice Outremont QC H2V 4B3, Canada

sion or hesitation, It means so much to me, you know, more

than I can ever say, to be able to be here today. Thats really
all that matters right now.
And I am humbled as he names something so basic: What
this means to him, to be here now. In that moment, I realize that it is not him, but I, who had been wandering away
from this moment. Even as I practiced what I thought I knew
about presence and awareness, I was lost in past stories of his
lateness and future concerns about appointments to come,
lost in ideas of what I had to servein what way, and how,
and when, and in a finite amount of time. But for him it was
not the quantity of our time together, but simply its quality.
He had no other point of reference; just this moment, just this
time, now. Whatever form it might take, whatever amount of
time that we had together, if he could be touched once again,
that was what was deeply meaningful.
Then I feel it, familiar, as I have felt it beforein other
situations, with other peoplelike a fresh breeze entering
the room, as the confusion of our words is gently blown
away and the quality of presence fills the space, drawing us
both into the room, into this moment, effortlessly. Now, there
is no trying to practice, no need to explain, and no words
piling up. Now, there is simply an opening into what is happening, guided by words, by silence, by breathand yes,
even by confusionand allowing it all to settle on its own.
Now, we are ready to begin the session, with the time that
we have, meeting one another in the moment. That is all that

A Life Once Shattered

She is young, but hardened by life, uneasy in her form; her
body and gestures are rigid, her words clipped, chipping off
at the end of each sentence. She does not want to speak, Im
just here to get some tension out, so lets get on with it, she
tells me.
I understand these words, looking at her fleshthe way
light penetrates and shines from within, the way her form is

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_10,

Springer International Publishing Switzerland 2015


S. Osorio


crafted; her skin so fine, her words so harsh. Looking at her,

I know I will be touching a hardness, fragile as porcelain,
luminous as alabaster; a persona created, yes, but from elements quite genuine.
I invite her to change, to lie on the massage table, while
I leave the room to wash my hands. I allow the water flow
over them, wondering when and how her body lost that sense
of natural flow and ease, that ability to move with and be
touched by the elements of life.
I reenter the room and place my hands on her body covered by the sheet, feeling for places where breath penetrates
tension, places that remember ease and lightness. As I do
this, I know the rigidity in her body is not surface tension.
This goes deep, to places where her breath dares not go. It
is layered over years, formed from something elemental,
coarseness smoothed into hardness.
I draw back the sheet and stand staring, stone-still, except
for the tremor in my hands. I place my hands on the table, not
her body, needing firmness to steady my hands, my breath,
before I can touch what I see. There is no luminosity here, no
fine crafting. Soft, white flesh marked by hard metal (it must
have been metal), rough-cut scars in a once-delicate form,
hollowed holes of paina body hardened, a life created and
then shattered.
Why would she want to be touched again? Im just here
to get some tension out, she had said. She wants me to
touch a pain that cannot be spoken, a hardness that keeps
pain outand pain in.
Porcelain, alabastercontainers for something elementalholding liquid, light; shapes giving form to what they
hold. So easily held and yet so easily shattered. But she is
not broken. Im here to get some tension out. Yes, I am to
touch what is held in her formand what needs to flow out.
What gave her form and what holds her light. I will learn
through touch where hardness holds fluidity, where breath
and life can flow again, where light can shine, giving new
form to a life once shattered but not broken.

Falling Away
I think my mind is falling in, he says to me.
Please hold me close,
Before I fall,
So I can feel before I fall
I hold him close,
Beside my arm
His tears so warm,
Upon my arm
His hands so withered, dry and cold
He seems so tired, lost and old

I do not know where he came from or where he went. Paranoid schizophrenia was the diagnosis given, which he despised. I do not know what he suffered from, but he did suf-

fer. He was young, but already worn from years of struggling

with his condition, from years of medication. I do not know
what was real, but the pain was real enough. It was an effort
for him to come to each session, his whole day would be
planned around it, but he came each time, on time. Then one
day, when I thought he was late, he simply never showed up,
ever again. He had fallen awayand I do not know where he
came from or where he went.

Returning Home
She enters the clinic for the first time with a blast of cold
air and activity. She hurriedly begins taking off her coat and
clothes that buffer her against the subzero Canadian climate.
As she removes multiple layers, she is apologizing for her
lateness. She speaks with a thick accent; her voice is hurried
and tremulous. It is so cold and windy, she had to fight hard
against the elements today. She was rushing to get here; she
had to take her granddaughter to school, she knew she would
be late. She hopes it does not disrupt things for any other
patients; she can take less time, if so, but she is glad that she
made it here.
She is a small thin woman, her hair finely cropped and
gray. The tendons in her neck are taut as she speaks. As she
slips her arms out of one last layer of clothing, I hear a sound,
as if small change has fallen from her pockets. I gaze down at
the floor and notice two rings lying by my feet.
Ive lost so much weight, I cant keep these on my fingers anymore, she says, as I bend down to pick up the jewelry and hand it back to her. She slips the rings carefully
back onto her frail fingers, hands slightly shaking, and veins
prominent through fragile skin. The rings are unusual in their
design; they appear crafted during another era, in another
Cancer. Surgery. Multiple metastases. Chemotherapy,
scheduled again. I jot down the notes as she tells me her
medical history. Then, a single phrase moves us into another
history, her life before the diagnosis and treatment, In my
country, we call cancer the disease of sadness, she says.
Please, tell me more about your sadness, I request.
She pauses, looks down at her hands, and touches her
rings, so loose now on her fingersreminders of another
time, another place. Her answer, twirled in the memories of
her rings, surprises me:
My daughter is my sadness. She was my reason for living and
now I cant understand who she has becomeits like she
doesnt love herself or her own child. It hurts me so much to see
that. Its like Ive accumulated all that in me over these years.
I had to leave my country to come care for my granddaughter
after she was born. The little girl needed me; her mother couldnt
cope; I knew that. And, now, she only needs me to care for her
daughter; I know that, too. She doesnt need me. The little girl is
my life now, like my daughter was. I know I will not live much

10 Embodied Wisdom: Meeting Experience Through the Body

longer, but I want to be as strong as I can, so that I can be there
for the little girl until the end of the school year. No one else is
there for her. She is only 10 years oldso young, and no one
there for her.

She traces her history, a story of strength and prideand

loneliness. She lists her losses: a husband, a brother, friends,
and her daughter to mental illness. She was a social worker
in her country, working in a childrens hospital. She loved
the children, as she loved her daughter, and they all loved
I could establish a connection with children just from smiling,
and they would smile back and open their arms and hearts to me.
Its my gift from God, that way of connecting. My daughter, she
lost that connection; its like she doesnt carefor me, for her
own daughter. I cant connect to her anymore. That, since you
ask, is my sadness.

In her late 60s, she came to Canada. I left my friends, my

life, to come to a place with a different language, different
attitudes, this brutal winter that never seems to end. I came
here for my daughter, for my granddaughter. I thought I was
so strong, but now I dont know with this disease.
She was the strong one; taking on others pain and
struggles, helping when no one else would. Her frailness belies strength, but now her energy is fading; she is tired, alone,
and in pain.
There are homeopathic protocols, yes, to support her
through the next round of chemotherapy. They may help reduce the nausea, the fatigue, perhaps alleviate some pain.
There are other options to support her vitality, which we can
discuss further. But I wonder at her suffering beneath this
disease of sadness: the loneliness, no one to care for this
woman who cared for so many others, who continues to care
even as her strength fades.
As with the layers of clothes on her frail frame there are
layers of pain lodged deep in her body. She came here to care
for another; here to the clinic on this grey winter day; here to
this country, where she has to fight the cold, battle a disease,
far from her home, living in anothers home, where no cares
about her, only about what she can do. But she is here to find
the strength to continue caring, in the time that remains.
Your granddaughter is fortunate to have you, I say.
She was fortunate, she responds, and I note the sadness, tinged with a deep tiredness, in the past tense of her
She returns for a follow-up a few weeks later. She moves
much more tentatively, each movement an effort. She is in
pain. She has lost more weight. She is exhausted. Her oncologist said chemotherapy was no longer an option. The cancer
is terminal. She is too weak. She may need a transfusion. The
winter cold has penetrated her completely.
I feel like Ive lost what little strength I had left. Its like
life is flowing out of me, she says, her head supported in her
hands, the loose rings still on her fingers.


What is that you need now? I ask.

I need enough strength to go home, she says. The little
girl will find her own way. She has the strengthI can see
that now.
And, I know that this is still a story of strength: the
strength to let go, to leave the little girl, to no longer struggle
in this place. It is time for her to return home, to her country, where life is not a battle against cold and a fight against
death, but a place surrounded by the warmth of friends, and
children who love her with open arms and open heart.
Your grand-daughter was fortunate to have you, I tell
Yes, she was, she says. And I reach out, to hold her
hand with the rings still there, from another time and another
place, which is home for her.

Meeting Experience
I have almost 20 years experience in somatic approaches to
bodywork, and practice massage therapy and homeopathy.
I also teach and mentor yoga and meditation practitioners.
My work, really, is the container for an ongoing practice:
meeting people in the experience of their struggle, pain, discomfort, confusionwhat one would call suffering. And, I
would include that place of meeting, to be one within myself
as well. As I meet that experience in myself, I can greet those
who come to see me where they are, and as they are.
How to return to what is happening in the momentand
then expand out into an exploration from thereis an ongoing challenge, since the tendency is to want to give meaning or explanation to our pain or struggle, which imperceptibly moves us away from experiencing it fully.
How often do we speak of the body versus feeling into
its experience? This is the essence of disease or unease, that
separation from the wholeness of experience. I am ever curious about what takes someone away from what is happening
in the moment, in their bodies, because that is sometimes
the very thing that can take us back to wholeness and health,
going right back through the same door that let us walk away.
So, the first place I try to return to is always the body: what
is going on in the clients body and in mine, in this moment?
That is all we have to work with. It may be held in an idea or
story, it may be held in a place of tension or pain, but within
those places and those stories, there is an experience, felt and
expressed through the body.
Through my practice and my work I endeavor to continually be with experience as it arises, internally and externally,
and be responsive to that. This, to me, has become the definition of compassion: meeting experience as it arises, deeply
grounded in a respect for our capabilities and each persons
capacity, including our own, in that moment. This is more
than mindfulnessit is, as Buddhist teacher and writer


Thich Nhat Hanh says, carefulness, being full of care. We

show up, open to whator more precisely, whopresents
before us and then to our own thoughts, feelings, sensations.
And, by some graceand with great carewe can be more
present with that person and the experience they evoke in us,
which is all that we have to go on.
The gentleman I mentioned at the beginning of this chapter, humbled me because I was reminded of this quality of
care: a presence and connection to what was required in the
moment. What that moment required was that my training
and my role fall away, and yet I had to trust that its basis
remained for me to respond to what the situation necessitated: a much more basic presence, not something learned or
taught or practiced, but simply opened to and experienced.
And when, howor even ifthis happens is not within our
control. If we can cultivate the seeds of presence and awareness, and fully step into what is happening, compassion may
naturally arise. Then, maybe a moment of true meetingand
perhaps the possibility of true healingthat sense of returning to wholenesscan occur.
What makes you feel most alive and free? How do you
want to live your life? I asked a woman whose cancer had
recurrednot because these were rote questions, but because they sprang from the ground of her experience as we
spoke in session, about how the diagnosis made her feel as
if she was trapped deep in the darkness of a cave, seeing a
light far away at the entrance that she sought to reach. That
light is the light that is in me, and I am struggling to reach it
again, she replied. But I know that light, that life, is inside
of me and I need live from there, no matter where I am. And,
I also know that I am the cave and I need to live from there.
This is a powerful reminder: to live from that place where
both light and darkness abide; to know that we are not separate from that experience. In fact, that experience is part of
who we are. We are the dark cave and we are the light that
we struggle to reach.
When I practice from therewhether meditation or bodyworkI include my capacity as well as my feelings of incapacity (e.g., distraction, boredom, frustration, doubts, the
desire to find a solution). It is a sense of including morenot
lessof what is going on, and there is a feeling of spaciousness and softening, of sharpness and clarity, around that.

S. Osorio

And, in that same moment, there is a realization that I have

been trying to do something or avoid something, trying to
direct a moment, wanting it to be other than what it was, and
creating tension around that. That spaciousness, that softening, that breeze of fresh air that comes in when I let go of
trying to control things, however subtly, even through the
practice itself, is what I have come to equate with a quality
or at least a measure ofpresence and compassion, an ability to simply allow what is, to be as it is, and to open to that.
In those moments, there is something palpableboth to
whomever I am working with and to myself. In those moments, the story drops and I can meet what is most present,
unconstrained by ideasand certainly unpredictable in its
outcome. When I know the least but feel the most, then I am
in presence. Neither the person in front of me nor I know
where we are going, but we are in that moment, that movement, together. It is vibrant, tangibleand the session begins
to open, unfold, and come alive from here. Questions, answers, experience, presence arise in that space that we move
intoand touchtogether. It is the place from which wisdom and insight arise from meeting and including confusion,
pain, and struggle. It is the ground of experience, that quiet
place of arising that is our very own body and breath, heart
and mindjust this, just now. And, it is all that matters, in
that moment.
The experiences recounted in this chapter serve as reminders of this innate potential and capacity to continually
open to experience as it is, to allow ourselves to wake up a
bit more, and to see into and through the stories of peoples
lives as they touch our own.
Sonia Osorio DH(RHom), DHom, RMT, CYTpractices homeopathic medicine, is a registered massage therapist, and a certified yoga
instructor with 20 years of experience in somatic bodywork and meditation. She has studied with senior teachers in Tibetan Buddhist and yogic
traditions, and has helped develop and facilitate teaching curriculums
for various mindbody training programs. Her approach is both practical and experiential, encouraging an integrative and individualized
approach to working with the various manifestations of stress, disease,
and trauma. For several years, Sonia worked as a writer and editor
in medical publishing, and continues to contribute articles to various
health care publications.

Minding Baby Abigail


Andrea N. Frolic

Cast of Characters
Andrea: Forty-something ethicist, harried, works in a large
childrens hospital
Lucy: Thirty-something social worker in the Neonatal Intensive Care Unit (NICU)
Joyce: Forty-something ethics consultant trainee and
nurse, works with Andrea
Emma: Thirty-something professional, exhausted but
well put together, mother of twins, Abigail and Rachel
Scott: Forty-something professional, stoic, father of Abigail and Rachel
Rachel: Four-month-old baby
Setting: Andreas office and the quiet room of the NICU
in a large childrens hospital

Act I
(Andreas office. A cramped space with a small desk piled
with stacks of paper, and a little table and chairs. The office
has a subterranean feel. The concrete walls are painted an
industrial off-white, covered over in lively childrens drawings addressed To Mommy with love. Andrea sits typing
on a computer.)
(Knock sounds at the door.)
ANDREA: Come in! (door opens) Lucy! Come in and
have a seat. (Lucy enters and sits the small table.) How are
the babes up in the NICU? I havent seen you in ages.
LUCY: Thanks. Well, its been pretty quiet lately in Neo,
but I have a case now Id like your help with. Do you have
time to chat now, or should I make an appointment?

Office of Clinical & Organizational Ethics, Hamilton Health Sciences,
McMaster University Medical Center, 1F9-1200 Main Street West,
Hamilton, ON L8N 3Z5, Canada

ANDREA: No, no, youre here now, lets talk. Just let me
send this message before I lose my train of thought. (Turns
back to the computer, reads, types another sentence, hits
Send with a flourish and turns back to Lucy.) Okay, Im all
yours, whats going on?
LUCY: We have a baby on the unit. Abigail. She was born
prematurely, about 27 weeks. Shes been here three months
or so. She has a twin sister Rachel who was also in the NICU.
Rachel did well and was discharged home four weeks ago.
Mom and dad are recently married. A lovely couple. Very
attentive, very articulate. But they are struggling right now.
ANDREA: Why? Hows Abigail doing? (pulls a notebook from her desk drawer, starts taking notes)
LUCY: Not so well. It was a complicated delivery and the
doctors suspect she suffered a hypoxic brain injury. She was
resuscitated at birth and placed on a ventilator. Shes off the
vent now but she continues to have these episodes where her
oxygen levels suddenly plummet. She needs deep suctioning
and a lot of stimulation to bring her levels back up. Sometimes she has 10 or more episodes like this a day. She had a
G-tube placed for feeding. They hoped it would decrease her
reflux and stabilize things, but these I dont know what
youd call them these mini-arrests have continued. The
physicians are beginning to suspect they are somehow related to her brain injury, which is a bad sign.
ANDREA: So whats her overall prognosis?
LUCY: Well, thats the catch. Her brain scans are inconclusive. I cant explain everything the neurologist said
in the last family meeting, but basically the scans show an
unusual pattern of injury. They know there will be some cognitive disability and cerebral palsy, but you know neurologists. (Lucy shrugs) A brain scan cant predict functional
outcomes. Which is true, but unhelpful. Theyve consulted
with other specialists around the globe. But at this point there
is no definitive prognosis. All the doctors can agree on is that
her funny brain scan and these episodes indicate shes likely
to die soon, probably of respiratory arrest or infection. But
whether thats this week or next month or years from now,
they cant be sure.

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_11,

Springer International Publishing Switzerland 2015


A. N. Frolic


ANDREA: So what is she like right now, day to day?

LUCY: Mostly shes not responsive. When she is stable
she seems to look around when you come into the room, but
that might just be a reflex.
ANDREA: Whats her current code status?
LUCY: Its A-N-D, Allow Natural Death. No re-intubation. No chest compressions. No work up for sepsis. If she
gets a big infection or goes into cardiac arrest, everyone
agrees it will be time to let her go. The real debate is about
continuing with G-tube feeding, which hasnt helped her respiratory symptoms.
ANDREA: Where are the parents at in all of this?
LUCY: Its a tough situation. They are both very clear
that they dont want Abigail to suffer. They arent a life-atall-costs kind of family. (pauses) This is almost the opposite
of the situations we usually call you about, where the parents
are demanding aggressive treatment and the team feels its
futile. These parents understand her brain injury is severe,
they accept that she wont live long. Mom finds these miniarrests very distressing; she is the one who brought up the
idea of stopping the G-tube feeds. (pauses) I cant imagine
what it must be like for that little baby, to almost die 10 times
a day. (pauses) Dad is also concerned about her suffering,
but hes been pushing to take her home. His priority is to
have her experience a normal life, outside of the hospital. He
doesnt want her whole life to be defined by the NICU.
ANDREA: So Mom and Dad are mostly on the same page,
but one wants to stop treatment to end the suffering, and the
other wants to get her home? (Lucy nods) Okay. What does
the medical team think about stopping feeds? That can be a
very contentious issue in Neo.
LUCY: The physicians feel Abigail is fairly stable now.
She isnt in pain or distress between episodes. They are creating a new cocktail of medications to try to lessen the frequency of episodes. They want time to see how she responds.
Yesterday the physician told the family that withdrawing
feeds isnt an option now, but she promised to revisit the
issue if Abigail deteriorates or develops complications. Mom
backed down at that point.
ANDREA: It sounds like youre in a holding pattern right
now. So how can I help?
LUCY: Youre right, there is no overt conflict now, not
like there usually is when we call you. But there is real potential for conflict if the new cocktail doesnt work and the
parents demand withdrawal of treatment. I think the doctors
could dig in their heels and refuse, given her inconclusive
neurological picture. I have a feeling this is the quiet before
the storm with Abigail. So I thought maybe you could meet
with the parents to get to know them now, before things heat
ANDREA: Oh, how proactive of you! Usually people call
for an ethics consult after everything has blown up. (laughs)

But your team is so good at supporting parents, Im not sure

what I can add.
LUCY: Oh, I think theyll appreciate how you approach
things. They are very thoughtful people. I think having
someone outside the team to talk to will help. Someone coming from a fresh perspective.
ANDREA: Okay. Id be happy to meet with them. Just
tell me when and where.
LUCY: Mom and Dad usually come to visit mid-afternoon. Could we meet up in the quiet room on Neo tomorrow,
say around 2 PM?
ANDREA: Sounds good. Id like to meet Abigail beforehand. Ill go up to the unit around 1:45. Would it be okay for
me to bring one of my ethics trainees with me? Theres a new
consultant who doesnt have much experience in pediatrics.
This would be a good learning opportunity for her.
LUCY: Ill ask the parents, but I think theyll be fine with
that. (Getting up from the table and moving to the door.)
Thanks so much Andrea. See you tomorrow.

Act II
(SETTING: Same office. Andrea is again sitting at her computer, typing. Stuck to the bottom of her computer monitor
is a small card that reads Right Speech. A knock sounds at
the door. Andrea gets up and opens the door.)
ANDREA: Oh, hi Joyce. Is it 1:30 already? Where has the
day gone? How was your shift in the ICU today?
JOYCE: Oh the unit is crazy. But not as crazy as the parking lot here. My God, I had to drive around for 20min.
ANDREA: Ive had a hectic day myself. Ive been in
meetings since 8 AM. And you know what meetings mean
more work! But of course I cant get any work done because Im in meetings. (shakes her head) What do you say
we take a minute to settle ourselves down and then well talk
about our approach to this consult?
JOYCE: Sure, Id love that.
(Andrea takes out her cellphone and fiddles with the buttons.)
ANDREA: There, Ive set the timer for 3min. So lets
just close our eyes for a moment. (Andrea and Joyce both
close their eyes.) Letting our bodies and minds arrive here
and now, in this room together. Letting go of whatever weve
done or not done this morning. Feeling the chairs holding us.
The spine rising up like the trunk of a tall tree. The top of the
head touching the sky, the feet resting on the floor. Focusing
attention on the breath. (pause) Noticing the refreshment and
release that comes with each in-breath and each out-breath.
(Andrea pauses for a moment. The two women remain still
and silent.) And as this quiet time draws to a close, setting an
intention for our meeting with our clients today. (A few sec-

11 Minding Baby Abigail

onds of silence, then the phone chimes quietly. The women

open their eyes and smile at one another.) Thanks. I needed
JOYCE: Oh me too. Thank you. That was refreshing.
ANDREA: What a difference three minutes of stillness
can make. (stretches and settles down) So lets talk about
our intentions first, and then well hatch a strategy for this
meeting. (Turning around to gesture to the card taped on her
monitor.) You know I randomly pick an intention card every
morning, especially on days I know are going to be wild. So
today I picked right speech. (pause) I have to admit, Im
a bit uneasy about this consult. Usually I have a clear sense
of what Im bringing to the table. Like what values or principles or policies might be relevant, or what tactic I might
take to negotiate a resolution. But this isnt a typical case.
There isnt a conflict to mediate, not yet anyway. I guess my
intention needs to be to stay present and deal intelligently
with whatever comes up. Hopefully Ill find the right words
in the moment.
JOYCE: Maybe just having an outsider, somebody more
objective, to talk through the issues with, will be helpful.
ANDREA: I hope so. It sounds like the parents may need
some education about their roles as substitute decision-makers for their child. Perhaps we can talk about the definition
of best interests too, to prep them for decisions they may face
down the road. Ill grab a couple of our educational pamphlets, just in case. (Stands and rifles through a file cabinet,
retrieves a folder then turns back.) What about you, what is
your intention for this meeting?
JOYCE: Well, Im still learning about the NICU, so Im
just happy to listen. If I feel like I have something to contribute Ill pipe up, but otherwise, I expect Ill be pretty quiet.
ANDREA: Alright. Thats fine. You can always help by
asking questions I havent thought of. Lets go up to the unit
now. I told Lucy wed meet her in the babys room. I always
like to spend a few minutes watching the baby and talking
to the bedside nurse before a family meeting. It makes the
conversation feel more grounded, like the patient isnt just
an abstraction. Okay, lets go. (Both women get up and leave
the room.)

(SETTING: The NICU quiet room. The walls are painted
light green, decorated with pictures of flowers. The furniture
is industrial-cozy; two vinyl couches face one another, separated by a plain wood coffee table. Three chairs complete
the circle. Emma is sitting on one of the couches, nursing
Rachel; Scott is sitting beside her. They are both silent and
relaxed, totally engrossed in watching the baby suckle. The
door opens abruptly.)


ANDREA: (registering what Emma is doing) Oh, Im

so sorry to interrupt. Im Andrea, the ethicist for the hospital. Would you like us to come back later when youre done
EMMA: No, no, its okay, come in. Shes just fallen
ANDREA: (comes in, followed by Lucy and Joyce who
sit on the opposite couch. Andrea sits down in a chair next
to Emma, smiles at Rachel) Oh, I remember those days. I
nursed both of my kids until they were two years old, mostly
because it was like giving them a sleeping potion. Ever since
I weaned them bedtime has been a battle. (turning to gesture
at Joyce) This is my colleague Joyce, shes also a member of
the ethics consultation team. I hope its okay if she sits in on
our meeting.
EMMA and SCOTT: Hi. Oh sure, fine. Nice to meet you.
ANDREA: Sorry were a few minutes late. Joyce and I
wanted to meet Abigail before we came in to speak with you.
She sure is a cutie.
JOYCE: I can see where she gets the dark hair! (gesturing
at Emma)
EMMA: Yeah, she came out with that full head of hair.
Whereas this one here (nodding to Rachel), she was bald as
a billiard ball. Now shes growing a little peach fuzz. It looks
a little red, like Scotts.
ANDREA: Shes pretty chunky already for a preemie. Is
she a good eater?
EMMA: Oh yes, around the clock.
ANDREA: Hmm, good for baby, but not so good for
EMMA: Oh its not too bad. Its amazing what you can
get used to.
ANDREA: Well, Im sorry youve had to get used to
being here in the NICU. Lucy told me a little bit about your
family. Youve been on quite a ride together.
SCOTT: Its been surreal. I cant believe its only been
three months since they were born. It feels more like three
years. (Emma nods.)
ANDREA: So tell me about that. Whats made it feel so
(Emma and Scott look at each other)
EMMA: Scott, you go ahead. Ive told the story too many
times already.
SCOTT: Okay. I dont know where to begin. (pauses)
Well, the birth I guess. It was like a bad dream you couldnt
wake up from. One day, were humming along, thinking
were having twins in like, three months. Feeling like we
have all the time in the world to get ready. And the next day
were in a delivery room and theres a million people rushing
around. Theyre calling out the babies heart rates, and they
keep dropping. Suddenly they need to get out fast. So then
were in the OR and the girls are born and we get one look


at them and then theyre whisked away. And the next time
we see them theyre in these plastic boxes with tubes everywhere and people are whispering and watching the monitors
and looking worried.
(Emma has finished nursing. She passes Rachel to Scott
while she adjusts her clothing. As he speaks he gazes at Rachel.)
So there we are, trying to wrap our heads around the fact
that these two little red critters are our children, and trying
to figure out how to be parents to them when we cant even
hold them. Rachel, she came out vigorous and we could see
she was getting bigger and stronger every day, like normal
babies do. But with Abigail nothing seems normal. Every
day theres another test: swallowing assessment, MRI,
bloodwork, head ultrasound, echo. It goes on and on. And
after every test theres another meeting with more dire predictions: brain damage, developmental delay, blindness,
hearing loss, pneumonia. They still dont know what is going
on with her breathing. When her rates drop its sometimes
hard to get her stabilized again. And on bad days shell have
10 or 15 episodes. So everyday we wake up wondering, is
this the day our daughter is going to die? I never imagined
living like this. (pauses)
And every week theres a new doctor who thinks up a
new plan. Lets try her on another medication. Lets try this
G-tube. Lets send her scan to Harvard to get another opinion. And we get this little buzz, like, oh this will fix things.
But then we come back to the reality that her brain is really
messed up. It isnt like a broken leg, it cant be fixed. No
matter what they do she wont live very long. So then wed
wonder, what are we doing all this for? Its enough to drive
you nuts.
EMMA: (nodding) Totally. So on bad days Ill be planning Abigails funeral, and at the same time Ill be taking
care of this little one (caressing Rachel) who is growing
and thriving. Now shes even smiling at us. But most of our
time is spent thinking and talking about Abigail. Rachel here
hardly gets a second thought. I practically live at the hospital
so she doesnt get to be outside or have any kind of normal
life. I feel terrible about that.
ANDREA: The good thing about newborns, well, healthy
newborns, is that their needs are so limited. If theyre fed
and dry and attached to mommy and daddy, thats pretty
much the definition of the good life. (smiling at Rachel) She
doesnt look like shes suffering. She seems happy just being
close to you guys. (pauses) I cant imagine how torn you
must feel, celebrating Rachels milestones and bringing her
home and setting up house with her. But then having to deal
with this situation with Abigail. Becoming a parent for the
first time is hard enough. Becoming the parents of twins is
doubly hard. But here you are, youve had the joy of birth
and the anticipation of death all mixed up together. Feeling
nutty seems like a very sane response to me. (pauses) So

A. N. Frolic

given all that youve told me, what are you hoping to get
from our conversation? How can I help?
EMMA: Well, Lucy said youre someone parents sometimes talk to when theyre feeling stuck or conflicted. Scott
and I, we havent always agreed on what should happen with
Abigail. (Pauses, looking at Scott; he raises his eyebrows,
but doesnt say anything.)
ANDREA: Youve had a lot of decisions to make, under
huge pressure. It isnt uncommon for parents to disagree
sometimes about the direction of care for their child. Can
you tell me a bit about where you feel stuck now?
EMMA: (takes a deep breath.) I think my biggest concern
is protecting Abigail. We get that she isnt going to live very
long. And until recently she wasnt very responsive, so it
seemed like her whole life was just getting poked and prodded. When her breathing stops she starts suffocating. Its just
just awful to watch. And I worry that she may be in pain
other times too and we just cant see it. I dont want her life
to be about pain. But it seems like that could be all she ever
feels. (becomes teary) You know, if she cant do any normal baby things, and if shes going to die anyway in a few
weeks or months, then what are we doing? (Pauses, wiping
her eyes.) I guess I feel like I havent done a very good job
keeping her safe. I couldnt keep her safe inside of me, and
I cant keep her safe outside either. I just want her to have
some peace. (Breaks off, Scott takes her hand.)
SCOTT: And I guess for me, I dont want her to suffer either. But I am less clear about stopping everything. I honestly
cant understand whats going on half the time. Ive heard so
many conflicting stories. Shes going to die. Shes doing
better today. You can take her home soon. Shes had a
setback. I have no idea whats around the next bend. And
because I dont know what her future holds, its hard for me
to say, Okay, enough is enough, lets stop now. I just cant
do it yet. I want to get her home to have some kind of normal
life with us and her sister and her grandparents. I dont want
this place to be all she ever sees of life. But then I wonder
if Im holding onto her for selfish reasons, because Im not
ready. (pauses)
Emma told me to talk it over with her, so I did. A couple
of nights ago I sat with Abigail. And I told her everything
that was going on, everything the doctors had told us. About
the little stars that light up on her brain scan, and why she
needs the feeding tube. And I told her about how her mom
and sister are here all the time watching out for her, and how
hard the nurses are working to keep her safe. (voice breaks,
continues in a whisper). And I told her that even though we
love her, we will be okay if she needs to go, if its too much
for her. But I told her we want her to stay, for a little while
longer, if she can, so she can sleep in the room weve prepared for her at home. (pauses, wipes his eyes briskly) Whatever. I dont even know if she can hear me, but I felt like I
had to explain it to her, why were putting her through this.

11 Minding Baby Abigail

(The room falls silent for a moment. Rachel shifts in her

sleep, grunts and passes gas. Everyone laughs.)
EMMA: Sorry.
ANDREA: Oh dont be. Its her full-time job, eating and
digesting and growing. Its all about throughput at this stage
of the game. (pauses) So let me make sure Ive heard you
both. Then I have some questions Id like to ask you. (takes
a breath)
First of all, let me say how lucky Abigail is to have such
loving, unselfish parents. Ive met many parents who are absolutely hell-bent on keeping their child alive at all costs.
Often they are so blinded by the terror of losing their baby,
they cant tune into the childs experience. They cant see
that the childs life may be entirely defined by suffering.
When we become consumed by the fight against death, its
easy to lose sight of what life is really for. Keeping the heart
beating, the lungs breathing, that isnt the end goal in and of
itself. Thats just the means to connection, pleasure, joy, all
the things youve talked about. I appreciate that you havent
let your own grief overshadow Abigails experience. That is,
hmm, I cant quite find the word. That is real compassion
and generosity. (pauses, Emma quietly blows her nose)
So preventing needless suffering is at least one thing you
have in common. Now youve already figured out that almost everything we do in medicine entails some pain. Even
a little poke to take a blood sample is painful. But that little
poke is worth it if we think the blood test will help us understand the patients condition better and help us design the
right treatment. Doctors often talk about the harm-benefit
ratio. That means the expected benefit of an intervention
must always outweigh the suffering or side effects that come
along with it. If the balance tips, then its time to rethink that
intervention. Thats what all of you are wrestling with. At
what point is her treatment causing more harm than good?
At what point is it just delaying her death, but not helping
her to really live?
SCOTT: (nodding) Exactly! But I dont understand how
the hell were supposed to figure out when we cross that
threshold. Emma asked the doctor the other day, point blank:
If Abigail is going to die soon anyway, and she cant experience much pleasure, and we know shes in a lot of pain
during these episodes, then what are we doing here? But
the doctor said, Oh we need more information, we dont
know enough yet, we cant say for sure that its time to stop.
It feels like this uncertainty could go on forever, like were
trapped in a labyrinth. And meanwhile our daughter is suffering and we are all stuck here in this hospital instead of
being together at home like a normal family. (pauses) But
then we feel terrible for even asking the question because the
last thing we want is for her to die. (Emma nods vigorously)
ANDREA: (pauses). A labyrinth is an apt metaphor for
this situation. I get how all the investigations and tests and
second and third and twelfth opinions could feel like, well,


like wandering in the dark. (pauses) Im just thinking. Has

anyone ever explained to you how physicians make decisions about a patients treatment plan? (Scott and Emma
shake their heads) Its one of those things we take for granted, like how fish dont feel the water theyre swimming in.
There is an internal logic to it all, though it may not appear
very logical sometimes. (Andrea flips to a blank page in her
notebook, leans forward on the coffee table and begins drawing a decision tree with a number of boxes and arrows.)
Okay, so first they look at the patient. What do all the
scans and blood work and monitors say about what is going
on with all of the organ systems, with the immune system,
They take that data and try to figure out the patients diagnosis. What is causing all of these reactions in the body?
They compare this particular patients condition to other patients with similar symptoms. Diagnosis is a process of pattern recognition.
Once they have a diagnosis, then they work on prognosis,
which basically means making predictions about the possible
outcomes of different treatments, to determine which one is
likely to be most helpful. They use two kinds of knowledge
to make these predictions.
One is medical evidence. Ideally they would follow
best practice guidelines that are developed through a consensus of experts. But sometimes the diagnosis is very rare, so
then they have to rely on published studies, or case reports.
The other kind of knowledge they use is clinical judgment.
This is a more intuitive way of thinking. The physician will
reflect on other similar cases theyve seen over the course
of their career. On the basis of that track record, they will
make an educated guess about what they think is going on
and what they think will help. All physicians use both kinds
of knowledge all the time. Both are about evidence. One is
more objective, the other is based on experience.
In this NICU a new physician takes over every couple
of weeks, so over time, youre getting access to the clinical
judgment of many physicians. Each of them has treated different patients and trained in different contexts, so that can
account for the different approaches. Does this make sense
so far? (Emma and Scott nod)
Usually the process of gathering evidence feeds into a
pretty straightforward path of decision-making. The prognosis leads naturally to defining goals of care, like discharge
home, for example. This leads to identifying treatment options, like tube feeding, or whatever will support the goal.
When the treatment options are clear, the docs come to the
parents to explain them and get consent.
Now, in a situation like Abigails, the physicians are stuck
way back here at step one, at the gathering evidence stage.
Her brain injury is so unique they cant nail down her diagnosis and prognosis. So they keep doing more tests, and
trying new things. Thats why it feels like flavor of the week.


This week shes getting better, next week its hopeless. The
flavor changes with each new data point, and her response to
each treatment they try.
The up side of this whole process is that you have access to the collective wisdom of many physicians, who have
treated thousands of patients. Theyve even reached out to
colleagues at other hospitals. While this only adds to the
murkiness now, when things do become clearer and decisions have to be made, you can feel confident that their predictions are as accurate as humanly possible.
SCOTT: (frustrated) Yeah, I get this. I get their need to
turn over every stone. I am grateful, I am. Dont get me
wrong. But in the meantime were sitting at her bedside
watching her writhe in agony.
We are her parents. We are her voice. We are the ones who
have to think about her future. About all of our futures (gesturing to Rachel). How are we supposed to make plans when
they cant make up their minds? I keep wondering, should
I be at home renovating the house because someday she is
going to need a wheelchair ramp to get in the front door? Or
should we be at the funeral home picking out a coffin? I get
that the doctors are stuck. But what about us? Were in this
state of, I dunno, suspended animation. This cant go on.
ANDREA: (leaning forward) Its maddening. I get that.
(pauses) Actually, I dont get it at all. But I can hear the frustration in your words and I can imagine being in your position. You are in this betwixt and between space. You dont
know whether to you should be planning a life with her or
without her. (pauses) I know this is going to sound stupid,
but Ill say it anyway. This is really hard because it is really
SCOTT: Im sorry, but what is that supposed to mean?
ANDREA: Often in times of stress, people retreat from
reality. They hang on to false hope or they deny anything is
wrong or they imagine the worst case scenario is about to
come true. But the two of you (pausing, looking both of them
in the eyes) you are both deeply in touch with the real ambiguity of this situation. Abigail may die tomorrow if her brain
is so damaged that it tells her lungs to stop working. Or her
brain may keep telling her lungs to breathe, but a year from
now she may get an overwhelming infection and die. You
know the book of her life will be slim, but the last chapter of
her story hasnt been written. Nobody knows when or how it
will end. You grasp this uncertainty, which in some ways is
harder than a clear death sentence.
SCOTT: I dont see how that is any help.
ANDREA: Well, it isnt frankly. But longing for certainty
when there isnt any seems to be causing you and Emma a
great deal of distress. It looks like Abigail is in charge here.
She has to declare herself. We wont know her future until it
unfolds. She has to show us what shes capable of, and that
will take time. This requires almost superhuman patience on
your part. (leaning back into her chair) I guess Im wonder-

A. N. Frolic

ing if finding ways to relax into the ambiguity, rather than

constantly fighting it, might help you stay sane. I have some
ideas for things you could try. Would you like to hear them?
EMMA: Yes, I would. (Scott shrugs)
ANDREA: So you dont have any decisions to make now,
but you will down the road. For people like Abigail, who
have never had the capacity to express their own wishes and
values, we use the notion of best interests to make decisions about treatments. Best interests is basically about
ensuring that treatments do more good than harm. The trick
is: how do you define benefit and how do you define harm?
Take the example of someone with advanced cancer who
can no longer eat and who is being kept alive with a feeding
tube. At some point the feeding tube might just be feeding
the cancer, rather than nourishing the person. As the tumors
grow, this might cause more pain. The feeding tube might
even cause bloating and diarrhea if the digestive system is
shutting down. In a case like this, the feeding tube is prolonging an inevitable dying process and causing more suffering for the patient. So we could reasonably say that the
feeding tube isnt in the best interests of the patient. Does
this make sense? (Emma and Scott nod)
Everyone defines harm and benefit a little differently,
based on their values. I suggest we take some time now to
talk about what values are most important to you. This could
help the two of you to work with the medical team to figure
out Abigails best interests when you get to a point where decisions have to be made. Defining values is easier with adults
because they have a life story you can draw on. Some adults
value independence, some value bodily integrity. Given Abigail is a baby, we have to think of values that are relevant
to her life as it is, right now. (Emma and Scott look at each
other, bewildered)
I know this is a little strange, but lets try brainstorming
together. What values do you want to guide you, as a family?
Okay, I can think of one. You didnt say it directly, but it
is evident in every word youve spoken about Abigail. That
is love. It seems important for you to be able to show
love to Abigail, by holding her, by talking to her, by allowing her to connect with her sister, by taking her home to live
with you. So if there came a time when medical treatments
interfered with your ability to demonstrate love to her, like if
she were going to be isolated due to a chronic infection, that
might not be a plan that would align with your values. Does
that sound right? (Scott and Emma nod) So can you think
of other values that might help guide decisions for Abigail
down the road?
EMMA: Well, avoiding pain and suffering obviously.
Thats important.
ANDREA: (writing in her notebook) Right, great.
SCOTT: But avoiding pain isnt enough. She needs to be
able to experience some sort of pleasure. Like being soothed

11 Minding Baby Abigail

by our touch or by music or whatever. I wouldnt want her to

be so drugged up because of pain that shes totally unaware
of her surroundings. That isnt a life, to me. (pauses) And
the ability to communicate. Not that we expect her to talk,
but she should have some ability to interact with her environment, like opening her eyes to see the world around her,
hearing our voices. When I talk to her I want to feel like the
words are reaching her, and that she knows we are there. If
she cant do that, I dont see any point in continuing.
EMMA: And Id add being able to rest and sleep to that
list. (laughs) It sounds silly but when she struggles with her
breathing she cant rest. She is constantly being stimulated.
Babies sleep, thats their nature. So if she cant rest, thats a
kind of suffering too.
ANDREA: (looking up from her pad) Wow that sounds
like an amazing list of values: love, freedom from suffering,
pleasure, communication and interaction, rest. Im thinking
of one more. You didnt say this, but it is implied in everything youve said. Relationship. The ability to forge relationship with her family. Does that sound right to you? (Scott
and Emma look at each other)
EMMA: Yeah, those sound good to me.
ANDREA: Great. Now these values can act as guideposts down the road. For example, if the doctors someday
say, Abigails condition has worsened. Shell need a lot of
medication to control her pain. She wont be able to interact with you. Based on these values you might say, Okay,
weve reached the threshold where the harm now outweighs
the benefit. Does that make sense? (Emma and Scott nod)
There is another strategy I sometimes recommend to
families who are facing difficult decisions about their loved
ones care. (takes a breath)
However Abigails life unfolds, or when and how it eventually ends, you are going to tell the story of her life for the
rest of your lives. You are going to tell her story to your
friends and relatives. You are going to tell her story to her
sister. And you are going to tell her story to yourselves. Over
and over, for years to come. So my question to you is, what
kind of story do you want to tell about Abigail?
(leans forward) The story you had planned for her, that
she would walk and talk and go to school, that story isnt
going to happen. This is a painful truth that you have courageously accepted. So given this reality, what story can you
imagine telling about her life? (Scott frowns)
This isnt a question that I want you to answer right now,
but its something you can think about and talk about together. For some families, its important to tell the story of fighting for the life of their child against all odds, even fighting
against the doctors if they have to. For some families faith
is important. Their story might be about the little miracles or
signs of grace that happen along the journey. For some families, the story that matters most is about giving their child the
most normal life possible. That might mean taking the child


home, even if the child dies more quickly than she would in
hospital. Every familys story is different. But it might be
useful to think about this question: if you were to create a
story for Abigail based on her circumstances and your values, what would it look like? (Scott shifts in his chair)
EMMA: Its hard to imagine her whole life story because
the day-to-day feels so overwhelming. But it might be worth
talking about.
ANDREA: Yeah, it is overwhelming. Try it out and see
what bubbles up. You might even put pen to paper and write
out her life story, as you imagine it, just to see what emerges.
(scanning over her notes) Okay, so weve talked about how
medical decision-making works. Weve talked about best interests and the idea of the harm-benefit ratio. Weve talked
about your values and weve talked about creating a story for
Abigail. There is one more thing Id like to leave you with.
(takes a breath)
Id like to give you some ideas for living day-to-day in
this state of uncertainty. We are so accustomed to thinking
about the future and making plans. But with Abigail you
cant make plans because her future is too murky. Some of
the best specialists in the world have looked at her case and
even they cant figure it out. So given that perpetual uncertainty is your new normal, how can you keep it from driving
you mad?
Perhaps one way to cope is to set small goals or intentions
every day. Instead of focusing on the big ticket items, like
should I renovate the house or choose a coffin, focus on the
little actions you can take to connect with her. Like, I dunno
(gesturing with her hands) today Im going to tell Abigail the
story of her crazy uncle Harrys stint as a circus performer.
Or, today I am going to sing the entire score of the Sound of
Music to Abigail. Or today I am going to give her a massage.
Try to notice and celebrate the small joys, in the midst of
all the chaos. Accomplishing little acts of connection, even if
the big questions remain unanswered, is one way to reclaim
your sense of purpose. And over time, these little acts will
make you feel like good parents to Abigail, however long
you have together. They may even become the threads you
weave together to tell her story. The story of your family.
(Rachel stretches and stirs, giving a short cry.)
Oh dear, I think it is time for another feeding. Perhaps
thats our cue to finish for now. Has any of this been helpful
to you?
EMMA: I think so. Its been helpful to talk about our values and her story. Ill keep thinking about that.
SCOTT: (handing Rachel over to Emma) Not really, honestly. It feels as confused as ever.
ANDREA: (sitting back, smiling) I appreciate your honesty. Confusion seems like a very reasonable response to
your situation. I wish I could wish away your burden. (closing her notebook) I have enjoyed meeting you, and meeting
Abigail and Rachel. They are both so beautiful, and they are

A. N. Frolic


so lucky to have you as their parents. Your courage and your

clarity have inspired me.
EMMA: Thank you Andrea. Its been great talking with
you too. Can we see you again, if we need to?
LUCY: I have Andreas pager on speed-dial so I can put
you in touch with each other.
ANDREA: Absolutely, we can pick up this conversation again, any time. (looking from Emma to Scott) I will be
thinking of you and Abigail and Rachel. I wish you peace,
someday, somehow.

Third, reading a play is like working out a puzzle. In expository prose, the author can tell the reader what is going
on, and can describe the characters inner thoughts, desires,
and schemes. But the reader of a play must piece these together for herself, using only the words spoken and actions
described. A play shows, it does not tell. In these scenes, I
have attempted to show how mindfulness infuses my practice as an ethicist.


Letting Go of Expectations At the outset of this case, I was

very anxious about my role and worried about how I could
help. Gradually, I softened into the unknown, trusting that by
showing up and listening carefully, I would discern how to
assist this family.

The above is a composite rendering of several neonatal cases

I have facilitated as an ethicist over the past 10 years working in a childrens hospital. Rendering is the operative word
here. While the narrative is structured in dialogue, it is not a
word-for-word transcription of any particular case; rather, it
has been stitched together from my notes and recollections
of various neonatal consults. In keeping with the goal of this
book, I focused on my own words and actions to illustrate
how I integrated mindfulness into my clinical practice as an
ethicist, omitting important clinical and contextual details
that would normally be part of a case report. I admit that
this narrative renders all of the characters, including myself,
in an idealized way. I am certainly not this clear-thinking
or present in every case, and a true transcript would betray
how inarticulate people sound when their speech is recorded
word-for-word. However, I feel the genre of a play is an apt
way to explore the application of mindfulness in clinical settings for several reasons.
First, for me mindfulness is not primarily about the practice of meditation. Meditation is what I do to train myself to
be mindful in everyday interactions. It is the means to develop basic competencies that enable me to be mindful in my
workspecifically the ability to stop, to listen to my own
body and feelings, to let go of the past and the future, and to
attune to the words, gestures, and motivations of my clients.
Mindfulness is about opening the door to greet the present
moment as it arrives. A play better conveys this sense of immediacythat the world is unfolding now, now, nowthan
conventional prose.
Second, mindfulness is an embodied practice. It acknowledges that our experience is always mediated by, and
expressed through, the body. Mindfulness brings awareness to ones internal environmentsensations, emotions,
thoughtsas well as ones external environmentthe
sights, sounds, and contexts that shape sensory experience.
The genre of a play facilitates expression of this embodied
dimension through the setting of the scene, the words spoken
by the characters, the stage directions, and indications of the
characters gestures and expressions.

Did You Spot the Mindful Practices?

Three Minute Breathing Space At least once each workday, I set aside a few minutes for formal meditation practice.
By simply stopping and bringing awareness to my breath and
my body, I am better able to transition from one mode or
activity to another.
Setting an Intention I keep a stack of intention cards in my
office [1]. I pick one from the deck every morning upon my
arrival. Sometimes the intentionsuch as honesty, responsibility, or compassionfits the flow and challenges of my
day intuitively. Other times, it feels like a struggle to understand how the quality relates to my current circumstances.
Throughout my workday, I try to reflect on how I can bring
the days intention to whatever activity I am engaged with.
Mindful Listening I try to begin conversations with clients
by inviting them to tell me their story, and then shutting up.
This second step is the most difficult and the most important. In the hospital environment, patients and families are
constantly interrupted by pagers beeping, by impatient learners wanting just the facts, by harried clinicians awareness
of the multitude of other patients waiting to see them. Mindful listening requires self-regulation to curb the temptation
to interrupt or to preempt the punch line of the clients story.
When I am mindfully listening, I wait for the client to stop
speaking; sometimes I wait through long pauses to see if
more of their story will emerge. Through this practice, I learn
what is most important to the client, rather than what I think
is important. It is astonishing how little time this actually
takes and how much wisdom clients uncover for themselves.
Throughout my clinical encounters, I also try to check-in
with my own emotions, thoughts, and bodily sensations. For
example, when clients resist my suggestions, I sometimes
notice defensiveness or fear arising as a knot in my belly.
Naming this feeling, I can take a deep breath to loosen the

11 Minding Baby Abigail

knot. This allows me to acknowledge my feelings, and the

feelings of others, and helps to prevent me from becoming
too ego-driven in my consultation practice.
Honoring the Present Clinical medicine has an inherent
bias towards the future. We are always trying to get somewhere that isnt here: get through the surgery; get over the
crisis; get out of the hospital; get rid of the infection. The
present is almost always a problem, and the usual solution
proffered is to identify and apply some medical technology that promises to make tomorrow better than today. This
future orientation is necessary for the advancement of scientific knowledge, and for planning and executing effective
treatments. However, it often leaves patients and families
wondering how to live now, especially in situations involving chronic or life-limiting illnesses, when there is every
chance that tomorrow will be worse than today. One way
of modeling mindfulness is to provide patients and families
with a repertoire of tactics to help them notice the small joys
available to them in the present moment. Setting daily intentions, creating a gratitude journal, stopping to breathe quietly with a sleeping loved one, storytelling, singing a favorite
songthese are simple practices that can help families to
find solace and peace amidst the chaos of a medical crisis.
Watering the Flowers This is the poetic phrase used by
Thich Nhat Hanh [2] to describe the practice of acknowledging and naming the good qualities of others. I am amazed
by how much trust can be built, and how much healing can
occur, by simply naming the strengths you see in the person in front of you. Ultimately, the question Emma and Scott
really wanted answered was: Are we good parents? The
answer, unequivocally, was, Yes! So I said it out loud.
Naming the values that are important to families can also
help them feel connected to their positive qualities, and they
can use these as anchors when navigating difficult decisions.
Whether or not it helps my clients, I know that practicing mindfulness helps me. Integrating mindfulness into my
clinical work enables me to surf the surging swells of suffering I encounter in the hospital setting, with its competing


priorities, its unsolvable moral conundrums, its inhumane

pace. By practicing first for and with myself, and by sprinkling mindfulness throughout my days, I experience a deeper
connection to others, and a greater sense of well-being and
purpose in my work. By deepening the well of my own selfawareness and inner peace, I can bring more clarity and compassion to my clients.
I recently reread Ram Dass and Paul Gormans classic
book How Can I Help? [3]. Only now, almost 15 years into
my career as an ethicist, am I finally understanding the answer. I can help most by resisting the urge to give false hope
or pat answers or technical solutions in situations of moral
ambiguity or unspeakable loss. Such responses may help me
feel better, but they will not help the client. Instead, I can
help by cultivating my own capacity to greet the people and
situations that come to my door with an open heart and a
quiet mind. This practice is what enables me, as an ethicist,
to recognize and cultivate clients own moral wisdom and
resilience, which is ultimately the most effective medicine
on earth.

1. Murdoch A, Oldershaw DL. 16 Guidelines for life: the basics. London: Essential Education; 2009.
2. Hanh TN. Happiness: essential mindfulness practices. Berkeley: Parallax; 2009.
3. Dass R, Gorman P. How can I help? Stories and reflections on service. New York: Knopf; 1985.

Andrea N. Frolic PhD is the director of the Office of Clinical and

Organizational Ethics at Hamilton Health Sciences, and an assistant
professor in the Department of Family Medicine at McMaster University in Hamilton, Ontario, Canada. Dr. Frolic is the administrative
lead of a project aimed at developing resilience and reflection with
healthcare professionals through mindfulness and arts-based interventions. She conducts research in the fields of ethics program design, arts
and medicine, and workplace wellness, and she explores the moral and
social dimensions of health care through her artistic practice as a choreographer and dancer.

Mindfulness in Oncology: Healing

Through Relationship


Linda E. Carlson

I met Stephen during my residency year before the completion of my PhD in clinical psychology in 1997. Stephen had
recently received a diagnosis of stage 4 non-Hodgkins lymphoma. I had some training in health psychology, but it was
my first introduction to working with cancer patients. I was
seeing people preparing to undergo high-dose chemotherapy
and stem-cell transplantation in the bone marrow transplant
unit, and was learning a lot about the cancer experience and
what it entailed both medically and psychologically. My job
was to help people cope through this grueling procedure
by applying principles of counseling and clinical psychology, providing support to patients and families in ways that
fit with their resources, personalities, and values. We were
learning to treat specific psychological reactions including
anxiety and depression, as well as and symptoms, such as
sleep disturbance, pain and fatigue, and existential concerns
around death and dying.
Stephen was to be one person I saw through his entire
intense medical journey, and well beyond, for over 10 years.
We became very close, with the kind of familiarity and deep
implicit knowing of one another that eventually results in
understanding without the requirement of much speech. The
relationship provided him comfort, familiarity, and a feeling of being seen, understood, and accepted. He also learned
concrete tools for coping and integrating mindfulness practice into his everyday life. But how did we get there? There
were considerable challenges to overcome, medically, and
psychologically. I will first tell you about his medical treatments, my role at that time, and how we integrated mindfulness into our relationships and into his process of healing
and recovery.

Department of Psychosocial Oncology, Tom Baker Cancer Centre,
1331 29St NW, Calgary, AB T2N 4N2, Canada
Department of Oncology, Faculty of Medicine, University of Calgary,
Calgary, AB, Canada

Autologous stem-cell transplantation (ASCT) is a procedure whereby people with systemic cancers, usually lymphomas, are subjected to extremely high-dose chemotherapy
which depletes the immune system. Before the chemotherapy, the patients own stem cells are harvested, cleaned, frozen, and stored for later reinfusion. This can only be done in
cases where the cells themselves are thought to be relatively
cancer free. In the case of most leukemias, donor marrow or
peripheral stem cells are harvested and those are later reinfused, rather than the patients own blood cells, which are
tainted with cancer.
Regardless of whether the procedure involves later infusion of the patients own cells or donor cells, after the harvest
they are subjected to high-dose chemotherapy, much higher
dosages than could normally be safely administered due to
immune depletion. Then after the chemotherapy, the clean
cells are reinfused into the patient with the hope that they will
safely engraft and reestablish a healthy immune system. This
process involves sometimes lengthy inpatient stays while the
person is immunosuppressed and the process of rebuilding
the cells is occurring. At the same time, terrible side effects
of the chemotherapy are common, including painful mouth
sores, diarrhea, hair loss, neuropathy, and overall extreme
fatigue and nausea.
Stephen was not well suited for this kind of treatment.
The cancer experience in general is fraught with uncertainty
and loss of control. No one can tell you what your chances of
survival are, or how your disease may progress. Death may
be imminent. Oncologists cannot even tell you exactly what
treatments you may need, or even, in some cases, definitively what the diagnosis is. They cannot tell you if or when it
might recur. Stephen was 36 years old, and was physically fit
and active. He was married but he and his wife had chosen
not to have children; they had a full life with a small but active social circle, family ties, and travel. He was well read,
intelligent, and a good conversationalist with a passion for
politics and music, but he had his own mental health problems that predated the cancer.

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_12,

Springer International Publishing Switzerland 2015



He grew up in a family with a history of depression, anxiety, alcoholism, and abuse, and had a long personal history
of anxiety and depression himself. He has been diagnosed
with obsessivecompulsive disorder (OCD), generalized
anxiety disorder (GAD), and had also suffered from major
depressive disorder (MDD) intermittently. While his anxiety symptoms had been quite constant throughout his life,
depressive symptoms waxed and waned. Despite these challenges, he was resilient. He trained in technical school and,
while he had periods of anxiety and self-doubt, became a
licensed tradesman. After a few years in the field, however,
the stress of trying to work in a job that required precision
and focus, where the consequences of slipping up could be
fatal to himself or others, had taken a toll. Escalating OCD
symptoms had led to leaving his job and taking disability a
year or so prior to his illness, as he was unable to function.
He doubted his own minds ability to complete the required
tasks, was constantly second guessing himself and checking
his work obsessively. This resulted in a high level of mental
fatigue and depression which culminated in a suicide attempt
and brief stay in a psychiatric unit within the 2 years previous
to his cancer diagnosis. He had been treated with medication and supportive counseling and been recovering from this
traumatic experience when he began experiencing symptoms
of lymphoma. Stephen did not do well with uncertainty, and
his obsessive personality style and chronic anxiety escalated
once again as he entered the cancer treatment system.
I am not sure what my supervisor was thinking in assigning me this case. I had no idea how to help him through this
experience, and certainly could not imagine trying to treat
all his other psychiatric problems during the storm of cancer
therapy. I got to know him and his wife gradually, through
the first intake interview where I learned a little about his
background, and more and more each time I visited his bedside during treatment. I was impressed by their bond, and
her commitment to stick by his side through thick and thin.
She was there most days and maintained an upbeat persona.
They talked about everything and were very open with one
another. They had already been through a lot, but she was
his rock. She was stable, good-natured and while she shared
some of his more minor obsessive personality traits, did not
suffer any serious psychopathology. She worked full-time in
a stable job, had many friends, maintained an exercise routine, and received a lot of support at the workplace. Stephen
was fortunate to have such a caregiver and partner in his life.
I wondered, as Stephen got sicker and sicker, whether I was
doing any good. I felt helpless and overwhelmed by his problems; and his prognosis was poor. All I could do was sit by
his bedside, sometimes I would help him relax by instructing
him in the use of deep breathing techniques. I talked with
his wife when he was sleeping or in too much pain; she was
practical and worked hard to hold herself together. She kept
busy with managing his needs.

L. E. Carlson

During our sessions over a period of months, I learned

more about Stephens background; he liked to talk and was
insightful about his childhood and how it formed him into the
person he became. He had been in counseling before and appreciated its value; he clearly wanted me to understand him
on a deep level. His father had been an alcoholic, distant, and
both verbally and physically abusive. His mother suffered
from anxiety and depression. As a child, he often shouldered
the brunt of his fathers rage to protect his mother. I felt like
I was just doing a lot of listening, and that I had to do something more to help him. He was suffering awfully though
the treatments, his anxiety was sky high and his side effects
from the treatment were torturous. He had severe mouth and
throat sores, and could not eat and barely could drink, but
the worst for him was not knowing the prognosis and fearing death. Radiation therapy was administered; it burned his
skin. The tumors did not respond the way the oncologists
had hoped. The lymphoma refracted to under Stephens left
arm, and a mass of tumors rapidly developed there. He was
informed that his odds were not good. To Stephen this was
a death sentence. He prepared to die. Things were spiraling
down and he felt out of control and in despair.
Through this all I continued to feel helpless, but faithfully remained by his side despite some days dreading the
visits and fearing what I might encounter. I held his hand
and listened to his fears. I do not even remember now what
I said, but I was there. I accepted what I encountered, and I
was present with the horror. After some time, my intention
became just that: to be present, to witness this relentless calamity. At times, I felt repulsed by the state of him, the smell
of the hospital room, but I soldiered on. I grew to respect
him and his strength in facing not only this, but everything
life had thrown at him, seemingly he had been dealt an unfair
After that first transplant, because he was young and fit,
miraculously his body recovered its strength, but the refractory lymphoma was relentless; his tumours grew again. The
medical team decided to try something almost unprecedented; a second ASCT. Could he handle it psychologically?
Could he handle it physically? We could do it together; Stephen, his wife, me, and his medical team. He decided to try;
it was his only hope to survive. We discussed the irony; how
he had tried to take his own life a short time previously and
now was fighting with every fiber of his being to save it.
He wanted to live. Desperately he wanted to live. He was
surprised by this primal drive to maintain life at seemingly
any cost. There was barely a reprieve and the preparations
for the second transplant and another course of high-dose
chemotherapy began.
Throughout all this time, which was about 46 months
by then, I had been talking to him about mindfulness, showing him how to use breathing techniques to help manage the
pain, to relax around pain, to see that this all was temporary.

12 Mindfulness in Oncology: Healing Through Relationship

It was hard for him to apply these ideas in the midst of the
whirlwind of treatments, tests, fear, and misery. I think he
shifted a little, but OCD is a powerful master. Stephens obsessions were largely mental, games he played in his head,
questioning even the processes of his own mind: was what
he perceived reality, or a trick his mind was playing? It was
hard to get him out of his head and into his body, which is
what we often do in mindfulness training; his body was not a
refuge either during those times due to unrelenting pain and
discomfort. So mostly I just listened, remained calm, and
tried to understand, breathed with him.
Miraculously, the second round of high-dose chemotherapy worked, and the transplant was deemed successful;
Stephens immune system began to rebuild itself. There were
many serious medical problems encountered and overcome
during this second ASCT, but eventually, Stephens immune
system and overall health began to rebound. Stephen was
then reassigned to radiation oncology for 40 more radiation
treatments to his torso. Now he also had to rebuild himself
in so many other ways. As is often the case, the terror and
despair really hit him after the treatments were completed;
then the fear of recurrence loomed large. Ultimately, Stephen
was informed that his remission would likely be brief, between 2 and 6 months. This was a very real threat; it had
come back quickly and aggressively before, and the initial
onset was also a swift blow. It was at this point he began attending our 8-week Mindfulness Cancer Recovery Program.
We had been offering it only a year or so at that time, and
were still refining the content, but it was an adaptation of
Kabat-Zinns mindfulness-Based stress reduction, with more
of a focus on cancer and the uncertainty it brings. Stephen
attended the program and practiced the meditation and yoga
exercises we prescribe faithfullyhis obsessiveness and
conscientiousness made him a good student. He attended all
the classes, participated, shared his experience, and did his
homework (45min of practice a day). But he struggled with
his mind still. Some question the utility of meditation for
people with mental obsessions; would this just become the
next obsession? Was self-reflection in the form of mindfully
watching the mind advisable for someone already obsessed
with an unreliable mind? I tried to assist Stephen, to move
his focus into the bodythis was a bit difficult too, though,
as he could become obsessed with analyzing minor sensations from his chest, where the tumors had been. Were they
growing back? What did that little tug mean?
We persisted nonetheless. I thought it would be useful for
him to become familiar with what it felt like in the body to be
anxious, versus tired, versus depressed, or actually physically sick. Through this work, he did learn to distinguish anxiety
in his body from physical symptoms, which he had been confusing. The typical pattern went like this, I feel something
funny in my chest, could this be the cancer coming back? Oh
my God, if its back Ill be dead, there is no more treatment


for me. What will happen to my wife? How will I die? Will
I suffer? How long is this going to take? I dont want to die!
Im terrified! Like a merry-go-round from Hell, on and on it
would go. Of course then the symptoms would escalate with
the fearIt is cancer! Im sure of it! Why else would I feel
this way? He would poke and prod his body constantly and
further exacerbate symptoms.
We persisted with individual sessions after the group
program, and practiced mindfully observing, identifying,
and responding to stress-related symptoms, rather than automatically assuming that he was on the path to his inevitable
death. Stephen was able to arrest the process over time. He
did a really good job of thishe surprised me somewhat. We
instituted a rule: If you feel what you think might be a symptom, note it, then immediately let it go, do your meditation or
breathing exercises, leave it for a week, and if it is still there
in a week, call the doctor. The symptoms almost always went
away. This practice reinforced the idea that stress can manifest as physical symptoms that mimic his cancer symptoms.
This practice was immensely helpful and he has continued to
apply it for years.
I would like to report that my work with Stephen was a
miraculous success story. However, despite some progress,
he was still symptomatic 10 years later. I think given his history it would be miraculous was he not, but he has certainly
made gains. A year or so after treatment we discovered something else; every year on the anniversary of his diagnosis, he
became depressed and anxious. He had vivid nightmares of
the hospital room he spent so much time in; the doctor telling him he was not doing well and his time might be limited. I diagnosed him with post-traumatic stress disorder
(PTSD). He had all the symptoms. Now what would we do?
I favor exposure therapy for PTSD, and in fact, mindfulness
training is just that: gradual controlled exposure to the full
range of content of the mind. This included flashbacks and
memories of the trauma of his diagnosis and treatment. We
reviewed it again and again; how one day he felt a lump in
his chest, he fainted due to a syncopal episode, and eventually was taken to the Emergency Room; the swift diagnosis,
the brutal treatments; seeing his roommates at the hospital
deteriorate until eventually two of them died. We went over
it again and again, hoping the memories would fade in their
potency. Over time eventually they did, but even as our sessions became less frequent, every year at the anniversary I
would get a call from him for a few sessions. He would tell
the whole story to me yet again. I knew it so well I could tell
it myself, but nonetheless I would try to apply beginners
mind and listen as if for the first timeI would even add in
bits if he missed them.
We actually came to laugh about Stephens storieswe
called them his bird songs. I had read somewhere that once
male birds of a certain species start their call; they cannot
stop until it is done. There is no interrupting. Stephen had a


range of bird songs. I learned that interrupting to say yes,

yes, I know this one, was not very helpful. At times, I would
notice myself getting really irritated when he would launch
yet again into a story about his parents, or his diagnosis:
Did he not know I had heard this many times? That is when
my mindfulness practice played an important role. I would
note the rising feeling of irritation in my belly and chest, the
tightness of anger and feeling like we were wasting valuable
time on this, the desire to control the encounter and move
to whatever was on my particular agenda for the day. Then
I would take a deep breath, look directly at Stephen, listen
to the story and feel his pain. I would feel my body relax;
subsequently I would usually see him relax a bit too. Then
we could move on.
There were other successes too; after completion of treatment he was on a pharmacopeia of psychotropic medications: antidepressants (which he had been taking before cancer), benzodiazapines and barbiturates for sleep. He hated
taking them all, but could not sleep or relax without them.
Eventually, maybe 5 or 6 years after treatment, he decided
to tackle this problem. He would wax and wane with formal
meditation practice, but on one occasion he upped his home
practice, started using our suggested sleep breathing exercises, and gradually decreased his dosages of one medication
at a time. It took over a year, but eventually he was down to
only his selective serotonin reuptake inhibitors (SSRI) antidepressant and the occasional Clonazepam as necessary. He
was elated and I was impressed; Stephen was nothing if not
persistent and committed.
Over the years, our visits fluctuated. Most years I would
see him maybe every two months and we would review his
progress, I would reinforce his mindfulness practice and we
would tackle any ongoing or new problems. A few times he
took longer breaks, but usually came back around his cancer
anniversary date. Ten years after we met I had a child and left
on maternity leave for a year. This was difficult for Stephen;
I was like his security blanket. He did not always need me,
but he really liked knowing I was there just in case. I referred
him to another psychologist at our service; he saw her once
and decided it was not worth the effort of starting over. When
I came back we met again a few times and reconnected, then
I went on another full year maternity leave; at this point, he

L. E. Carlson

was 12 years post diagnosis and doing as well as he ever had.

He was still on disability from work; the anxiety disorder
had never abated to the extent that he felt comfortable returning to his career. However, his cancer never recurred; his
relationship with his wife survived and even thrived despite
some ups and downs over the years. I have not seen him in
3 years now, but I would not be at all surprised to get a call
from Stephen out of the blue. As much as I would like to see
him, I hope I never do get that call.
This ongoing relationship I have had with Stephen has
seen me through my entire career as a clinical psychologist
working with cancer patients, researching the benefits of
mindfulness training for people like Stephen. We both grew
and changed and developed together through this relationship; each of us brought our own new learning and ideas and
outside experiences to our encounters. Stephen was both one
of my most challenging and rewarding clients. He taught me
patience and the value of simple mindful presence: things I
continue to value. He also taught me to let go of outcome.
There was just no way I was going to fix him, so I did
not really even try to. My intention changed from problem
solving and fixing to being, connecting, understanding and
sharing what I knew. It took the pressure off me as a junior
psychotherapist; I could simply be myself in the encounter. I
did not have to pretend to be an expert. Being me was good
enough for Stephen; in fact it was just what he needed. Applying the attitudes of acceptance, non-judging and letting
go to me, Stephen, and our relationship was liberating and
ultimately healing for us both.
Linda E. Carlson PhDholds the Enbridge Research Chair in psychosocial oncology, is an Alberta InnovatesHealth Solutions Health
Scholar, and full professor in the Department of Oncology, Faculty of
Medicine at the University of Calgary in Alberta, Canada. She works as
a clinician at the Tom Baker Cancer Centre Department of Psychosocial
Resources teaching mindfulness-based cancer recovery (MBCR). Dr.
Carlson published a patient manual in 2010 with Dr. Michael Speca
entitled Mindfulness-based cancer recovery: A step-by-step MBSR
approach to help you cope with treatment and reclaim your life, in
addition to a professional training manual in 2009 with Dr. Shauna Shapiro entitled The art and science of mindfulness: Integrating mindfulness into psychology and the helping professions

Choosing to Survive: A Change

inReproductive Plans


Kathy DeKoven

I do not recall what state I was in when I began my call, but

I can guess based on the way I usually feel in the hours preceding a call. I often experience sensations of anxiety, dread,
and foreboding. As an anesthesiology resident, I was trained
to assess and anticipate risk. Unfortunately, over time, my
brain seems to have colored outside of the lines of that concept, and I find myself anticipating all sorts of imaginary crises before my work shift begins. Sometimes, my intestines
get caught up in the drama, and I take an Imodium before
leaving for the hospital, to be sure that my body cooperates
when needed. Often, I will do a session of yoga at home to
ground myself and to cultivate courage and curiosity. Sometimes, I visualize the way I would like to feel and behave
while I am at work. Many c words come to mind: calm,
compassionate, courageous, clear, quick (OK, not quite c)
and curious.
This 4pm call begins in a typical fashionlots of rapidfire decisions waiting to be made. One of my stay-late colleagues wants to know if he can go home, despite a number
of outstanding cases. I feel flustered by my perception of him
breathing down my neck, but I manage to keep my cool (another c word to add to the list). There is a premature baby
with a necrotizing enterocolitis in the neonatal intensive care
unit (NICU), waiting to be reexplored and either have a reanastomosis or be deemed palliative. The obstetrics team is
asking me to wait before committing to any general surgery
cases, because they have a patient in labour with premature
twins. She needs a cesarian (C) section but the NICU has
not confirmed that they have beds for both babies. Once the
NICU signals that they have room, the mother decides that
she is not yet ready to accept delivering her twins via C-section. I send my back-ups home, and we prepare the operating
room (OR) to receive the baby with necrotizing enterocolitis.

Department of Anesthesiology and Pain Clinic, Centre Hospitalier
Universitaire Sainte-Justine, Universit de Montral, 3175 Chemin de
la Cte-Sainte-Catherine, Montreal, QC H3T 1C5, Canada

I am aware that I am a bit less stressed than I usually would

be for such a sick patient, given the baby is considered quasipalliative.
As I am assembling my team to transport the premature
baby to the OR, the obstetrician calls me back. A pregnant
woman with a placenta previa is having flushes of blood. Her
baby has a cardiac malformation. She needs a C-section as
soon as possible. We bring her to the OR immediately. Unfortunately, her husband has not made it to the hospital yet,
so I accompany her through the delivery of her baby. I hold
her hand until the baby is delivered and then I perform one of
the key roles of a partner at a birthI take lots of picture of
the baby with my iPhone, and email them to the mother. She
does great and happily so does her baby.
It is 8pm, and my resident and I are about to have supper before we finally bring the premature baby into the OR.
But the Obstetrics/Gynecology team is not done with us yet!
They tell us a woman in her 30s has arrived, and she is rapidly losing blood from her vagina, subsequent to a hysteroscopy she underwent the week prior. She needs a dilatation
and curettage (D+C) at the very least, likely accompanied
by the placement of an intrauterine balloon. I am hungry. Oh
well. Onward.
When I enter her room, the patient (Madame N) is being
examined. Her legs are in stirrups, with blood pooling on
her bedsheet. She is white and shaking. Extraordinarily, she
smiles and says Bonjour, reminding me that I was her
anesthesiologist the week before, when she came in for a
hysteroscopy. This will not be the first time she smiles that
night. Through her ordeal, she continues to smile whenever
she can. A light shines from her, transilluminating her pallor
as she loses blood.
As soon as she says she knows me I remember, and suddenly everything feels more personal. In my work as an anesthesiologist, excluding my work as a pain physician, it is
rare that I spend more than 30min with any given conscious
patient in their lifetime. When I remember who this patient
is (and I remember that I enjoyed engaging with her in the
past), I feel like I am seeing a friend in danger. My lens

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_13,

Springer International Publishing Switzerland 2015



changes slightly. It is hard to say if the experience becomes

more real or surreal.
I remember being a resident covering obstetrical anesthesia when my best friend was due any day. I was so worried
that I would have to be the one to place her epidural. I found
it so much easier to focus while performing a medical procedure on a patient with whom I did not share a special rapport.
Instead of needing to give an epidural to my friend, I gave
one to the wife of a National Hockey League player, which
unexpectedly proved to be a much less stressful option.
Anytime I see a person lying in a stretcher whom I have
known in a different context (or for a flash of a second, mistakenly think a patient is someone I know), I feel surprised
and I grow uncomfortable. Maybe it is an unexpected reminder of my mortality, and the mortality of everyone I love.
One may think working in a hospital would be enough of a
regular reminder of the universality of mortality. Somehow,
I still manage to unconsciously lie to myself, reassuring myself that I am somehow (magically?) exempt from the forces
of nature dictating my patients destiny. I feel grateful for my
health and the health of my family, but I hope that we will
always stay healthy. Impossible. But, I digress.
When I met Madame N the week before, she was coming
for a hysteroscopy and a potential lysis of uterine adhesions,
to improve her chances at fertility. I remember liking her.
She was so easy going, kind, positive and unimposing; I had
really wanted to take good care of her. She was prone to postoperative nausea and vomiting, but she had let me know that
her previous anesthetic (provided by a meticulous colleague
of mine) had gone well. I gave her the same prophylaxis for
postoperative nausea as she had received previously. When
I visited her in the recovery room, she looked well. And that
was the last I saw of her until her current readmission.
But now, when I ask her how her anesthetic the week before had gone, she admits that she was nauseous after receiving morphine. I am disappointed to hear that her anesthetic
had not been perfect, but, ever the gracious and rational
patient, Madame N reassures me that this past surgery was
more painful than the previous one, which could explain her
less-than-perfect awakening.
Lying in the gynecology (GYN) emergency examining
room, Madame N looks so vulnerable: pale, shaking, socks
in stirrups, and streams of blood flowing. The team moves
quickly to draw her blood and place two large intravenous
catheters. Her vital signs are stable and, for the moment, she
does not have orthostatic hypotension nor does she report
feeling dizzy.
I am worried about her safety and her future fertility. I
am well aware that what had initially catapulted her into her
unfortunate circumstances was her desire to have a second
child. I understand her desire to have two children. I am forever grateful that I managed to swing having two healthy
kids by age 40. I feel like I just slipped under the wire.

K. DeKoven

Madame N is here by herself because her partner is at

home taking care of their child. I do not want her to feel
alone. I hold her hand as often as I can. I lend her my phone
so that she can call her partner (the second time that night
that my iPhone has allowed for human contact instead of its
usual distracting role). I remember having my husband come
in to accompany me for my previous D+Cs for retained placenta and endometritis, and I am impressed by her strength
to live through her experience without her partners physical
Throughout her ordeal, Madame N frequently asks us to
contact her partner to keep him up to date. The GYN resident
is very good about fulfilling her wishes, despite her overloaded workload. I am relieved that the GYN team is taking
such good care of her. Later in the evening, in the recovery
room, I offer to lend her my phone again, but she will decline, stating that she is too confused to call her partner. I am
impressed that she assesses herself that way. She does not
appear to be confused or in an altered state from an observers perspective. Furthermore, typically, patients who appear
disoriented while waking up from an anesthetic do not have
access to the insight that they are confused.
Initially, we bring her down to the OR; I have to hurry
things along. It is now my turn to breathe down peoples
necks. There is a new OR clerk who does not clue into the
fact that we want to do the case immediately. I am frustrated by the misunderstanding; I feel myself sighing as I walk
away from him. Thankfully, I am able to let go of my frustration and move on once Madame N lies on the gurney before
me in the OR.
She has moments of feeling dizzy, but remains hemodynamically stable. The anesthesia resident (with a very kind,
calm, unassuming disposition) puts her to sleep as I hold her
hand. This is my way to transmit a sense of security and hope
to her before she falls asleep. We will repeat the same scenario two more times in the following hours! This is a very
uncommon experience for the resident and me.
Procedure #1 is uneventful. The gynecologist (who performed my second amniocentesis) is competent, experienced, relaxed; importantly, she inspires confidence. I like
working with her. She decides that it would be best to follow-up Madame Ns D+C and balloon catheter placement
with a visit to the interventional radiology suite for an embolization of the patients uterine arteries. The gynecologist
assures us that the radiologist can do the procedure without
an anesthesiologist, so we awaken Madame N. Each time
she wakes up the same way: calm, eyes closed, nodding and
shaking her head to answer our questions, following our instructions without complaint.
The anesthesia resident and I bring her to the recovery
room, and we go to eat supper before attending to the rest
of our caseload. I find a moment to Skype my kids on my
phone. It is already late, and the cafeteria is closed, so I

13 Choosing to Survive: A Change in Reproductive Plans

share my hippy vegetarian squash soup and some leftover

stale bread with my resident. There is often a feeling of intimacy and group survival among coworkers during a busy
overnight shift. While we are eating, the interventional radiologist calls my resident. She wishes to have Madame N
anesthetized for the procedure, requesting that the anesthesia
team be present in case the patient becomes hemodynamically compromised. We concede.
While waiting for the radiology team to mobilize, I visit
the premature baby waiting to have his abdomen re-explored
to reassure myself that his case is not urgent. I also have time
to visit a very cute 3-year-old boy with a rare intra-abdominal cancer to assess his postoperative pain control. I have
met him before. He is shy, apprehensive, and withdrawn. His
experience in the hospital has been long, full of uncertainty
and at times very uncomfortable. He has the greatest parents
as caregivers. His mom is nurturing and has worked as a hospital nurse. His dad is logical and inquisitive; he is not shy to
ask questions to be sure that the best choices are being made
for his son. I am so inspired by them. Their presence is a gift
for their child. I always feel satisfied when we work together
for the good of their son.
Next, I head to the OR to get narcotics for our next anesthetic, and I discover that the team is already in radiology. I
rush down to the radiology suite, to discover that Madame
N is already being anesthetized by the anesthesia resident.
I feel uncomfortable, out of control that the anesthetic has
begun in my absence. I feel a vacuum in my chest and hot in
my head. I try to reassure myself that my resident is near the
end of his training and that he is more than capable of putting
the same uncomplicated patient to sleep twice. I move on to
the next moment.
The interventional radiologist has similar qualities as the
gynecologist: experienced, technically skilled, good clinical judgment, calm and confident. She manages to embolize
the right uterine artery, but she is not able to embolize the
left one. Apparently, the left artery is in spasm; therefore, it
would not be supplying the uterus with much blood anyway.
We wake Madame N up yet again. It is another calm
awakening. But when she coughs, more blood flows from
her vagina. The GYN resident looks concerned. Frown lines
appear on her face and her body subtly contracts. She mentions that the blood is very clear, these are not merely clots.
As we wheel Madame N to the elevator to transport her to
the recovery room, she says that she can feel more blood
dripping out of her vagina. Up until now, she has been a very
reliable historian. I notice a feeling of dread emerging in me.
Upon arrival to the recovery room, the nurses lift the sheets
to discover that our patient is still bleeding. We prepare to
transfuse her. We call the GYN resident who calls the GYN
fellow who calls the GYN attending; each call upping the
level of apprehension along with the hierarchy of decisionmakers. The resident discusses the possibility that we may


have to remove her uterus. This is the first time that I see Madame N cry. It is almost a relief to see her expressing some
of her suffering. Until now, she has managed to remain so
cheerful, pleasant, and stoic in the face of such difficulties. I
really wish her partner could be here. I feel so alone with her.
I am conscious that I am projecting my own fears and past
traumas onto my patient: my D+Cs, a debilitating bike accident shortly after a romantic break-up, my ultimate fear of
suffering alone, and my neediness. I am more afraid of aging
alone than I am of dying. I have a flashback to 6 years ago,
when I took a month leave from my regular life to take a
meditation course in a Tibetan Buddhist monastery in Nepal.
I was sweeping the floor with my androgynous roommate,
a woman who had been plagued by spaghetti-like intestinal
worms during our time together at Kopan. Chatting with my
roommate, I had the realization that my only hope of happiness was if I let go of my desperation to have children. I
believe that this new mental stance contributed to my husband finally agreeing to have a family with me. This was a
great victory for me which temporarily appeased my fear of
dying alone.
In the recovery room, shortly after the discussion of a
possible hysterectomy versus other options, Madame N becomes cool, sweaty, even paler and her heart rate drops to
45bpm. I switch gears into emergency mode, quick decisions followed by actions. It is a familiar mode for me: crisp,
clear, rational, vigilant, goal-directed, emotions on hold.
When the emotions break through, it becomes much harder
for me to think clearly and perform efficiently. The hardest
times I have had trying to keep my cool at work have been
anesthetizing sick little babies, while my little baby was at
home. The fragility of the tiny patients combined with their
resemblance to my own precious brood posed a challenge for
me upon my return from maternity leave.
The gynecologist makes a definitive decision Madame
N, we will remove your uterus. There is no more time to
waste. The patient accepts, and we rush her to the operating room for her third anesthetic that night. Take 3. I hold
her same hand. It is cold, pale and damp, but still very alive.
The resident puts her to sleep. She is stable throughout the
operation, although she requires numerous blood products. If
we had waited any longer, it may have become more difficult
to resuscitate her safely. I am relieved that she is safe, but I
feel melancholy related to her losing her uterus. Presumably,
this represents the loss of hopes and dreams for her and her
family. I know that my children are my crown jewels. There
is nothing more precious to me than my family, and I can
only hope that others who wish to can experience the same
joy (and chaos).
This operation represents the loss of an unknown seed, an
unknown potential, an unknown love. During the procedure,
I am surprised by the appearance of her uterus. From the
outside, it looks so innocuouspink, shiny, little and firm. It


is hard to believe that it could have killed our patient; it had

harbored the power to shelter and nurture a foetus until birth,
until now. Like any non-gravid uterus, it simply looks like a
small, smooth, and healthy organ. Really, it is just another
visceral player in Team Body. Appearances can be ridiculously deceiving.
Once the surgery is completed, Madame N wakes up in
the same condition as both other times. She is calm, cooperative, taking her time to re-emerge. By now, it is 3am We
have spent 7h initially trying to save her uterus, and settling for saving her. I am pretty exhausted. I have poured my
physical and emotional energy into her care, and I am ready
to retreat to my call room to rest my body and spirit. My
heart aches. I am relieved that she is alive and safe, but I had
hoped for an even better outcome.
I visit Madame N at the end of my shift, after rounding
with my pain patients. She appears exhausted, drained, and
sad. She is with her partner, and the reality of their situation seems to be coming into focus. When I visit her again 2
days later, she seems a bit stronger; apparently, the healing
process has begun. Presumably, she has been resting, caring for her altered body, connecting with her loved ones and
reframing her experience in a way that brings her comfort.
I ask her permission to write this narrative and she smiles.
When I ask her why she is smiling, she explains that she is a

K. DeKoven

psychologist who includes mindful practices in her therapy.

It all makes sense, since all of her responses to date have
been so adaptive. I comment on how impressed I have been
with her ability to cope and function throughout her ordeal.
She recounts a previous experience of her first D+C. She
was scared of the unknown. In the waiting room to the OR,
she saw a 4-year-old patient playing and exploring her crib.
Madame N decided: I too can bring that curiosity and playfulness to my unknown encounter! I am astounded by her
During our final meeting, Madame N mentioned that she
felt well supported and accompanied by our team throughout
her experience. I was relieved to hear this since I had been so
concerned about her feeling alone. This was also a comfort
for me with regard to my personal fear of loneliness. I was
reminded that the connections we can have with others in our
life are limitless, if we approach others with an open heart.
Kathy DeKoven MDis a pediatric anesthesiologist who works at
Sainte-Justine, a childrens and womens hospital affiliated with the
Universit de Montral in Montreal, Canada. She divides her time
between the operating room, the pain clinic, her yoga mat, her partner
Gordon, and her young children Penelope and Jasper. She occasionally
visits her meditation cushion and less occasionally walks her dog

Mindfulness in the Realm of Hungry



Ricardo J. M. Lucena

It is only with the heart that one can see rightly; what is essential isinvisible to the eye
Antoine de Saint-Exupry

In this chapter, I describe a case of a patient with comorbid
alcohol use disorder and paranoid personality disorder. The
patient agreed with the description of his case in this chapter under the condition of maintaining his identity and the
identity of his family members anonymous. The case will
be described according to its 4-year follow-up in my private
practice as a psychiatrist in the Northeast of Brazil. I used
mindfulness as part of dialectical behavior therapy (DBT),
which was originally designed to treat individuals with borderline personality disorder by a psychologist, Dr. Marsha
Linehan [1]. It stems from cognitive behavior therapy and
differs from it in its emphasis on validation which consists of
helping the patient accept uncomfortable thoughts, feelings,
and behaviors rather than struggling with them. The term dialectics refers to the balance between acceptance and change
[2]. The therapist leads the patient in the process of change
from the old behavior (e.g., drinking) to the new behavior
(e.g., abstinence) by helping the patient develop a set of coping skills involving mindfulness, distress tolerance, emotion
regulation, and interpersonal effectiveness.
Before moving forward, let me write a few words on the
title of this chapter. It refers to a well-known book on addiction In the Realm of Hungry Ghosts: Close Encounters with
Addiction [3]. Hungry ghost is a Western translation of a
concept in Chinese Buddhism representing beings who are
driven by intense emotional needs. These beings are ghosts
only in the sense of not being fully alive; not fully capable
R. J. M.Lucena()
Department of Internal Medicine, Centre of Medical Sciences,
Universidade Federal da Paraba, Rua Monteiro Lobato,
691/APT 1101, CEP58039-170 Tamba, Joao Pessoa-PB
CEP58039-170, Brazil

of living and appreciating what the moment has to offer [4].

The book describes the compelling experience of Dr. Gabor
Mat, a physician who cares for drug addicts in Vancouvers
Downtown Eastside. As hungry ghosts, individuals with addiction constantly seek something outside themselves to
alleviate the perpetual aching emptiness and to curb an insatiable yearning for relief or fulfillment as perceived in the
narrative of each drug addict depicted in the book. It was
in the realm of addiction that I saw mindfulness in practice
helping individuals to find relief to their suffering.

A Journey Towards Change

The journey begins with a brief description of the core features of the case. I named the patient in the case Emilio
who was the firstborn of a family of four children. He grew
up in a prominent family of money, power, and political influence where he is perceived as the black sheep due to his
drinking problems and his poor school record since he was a
child (difficulties in learning, in understanding and following instructions, in respecting rules, and so on). He has no
medical problems in his past history or family history to explain his poor performance. No mental retardation was identified in neuropsychological testing. In the 4-year period of
medical follow-up, the following symptoms were identified:
(1) difficult to follow oral explanations (about his situation,
for instance), so I needed to write the information down or
make a drawing to explain a subject; (2) continuous distrust
and suspiciousness of others, especially his family members
(wife, parents, and siblings), persistent grudge due to unforgiving insults of his parents as well as recurrent suspicions
regarding fidelity of his spouse; and (3) regular heavy alcohol binge episodes with harmful consequences.

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_14,

Springer International Publishing Switzerland 2015



In 2009, I received a phone call. Dr. Ricardo, my name is

Mara and I made an appointment to see you with your secretary at the office. It is not for me, oh no. It is for my son
who refuses any treatment. Maybe I should go first to see you
with my husband to explain my sons situation. Is that okay or
should we force him to go, too? If you say so, we will take him
anyway. I said okay. Lets start with you and your husband
and then we will make the arrangements to see your son.
A week later, the couple arrived in my office. Both the father and mother came from economically prominent families
and both were in their late 50s. Jos, the father, was very formal, and stern. Maria, the mother, was also formal (lacking
the typical Brazilian warmth in interpersonal interactions).
She reported the problem. We are both very concerned
about our son Emilio. Since childhood, he has been a troublemaker. He lies all the time, never does well at school and
does not get along well with his three siblings. Our family is
very well adjusted. He is the problem. He started drinking as
a teenager, and has drunk a lot ever since. He was involved
in two automobile accidentsin one of these accidents he
almost died and spent a month in an intensive care unit. He
had to appear in court for the accidents, and is about to have
his drivers license canceled.
She continued: Furthermore, he has no control of his
expenses. He spends his money mainly on alcohol which
he uses in rodeos, bars, discos with drinking buddies and
women. He also spends too much on clothing, and bought
a luxurious used car whose maintenance requires a lot of
money. He has built up so many debts he is now at the point
of borrowing money from gangsters. Can you believe it? He
works in our family business, a grocery store, and makes a
little more than the minimal wage. He claims he can have
a similar lifestyle to that of his siblings. However, his siblings are professionals and hard workers. He is not. He could
barely graduate from a low-quality university with our significant help in hiring tutors, otherwise he would not even
have a college degree. He is not aware of his difficult situation, and we are growing older. He is not going to have his
parents forever. He will have no one for him. He was married
for two years, and had a daughter. But his wife, whom I love
to death, could not deal with his drinking problems anymore.
She divorced him three years ago. We do not know what to
do. We have consulted other professionals before, but Emilio
does not comply with any treatment. We hope it will be different with you. The father fully agreed with the mothers
report of Emilios background. Proudly, with a deep voice,
he added, Undoubtedly, Emilio is a problem. But we have
three other children: two physicians, Pedro and Francisco,
and one lawyer, Gilda. They are outstanding.
As planned, the appointment with Emilio took place in
the week following his parents first appointment. He arrived
on time, well dressed, and made his first remark even before
taking a seat: I should warn you that I do not know what I

R. J. M. Lucena

am doing here. I have no problem. My parents are the problem. They should be here. Not me.
I thanked him for coming and suggested that we talk for
a while. He was clearly annoyed to be there. He took a seat
and continued, My parents humiliate me as much as they
can to the point of sending me to another shrink. You cannot do anything for me. They say I drink too much. I see no
problem with that. You should treat them so they respect me.
Besides, I do not trust anybody. Do not even try to fill me up
with meds. I will take none.
Applying one basic principle of motivational interviewing [5], to roll with resistance, I told Emilio the following:
I can imagine how difficult it is for you to be here, and I do
not want to make it worse. I am not here to judge you or to
prescribe medication for you at this moment. I am here to
listen to you. I met your parents last week, and they talked to
me about you. Now I would like to hear you.
Emilio, with an attitude of surprise and suspicion, agreed
on talking: Fair enough, Doc. I do not know what kind of
arrangement you have with my parents, but I will let you
know my side of the story, although they might have bought
you. I interrupted him by saying Emilio, please, let me be
clear: they did not buy me. They paid for an appointment
with me. Can you see the difference? In fact, they paid for
two appointments: one for them, one for you. So take advantage of your time here and tell me your story.
Emilio started by saying, My parents always devalued
and criticized me. I never did anything right. They compared
me with other kids, my cousins, for example, who were always better than me. My parents never missed the chance to
put me down, especially when other people were around to
witness. I felt humiliated all the time. I wanted them to spank
me instead of humiliating me.
For the first time in the appointment, at a glance, Emilio
showed his broken heartbehind layers and layers of anger
and suspicion. He continued, My parents criticize me for
drinking, but drinking brought me this far. I could not be
here today if I did not drink. I started drinking when I was
15 years old, and I remember why. I was eager to park my
fathers car in the garage. He let me do it while he observed
me. I was almost done when I lost control of the car and hit
the gate and smashed one side of the car. Right away, my father screamed at me at the top of his lungs. You idiot, you
jackass! Do you see what you did? Get out of my sight! My
grandfather, my uncles, my cousins, the maids of my house,
they all saw what happened. I was so ashamed that I did not
know where to put my face. Everybody was laughing at me.
He continued, I left my house and went to the beach with
some kids from our neighbourhood. It was carnival time with
lots of people drinking. The kids and I started drinking, and I
drank until I could barely walk. I just heard my father telling
my grandfather, There he isas drunk as it gets! Lets go
home, you ass! You are embarrassing our family in front of

14 Mindfulness in the Realm of Hungry Ghosts

your grandfather. The next day I realized that alcohol had

drowned my shame and frustration. To date it has helped me
to overcome lots of shame and frustration caused by my family. For this reason, do not tell me like everybody else that I
need to stop drinking.
I simply said, I am sorry for your first experience with
the car, and at the same time I can understand how alcohol
has helped you over the years. I would like to explore more
with you the role of alcohol in your life. Could you come
back next week? Emilio agreed and a long-term follow-up
was initiated.
Throughout the first year of the follow-up, a relationship
of trust was built on a weekly basis (50-min sessions). I compare this period of relationship building to that described in
Saint-Exuperys book, The Little Prince [6], where the little
prince carefully tames the suspicious fox. First, they meet
from a distance, as the fox requires. Then they get closer, little by little every day. With Emilio, the work required space
and time as well. In building trust with him, two basic rules
helped: (1) to be honest always with Emilio whether or not
he liked it and (2) to choose carefully my words at the moment of truth.
During the first year, Emilio described different situations
related to alcohol use and its negative consequences, which
were perceived always as problems created by his family.
Blaming others and claiming to be a victim were frequent
defense mechanisms Emilio employed. For instance, drinking and driving, this dangerous combination was a common
source of conflict between him and his family. He would explain, Last Saturday, I went to a rodeo, and had a lot of fun.
I met my friends and many hot chicks. I drank and went to
a motel with two women. We had wild sex and went out to
a bar. As the day was dawning, I drove back home, better
said, the car followed the way home. When I got there, my
father was screaming at me. My mother was all agitated. I
just drove back to the motel, and stayed there until the steam
cooled off. My parents never leave me alone. The minute I
put my foot in the house, they start on me and my driving
drunk. It just is unbearable!
Excessive debts and promiscuous sexual behaviorleading to sexually transmitted diseases (STDs) were negative
consequences of alcohol consumption. He used to explain,
My parents do not accept my girlfriends. They say they
are vulgar, and I should not bring them home. However, my
brother Francisco, the physician, who lives at home with us,
can bring his girlfriend home. I dont get that. He has a fancy
car, fancy clothes and has a lot of influence in the family
business, and my parents do not complain about anything he
does. On the contrary, they fund his expenses. Me, oh man,
when I buy fancy clothes, boots for my rodeos, or pay for the
maintenance of my car, they say I cannot afford spending so
much. Why can he and I cant? My parents have always been
too tough on me.


In his worldview of injustice and mistreatment, there

was only one person Emilio perceived as praising him: his
5-year-old daughter, Elisa. He said about her: She gives
meaning to my life. She is the only reason why I have not run
away. But my mother puts me down in front of my daughter.
I say, Darling, daddy does not want you to go out by yourself with your nanny. My mother immediately says There
is no problem, sweetheart, you are just going next door with
your nanny. Go ahead. I get mad, but my mother always has
the final say.
He continued to explain, My mother tells me You know
what? Your ex-wife, Jessica, is rebuilding her life with another man. And you, you are going to lose your daughter.
She will have another father, a decent man. You are a loser.
You just want to drink. Can you believe that? Do you think
I am really going to lose my daughter to this other guy?
I promptly responded to him, Of course not, Emilio. You
are Elisas father. It is a fact. Nobody can change that. She
loves you, and she will always be your daughter. She might
have a stepfather, though. However, it does not change your
relationship with her. The stepfather could even be one more
person to look after Elisa. Think about it.
After the first year of follow-up, when a relationship of
trust was built, Emilio and I scheduled an appointment for
his parents. At the beginning of the appointment, Emilio entered my office by himself and said, You are the only person
who understands me. Do not let me down. They are going to
say horrible things about me. Do not believe them. I said,
It is okay, Emilio. We are going to provide your parents
with general information on your follow-up here. They are
funding our work together, and they want to have feedback
on your progress. Take your seat, please, and I will ask your
parents to come in.
The parents came in. The mother started talking, He is
still drinking. However, he agrees to take a cab instead of
driving. Next, the father asked, Isnt there a medication
you could give to him so he stops drinking? Before I said
anything, Emilio answered his father, I refuse to take any
medication. You know what happened to me the other time I
took medication, my neck became stiff and I could not get an
erection. No medication. The father raised his deep voice,
You want to be cured or not, you ass? Do you know how
much money we spend on you? We pay for your clothes, for
the gas of your car, for your food, for the alimony for your
daughter and for your treatment here. Be responsible! Do
you want to spend the rest of your days as an alcoholic?
The air became thick and I was able to have a better idea of
the atmosphere at their house. Emilio in a very humble voice
said, Do you see how they treat me? Ive had enough for
today. May I leave the room, Doc.? I said Yes. I will see
you next week, as scheduled. Call me, if you need to talk to
me before that.


I continued the session with the parents and explained to

them my diagnostic impression on the case, as well as the
basic principles of our therapeutical approach. I explained,
It takes time to change a persons behavior. The first step in
the process of change is the awareness of the need to change.
In Emilios situation alcohol has helped him to deal with distress. He perceives this substance as an important tool to deal
with difficult situations in his life. At this point, he cannot
see the negative consequences of his drinking behavior. This
twisted view about alcohol creates a huge conflict between
him and the others. It is obvious to you and me that alcohol
has impaired his life in many ways. But he does not understand it. Furthermore, he has had a learning disability since
his childhood. This gives him an extra obstacle in processing
information, both in terms of understanding stimuli from the
environment and in responding to them appropriately. As a
result, his perception of reality is very peculiar and different
from ours.
I continued, If I may suggest to you, do not use hurtful
words like you ass, you loser, you drunk, etc. They make
him feel under attack, and he drinks even more. I know you
both love Emilio and want to see him well. I can assure you
he is responding to treatment. As you know, he never stayed
this long in medical follow-up before. He has never missed
an appointment here. I believe we can make more progress
as soon as he begins to share with us a similar understanding
of his situation.
In the next appointment, to my surprise, Emilio showed
up in a pink cloud state (overly optimistic): Dr. Ricardo,
you are not going to believe this. In the weekend, in the midst
of one dose of scotch and the other, I met the woman of my
life, Rebeca. She is a goddess! She has been glued to me ever
since. She is kind with me, and treats me with lots of respect.
She is in the waiting room. I told her I came here to see my
cousin who is a physician. She does not know about you. I
could see there was something special about this woman, because he never talked like that about any other woman with
whom he had been beforeand they were many; almost one
per week.
I asked him Do you think you will be with her next
week? He answered What a question! Of course! I want
to be with her forever! Then, I said, Well, you will need to
explain to her why you will come here next week. You need
to find a better explanation for her. Suddenly, he said, Oh
man, what can I tell her? Think about an explanation with
me. I suggested the truth: Have you considered telling her
the truth? You could tell her that you are undergoing psychotherapy without telling her many details. He accepted the
suggestion and moved way ahead of the suggestion.
The next week Emilio came in with Rebeca. She was a
good-looking woman visibly from a lower social class than
Emilios. She worked as an administrative assistant in the
local office of a national chain of grocery stores. She gradu-

R. J. M. Lucena

ated in administration from a local university, and was enrolled in an MBA program funded by the company. She was
a very smart and ambitious young woman. In one of the several appointments, when she accompanied Emilio, she said,
I want to be in charge of my office when I finish my MBA.
And I want Emilio on my side. He will change for the better.
He just needs to control the amount of liquor he drinks.
By then, Emilio had evolved in his understanding of the
problem of drinking and considered changing his drinking
pattern. I explained to both of them the basic concept of addiction as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful
consequences [7] in which one loses control of the substance
use. Due to this feature of loss of control over the substance
use and potential relapses, a person addicted to a substance
cannot be continuously exposed to it. Substance abstinence
is the most viable alternative to interrupt the out-of-control
pattern of substance use and to prevent relapse. Rebeca believed Emilio could control his drinking to moderation, but I
explained this is not an alternative in the context of our treatment, where abstinence is an ultimate goal to be achieved.
A couple of months went by, and Emilio came to the session announcing that Rebeca was pregnant, and they were
going to get married. He added, My parents are not happy
with the news. The first question they asked was where I was
going to live with her. I answered right away: Not under your
roof! I am going to live with Rebeca at her mothers house
where I am treated like a king.
A few weeks from that announcement, Emilio and Rebeca
got married. Emilio stopped going to rodeos and seeing his
drinking buddies. He just went to bars with Rebeca. Emilio
claimed that he was drinking much less and just with Rebeca. However, the honeymoon period did not last long. When
Emilio heard a rodeo song or met an old drinking buddy by
chance, he could not resist. A deep urge to drink kidnapped
him from Rebeca, and he went out to drink. That is when
Rebeca would look for Emilio in bars and bring him back
home, very angry at him. This pattern of behavior became
more frequent after their daughter Stella was born.
The stress of having a newborn in the house was too much
for Emilio. He was coming to my office twice a week and
was exposed to DBT, beginning with distress tolerance strategies. For the first time, he accepted to take a medication
(Naltrexone) to help him cope with cravings. This was in
the second year of treatment. Emilio was very much aware
of how primitive it was to use alcohol to deal with distress,
every time he had a fight with his parents or more recently
with Rebeca. However, he was still learning the alternatives
to drinking every time he was angry, frustrated, feeling humiliated, and so on. He continued to drink at home with Rebeca, who did not see a problem in social drinking. However,
frequently when Emilio drank, the result was a fight with

14 Mindfulness in the Realm of Hungry Ghosts

Emilio described one of the fights in a session. I was

drunk and jealous about Rebeca, so I asked her how many
men had slept with her. She answered the same number of
women who slept with you. I went nuts. I thought I married a whore. Later, when I was sober and things were calm,
I asked her again: How many guys slept with you? She
answered just a few. Then I asked who they were, and she
named almost all my drinking buddies! I could not believe it.
I got so angry, and I called her You fucking slut! I am going
to divorce you! I left the house and thought about drinking. But I remembered that you told me that I could choose
not to drink. And I chose to come here. Thank God I could
make this extra appointment with you. What do I do now?
My mind is taken by the idea of guys fucking her. Who can
assure me that she is not betraying me at this moment? Why
did she do that to me? I dont think I can ever forgive her.
Help me please!
That is when I introduced to Emilio the idea of mindfulness: Emilio, accept what you cannot change. The past is
over. Neither you nor Rebeca can change what happened.
Be in the moment. Enjoy your life in the present. You have
the chance to become a better person. I am a witness of your
progress. You have the understanding of who you are.
I explained to him how complex and impaired his mental
functioning was and that he has survived bravely with all his
limitations. I explained to him that he should not be angry
at people who did not have the capacity to understand him,
and see the beautiful feelings he had inside, way beyond his
troubled behavior.
I said, You have a wife, a second daughter, and a new
house away from your parents. You have the chance to write
a different story for yourself in the present moment. Please,
write this on your cope alert (a small card Emilio kept in his
wallet with the photos of his daughters so he looks at them
before making the decision to drink): The past is history, the
future is a mystery, but today is a giftthats why they call
it the present.
The past haunted Emilio via different thoughts: Rebecas
previous sexual experiences, hurtful words used in fights
with Rebeca and his parents, etc. Those thoughts elicited
negative emotions which triggered Emilio to drink and numb
the pain. To break this pattern of thought/emotion/drinking behavior, I recommended that Emilio practice informal
mindfulness: shift the attention from negative thoughts and
focus it on a present action. For instance, take a few moments to concentrate on his meal. Observe his food. Look at
the plate filled with food. Notice the smell, taste, and texture
of his food. We practiced with a cereal bar at the office so
he had an idea of the exercise. He developed his own ways
of distracting himself from negative thoughts. After a fight
with his mother at work, which would take him directly to a
bar before, he would drive aimlessly along the beach or sit


quietly in his parked car and count cars in traffic (e.g., in an

hour, he would count 20 red cars) until he could pull himself
together again.
By the third year of follow-up, Emilio had been exposed
to the basic skills of mindfulness, distress tolerance, emotional regulation (identifying his emotions and avoiding acting out, especially in reaction to negative emotions), interpersonal effectiveness (how to make a request, accept no as
an answer, and to communicate in a more assertive way),
and relapse prevention (identifying and avoiding internal
and external triggers). He was able to interrupt his regular
drinking pattern on weekends. However, in Rebecas company he would drink socially until he passed out. (Rebeca
still thought Emilio should have the will power to control the
alcohol intake, in spite of several sessions on addiction psychoeducation not supporting this line of thought.) Rebecas
(and Emilios) social events became more and more frequent
when Rebeca finished her MBA, and got a big promotion to
run the office of the company in a different town.
Emilio had to follow his wife and moved out of town.
That is when we reached our fourth year of medical followup. On-site appointments became rare (only when Emilio
was in town) and brief interactions took place via telephone,
Face Time, or WhatsApp in moments of crisis. At this point,
it was rewarding to hear Emilio say, Alcohol is not my
friend anymore. It is my tormentor. In vain I try to escape
it, because I end up coming back to it. Help me! What a
shift in perception! He was very motivated to stop drinking, in spite of all the new challenges: living in a faraway
town, looking for a job on his own (he always worked for
his parents), and facing a sour relationship with Rebeca, as
he described it: I keep looking for the goddess. Where is
she? Today, I just see this abusive person telling me to find
a job or accept the role of the housewife, because she is the
breadwinner. She humiliates me all the time, as my parents
used to do. But I still prefer my life today than before with
my parents and siblings. I need to invest in my sobriety and
in my professional skills.

Closing Thoughts
At the beginning, I was taken by the parents negative attitude towards Emilio. They could only see the negative facts
about him. Later on, I could see in Rebeca, his wife, a similar
attitude. In their view, Emilio was to blame and should be
punished. He was given every chance to be a better person.
But he spoiled each opportunity. I saw first his parents and
then his wife express many complaints about Emilio and
very little compassion and understanding of his psychopathology, in spite of my efforts to inform them accordingly. I
also understood that Emilios disruptive behavior had deeply

R. J. M. Lucena


wounded his parents and wife over the years, and to make
the situation even more complex, Emilio had little insight
into the harm he was causing himself and his family. Emilio
blamed his family for his misfortune. As described in Virginia Satirs [8] styles of communication, the person blames,
judges, accuses, dictates, and oppresses the other, making it
difficult to see each other with empathetic eyes and to discover a compromise.
In this scenario of blaming from both sides, I played the
role of a mediator. On one hand, I explained to Emilio that
his family was there for him and helped him express that
understanding to his parents and wife. On the other hand, I
explained to his family Emilios limitations and long-term
progress. For all of them I constantly had to renew their
confidence that improvement was possible. In reinforcing
confidence, being in the moment for all of them helped tremendously to overcome the interference of rumination of a
past filled with pain and frustration. As a result, Emilio could
achieve some change in his maladaptive patterns and to a
certain extent change in his familys dynamics. Compassion,
understanding, and perseverance were the main ingredients
of the work in this case.

1. Linehan M.M. Skills training manual for treating borderline personality disorder. New York: Guilford Press; 1993.
2. National Alliance on Mental Illness. Dialectical behavior therapy.
About_Mental_Illness/About_Treatments_and_Supports/Dialectical_Behavior_Therapy_%28DBT%29.htm. Accessed: 28 May 2014.
3. Mate G. In the realm of hungry ghosts: close encounters with addiction. 7th ed. Toronto: Knopf; 2008.
Hungry ghost [internet]; 2014. 
gry_ghost. Accessed: 29 May 2014.
5. Miller WR, Rollnick S. Motivational interviewing: helping people
change. 3rd. ed. New York: Guilford; 2013.
6. Saint Exupry A. The little prince [internet].
books/little_prince/ch21.asp. Accessed: 28 May 2014.
7. National Institute on Drug Abuse. Science of addiction. http://www. Accessed: 28 May
8. Satir V. People making. Palo Alto: Science and Behavior Books;
Ricardo J. M. Lucena, MD, PhD, is a psychiatrist and an associate
professor in the Department of Internal Medicine, Centre of Medical
Sciences at the Universida de Federal da Paraba, in Brazil. He maintains a private practice and specializes in addiction and personality disorders. He offers dialectical behavior therapy to his patients.

In the Heart of Cancer


Christian Boukaram

I was sitting on a pale rock, in the midst of a dark deserted

area. My only point of reference was a cyclic hovering sound resonating in the space around me. This hollow
noise reminded me of the sound of my own breath. When I
turned my attention to my skin, I did not feel a physical limit
between my body and the vast space surrounding me. It was
a very comforting feeling.
Open your eyes Christian, the teacher said with a terse
comment, You are missing out on vital information.
I never liked lectures about literature describing music,
but I had to sit still on a hard bench in my music history
tenth-grade class. It was part of the curriculum for art school.
I considered becoming a musician but instead began medical
school at a young age. My scientific father had remarked,
Medicine is both a science and an art, and it will offer you
more than music. After considerable hesitation, I followed
his advice.
I never stopped playing, recording, or composing during
my pre-residency programe. Music eased me through my
medical studies. When studying medicine got boring, music
evoked wonderful feelings in me. It was similar to pushing a
refresh button, allowing me to dwell in my creative space
and maintain balance. When I entered residency, my free
time practically vanished and, eventually, I no longer could
squeeze music into my life. My activities revolved around
studying, working, and sleeping. During my second year of
internal medicine, I abandoned my dream of becoming a cardiologist, simply because the work shifts were too demanding. Exhaustion and a lack of a social life compromised my
judgement. Being on call for 24 h, covering the intensive and
emergency care units of a large trauma hospital was just too
much. These unyielding shifts were often scheduled twice
a week. Considering that the patients I was treating were
often sedated and on respirators, I did not feel close to them.
Maisonneuve-Rosemont Hospital, Universit de Montreal, 1170 Rue
Dutrisac, Montreal, QC H4L 4H9, Canada

Rather, I had to gaze at computer screens and test results to

get some sense of my work being useful.
Because of this sense of disconnection, I opted for a residency in radiation oncology. As I stepped into the world of
cancer, I was struck by the differences between cancer patients and those with heart diseases. Some cardiac patients
in the intensive coronary unit were proud of having a heart
disease. In oncology, no one was proud about being a patient
with cancer. Radiation oncology is a very specialized and
innovative branch of medicine. Its main focus is on destroying or controlling the growth or spread of tumours with rays
(gamma rays, X-rays, electron particle, etc.), while minimizing side effects. It evolves quickly with frequent technological upgrades. We use computed tomography (CT) scans and
computers to calculate radiation doses for tumours we aim to
eradicate, while protecting healthy organs as best as we can.
Our interventions are evidence based:
If we apply dose X versus dose Y, would we offer an advantage
in survival for patients?
If we apply dose X with chemotherapy, versus dose X without
chemotherapy, what percentage of patients would develop more
side effects?
If we give dose X twice a day, instead of once a day, would it
make things better? Would it be worth the extra load?

In sum, we had to master the facts of science. During our

oncology curriculum, we had little training regarding how
to deal with people, mostly distressed ones, nor were we encouraged to take care of ourselves. At that time, I did not
even think that it was necessary.
Radiation oncology afforded me tolerable work schedules
and a sense of human connection. Many patients were in despair and sought help. I wanted to be of use and contribute
to society. Nonetheless, while the shifts were physically less
exhausting they were emotionally draining. As a caregiver,
other peoples burdens can weigh heavily on your mind and
heart. Confronting death daily is demanding, especially when
you, yourself, are afraid to die. The word cancer evokes fear,
death, and suffering. And it is exactly why, during social
events, I would refrain from answering the question, So,

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_15,

Springer International Publishing Switzerland 2015



what do you do for living, Christian? If I mentioned cancer,

the party would come to a standstill, as some shared their sad
stories with me about a relatives suffering from this or that.
When I said that I was a radiologist, instead of a radiation
oncologist, this simplified everything for everyone.
When you are a radiation oncologist, your job does not
end when your shift is over because too often someone calls
you for a medical favour regarding some friends relative
that has cancer. It is hard to refuse. As the years passed, my
personality changed, albeit, insidiously. My thinking became
hardened, analytical. I relied on logical answers for every
question asked. I was increasingly sceptical and judgemental. Was it my youth at the time? Was it because I had stopped
playing music? Was it because I had conformed? While
these questions remained unanswered, the smile on my face
was replaced by a frown and I was becoming increasingly
anxious. At the time, I was not fully aware of all of these
changes. Seasons passed from cold to warm, warm to cold,
and I found it increasingly painful to deal with my patients
issues. I remember when, towards the end of my residency,
I checked my watch as often as I did laboratory test results.
The grind of work was wearing out my heart. The existential aspects of my work were unexpected. I did not know
that exposure to constant suffering would eventually catch
up with me. I had faced death as a child in the1980s during
the Lebanese civil war. Death was part of life in my homeland. We accepted and coped with it by coming together as
families and communities. Few of those social supports were
available in the world of cancer I was working in then. A solid
sense of human connection has helped people overcome the
darkest tragedies. What happened? Did I view death as a failure? Did I have more to lose? Was I getting older?
Early in January 2006, my friend Chad1 called me at 7
p.m. with news that altered everything.
With a trembling voice, he said: Hey Christian, you have
a minute? I just want to share something about me that has
brought my life to a halt.
Yes Chad, whats up? I am studying for my final exams.
Im kind of tired. What have you been up to lately?
I am at a hospital in Laval. Ive been here for the past
three days. I had an incident with a head injury. I was brought
to the hospital, and given I had apparent bruises, the doctor
thought I should undertake a head scan, to rule out internal
Oh my God, how and where did it happen? Are you OK?
Do you have any other injuries?
I am OK, there is no bleeding in my head, but the doctors
say that they found a brain tumour. They dont know how
long its been there. Perhaps its been there for years.

Chad has read and contributed to this chapter.

C. Boukaram

What do you mean, a brain tumour? Im sure its just an

artefact! A brain tumourcome on, what are the chances?
What exactly did the doctors say?
I had an MRI done by the neurosurgeon. He says it looks
like a brain tumour. And because of the injury to the head,
it was swelled. My foot is dragging a little bit as I walk. He
says I may need surgery or radiotherapy. What do you know
about these tumours? Will I be able to walk normally again?
Chad called me just as I was studying the brain cancer
facts for the Royal College exams. I was shocked. Brain tumours are ultra-rare. I didnt want to share the statistics with
him then, because they are discouraging. Most of these tumours are considered incurable. He went on to explain that
there would be a biopsy done soon that should reveal the
type of tumour to guide treatments. The next weeks were
horrible, as my anxiety got a hold of me. What will the biopsy reveal? What is going to happen to him? Will he lose
his hair? Will he become paralyzed? Will he lose function
of his eyesight, his hearing, his memory? What will happen
with hormonal regulation?
I tried to comfort him the best I could, but I was also
afraid, since I was imagining that this could also happen to
me one day. I didnt want to see my friend suffer. Usually,
as a radiation oncologist, I see patients at the hospital when
all tests have been done and the diagnosis is clear. For the
first time in my life, I was vicariously experiencing what
patients go through before their diagnosis is established.
Stress mounts while waiting for a diagnosis. I realized how
painful this period can be and that the mind can play tricks
during this waiting game. I accompanied him to his medical
appointments. For once in my life, I was sitting at the patients side of the desk while the expert doctor was on the
other side explaining possible side effects of the biopsy, the
therapy, what would happen if they treated or did not opt to
treat the tumour. All perspective was lost.
I realized that his distress went beyond his failing physical health, as other pressing questions infiltrated his mind
such as, Will I have to abandon the idea of getting married?;
What will happen if I die?; How can I pay for expensive
medication if my insurance ends and I cant work? Cancer
is a wake-up call. In the following weeks, Chads spiritual
beliefs evolved as he became part of a Catholic Charismatic
church. Chad focused his attention on healing scriptures
from the Bible and other Christian evangelical booklets. I
noticed that he became increasingly more peaceful during
this period, but it surprised me, since I had never seen that
spiritual side of him before.
His biopsy revealed an incurable tumour with a prognosis
of 57 years according to the radio-oncologists statistics. He
required surgery but the neurosurgeon did not recommend it
because of the tumours proximity to the motor area of the
left leg; thus, radiotherapy and chemotherapy were recommended. Given that my friend did not blindly trust his doc-

15 In the Heart of Cancer

tors nor did he want to follow their advice, it was a rough

ride. He was not willing to live with the side effects from
treatment when there was no hope for cure. Chad contemplated his options before making a decision. He started surfing the Internet. He asked me many questions about natural
approaches and experimental studies described on the Internet. Being the sceptical doctor that I had become, I was concerned about quackery, but since he was my friend, and
I knew that our current therapies were insufficient to cure
brain cancer, I listened with interest.
I started examining what I considered his alternative
options. My intention was to guide him away from dangerous methods. He eventually did undergo surgery 4 months
later at another hospital but the neurosurgeon could not take
out much because it was in the motor area and he had two
seizures during surgery. The tissue excised revealed that his
diagnosis changed from a malignant to a benign tumour resulting indicating an unknown survival rate. Thereafter, he
underwent chemotherapy treatment following the teams
advice for a year and a half and coped very well. Chad returned to work while on treatment. Then in June 2012, when
he had four grand mal seizures and was brought to the hospital, after the fourth one he suffered weakness in his left leg
and foot. Magnetic resonance imaging (MRI) did not show
an increase in size of the tumour but some parts were more
dense and responded more to the injected liquid during the
MRI. The tumour boards conclusion was that the tumour
could be changing in nature or at least parts of it and they
did not want to take a chance. They suggested 30 sessions
of chemoradiotherapy followed by 1 year of chemotherapy.
Chad finished his treatments in November 2013. According
to his neurosurgeon, the last MRI showed a major decrease
in the size of the tumour and his prognosis was decades. Currently, he wears a tibial orthoses and is in physiotherapy and
goes to the gym and trains as if he never experienced illness.
It has been more than 8 years since he was first diagnosed
and, happily, he is still doing great. He remains an inspiration
for me. He feels blessed, and praises God for the healing that
he experiences every day.
This incident completely changed my perspective regarding my patients. It became easier for me to sit on their side
of the desk. This was good in some ways because I could
relate to them much more; I considered the biopsychosocial
and spiritual aspects of their health, guiding them the best
I could through their cancer experiences. Yet, there were
not so good consequences for me because feeling empathy
connected me more fully with their distress. I worried about
what would happen yet did not know how to advise them. It
created pressure to do more. But what is best when the future
is unpredictable and patients present with countless unmet
needs? With good intentions, I gave more and more of me
to the point where I slept poorly, became less focused on my
own needs, and began to burn out. I no longer felt whole, nor


could I relax or reassure my patients. I needed to find inner

and outer balance to be an attentive and effective doctor.
Consequently, I embarked on a quest by reading books
written by extraordinary cancer survivors. I sought to understand what helped them to cope and determine if their recommendations could work for my patients. Over the course
of a year, I read hundreds of documents, books, and clinical
trials. My favourite was David Servan-Shcreibers book, Anticancer [1]. This psychiatrist suffered from a brain tumour
and he details in his book complementary healing lifestyle
methods that had helped him fight it. I experimented with
natural therapies that these extraordinary survivors were
describing, from yoga to meditation, hypnosis to chi gong,
from diet to exercise and so on. I even attended classes with
patients, which felt a little strange, since very few doctors
did this at the time.
After 3 years of practise, research, and piecing these elements together, I saw one component that was central to
what these survivors were recommending: mindfulness.
While following traditional medical therapies, these special
people engaged in some form of complementary therapy
that had enabled them to feel empowered, peaceful, and reconnected to the present moment. It moved them out of a
full mind into being mindful. They were not advocating one magic method nor were they encouraging people
to just think positively. They found within themselves, a
tremendous force that they could access through awareness,
self-care, and a healthier lifestyle. That was exactly what my
friend Chad was seeking.
In 2011, I wrote a book, Le pouvoir anticancer des motions [2]. It contains interviews with extraordinary survivors
at my hospital. Here is an example of one patients insight:
I think that, when you live through a prolonged period without
happiness, thinking about the past or having negative thoughts,
your life goes off the rails. Not being in touch with your deep joy,
you get out of balance. For several years, I managed to pretend
that everything was fine, and to keep things going, but then I
went through a time when there were simply too many bereavements, very significant losses of people I loved deeply. After
my husbands death, his two brothers also died, then one of his
cousins, and my mother-in-law. All that and I was also supporting two close friends who had cancer. When another of my best
friends died from a heart problem that was the drop that made
the glass spill over. I remember very well that at that moment I
had an overload in terms of career, an overload in terms of stress,
and so, when you put all that together. For me, the cancer was
the point of departure, the obligation to transform my life, to
rediscover my health, my joy in life, and my happiness.

My concept of cancer has changed during this process, but

most importantly, I have changed. My view of life has been
transformed. By accompanying my friend, I was able to see
cancer from a patients perspective as well as a doctors.
I learned the science of oncology and then discovered the
heart of cancer. Yes, we can eradicate tumours to cure the
disease, and we can also foster healing. We can go beyond

C. Boukaram


solely applying protocols or analysing statistics and chose to

care for the whole person.
Incorporating the science of mindfulness on a daily basis
was a tremendous task. My mind was overtrained to think.
I made being mindful a priority. In the beginning, I did not
even understand what centring myself meant, nor did I grasp
the concept of opening my heart. Stilling my mind took its
time, and when it finally became somewhat calm, it became
overactive once again. As I practised mindfulness meditation, my capacity to experience its benefits increased. I was
able to breathe fully and slow down my thought processes.
Reminiscent of the tenth-grade boy who was reprimanded
by his teacher, I was able to access the inner space will that
allowed me to be unified with my core. I let go of memories
from the past and was filled with a sense of peace. I became
aware of the need for a healthier diet and exercise after work.
The more I heeded my internal guide, the better I felt, and the
more encouraged to pursue this process I became.
Now, during a charged workday I pause and meditate at
least three times a day. Practising mindfulness on a daily
basis has improved my mood and my social exchanges. This
has increased my capacity to understand others and grasp
their real needs, through their tone of voice and non-verbal
cues. When I am with my patients, I can communicate on
a much deeper level and hear what their hearts are saying.
They trust me. Mindfulness has also helped me as a scientist.
I accept that it is essential to take breaks in order to think
more clearly and make better decisions. Empathy is beneficial, but compassion is more powerful. Mindfulness has
turned me into a caregiver who prescribes treatments while
offering a sense of serenity and humanity. As for my musical skills, I noticed an increase in creativity and my voice
techniques have been enhanced. These benefits reinforce my
mindfulness practices.
The medical culture of self-sacrifice is dominant in our
field. I watch my older colleagues struggling to take more
than 10min to eat in a 10-h work daywhile mindfulness
is being taught to medical students [3]. They are learning
that in order to care for others, you need to care for yourself.
They are being taught that it is essential for providing proper
care because a calm doctor builds trust in his patients. We are
living in an era when patients are empowered and take part in
decision making. Mindful patients are able to communicate
their needs better, have fewer side effects during treatment,
and adhere to the prescriptions more fully. Considering that
we still have much to learn about cancer, and that we can-

not promise a cure, patients have to live with insecurities

about their futures. Mindfulness quiets the internal dialogue
about the future and helps them live in the present moment.
It invites them to be their own source of healing, instead of
grasping at empty promises for cure. As for my friend Chad,
he puts all his trust in God to take care of the present and the
future; he is not afraid of dying. He lives as if he was healed.
Currently, Chad attends a Pentecostal church and feels better than ever. The only thing he regrets is not having been in
close relationship with God before being diagnosed with a
brain tumour. He recently told me, You know Chris, God is
there not only for patients He can be a very good guardian of
doctors health, peace and well-being too enabling them to
care for those who are suffering.
There are many ways one can react when facing death.
Some retract, some attack blindly, some believe in magic
cures, while others chose to empower themselves realistically. We can help them reconnect with that power. Do we have
influence over a fatal diagnosis? Many patients want to hear:
Yes, you can do it.; We trust in you. But can you promise
something when you doubt your own abilities? When you,
yourself, are afraid to die? The best gift I received from practising mindfulness is that it dissolved my ego-based fear of
death. Oncologists who accept death broaden their understanding about health, and aim not only to maximise quantity
of life in patients but also take into account their own and
their loved ones wellness.

1. Servan-Schreiber D. Anticancer, a new way of life. Paris: ditions
Robert Laffont; 2007.
2. Boukaram C. Le pouvoir anticancer des motions. Montral: ditions de lhomme; 2011.
3. Dobkin P, Hutchinson T. Primary prevention for future doctors: promoting well-being in trainees, Med Educ. 2010;44:2246.

Christian Boukaram, MD, is the chief of Radiosurgery at Maisonneuve-Rosemont Hospital in Montreal, Canada. He is a professor at
the Universit de Montral and an associate researcher and radiation
oncologist at Maisonneuve-Rosemont Hospital. He presently serves as
a co-chair of the Education Committee for the Society for Integrative
Oncology. He is the author of a book, Le pouvoir anticancer des motions, focussing on mindfulness and mindbody therapies in oncology.
One of his missions is to promote whole person care by bridging the
language barrier in the French-speaking health world and opening up
the opportunity for collaboration.

Hiking on the Eightfold Path


Ted Bober

A short drive away from my urban home is the Bruce Trail,
an 800-km hiking trail, stretching along the Niagara Escarpment in Ontario. Over millions of years, this landscape was
shaped by the flow of water and the movement of glaciers.
A landscape first travelled by humans over 12,000 years
ago. Nowadays, my hiking pal Dawson, the family golden
retriever, and I walk the trail through Carolinian and boreal
forests among dozens of species of trees, sugar maples, red
oaks, balsam firs, white spruces and 700-year-old cedar trees
growing from limestone cliffs. We may pass one of the 60
waterfalls and the remarkable diversity of nearly 500 species
of birds, mammals, reptiles, fish and amphibians. Among
them are screech owls, trumpeter swans, the warblers, great
blue herons, the lesser scaup, the Jefferson salamanders, red
foxes, white-tailed deer, striped skunks and spotted turtles.
Rare orchids are among the 1500 plants coming and going
over the seasons. Some of the plants and animals are abundant and others at risk of extinction.

Change is Ever Present

In the spring, thousands of hawks, falcons, vultures and
eagles migrate overhead and come summer, the Niagara air
is fragrant with blossoms and carries the sounds and sights
of buzzing bees, fireflies and whining mosquitoes. In the
fall, the foliage turns to yellows, red, browns and oranges.
Through the changing seasons, we may walk on a path of
cold crunchy snow or it may feel soft and spongy from the
spring rains or feel warm, dry and hard in the summer heat.

Physician Health Program, Ontario Medical Association, 150 Bloor St
W., Suite 900, Toronto, ON M5S 3C1, Canada

Dawson brings his full focus and attention to the trail

whilst maintaining my own attention is a work in progress
for me.
One of the things I do routinely is take notice of the trail
blazes, white painted rectangular markers about 15cm high
and 5cm wide seen intermittently on trees, stiles or fence
posts. These white blazes indicate a straight-ahead hiking
path or a noteworthy directional change of the trail [1]. I
have veered off the trail while being lost in thought, distracted by the summer mosquitoes, caught in an unexpected
snowstorm or sidetracked by emails that can still reach my
smart phone. Getting back to the right path is as simple as
taking notice of the markers on the trail.
In health care, there are many trail markers providing direction on how to practice: research and empirically-based
clinical guidelines, professional values and ethics, the hidden curriculum in training programs, and the larger culture
of medicine and health care. How to be at ones best throughout a career path or in a specific clinical encounter with a
patient, in a challenging conversation with a colleague, in a
hospital budget committee, or during an academic meeting
may be informed by professional training, our life experience and the 2500-year-old wisdom of mindfulness practices
as espoused by the Buddha. Krasner and his colleagues [2]
define mindfulness as the quality of being fully present and
attentive in the moment during everyday activities.
Mindfulness is a capacity we all have and use every day
and mindfulness in itself is one part of a larger prescription
offered by the Buddhas secular guidance. The Buddha has
been compared to a physician offering a prescription. In this
case, the prescription is called the eightfold path, an integrated set of practical steps towards living a wise, ethical
and happy life. The eightfold path may be also understood
as a kind of relationship counselling on how to relate to
ourselves, to others and the world. The eight practices have
much to offer health care practitioners. These eight practices
or steps are right view, right intention, right speech, right action, right livelihood, right effort, right mindfulness and right
concentration. The word right is in this context less about

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_16,

Springer International Publishing Switzerland 2015



the right versus the wrong way and more so about right as
an appropriate, skilful or wise practice for living and working [3].
In this chapter, the focus is on two practices, namely skilful intention and skilful speech using narrative examples
drawn from personal and professional experiences and applied practical research. There are several ways to read this
narrative: quickly scanning for themes, slowly savouring
ideas, attending to ones thoughts and reactions, including
ones physical sensations or thoughts of the material being
interesting, boring, pleasant, instructive, uncomfortable or
familiar. My invitation to you (the reader) is to consider the
chapter as an opportunity for personal reflection, a kind of
personal workshop to read, reflect and engage with the information and questions.

Skilful Intention
My older brother had many wonderful qualities including
natural athleticism, strength and speed. As a handsome,
gentle man he enjoyed sketching and history, particularly
Egyptology. He drew Nefertiti and Tutankhamen and told
me about times and places I had never heard of as a teenager. Tutankhamen or more commonly King Tut, became a
pharaoh at the age of nine suggesting that anything is possible. Understandably, I admired my brother or at least until he
began making the rounds of emergency and inpatient admissions. As a young adult, he was diagnosed with schizophrenia. I struggled to feel and understand my own emotions.
In retrospect, the loss of the brother I thought I knew was
heartbreaking. The heartbreak deepened as my brother tried
to come to terms with the effect of this illness on his life,
including how otherspolice officers, nurses, doctors, community workers and I were generally kind and compassionate, but sometimes careless, and on occasion callous.
Around the time of his first bouts with illness, slowly and
subtly, I shifted from admiring, wanting to emulate my brother, to distancing myself from him. Stigma crept its way into
my life and bundled itself up with my sense of loss, fear and
anger. I recall sitting on a bench in a leafy peaceful neighbourhood in Torontos west end. On that day, my brother was
beleaguered and looked unwell. For the first time I noticed
how some people, as they walked near us, averted their gaze
while others made a conspicuous directional change away
from us. I do not know what they were thinking or feeling
but it struck me I had been doing much of this myself, making a significant emotional and behavioural change in direction, moving away from caring to disconnection and distance
without being fully aware of this shift. Over time, l learned
something about myself, even if there are limits to reducing
suffering in the moment, compassion is a basic necessity for
others and oneself. Moreover, mindfulness is helpful particu-

T. Bober

larly when we apply it to our interactions with others. My

brother taught me three lessons: vulnerability and resilience
often coexist; illness and happiness are not mutually exclusive; and stigma is corrosive while compassion is restorative.
Although my brother is deceased, what I learned from our
relationship through many encounters with health care professionals, during my own training as a social worker, and
through a mindfulness practice were invaluable lessons that
inform my everyday life and work in health care.
Does a label change our thoughts, emotions or behaviour?
Hospital emergency personnel are usually focused, deliberate and thoughtful in their actions with their patients. I want
to believe that our emotions, biases or personal judgments
can be separated from the work at hand. Yet, it is not so easy.
It was interesting to observe the diversity of people and
health problems that arrived in the old cramped emergency
department I worked in. There were: anxious parents holding
a feverish baby, a construction worker with a crushed hand, a
middle-aged, unemployed, depressed South Asian man who
spoke little English yet managed to convey discomfort in his
chest, a dishevelled homeless man with uncontrolled diabetes, a teenager who arrived Vital Signs Absent due to a motor
vehicle accident, followed by a second ambulance bringing
a second teenager with serious injuries who smelled strongly
of alcohol, along with a growing number of worried friends
and family members crowding the triage space.
Research has shown that people with a mental health disorder or substance abuse problem often receive poorer quality of care [4]. Clinicians can be slower to order tests or there
may be delays in the medical care offered. No one sets out
in their career to provide lower standard of care to any group
of patients, but it happens. This happens with community
members labeled as mental health patients and with health
professionals (including physicians) who have experienced
a mental health problem such as depression [5, 6]. In one
national study with physicians, the researchers concluded
that stigmatizing attitudes towards colleagues with mental
illness were evident [7]. In my work at a Physician Health
Program, I learned the rates of depression among physicians
are at least equal to or higher than the general public, and
stigma, embarrassment and/or a false sense of coping effectiveness or believing it will go away often leads to delays
in physicians seeking treatment. Many find it difficult to ask
a colleague who is showing some signs of distress Is everything OK? or How about a cup of coffee?
It may be useful to start with the intentions we set out for
ourselves. Intentions are not like goals that we can strive to
achieve and check-off as tasks accomplished. Intentions are
present focused aspirations that reflect our core values and
serve as a compass in life. Intentions require us to ask what really matters to us, what kind of person do we wish to be on the
whole, as well as in the various domains of life such as, in our
clinical role, as a colleague or friend, a spouse or a brother.

16 Hiking on the Eightfold Path

Health practitioners are often highly regarded for their

confident, astute and timely decisions. Can ones better self
and clinical decisions be compromised by hurriedness, fatigue or irritable moods (our own and others)? Can we let
go of labels and see the person beyond our judgments? During a candid conversation with a colleague, we discussed
a judgmental thought that arose after seeing an obese man
with a degenerative disc request stronger pain medications.
Another colleague shared his discomfort in becoming aware
of a judgmental thought upon seeing multiple tattoos on a
patients body and listening to complaints about the cost of
medications. It is not so much whether a judgmental thought
or an emotion arises, for this reflects the challenges and complications of our human nature, it is whether we monitor and
act in accordance with our highest and best intentions that is
essential to our work. Monitoring the gap between our intentions, values and actions is a mindful eightfold practice.
It is also useful to observe the congruency or gap between
personal values and the values outlined in our departments,
hospitals, and healthcare systems. Interestingly, a study by
Leiter etal. [8] found that both workload and the incongruence between the values of a physician and the values of
their workplace contributed to burnout among physicians.
Traditionally in the eightfold path, having skilful intentions or aspirations includes three components, namely, the
ability to let go, to experience and express goodwill, and to
offer compassion. Letting go is an act of generosity and not
an indication that one has caved in or been weak. It is possible to be both a strong advocate and have the sensibility
of knowing when an opinion or an attitude may be obsolete,
unhelpful or harmful.
Letting go may include the habits of the mind such as,
critical curiosity and beginners mind [9]. Critical curiosity refers to having the openness to self-reflect rather than
self-defend, an openness to make statements as well as hear
questions, an openness to be directive and at other times to
follow along and to be guided. Beginners mind is having
the capacity to hold ambivalent or contradictory information
without landing on what is true hastily. Beginners mind
includes recognizing the familiar, seeing how all the clinical
observations and data line up to support our conclusions and
yet being open to or not discarding too quickly what may be
novel, perhaps not quite fitting the picture. It can take some
cognitive effort not to slip into an autopilot mode of working
during a busy routine day. At the beginning of a day, one may
set intentions to work by such as may I be open to noticing
without reacting to an internal tension or urge to abruptly end
a colleagues or patients conversation or may I be aware
of the of the ebb and flow feeling engaged or hurried or distracted.
One other aspect of skilful intention is meeting our own
selves and others with goodwill and compassion. There is a
growing body of literature showing that compassion in health


care as essential step to patient-centred care. Compassion is

a cognitive, emotional and relational process including the
sensitivity to and recognition of the suffering experienced
by others, an emotional resonance with the suffering and a
commitment to try to prevent, mitigate or alleviate it [10,
11]. Compassion is a coordinated head, heart and hands on
effort. There are three pathways by which compassion is offered: by offering compassion to others, by being open to
receiving compassion from others, and by offering compassion to oneself. Self-compassion appears to be a powerful
health care practice promoting self-learning and self-regard
in a healthier, more sustainable manner than the pursuit of
self-esteem or learning through persistent self-criticism [12].
Fronsdal offers suggestions pertaining to understanding
and practicing with intention when he writes, a daily sitting
practice is extremely beneficial. But I believe there is even
more benefit in spending a few minutes each day reflecting
on our deepest intentions another way of including intention in our practice is to pause briefly before initiating
any new activity, which allows us to discern our motivation.
Being aware of an intention after an action is started is useful but it can be like trying to stop a baseball after you have
thrown it [13].
An excellent place to see how our intentions are enacted
is to notice and reflect on whether our speech expresses caring, goodwill and compassion in our daily life.

Skilful Speech
There is evidence of the development of modern language
and speech extending back thousands of years. Today there
are more than 7000 languages and typically men and women
speak an average of 16,000 words per day, at least in North
America. We have survived in part because we have developed the remarkable ability to effectively coordinate our
thinking, emotions and speaking and this coordination can
be difficult at times.
Are we that easily thrown off our well-intended, skilful
communication skills? For the past 10 years, I have asked
residents attending workshops on physician wellness, resiliency and excellence if they have ever been irritated or annoyed after reading an email or text or regretted what they
have said moments after speaking. Virtually everyone raises
their hand indicating yes. Imagine that, we see a lit flat
screen with some black lines and within seconds, we can feel
irritated, angry or hurt. Words can be hurtful and it is useful
to be aware of the speed of our emotions and reactivity as
well as the accuracy of our interpretations. In this section,
the discussion of skilful speech includes the many ways we
communicate such as, text messages, images and non-verbal
behaviour. This section also considers how we speak to ourselves and how we listen as integral parts of skilful speech.


Watzlawick etal. stated that people cannot not communicate [14]. Words and mostly our non-verbal behaviours
communicate a message and meaning. We can express care
and compassion for others as we share information and
make collaborative decisions. We may communicate about
our needs, status, power and control in our relationships. We
may talk lightly about the weather or just shoot the breeze or
gossip or be hostile and divisive.
Salzberg insightfully observed, There are three aspects
to every action or speech. There is the intention behind it,
there is the skilfulness of the action, and there is the immediate response to the action. We tend to ground our identities
only in the third aspect, and to ignore the first two. Yet the
first two are by far the most important. Plus there is also a
long term response to a communication that we also usually fail to take into account [15]. Compassionate patientcentered communication as a form of skilful speech takes all
this into account. A substantial amount of evidence demonstrates that patient-centred communication has a positive impact on important outcomes, including patient satisfaction,
adherence to recommended treatment, and self-management
of chronic disease [16].
In a medical inpatient unit, I, in my role as a social worker, worked with a robust interdisciplinary team to assess,
make recommendations and arrange follow-up services in
the community. As a team, we took pride in patient-centred
care and communication, which was often challenged by the
shorter lengths of inpatient stays and stretched hospital and
community resources. I often felt the pressure of the need
for the inpatient bed by the ER staff and patients waiting in
hallways of the emergency department, as well as knowing
the community services were limited for many discharged
patientsa reality reflected in the look in the eyes of caring,
though overburdened family members.
One of my best teachers in patient-centred communication was a woman who spoke English, quietly and with a
strong Portuguese accent. She, along with her thorough
cleaning skills, was valued as a vital part of hospital infection
control. As she worked her way around a patients room, she
often paused at the bedside, made eye contact, said hello and
asked how the person was feeling. For some patients who
were quite unwell, she leaned in as she listened. She completed her full workload in a timely manner. This woman,
whose name I cannot recall, taught me about the importance
of the pacing and connection in a conversation: brief pause,
relaxing into listening, showing openness to whatever answer came and acknowledging what she heard. All of this
took less than a moment; on some hurried days, that moment
may have been the most validating and therapeutic encounter
the patient experienced in the unit.
Years later, I began to learn about Insight Dialogue, which
furthered my own communication skills. The first three steps

T. Bober

of insight dialogue include pause, relax and open (PRO) [17].

Pause is the simple and, at times, not easy step of taking a
moment, to sense a breath, to be in the experience of listening and not preparing a response, an opinion, advice or a prescription. One may pause before, during or after beginning
to speak. To relax, one may simply notice any impatience
and ease up on the urge to talk long enough to notice how
one is actually feeling in the moment. With our awareness of
any tension we are carrying, we may breathe into and relax
the tension. Openness is a willingness to listen to both our
internal thoughts and feelings and openness to the external
words, tone and mood of the speaker. One beneficial, yet at
times effortful, practice to undertake is to pause, take and
notice a breath before responding to an email, a voice message, a statement that feels confrontational or before making
a critical remark to oneself or to others.
With PRO, we may add a common acronym that is offered to guide our speaking and listening, THINK. I have
heard several versions of this acronym over the years in
mindfulness talks. The acronym THINK, like a trail marker, may be useful to guiding and monitoring our speech in
alignment with our intentions. Is our speech (in the broader
sense outlined here) timely/truthful, helpful/harmonious,
intentional, necessary and kind/compassionate? In practice,
THINK may serve as a guide although refining it requires
our commitment. We can strive to communicate in a manner that is respectful, beneficial to others and that promotes
harmony in the relationship. Noticing whether our speech
promotes connection and collaboration or divisiveness
among others merits our efforts. Our communication can be
experienced as helpful and necessary if it is in keeping with
our best intentions for others. Informing someone that they
have a life-altering or threatening illness may be difficult and
feel hurtful, though in the context of striving for a respectful,
compassionate and empowering conversation it may also be
a step towards supporting the dignity and patients decisions.
Compassionate, skilful communication is a choice we
make and it takes resolve and practice [18]. As part of an
eightfold path exercise, one may write the letters P-R-OT-H-I-N-K (pause, relax, open, timely/truthful, helpful/
harmonious, intentional, necessary and kind/compassionate)
on a page. Circle one letter and consider the skills and attitude it represents and, over a few days or a week, continue
to deliberately practice, monitor and reflect on your skills,
attitude and intentions as they unfold in your day-to-day
interactions. Self-reflection is a powerful learning method.
Another way to enhance our insight and learning is to do this
practice with others with whom you discuss your reflections
and questions. There is growing evidence that incorporating
mindfulness, self-reflection and self-monitoring activities
into our everyday life enhances our well-being and clinical
practice [19, 20].

16 Hiking on the Eightfold Path

Concluding Thoughts
Late one winter day, the thawing and freezing of the snow
and ice created interesting markings along the Bruce Trail.
Dawson scampered with ease. Being a human with only two
legs, I walked more slowly than usual, particularly on the
steeper sections. Just as I reached the end of the trail and
was about to head back to my car, my footing gave way. My
legs shot straight out, for a moment both feet were pointed
in unison as if I was trying to collect scoring points on the
fall. I had experienced an unexpected, unwanted directional
change as I flew up off the path. A second later, I hit the
ground with a thud, slid downhill and then sensed an ache
in my right side. I took a breath and all seemed intact. The
trail was well marked, I had taken it many a time and I was
dressed comfortably in layers of cotton, wind and water resistant clothing. My intention to be present, safe, at ease and
happy was interrupted when I picked up the pace and let my
mindfulness fall by the wayside during that final stretch of
the hike.
It called for short measured steps, feeling ones footing
underneath; yet, I sped up precisely when I needed to slow
down. The eightfold practices can guide us in taking mindful
and skilful steps. With clear intentions and skilful speech, we
will go a long way for ourselves and those we care for when
unwanted change or interruptions in life or health arise. For a
moment I was annoyed with myself, I paused, and then with
a slight smile, Dawson and I headed home.

1. The Niagara Escarpment. Available from:
pages/show/the-niagara-escarpment. Accessed: 21 March 2014.
2. Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman
B, Mooney CJ, Quill TE. Association of an educational program
in mindful communication with burnout, empathy, and attitudes
among primary care physicians. JAMA. 2009;302(12):128493.
3. Gunaratana BH. Eight mindful steps to happiness. Somerville: Wisdom; 2001.
4. van Boekela LC, Brouwersa EMP, van Weeghel J, Garretsena HFL.
Stigma among health professionals towards patients with substance
use disorders and its consequences for healthcare delivery. Syst Rev
Drug Alcohol Depend. 2013;131(12):2335. doi:10.1016/j.
5. Atzema CL, Schull MJ, Tu JV. The effect of a charted history of
depression on emergency department triage and outcomes in patients
with acute myocardial infarction. CMAJ. 2011;183(6):6639.
6. Center C, Davis M, Detre T, etal. Confronting depression and suicide
in physicians: a consensus statement. JAMA. 2003;289(23):31616.

7. National mental health survey of doctors and medical students;
2013. Available from:
programs/workplace-and-workforce-program/programs-resourcesand-tools/doctors-mental-health-program. Accessed: 21 March
8. Leiter MP, Frank E, Matheson TJ. Demands, values, and burnout
relevance for physicians. Can Fam Phys. 2009;55(12):12245.
Available from:
Accessed: 21 March 2014.
9. Epstein RM. Mindful practice in action (I): technical competence,
evidence-based medicine and relationship-centered care. Fam, Syst
Health. 2003;21(1):110.
10. Cameron RA, Mazer BL, Deluca JM, Mohile SG, Epstein RM. In
search of compassion: a new taxonomy of compassionate physician
behaviours. Health Expect. 2013;1:114. doi:10.1111/hex.12160.
11. Gilbert P. The compassionate mind: a new approach to life's challenges. Oakland: New Harbinger; 2010.
12. Neff KD. The science of self-compassion. In: Germer C, Siegel
R, editors. Compassion and wisdom in psychotherapy. New York:
Guilford Press; 2012. pp.7992.
13. Fronsdal G. The issue at hand: essays on Buddhist mindfulness
practice. 4th ed. Redwood City, CA: Insight Meditation Center;
2008. Accessed 21 March 2014.
14. Watzlawick P, Beavin-Bavelas J, Jackson DD. Pragmatics of human
communicationa study of interactional patterns, pathologies and
paradoxes. New York: W. W. Norton; 1967. pp.2952 (Chapter 2,
Some tentative axioms of communication).
15. Right speech with Sharon Salzberg. The journalist and the Buddha:
seeing the way it is now; 2007 Oct 2. Available from: Accessed: 21 March 2014.
16. Levinson W, Lesser CS, Epstein RM. Developing physician communication skills for patient-centred care. Health Aff. 2010;7:1310
8. doi:10.1377/hlthaff.2009.0450.
17. Kramer G. Insight Dialogue: the interpersonal path to freedom.
Boston: Shambhala; 2007.
18. Jamison, L. The empathy exams: essays. Minneapolis: Graywolf;
19. Leung ASO, Epstein RM, Moulton CAE. The competent mind:
beyond cognition In: Hodges BD, Lingard L, editors. Reconsidering medical education in the twenty-first century: the question of
competence. Ithaca, NY: ILR; 2012. pp.15576.
20. Moulton CA, Regehr G, Lingard L, Merritt C, MacRae H. Slowing
down to stay out of trouble in the operating room: remaining attentive in automaticity. Acad Med. 2010;85(10):15717. doi:10.1097/
Ted Bober, MSW, RSW, is the Associate Director of the Clinical Services at the Ontario Medical Associations Physician and Professional
Health Program (PHP). The PHP works to prevent and mitigate occupational stress, mental health or substance-abuse-related problems in lives
of physicians while promoting well-being and excellence. He has more
than 25 years of experience as a clinician, educator and administrator in mental health and addiction services. Mr. Bober has maintained
a mindfulness practice since the early 1990s and teaches mindfulness
practices to medical students and physicians. The PHP is located in
Toronto, Canada.

Strengthening the Therapeutic

Alliance Through Mindfulness:
OneNephrologists Experiences


Corinne Isnard Bagnis

From Normal Nephrology to Mindful

Working as a professor in nephrology for years has allowed
me to meet hundreds of people, each of them arriving with
some degree of anxiety and stress, seeking answers to their
health problems. My medical education failed to train me to
interact effectively with patients. I was simply exposed to
clinical situations early on where I observed how my mentors handled various situations. Basically, we were left to
learn by ourselves as best as we could.
Being exposed to patients suffering is one cause of physicians distress and many of us have found our own ways
of strengthening ourselves and surviving. At one point, the
overall strain I experienced in my professional and personal
lives led me to discover how mindfulness could cultivate resilience in me. I realized that the goal to help patients (the
positive intention) may not necessarily lead to finding appropriate approaches and ultimately the best treatment plans for
patients (the wrong answers). Learning to listen mindfully
allowed me to be aware of and accepting of my own emotions as medical encounters unfolded. Gaining insight into
each patients inner and outer lives helped me to discard my
plug in and play answers and led me to customize health
plans, sometimes including strategies that were outside the
normal field of nephrology.
Following training in the USA as an instructor, I began to
offer mindfulness-based stress reduction (MBSR) programs
to my patients. In order to do this, it had to be part of our
patient education program in the renal diseases department
because meditation in medicine has yet to be recognized as a
means of helping patients in my hospital. A qualitative study
Apprendre apprendre soin de soi [1] conducted by Dr.
Khaldi, a sociologist working with me in Paris, explored
C.Isnard Bagnis()
Service de Nphrologie, Institut dEducation Thrapeutique,
Universit Pierre et Marie Curie, Hpital Piti-Salptrire,
83 Boulevard de lHpital, 75013 Paris, France

the experiences of patients who took the MBSR course. She

was a participant observer in the course. The investigation
revealed that patients were able to become actively involved
in coping with their various illnesses. For example, they reconnected with their bodies, managed stress, frustration, and
pain better. Patients also learned the importance of taking
time for self-care. Importantly, mindfulness practice enabled
them to work more effectively with their environment, including other people. MBSR was a turning point in their
lives that led to resilience which lasted after the program was
over, even for those who did not practice meditation regularly. Patients found it helpful that the course was offered in
the hospital setting and taught by a doctor; both of these factors led to its credibility as a valid treatment. This experience
showed many patients that their need for cure is actually a
need for care.
Mindfulness is, for me, a stimulating way of being present with my patients while not feeling weighed down by the
burden of their suffering. My expertise in nephrology (that is
the result of experience over time) and my mindful clinical
practice together help me to acknowledge and accept that we
do not always have answers to clinical problems. We may
concede that we do not know how to help; nonetheless, simply being there and listening with loving kindness provides
patients with solid support. Many times I have experienced
how just recognizing things as they are may not be an acknowledgment of failure but, on the contrary, a fertile means
for developing a caring and confident therapeutic alliance.

Close Encounters
I first met Charlotte last year; she was referred by her general
practitioner (GP) who wanted me to assess the need for diuretics. Both the GP and her endocrinologist contended that
she should stop taking these dangerous medications, but she
disagreed. Charlotte had been a pretty heavy smoker; she

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_17,

Springer International Publishing Switzerland 2015


C. Isnard Bagnis


had no other medical problems other than hypothyroidism

and did not take other drugs. In her early 50s, postmenopausal she was thin, blue-eyed.
During our first encounter, she stated spontaneously that
this situation cannot go on any longer, that her life really
depended on the drugs that helped her to not feel swollen. In
fact, all of this began when she received treatment for infertility 14 years earlier. Since then, this unbearable feeling of
her body being heavy and swollen had prevented her from
leading a normal life. A painter, Charlotte described feeling
insecure when she climbed the ladder to work as she could
not balance and experienced dizziness frequently. From her
perspective, medical advice failed to offer a solution other
than to stop diuretics. When she last visited her endocrinologist he stated that the risks of a prolonged treatment
outweighed the benefits and therefore the prescription was
not renewed. Charlotte declared that the only relief she ever
experienced resulted from a combination of thiazides and
amiloride chlorohydrate dehydrate.
While I led the medical interview, I was puzzled by the
despair etched on her face which was accented by deep sadness, but I did not mention it. Her blood pressure was at the
lower limit of normal. Charlotte had no edema and a normally hydrated body. I reviewed her blood tests and prescribed
an extended workup to determine the impact of prolonged
diuretic treatment on her physiological functions and to ascertain if other abnormalities were present. I explained that
the symptoms she experienced were not necessarily related
to an excess of salt and water; I did however, concur with
her other doctors about the potential risk of long-term use of
diuretics. Nonetheless, I gave her a diuretic prescription indicating that we would try to find exactly where her symptoms
originated from. In the meantime, since she felt relieved by
diuretics, she could take them. When she left, I was certain
that diuretics were not needed. I wondered how I could help
her in a better way. I pondered how her history of infertility,
a trauma for many women, impacted her but, again, I choose
not to speak up about this.
Charlotte returned to see me long after planned. So very
thin she gave me the impression that she was gliding along
the floor in a discrete and silent way. I welcomed her, emphasizing that I was glad to see her again. She sat and I inquired
about her life since our last meeting. I probed to learn how
she saw the situation given that the diuretics had not changed
anything. Her eyes brimming with tears, Charlotte described
how bad she was feeling. She recognized that the assisted
procreation process had been the beginning of her discomfort. While I listened closely, I noticed that her face was
blank and her hands were pushed down deep in her raincoat
pockets. I simply said, Your face expresses such suffering,
while I may not comprehend your swollen legs and dizziness
I can see your pain. How can I help you deal with this terrible
suffering? I appreciate how distressing your search for a cure

of infertility has been. It can be an incredibly challenging

time in a womans lifeespecially when the treatment fails
to help you reach your dream for maternity. Did anybody
help you during that time?
She stayed silent for a while and replied, No, the pain is
still there. I know these procedures have harmed my body.
Do you think my symptoms have anything to do with that
event? We discussed at length how suffering in the heart
can be expressed bodily. I looked at her blood tests, considered her clinical exam, and carefully reviewed the medical
records. I told her I did not see any medical reason for taking diuretics; moreover, her dizziness could be the result of
taking the diuretics. I asked whether she would be willing to
be seen by a psychiatrist (who is trained in mindful clinical
practice) to assess trauma stemming from infertility. Charlotte noted that for the first time she felt heard and that her
suffering was acknowledged. She said how much she wanted
relief and that she was open to meeting my colleague. When
I encouraged her to keep me posted, she smiled, appeared
grateful, and left. My door and heart remained open to her
should she need to see me again.

Lisa stepped into my office with her son, a tall obese young
man in his twenties presenting with a severe skin disease
affecting his face and hands. Both independently weighed
more than my scales could quantify. Lisa, with a long story
of renal stone disease, recently had been treated for bilateral
stones by endoscopic ureteroscopy. She was referred to me
for a medical approach to her stone disease to prevent recurrence. Comorbid for severe depression she took medications
to control anxiety, sleep disturbance, and depression. Moreover, she was being treated for diabetes and hypertension.
I rapidly concluded that her urinary stones were from uric
acid and explained to her how to prevent stones from recurring. I indicated that we could meet together with our dietician to suggest ways to increase the volume of her drinking,
decrease her salt intake, and increase her bicarbonates input
to decrease urinary pH. In order to improve, she was offered
to either take ten large pills or to drink 1.5L alkaline drinking water a day. Given that we have been running a renal
stone clinic for some time, experience has shown how difficult it is to change dietary and drinking habits, along with
related behaviors. We typically offer a year-long program
to our patients and explain that time is necessary to change
their lifestyles. Patients are followed by the nephrologist, the
dietician, and a nurse and are offered individual and group
educational sessions.
The first few times we met, Lisa appeared to be totally
disconnected, listening to what I was saying but constantly
claiming that it would be impossible for her to follow my

17 Strengthening the Therapeutic Alliance Through Mindfulness: One Nephrologists Experiences

treatment. She also disclosed that she had been asked to

change her eating and drinking habits to lose weight before
but it did not work even though she does not eat much or
does not drink much either.
The last time we met I allowed her to retell, again, how
impossible it was for her to follow our recommendations,
stressing how bad she was at making the drinking changes.
I listened to her and found myself curious about how her
home life was with her son. For a few months we had been
trying to help her change her dietary habits. I always feel
peculiar when patients present with a record of repeated failures. I ask myself: Is it their failure or ours? How should
we respond? Apparently, our expectations and requests for
lifestyle modifications that she could not make simply led
her to feel guilty.
After listening to her for a while I said, Lisa you are
right. In the past months, we have offered you a strategy that
does not fit you. We were wrong. It works for some people
but not for you and I am sorry for that. You dont have to feel
guilty for not achieving a urinary pH of 8, I know it is difficult. Lets find a more appropriate way together. What do
you think you could do for your renal health?
She stared at me, stunned, and stayed silent. I asked her
son who has never said a word, What do you think your
mother is already doing for her health and how could we/you
help her do even more? Her son looked at her and then at
me and said with red cheeks, Mum is drinking more water
than she did before and she doesnt add salt to her plate anymore. I could then, given what her son had just said, congratulate her and stress the fact that indeed she had initiated
changes. Her face changed and I sensed her relief. She knew
then and there that I am on her side.

Reflections on Mindful Practice in Nephrology

Medical training is a time when a students energy is devoted
to learning about symptoms, diseases, treatments, and how
to diagnose and provide cure. It is critical that physicians
be able to conduct an excellent clinical examination, use
scientific reasoning, and offer evidence-based medical treatment. Yet while listening to patients, we often try to match
their complaints to whatever symptoms we know because
we need to find, embedded in the patients language, some
keywords that match our flowcharts. Unfortunately, medical
schools often fail to teach us how to listen deeply or how to
truly be fully present with our patients. There is no instruction pertaining to importance of being open and nonjudgmental. We are not informed about how critical it is to create
a safe space and have a caring relationship, one that enables
the patients words to reveal what we need to know to provide excellent service.


When I was less experienced, prior to my mindfulness

training, my only aim meeting Charlotte would have been
to convince her to stop diuretics. I would have appealed to
her logic to understand how useless the treatment was and
how good for her it would be to stop. When patients fail to
adhere to our prescriptions, it sometimes induces distress in
physicians because in such situations we lack answers and
do not know how to proceed. Charlottes situation appeared
to me as a typical case of doctors insisting that she stick to
a strategy that did not make sense for her. Because the real
cause of her suffering was not explored, she kept taking diuretics convinced that it was her only way to cope. Often, not
complying with doctors recommendations leads to a futile
breach in confidence between the patient and doctor. Charlotte had been labeled as a bad patient reflecting a judgmental opinion that blocked her and her team from finding
an acceptable solution.
Being mindful enabled me listen otherwise, to help her
reflect on her suffering and realize that she could find a solution. When I am mindful, besides being present and open to
what is occurring in the moment, I am more of a prompter
rather than a doer. Mindfulness allows me to observe the patient and the situation with a beginners mind. Mindfulness
clarifies for me the data that emerge from a dialogue with a
person. With Charlotte, being mindful allowed me to pick up
information I needed for a medical diagnosis; furthermore,
it enabled me to perceive and evaluate her distress. I could
experience our respective emotions as I listened to her relate
how desolate it felt to not be able to have a child and the suffering she endured during the infertility procedures. Often, a
patients distress is viewed as distracting or uncomfortable
for physicians because they may not know how to deal with
it, fearing that it may overwhelm them or take too much time.
Mindfulness makes me aware of and able to accept what
I know and what I do not know. It prepares me to welcome
each patient as they are when they enter my office. Mindfulness helps me to tailor care to each individual patient. In
Lisas case, mindful listening allowed me to realize how our
treatment propositions were too much for her and therefore
how her self-esteem was challenged. Revising our goals and
stressing more precisely and positively what she had actually been doing for herself strengthened our relationship and
enhanced confidence.
The question of finding time to practice mindfulness
when we are already overwhelmed by work is often raised in
those interested in learning to work this way. Resisting burnout while adding yet another new task to the daily agenda
may seem illogical, but for those of us who have experienced
the effects of regular meditation practice we know that making time to meditate helps one manage time better in the long
run. Another benefit that I have experienced is that my concentration has improved and therefore I am more focused

C. Isnard Bagnis


when fulfilling the many tasks listed in my agenda. As a person who could hardly say no to anyone at work (consistent
with the notion I held that a physicians job involved taking
care of everyones needs), I realized that by discriminately
choosing my engagements I became better able to attend to
them and importantly, I experienced a renewed sense of satisfaction.
Being more mindful has transformed my medical practice. More openness and loving kindness in my clinical approach enables a therapeutic alliance to be developed. Without overlooking the scientific aspects and evidence-based
medical reasoning, mindful care of our patients is the key to
personalized holistic care.
Recently, I offered a pilot course for medical students;
their feedback was encouraging. This suggests that mindful
medical practice may be included as a part of the medical
curriculum in France, as it is elsewhere in the world [2].

1. Khaldi C. Apprendre apprendre soin de soi. Rapport final enqute
MBSR. Paris: Universit de Rouen; 2013.
2. Dobkin PL, Hutchinson T. Teaching mindfulness in medical
school: where are we now and where are we going? Med Educ.

Corinne Isnard Bagnis MD, PhDis a nephrologist at the Hpital

de la Piti and professor at the Universit de Pierre et Marie Curie, in
Paris, France. Her scientific and medical interests are twofold: clinical
research in the field of kidney and viral diseases and patient education. She has initiated the Institute for Patient Education in Chronic
Diseases at Pierre and Marie Curie University in 2009 and launched
the first French Patients University in 2010 together with C. Tourette
Turgis. After training at the Center for Mindfulness with Kabat-Zinns
team, she implemented mindfulness-based stress reduction (MBSR) in
a French university hospital for chronic disease patients; then in 2014
she offered the program to health-care providers and medical students.


Richards Embers
Elisabeth Gold

Only connect [1]

I write this on the winter solstice, the darkest day of the year,
here on the cusp of turning once again toward the light. It is
a 1-year odyssey of coming home, of rekindling fire from
embers. Loving intention and attention stir the embers until,
at long last, flames:
The first duty of love is to listen. [2]
Attention is the rarest and purest form of generosity. [3]

The office walls, soft lime-green in two shades rise from

the beige carpet. There is a large money plant and a small
African violet, a dark brown bookcase with psychotherapy
and mindfulness books, two facing chairs, and a thick round
wooden table off to the side. You will find a box of tissues
on the table and, sometimes, a slender vase of carnations or
Two generous windows look onto the expanse of sky
above, lush evergreens, and uniform rows of concrete condo
balconies. Below, people glide along the sidewalk; cars and
buses stop and go. These windows reveal the seasonsthey
actually open, rare for a medical building. I like this space
that evokes openness and the low-set, weathered brick building which houses it, contrasted with the newer, sealed, and
imposing medical tower nearby.
This room is found on the third floor of the four-story
Medical Arts Building: I like this name because medicine
is an art, not a science as commonly construed. Medical
Arts Building not the usual Medical Sciences Building
where I trained in Toronto, Canada. Medicine is an art based
on science, including biology as well as sociology, psychology, the arts, humanities, and more. Every life experience
forms and informs the physician as it does the nurse, writer,
or dancer. On a good day, medicine is a privilege, a dance of

Family Medicine and Division of Medical Education, Dalhousie
University, Medical Arts Building, 5880 Spring Garden Road,
Suite 308, Halifax, NS B3H 1Y1, Canada

mutual healing, what Santorelli calls a crucible for mutual

transformation [4].
Richard (a fictional name) sits in the dark-blue cushioned
armchair, while I face him in the wooden captains chair. I
am glad to see him. An orange file folder on the table to my
right holds the notes of our meetings over the past 4 years,
his chart (chart meaning a map, a musical arrangement,
a tabular form of information, a weather chart, a marine
map), charting the depths of the human psyche, his and mine
through the seasons.
Each of us has a mug of herbal tea on an orange coaster
on the table. The walls display a few diplomas, photographs,
bluegreengoldpink textured paintings, and a black-andwhite hand-painted Tibetan calligraphy which translates as
love and compassion, the basis of healing.
Fellow travellers, Richard and I have known each other
for about 20 years. I was his family doctor until I closed my
practice 5 years ago to focus on medical psychotherapy along
with medical education and teaching. A year later, Richard
requested psychotherapy, and we continued our journey.
Richard is late middle-aged with an earthy physicality
and, at times, (not in the dark time), a big laugh. He wears
vibrant colors. He is articulate, very talkative when well,
highly intelligent, and well read. Richard fills the room with
his abundant and generous spirit.
Richard had participated wholeheartedly in a mindfulness-based cognitive therapy group which I had offered a
few years earlier. He describes mindfulness as one of the pillars of recovery from the depths of severe depression and
compulsive overeating back to life, a transformation from
ashes to embers to flame.
In the dark time, Richard withdrew and sequestered himself from friends, family, social workers, and from his body.
He gained 100lb by swallowing anger. He was angry at himself, punishing himself with daily food binges. He described
himself as a walking dead person and overall numb. Sad
about lost opportunities, he either shut down or talked compulsively to avoid feeling. Richard was self-critical about his
weight. I dont feel human anymore. He felt heavy, dense,

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_18,

Springer International Publishing Switzerland 2015



pushed down, and struggled to walk or move. He often cried,

feeling helpless. He became aware that he was overeating to
fill a void, a tension between unworthiness and arrogance.
Richard avoided grief and distracted himself by caretaking others. He felt overly responsible for others, as learned
in his family of origin. He judged himself severely by means
of should, an obstacle to self-compassion. Perfectionism
and over-criticalness roused the rebel in him, placing the rebellious inner child in charge of eating. He rebelled against
Weight Watchers and rebounded from hospital weight-loss
Through the office window, I noticed snow on the swaying Jack pine branches. The north wind blew bone-chilling
cold. At times, as Richards therapist, I felt oppressed, sad,
and scared, yet steadynot sucked into the vortex. I practiced mindful awareness of my emotions and set the intention to rouse compassion for both of us.
In the dark time, sitting with Richard after he lumbered
into the office, I did not know when the sun would rise; I
tasted uncertainty and, at the same time, a nonreligious faith.
As the therapist, I held faith in both my own and Richards
unconditional sanity especially when he had lost touch with
his. I had faith in recovery when Richard had none, faith in
the healing relationship, in the power of time and change,
faith in steadiness and in not giving up. Not giving up on
Richards embers of recovery, and not giving up on myself
as therapist.
Faith feels like deep patience, willingness to persist
in being with the person and letting go of expectations as
they arise. It was a profound experience, deeper than words,
subtly encoded through psychotherapy training, watching
exceptional role models, and years of ongoing mindfulness
practice and study. Richard later told me that it had meant a
lot to him when I had said, I wont give up.
I may have been the only one who trusted Richards intrinsic sanity at this time, as family and friends were frightened and had lost heart. in this case, faith is based on
recognition of the intrinsic goodness of the helpers and the
helpees, which exists constantly. When we communicate
with anyone at all, there is a ground of trust, faith, or mutual
inspiration which comes from acknowledging each others
basic goodness. Because of that faith, individuals can begin
to learn to help themselves, work with themselves, and take
some pride in their existence [5].
This arduous and meaningful expedition demanded everything of the fellow wayfarer, honored to share this path. I
experienced the paradox of working hard, while not working
hard and accepting Richard in order to allow him to change.
We were mindfully present together, with suffering, with the
healing intention. I will not describe the therapeutic details
in this telling of Richards story except to mention that I used
a variety of psychotherapeutic techniques. To pay attention,
this is our endless and proper work [6].

E. Gold

Out the window, behind Richard, snow softly fell on the

pines as bundled people scurried to survival, bent in the
wind. In the dark time, I faced my fear, groping, lost without
guideposts; nothing and everything in my training having
prepared me for this challenge. I have learned much from
mindfulness practice of the past 38 years, and yet am certainly still a beginner. A beginners mind is open to many
possibilities, while an expert may be unable to learn more.
There is no end to learning about mindful awareness for it is
limitless. My practice was to give full affectionate attention
and to come back when my mind wandered. I learned to accept the present reality in the room with Richard as well as
contemplating him in the aftermath of our sessions.
Spring brought longer days, a different angle of light,
and the joy of birds once again. In the very, very dark time,
we discussed hospitalization; Richard declined; he wanted
to continue without medications which he had chosen to
stop a few months earlier, unconvinced of their benefit for
him. As he was not actively suicidal, we agreed to wait and
revisit hospitalization the next week if needed. He mused,
If I havent already killed myself by my age, what was the
point now? It was a rhetorical question; I listened and felt
relieved. He later told me that my concern for his survival
empowered him to rouse himself, to say, No. No hospitalization now. I can do this.
Richard cancelled appointments when he felt resistance.
My task was to not feel rejected, to not take his no-show
personally as a sign of the inadequacy of the therapy. We
agreed that I would go to his home for a meeting when he
was unable/unwilling to come to see me; subsequently, Richard cancelled this plan at the last minute and came to the
office. I like making house calls when needed; seeing people
in their own habitat rather than always in mine. Richard was
ashamed to come and see me when unwell; Here I go once
again, he sighed, trapped in the cycle of despair, resentment, and guilt.
Summer sun painted the office walls with rainbows from
the crystal window ornament. The noisy window air-conditioner ran for a few minutes between sessions during the heat
wave. In the dark time, I referred Richard to a psychiatrist,
a mindfulness practitioner, for group therapy. He went, then
started missing sessions, and then quit. He later told me that
the psychiatrist and I had both held the space for him until
he had become strong enough to hold it for himself, the space
of worthiness and fundamental sanity. He knew deep down
that this was his birthright, yet he had lost the connection.
People on the sidewalk below now moved in the open,
sandalled way of summer. I dont know if I want to be
well, posited Richard, feeling fearful of healthiness with
its attendant burden of responsibility. He was familiar with
being overweight and depressed, on and off, for over 30
years. Food equalled love, and he expressed a love/hate relationship with food. He was not actively suicidal, yet wished

18 Richards Embers

for death. He revealed that he was not safe with medications

in case he might overdose in an impulsive moment; he had
never done so. We were both sweaty in the heat of the impasse.
Richard was stuck and not hopeful for recovery. I feel
OK about not feeling OK, he explained, recognized the
twisted logic, and continued: I cant fail if Ive already
failed at getting well. He described himself as comfortable
in misery. Yet, Richard also harboured yearnings: Deep
down, I value life, I want to get unstuck. He shared feelings of profound shame and embarrassment at his current
dilemma, and stated, I should be able to get out of this;
shoulds himself in the foot. He then revised his view to I am
not OK in my not-OK-ness. He felt arrogant and wanted to
be humble. I accommodated him, witnessed the embers, and
paid attention. I stayed present.
In the dark time, Richard remembered childhood Sunday dinners at his grandparents place: There were too many
people, he felt lost with a lack of attention and was very distressed. I felt sad hearing this pivotal story that resurfaced
from time to time, like an old movie. It was important; attention is a fundamental form of love. He was angry at the lack
of love as a child. He felt pushed away, rejected, abandoned,
hurt, angry, scared, sad, and ashamed. Richard longed to be
seen as a real person, as we all do. Often, the doctor is seen
as other, as different, not human, and not a three-dimensional
human being.
Richards past was palpable in the room. His sibling and
others in the family received a lot of attention by being sick,
and attention is psychological oxygen. Richard developed
the insight that his deep-seated belief that sickness meant attention was a barrier to his current recovery. As a child, he
overate and at times was overfed, ate for two. He perceived
that he now weighed as much as two people. He recalled that
his parents had given him food whenever he had cried. He
now swallowed his feelings of fear, anger, and fear of anger;
suppressed anger furthered depression. Richard realized that
he overidentified with his father who had untreated depression.
Autumn leaves circled along the sidewalk below. People
sported jackets again in the face of the fall breeze. Richard
was coming to terms with pain from his past, and was finding meaning and growth. I could relate to him; food also
meant love in my childhood family. I dont think you can
be a physician and not see yourself reflected in your patients
illness [7]. No pedestal; instead, the common humanity of
Richard and I.
In the dark time, we sat in silence, and, when Richard
requested, we meditated, a short body and breath scan guided by me for 3 or 4min. Practicing during a session often
refreshed me as well as the other person, providing mutual
restoration. After the practice, we would debrief; I asked,
what did you notice, in body, breath, and mind? What sur-


prised you? Surprises are important clues to the road beyond

expectations. Richard shared that mindfulness practice kept
him alive: his debrief was, Im OK in this moment. He felt
alive at that moment as did I; felt a sense of attunement, a
positive alliance which was complex, subtle, and deep.
In the dark time, Richard felt guilty, believing that he
was bad. It was hard to accept himself as he was, and he
was angry at self for not taking care of himself. He wrote a
journal, a compost of thoughts. I too have written many
journals in the past, a way to keep sane. Writing is a reflective awareness practice that helps me process life at large. I
return to it time and again.
In the dark time, Richard believed that he was unlovable.
He reinforced this belief through rigid perfectionism, believing I would be perfect if I lost weight. He tried to control
himself and others. Mindfulness is a paradigm shift beyond
the notion of control, reframed as intention, will, and choice,
dealing with and working with situations rather than controlling anything (including ones thoughts, emotions, and
In the dark time, Richard felt useless, and he overgeneralized. Everything is wrong. He discounted the positive and
was self-stigmatizing for mental illness. I deserve this isolation. His motivation to eat was at times based on loneliness.
He confided in me that for the most part he was spending his
days hiding at home.
I now felt very familiar with his plight; I wanted to get
beyond it, back to life and warmth. I wondered if he would
get unstuck this time, would lift the veil of unworthiness, or
remain in the mire without end? How many weeks would we
continue to meet like this in the interminable dark? I experienced faith and flashes of doubt. What was the next stepa
referral to another psychiatrist? I could not think of one who
would be a good fit, who would understand Richards wish
and determination to stay off medication.
At this point, the nadir, Richard was in a place darker than
any previous episode. I longed for the light. Then, Richard
tapped into rage. He began to feel again, sentient and cognizant of this rage. He slowly woke from hibernation.
After a trajectory of four seasons, free falling around the
sun, a shift and Richard stopped gorging on television and
junk food. Hopelessness made room for willingness. Orange
warm soft sun rose as his intrinsic healthiness re-emerged.
Morning had broken. Richard divulged: I feel my spirit
Self stand up to the darkness. Enough is enough. This being
human is a mystery beyond science and art. I felt surprised
and not surprised, baffled and confident, astonished, amazed,
and relieved.
Autumn is my favourite seasonthe colors, relief from
heat, and an appreciation of sadness. Richard described himself as, coming out of quicksand with some clinging to me
and also, crawling out of a hole. He described utter joy in
watching birds in a puddle, in watching trees sway. There


was movement, hope, the perfume of rebirth. A perceptive

neighbour greeted him with Welcome back to the living.
After the dawn, Richard strode into the room and braved
eye contact again. He shared his current experience: He was
seeing patterns, aware of old tapes, and was letting go of
being perfect. He realized that thoughts were not facts, and
he noticed the space between thoughts. Self-compassion
poked up through the thawing ground, some seeds planted in
the mindfulness-based cognitive therapy group, and reunions
as well as in the recent group therapy and other sessions with
the psychiatrist. Seeds that found fertile soil during daily formal and informal mindfulness practices; the latter including
mindful eating, washing dishes, and walking. Richard started
to see his habitual patterns of autopilot, whether aggressive,
grasping, or ignoring. He was growing in kindness and affection, beyond judging.
After the dawn, Richard recognized the need for quiet,
for not talking. He had gained insight into how talking was
at times a form of avoidance. He felt the need to be in the
natural world and joined a community garden; I understood
this as I too felt the undeniable need to be outside, to prevent
nature deficit. He gave away the TV set. He began to buy
groceries again. He stopped pushing people away, including me.
After the dawn, Richard turned toward mindful conscious
eating (there is no abstinence option with eating), with enjoyment and awareness of satiety. His weight diminished
from almost 300 to 200lb. Frightened of weight loss after
losing more than 100lb, he regained some weight. Richard
found it hard to walk at first due to his size, density, and
being bloated. This heaviness gradually eased over several
weeks of mindful eating. We both breathed more easily.
After the dawn, Richard realized: I am not my illness,
and began to let go of overidentifying, one of the barriers
to self-compassion [8]. He recognized his arrogance and the
pitfalls of comparisons; he knew he was as worthy as others,
no more and no less. I noticed that Richard and I were different each time we met, that each visit was the first visit in a
way. I set the intention to let go of expectations and look and
listen in a fresh way.
After the dawn, Richard and I explored working with difficult emotions using mindfulness psychology from Recognizing, Accepting, Investigating in the body, and Nonidentifying (R.A.I.N) [9]. He learned to recognize anger while it
was happening. Anger as an acceptable emotion was a new
approach for Richard. Recognizing anger as early as possible, accepting that it was happening whether he liked it or
not, and becoming aware that it was temporary. Then, investigating the bodily experience of the anger before letting go
naturally followed. I often use this helpful approach when
facing a challenging emotion or an adherent thought pattern.
After the dawn, Richard shared with me one of his poems.
Mindful of my true nature/the very core of my beingI soar

E. Gold

into silence. We continued to do mindful awareness meditation together for a few minutes at the start of our sessions.
Learning to be quiet, to be still, to say no, and to change his
pattern of rescuing others, Richard realized that he shapeshifted emotions to please others. He now started to build
healthy boundaries rather than trying to fix others, manifesting true compassion which includes self-compassion. He
was no longer responsible for making everyone happy, his
typical role in his birth family. Richard let go of this burden
and, when needed, said no. This dance we all need to learn,
the setting of healthy boundaries.
After the dawn, Richard committed himself to daily formal mindfulness practice. He described letting go of excess
baggage, other peoples stuff. He set the intention to listen
mindfully to others, to notice his wandering mind, and to
come back to others because people need to be heard. He
chose to listen more, to speak mindfully with more ventilation, and to comment less on others experiences. I appreciated Richards emerging wisdom, and resonated with his
view and aspirations.
After the dawn, Richard recognized the importance of the
bodyembodied mind, or bodyfulness. He ate smaller
portions with awareness, and was fundamentally befriending himself. He began to deal with emotions without eating
them. He felt a deeper experience of body, lighter now and
able to move forward.
After the dawn, Richard described his experience as a
veil lifted, a hibernating bear wakes. He cried much less
often in sessions, although still teary at moments when tenderhearted. It was fall now, and there were still tissues on
the table, several boxes later. I looked past Richard at the
moody late-autumn sky and felt glad that Richards season
had transformed.
After the dawn, Richard worked part time as well as volunteered. He enjoyed an array of friends and family, and
overcame isolation by reconnecting. He set healthy boundaries with assertiveness rather than the old habitual pattern of
people pleasing. He once again enjoyed swimming, walking,
yoga, and painting.
After the dawn, Richard recognized his resistance as part
of the mindful journey. He consciously set the intention not
to skip steps, to grow patient. He realized, Nothing outside
of me can do it. He took responsibility on the path of learning to be an adult. Richard knew there was a place for him in
this world and shared with me that he felt love in each cell.
He knew in his heart he was a good person, not a patient, client, consumer, or a case.
After the dawn, Richard asked for and offered a hug when
leaving. We are the same, on this human trek requiring courage and humility. We are unique, equal, and different, dancing to the same music: love and loss, fear and bravery, fortitude and fatigue, avoiding or approaching, closing or opening, birth and death in each moment, and grasping/clinging

18 Richards Embers

or letting go. We hugged for a moment in this office with the

soft limegreen walls and then let go.
Embers (by Elisabeth Gold)
Love is the stirrer:
the ashes, unworthiness
the embers, the part that knows
(ashes to ember
ember to flame
flame to blaze)
what love is.
it feelspang and heat
love is the stirrer,
the ashes
and the flames

A Poem (by Richard)

I wanted them to love me. (I EAT)
I wanted to meet their expectations. (I EAT)
So, I listened to them on the outside. (I EAT)
My voice weakened on the inside. (I EAT)
One day, my real voice wasnt there!
It was buried under the fat, which represented the lies, anger,
hurt, jealousy, disappointment, resentment, guilt, shame and
It was so buried that it became numb with the weight of my body
of all these emotions.
I drifted into a slumber of helplessness and hopelessness,
(I EAT).
culminating in morbid obesity, depression and desperation
Many years passed and one day after much darkness and doubt,
there appeared a crack in my suit of armor,
created by the voice of truth in the name of love

this spark grows bigger and biggerand as it grows
my vessel becomes lighter and lighterfreer and freer
ready to fly
way up high.
I am home once again.

1. Forster E.M. Howards end. Epigraph. London: Edward Arnold;
2. Tillich P. Accessed 2 April 2015.
3. Weil S.
Accessed 2 April 2015.
4. Santorelli S. Heal thy self, lessons on mindfulness in medicine.
New York: Bell Tower; 1999. p.20.
5. Trungpa C. The sanity we are born with. London: Shambhala;
2005. p.161.
6. Oliver M. Owls and other fantasies: poems and essays. Boston:
Beacon Press; 2003. p.27.
7. Verghese A. Cutting for stone. Toronto: Vintage; 2009. p.486.
8. Neff K. Accessed 2 April 2015.
9. Salzberg S. Real happiness, the power of meditation. New York:
Workman Publishing Company; 2011. p.108.
Elisabeth Gold MD, is a family physician and mother, who currently
works as a psychotherapist, counselor, and medical educator in Halifax,
Canada. She is an associate professor in Family Medicine and the Division of Medical Education at Dalhousie University where she engages
in tutoring, tutor training, and communication skills facilitation. Dr.
Gold is passionate about mindfulness (since 1975), music (plays the
clarinet), writing, whole food, and is continually amazed by mutual
teaching and learning.

Mindful Decisions in Urogynecological

Surgery: Paths from Awareness
to Action


Joyce Schachter

I have a surgical referral practice in urogynecology and

reconstructive pelvic surgery and treat pelvic floor disorders
in women. I perform hysterectomies, reconstruct vaginas,
and install urinary incontinence slings. Following a dozen
years of experience, it has become apparent that repairing
anatomy is relatively easier than managing the biopsychosocial impact of pelvic floor dysfunction within a holistic
approach. Despite five years of residency, and two years
of post-graduate fellowship, problems that stretched me
beyond my boundaries of knowledge and expertise were
those requiring patience, attentive listening, empathy, and
compassion. Over time, I recognized that mindfulness, or
awareness in the present moment [14], enhanced my therapeutic relationships with patients.
Easier for me was to select surgical procedures and manage perioperative care compared to problems that caused significant suffering and cut deep into my patients lives. Issues
such as deficient self-care, unexplored aspects of sexuality,
and blocks to emotional intimacy in relationships masqueraded as gynecological problems. Voluntarily expressed, inadvertently exposed, or furtively revealed clandestine issues
emerged from behind a gynecological veneer and pushed
me past my scope of training. Mindfulness invited temporal pauses as inherent parts of a health-care partnership, increased my awareness of the decision-making process, identified patients ambivalence and resistance, allowed feelings
to be ventilated, and increased respect for patient autonomy
[5] by sharing control of the therapeutic plan. Mindfulness
enlarged the capacity of intervention to include wellness and
enabled me to interact with patients as medical expert, resource person, and learner.

Harmony Health, Ottawa Hospital, 152 Cleopatra Drive, Suite 101,
Ottawa, ON K2G 5X2, Canada

Start from Where We Are: What

Is the Diagnosis?
Barbaras eyes filled with tears, and she fidgeted in her chair.
Im healthy. I dont take any pills. Ive never had an operation, she said. Proactive health wise, she exercised regularly and maintained an optimal weight; moreover, she was
able to balance work and family life. This was her initial
consultation, and she was already defending herself against
an anticipated negative diagnosis. When I had asked if she
was sexually active, she said, Well, he is, to which we both
You have stress urinary incontinence and uterine and
bladder prolapse, I said. Its not emotional stress; it means
stress on the bladder causing leaking with laughing, coughing, sneezing, exercising, and sex. Your uterus and bladder
are leaning on your vagina, so to speak. Its like having a
hernia in the pelvic floor. Then, I reviewed her exam and
covered some basics about pelvic floor relaxation.
At 48, this fit executive in a fashionable pin-striped suit,
at the top of her game, rapidly lost her composure. An overachiever with a tough-girl veneer, she tried hard to mask
what she knew was not right. I had honed this coping skill
myself during medical training and recognized it in others. I
offered tissues.
Sorry! She reached for one and blew her nose. Her tears
said overwhelmed or incompletely resolved conflict to
Not a problem, I said. Its not your fault. Vaginal deliveries are the main risk factor and theres nothing else you
did or didnt do to cause this. It happened despite your best
Ive never heard of this. My family and friends dont talk
about it! She looked away. I sensed resistance and paused.
Despite our modern society, body changes, as consequences
of aging, pregnancy, childbirth, and value of body image, are
still wrapped in mythology and shelved in the closet behind
a veil of cultural mystique.
Whats going to happen to it? she asked.

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_19,

Springer International Publishing Switzerland 2015



Its not going to fall down on the road and it doesnt turn
into cancer.
I was worried about that, she smiled as her shoulders
dropped and she exhaled. She dried her tears. I have learned
that these two fears, barely contained, are often unspoken
and best addressed at the first visit.
Will it get worse?
Todays exam is a snapshot of you in time, I said. If it
progresses, it typically takes months or years. Its moderate
now, and this may be the worst it ever gets but its unlikely to
get better. Youve noticed it more over the past couple years.
Hows your body-image and self-esteem doing? She shook
her head, crying new tears, dabbing her eyes.
Its completely understandable. We dont always meet
our own expectations of ourselves, I said, whether or not
those expectations are realistic. She smiled and blew her
nose. We engaged in a brief conversation on the prevalence
of these problems, and I mentioned available treatments, including doing nothing. Then I paused and checked in again.
Too much detail about any particular modality would leave
her emotional reaction behind and with it any therapeutic
engagement. In elective gynecological surgery, we have the
luxury of a mindful pause, when required. When the patient
cries, becomes indignant, refuses treatment, challenges my
expertise, or repeats questions previously answered, it is
time to rest and let the situation simmer.
You mean I can leave it alone? She brightened.
Its not dangerous to live with it the way it is. It wont
make you sick by staying there. It can lead to other problems
like not exercising or socializing, or withdrawing from sex,
I said.
But is it safe to wait?
Reassured about the pace of the natural history of these
conditions, she rejected the idea of surgery and was keen to
pursue limited intervention with pelvic floor exercise, and to
return for reassessment in 6 months.
This was a good place to pause and allow her time to digest information. Patients often react to a diagnosis of prolapse with fear and express a sense of inhabiting a foreign
body sometimes for years. The central tendon where pelvic
floor muscles insert, the perineal body, is attenuated, weakening the supportive root of the pelvis. Body image created
through the senses, including proprioception, is reconfigured with negative or abnormal contributions to a new selfconcept with physical and emotional impact. This reinforces
concomitant lack of exercise and sexual disengagement
which may have adverse effects on wellness.
Cycling through feelings of fear, anger, and powerlessness may occur with a sense of loss of control, in this case
over anatomy and self-concept. The ease of navigating the
transition to resolution depends on anxieties, coping skills,
pain/discomfort tolerance, values, social support, and articulating this in a supportive environment. Mindfulness has

J. Schachter

helped me confront my own boundaries unpacking female

sexuality and learn communication strategies and language
skills from patients who helped expand my expertise. Pausing the intervention button when emotions were overwhelming was a mindfulness tool that let Barbara drive the decision-making process, within a bandwidth of safety, allowed
her to build a data bank of experiential evidence, and finetune different treatment options. This collaborative approach
validates the effectiveness of partnership in health-care decision making [6].

Ambivalence in Decision Making: Issues

Creating Resistance
Barbara returned for a follow-up 6 months later.
Can I ask you something? She crossed her legs, shoulders hunched forwards. I dont feel much during sex. It
feels like Im all open, she grimaced. Its just not like it
used to be and Im hardly even interested. I can take it or
leave it. She flushed. Ive never said that before, she said.
My husband says its different for him and he doesnt want
to hurt me, so he stays away too. Tears overflowed, and she
reached for a tissue.
Its stressful to see something you value in your marriage changing, I said. You have options here.
Im healthy, she said. But I cant exercise properly, I
hate the way I feel and look, and Im too young to kiss my
sex life goodbye! I nodded. This happened just because I
had kids?
Thats the main risk factor, I replied. A third to a half of
women has some degree of prolapse, and one in ten chooses
a surgical repair. Youre in good company.
I want to strengthen my pelvic muscles, she asserted.
Can you refer me to physiotherapy?
Barbara, a woman in my age bracket, valued fitness and
sexual activity as vital parts of a healthy lifestyle. She felt a
negative impact on her quality of life as a result of withdrawing from them. For other patients, sex is less important, or
they may be unmotivated to examine details in this arena.
Sexuality has the power to stir an abundance of feelings and
conflicts with issues relating to pleasure, privacy, embarrassment, vulnerability, pain, and self-actualization. Sexually
and/or emotionally abusive experiences may not have been
articulated or integrated into adult life, yet may continue to
influence decisions.
By defining enjoyment of sexual activity as a priority
value, Barbara recognized an aspect of herself that needed
attention and care. Knowing that significant change would
be modest with conservative modalities, I believed Barbara
would eventually choose surgery as the best chance of realizing her goal. She endured discomfort from loss of physical
activity and sex that contributed enough negative impact on

19 Mindful Decisions in Urogynecological Surgery: Paths from Awareness to Action

her lifestyle to motivate her to act. The next level of insult on

quality of life could involve distortion of her sexual identity
or her ability to eliminate waste efficiently. I did not believe
she would cross either of those lines. She had made some
progress with pelvic floor exercise and wanted to keep trying.
I dont want surgery. She shook her head, raising her
palm toward me. And I dont want a pessary either. A pessary, or plastic support worn in the vagina, like a vaginal
bra, could be cumbersome for Barbaras active lifestyle,
and surgery seemed too invasive and remote as an option for
the time being.
You can always buy a ticket for surgery, I said. Its
not like you have only one chance, its available to you anytime.
But if I wait, will the surgery be more complicated and
harder to recover from?
The operation may take longer if the prolapse progresses.
As long as youre general health is good, youll heal well.

How Much Is Enough Discomfort: The Precipice

(Decision Point)
Barbara bumped up her next appointment by 3 months. Improvement was not happening fast enough. The prospect of
surgery, previously a distant action on the horizon, was now
nearby in the landscape. However, the invasiveness and the
6-week stay-at-home postoperative recuperation seemed unbearable, but she had reached her limit with the status quo.
Its not getting better, she stated, leaning forward in her
chair, looking me in the eye and tapping her foot.
Sounds like its bothering you more than it did three
months ago, I said. She nodded.
How much does it bother you now: a little, medium, or
a lot? I asked.
Medium, I guess, she said. I noted medium as well as
her tendency to underestimate her discomfort.
Do you think its worse now or are you tired of putting up
with it? The additive effect of a low-grade chronic irritation
over months or years can be as irksome as a high-intensity
acute insult over days or weeks. Even when sufficient impactful data are accumulated and a tipping point is reached,
oscillating between core decision and action generates mental friction lessened with further information and exploration
of feelings and attitudes. I answer patients questions and
prompt for uncertainties to build a foundation of supportive
awareness to allow them to take the next step within an acceptable risk framework. Repeated micro-decisions that reinforce a consistent action plan take time, insight, patience,
and self-compassion. For some patients, the inability to exercise becomes burdensome, leading to secondary health risks.
In others, interrupted sexual intimacy or comfort with ones
body is the determining factor.


Im fed up, she wrung her hands. She spoke briefly of

her travel plans and a friend who was happy after having
similar surgery.
At this point, I recognized that a surgical intervention
could be more palatable than the status quo, despite its risks
and under the right conditions.
Do you think youll have an operation for prolapse at
some point in your life? I asked.
She sat still; staring at me, slowly she nodded. Probably
was her reply.
Do you think youd have surgery within the next year,
two years, five or ten years? She stared at me and paused.
Finally, she said, Probably within the next year. Weve
got a trip to China this spring, and we want to spend time
with our kids over the summer.
It was January. Would you want surgery in the fall or
winter? I asked. She paused, and then nodded. Travelling
with her husband trumped distress with sexual discomfort,
despite verbalizing the latter as her priority.
Patients often request my opinion about what they
should do. Mindfulness has allowed me to mirror what I
perceive are my patients priorities and to interpret this question as an opportunity for them to gain perspective by connecting to my experience. Mindfulness, or the awareness that
unfolds as we pay attention, on purpose, in the present moment [1], gave me the prerogative to ask questions patients
did not think or have not permitted to ask of themselves, yet
need answers.
How much time would I need to be off work? I knew
her decision was formed at that point, and she was past the
fork in the road. Details like this serve to refine, clarify, and
personalize the plan to make it fit, even if the timeline is
still undefined. She had committed to the next step. I explained postoperative care and Barbara brightened, nodded
and agreed to the plan of surgery in the fall.
To believe one has a right to determine the nature of ones
corporeal environment is an act of assertiveness. The rate of
change in Barbaras decision making seemed directly proportional to her motivation, adaptability, and ability to clarify her goals and identify impedance to progress. She was
willing to accept reasonable risks of surgery that were previously unacceptable when she acknowledged inadequate improvement with current strategies. Barbara traded protracted
discomfort at the brim of intolerance for the possibility of
relief when she became weary of resisting an excellent opportunity for change. Personal comfort slowly revealed itself
to be more highly valued than previously gauged. Collecting specific experiential information helped redefine Barbaras status quo and allowed resistance to action to slide
away as she moved forward in her process. Overall, it took
more energy to resist her fears than that required to allay
them with attention and inquiry, clearing the way to a viable
solution. Mindful engagement allowed me to offer empathy


and support, more likely to facilitate change than directive

approaches [7]. A tipping point was reached, and a decision
recognized, first peeking, and then more fully emerging into

Boundaries Between Awareness and Action:

I Want Treatment Now
Barbara returned early September.
I want the surgery, she said when I entered the room. I
felt it the whole time walking the Great Wall of China. Ive
had it and the timing is good. We had a great trip and a terrific summer, and now I want to fix myself up. Can I have it
next week?
Once a decision is acknowledged and options clearly defined, actions to achieve the goal are enabled. Barbara had
disengaged from her initial emotional reaction to her condition, adjusted her attitude to treatment, and was ready for the
next step. She was willing and able to prepare her work and
home environment to assist her recuperation [8].
Well make your reservation, I smiled.
Im still afraid of the surgery, she said, after we discussed the details.
What about it concerns you?
Im afraid I wont wake up. She denied a previous bad
experience. I told her many people share this fear and that
statistically, it was more dangerous to drive to work every
day. I shouldnt have looked on-line. I was petrified! Reframing the risk, her lack of past trauma, and acknowledging
negative thinking helped deflate the phobia.
We booked a vaginal hysterectomy with reconstruction
of the vagina.

Beyond the Fork in the Road: A New Corporeal

Six weeks after her surgery, Barbara returned to my office
looking rested, relaxed, and excited.
I feel great! Can I get back to the gym?
I examined her and lifted her restrictions. And you can
travel wherever you want now, I said. And have sex.
My husband will be really glad to hear that.
Go slowly the first time and use lubrication, I said. She
nearly skipped out of my office.
Some patients motivated primarily by exercise, sports, or
physical comfort joke they will tell their partner they can resume intercourse in 6 months, doctors orders. The range of
libido and sexual activity in my patient population is leagues
wider than social media suggests. Sexuality plays a vital role
in womens lives, in positive and negative ways of varying
intensity, but is rarely neutral.

J. Schachter

Three months later, Barbara returned for her final checkup. Her bladder and bowel function were normal, she felt
support in her vagina, and her sex life had improved.
Why didnt I do this before? I cant believe the huge
difference its made in my life. I feel normal again. I dont
have to think twice about doing an exercise class, and sex
is so much better. Its liberating. Im telling all my friends,
she said, echoing a common sentiment I have heard from
many women after reconstructive surgery. She thanked me
profusely and hugged me, one of the many reasons I find my
job satisfying.
It seemed that Barbara accurately assessed the importance of travel in her decision but may have overestimated
the importance of sex. She had a strong relationship with
her husband and delaying her surgery to enable travelling
spoke volumes about what her true priorities were. Barbaras
sexual identity was a vital part of herself, but a lower priority
compared to enjoying leisure time and companionship with
her partner. The hierarchy of these values is often recognized
at a critical decision-making point or in hindsight.
Over a 2-year period from initial consultation to postoperative checkup, Barbara eventually chose surgery. What determines the timing of the decision-making process and why
do some patients live with significant discomfort for prolonged periods, while others complain with the emergence
of the first sensation suggesting that something is awry? I
regard this as an analogue to pain tolerance, distributed over
a bell curve similar to other human characteristics. Along a
decision-making path, there are a number of exit points that
may match treatment to needs. Patients may choose conservative therapy and return for surgery years later. I encourage
patients to weigh in on their preferences and treatment goals
to resolve their problems with practical and realistic solutions. Patients presenting with recurrent prolapse say they
sought help earlier because they recognized the symptoms
and chose to act sooner than the first time. Repetition reinforces learning and facilitates adaptation.

Mindful Partnership: Rational Mind (Thinking)

and BodyMind (Feeling)
As a physician, I was trained to manage information, weigh
risks, communicate results, and perform procedures. I use
my collecting, comparing, contrasting, and communicating
mind to analyse and manage measurable data. The power of
the scientific method rests in measuring quantifiable variables to produce evidence-based medicine. The healing potential of a wellness tool, such as mindfulness, may be challenging to quantify though approachable with quality-of-life
parameters [9, 10]. Mindfulness applied in my work invites
womens feelings and attitudes about sexuality, self-image,
and self-esteem, while parking my opinions and judgments

19 Mindful Decisions in Urogynecological Surgery: Paths from Awareness to Action

out of therapeutic range. Recognizing the potential power of

my opinions and judgments serves to amplify my responsibility to discern how and when to express them.
In planning elective urogynecological surgery, we have
the luxury of time. Mindfulness in my practice provides tools
to include unmeasurables in the decision-making process.
By pausing, slowing down, noticing emerging issues, intuitively exploring salient moments with patients, and inviting
their input, I am a partner to change, and I am changed in
the process, by increasing my awareness, experience, and
skill. Observing resistance, fear, ambivalence, sensitivities,
attitudes, shifting values, and turning points, then mirroring
these, asking questions, and agreeing on a plan give patients
a sense of validation and control. I have the honour of bearing witness to the subtle and powerful role female sexuality
plays in womens lives: How body structure and function affect emotional wellness and self-esteem, seeing how values
shift attitudes as patients articulate their conscious needs.
Expressing this can be cathartic, especially when its impact
has been undervalued or suppressed. My role as physician
has evolved to mirror patients situations, feelings, and attitudes for the purpose of increasing awareness to facilitate
joint decision making to improve quality of life. It is possible
to learn to care empathically for patients without draining
ones sympathetic reserve. I care with you rather than for
you implies responsible partnership rather than a hierarchy.
Inherent in the natural history of pelvic floor dysfunction
is an emotional process of loss, grief, and acceptance that
progresses at the patients own pace. Awareness that these
conditions are not serious health threats and acceptance that
these problems are common, repairable, or tolerable is a
relief for the patient. A safe environment can be cultivated
by inviting patients contributions in feelings and attitudes
about typically hidden or taboo topics and assigning weight
to these factors in surgical decision making. I incorporate
subjective physical and emotional impact statements into the
objective assessment to invest in informed choices.
Decision making in gynecological surgery starts with the
shock of incongruence between physical and mentalemotional selves. In a model of mindful surgical practice, I start
from where the patient is and accompanying her through a
decision-making process in which we cocreatively redraw
boundaries according to her needs. This helps her arrive with
confidence at an action plan, and helps me reduce my stress
by empowering her to share the directors chair. Patientcentered treatment incorporates the decisions and preferences of patients into the clinical calculus [11]. As medical
expert, witness, and coach, I encourage and modulate patient
choices within a framework of safety, efficacy, and compassion. When structure, function, attitude, and emotions move
toward reintegration, healing begins.


Limitations in Gynecological Surgery Decision

The course of decision making depends on knowledge, attitudes, statistics, mythology, feelings, hopes, anxieties,
recognition, and trust. High-inertia resistance may remain a
large undefined area dense with entanglements beyond my
ability and scope. Issues such as sexual or emotional abuse,
conflicted caregiver roles, post-traumatic stress disorder, and
undiagnosed and/or untreated psychological disorders may
make resistance difficult to overcome. Discussing relevant
matters may be frightening and overwhelming. I may enquire about social support at home or during appointments,
or whether the patient is engaged in psychotherapy.
Figuratively, repairing the lowest part of the core body is
a metaphor for root support, physically and emotionally
both central to female identity. However, the metaphor of
structurefunction integrity extends only so far. Restoring
pelvic floor anatomy cannot fully mend an ailing relationship or emotional dissonance between intimate partners,
trauma related to sexual abuse/assault, or deeply rooted dysmorphic body image. This is beyond the scope of my practice although relationship dynamics are regular parts of my
patient encounters, directly or indirectly.

Decision Making in Womens Health

In addition to evidence-based medicine, women place as
much priority on personal values, family history, community culture, peer opinions, web testimonials, multimedia
reports, and their doctors recommendations [1215]. They
often face initial confusion, move through ambivalence, and
end with a decision to take a step with conservative treatment, proceed with surgery, or postpone the decision. Ambivalence can be as brief as a moment or as long as a lifetime. Early in my practice, I would get caught in a patients
dance of ambivalence and rationalizations about treatment
until mindfulness awakened me to patterns in the decisionmaking process. It behooves us as clinicians to recognize,
in a nonjudgmental manner, that these factors play an important role in patients decision making. Given the power
of media in modern health care, it is imperative to weigh in
on our experience, skills, and knowledge as physicians, and
on the strength of the therapeutic relationship to modulate
on-line information and extend the patients perception of
her autonomy. Mindfulness provides tools to enhance our effectiveness in this endeavor, facilitates decision making, and
embodies the art in medical practice.
It is clear that each stage of the decision-making process
serves a function. At our first meeting, if a patient says she


wants surgery, I guide a cursory tour through relevant considerations to ensure they have been adequately reviewed.
Rewinding and replaying through nodes in the decision process creates opportunities for questions, exchanges of useful
information, and explores what the patient may not realize
she did not know, or think to ask. Mindfulness helps fill information gaps to enable informed consent, adjust expectations of outcome, and lessen the tendency toward blame regarding complications. When a patient comes to surgery, and
unfortunately sustains an adverse event, she needs to be able
to remember why she took the risk in the first place. Creating
a story that links patients subjective experience with evidence-based data and experienced medical judgment allows
her to understand its impact on her life more tangibly. Pausing, rewinding, listening, mirroring, confirming, accepting,
and proceeding are mindful ways of ensuring patient and
caregiver move together as a team through the therapeutic
process. Decision aids have also been helpful in this regard
[16]. Mindfulness places equal importance on each step in
decision-making with adjustments to suit the patients needs
and desires at any stage. Action then follows naturally, including living with conditions exactly as they are, sometimes
even with acceptance and grace.

1. Kabat-Zinn J. Wherever you go there you are: mindfulness meditation in everyday life. New York: Hyperion; 1994.
2. Kabat-Zinn J. Full catastrophe living: using the wisdom of your
body and mind to face stress, pain and illness. New York: Delta;
3. Santorelli S. Heal thy self: lessons on mindfulness in medicine.
New York: Bell Tower; 2000.
4. Hahn TN. Peace is every step: the path of mindfulness in everyday
life. New York: Bantam Books; 1992.
5. ACOG Committee Opinion. Surgery and patient choice: the ethics
of decision making. Obstet Gynecol. 2003; 102(5 Pt 1):11016.
6. Barry MJ, Edgeman-Levitan S. Shared decision makingthe pinnacle of patient centered care. NEJM. 2012;366:7801.
7. Engle DE, Arkowitz H. Ambivalence in psychotherapy: facilitating
readiness to change. New York: Guilford; 2006.

J. Schachter
8. Miller WR, Rollnick SR. Motivational interviewing: preparing
people for change. 2nd ed. New York: Guildford; 2002.
9. Al-Badr A. Quality of life. Questionnaires for the assessment
of pelvic organ prolapse: use in clinical practice. Urology.
10. Schurch B, Denys P, Kozma CM, Reese PR, Slaton T, Barron R.
Reliability and validity of the incontinence quality of life questionnaire in patients with neurogenic urinary incontinence. Arch Phys
Med Rehabil. 2007;88(5):64652.
11. Gee RE, Corry MP. Patient engagement and shared decision
making in maternity care. Obstet Gynecol. 2012;120(5):9957.
12. OConnor A, Rostom A, Fiset V, Tetroe J, Entwistle V, LlewellynThomas H, Holmes-Rovner M, Barry M, Jones J. Decision aids for
patients facing health treatment or screening decisions: a Cochrane
systematic review. BMJ. 1999;319(7212):7314.
13. OConnor AM, Drake ER, Wells GA, Tugwell P, Laupacis A,
Elmslie T. A survey of the decision-making needs of Canadians
faced with complex health decisions. Health Expect. 2003;6(2):97
14. Elwyn G, OConnor A, Stacey D, Volk R, Edwards A, Coulter A,
etal. The international patient decision aids standards (IPDAS)
collaboration. Developing a quality criteria framework for patient
decision aids: online international Delphi consensus process. BMJ.
15. OConnor A, Wennberg J, Lgar F, Llewellyn-Thomas H,
Moulton B, Sepucha K, Sodano A, Staples King J. Towards the
tipping point: accelerating the diffusion of decision aids that help
patients to weigh benefits versus risks. Health Aff. 2007;26(3):
16. Stacey D, Lgar F, Col NF, Bennett CL, Barry MJ, Eden KB,
Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Thomson
R, Trevena L, Wu JHC. Decision aids for people facing health
treatment or screening decisions. Cochrane Database Syst Rev.
2014 (1). Art. No.CD001431. doi:10.1002/14651858.CD001431.
Joyce Schachter MD MSc FRCSC is an assistant professor of obstetrics and gynecology in the Division of Urogynecology and Reconstructive Pelvic Surgery (URPS) at the University of Ottawa, in Ottawa,
Canada. She is the program director for post-graduate fellowship
training in URPS, manages a full-time clinical practice, and teaches
residents and medical students. She serves on the Physician Health and
Wellness committee at The Ottawa Hospital. Mindfulness is a key element in Dr. Schachters practice. According to Dr. Schachter, mindful
surgical planning empowers and motivates patients to determine elective interventions at their own pace and increases patient satisfaction
with outcome.


The Good Mother

Kimberly Sogge

We dont see things as they are. We see things as we are.Anais Nin

This is a story about a therapeutic conversation in which a

patient and I both journey to embodying psychological flexibility in our consultations and in our lives outside the consultation room.
I am a clinician who spends her days in psychotherapy
with adolescents and adults. In my years of practice, I have
discovered that the psychological flexibility perspective allows me to weave mindfulness in a profound way into my
moment-to-moment interactions with patients during psychotherapy process, to let go of my own habitual perceptions
and habits that may limit the growth of my patients, and to
more skillfully intervene with patients when their ability to
encounter their own mindfulness, their most profound humanity, has been compromised due to learned patterns of
perceiving, thinking, feeling, or sensing.
Of course, in psychotherapy, healing is a function of the
profound interconnectedness between clinician and patient;
because I am so interconnected with my patients, although
my intention and priority is always their healing and transformation, not infrequently my patients heal and transform
me. The patients who have made me the clinician I am today
are too innumerable to single out, so this narrative is a composite of these innumerable unintentional bodhisattva patients, who in seeking their own healing have allowed me
to contact more deeply my own humanity, as we have journeyed together through the process of psychotherapy. I hope
that this hybrid narrative, the sum of innumerable encounters
and patients, offers the reader one flavor of what mindful
clinical practice looks like in psychotherapy. In the work
that I do with patients, I frequently seek ways to creatively
contact the six components of psychological flexibility described in acceptance and commitment therapy (ACT), a
University of Ottawa, 9 Lewis St., Ottawa, ON K2P 0S2, Canada

mindfulness-based psychotherapeutic approach that may or

may not include formal meditation but which, in my experience, supports the kind of nonjudgmental attention, embodied relationship to present moment experience, and support
for heart-led living frequently found in formal meditation
practice. For those readers who experience the world more
through metaphor and visual means, I have included a visual
representation of the relationship between the components of
the psychological flexibility model in Fig.20.1, with thanks
to the founder of ACT himself, as well as the developer of
this particular figure, who referred to the generous nonproprietary values of the contextual behavioral science community in immediately and generously sharing this visual with
the mindful clinician community [14].
The psychological flexibility model, originally developed by Strohsahl etal. [5], has six key components that
are addressed in a nonsequential manner as they arise in the
dynamic interplay of the relationship between clinician and
patient. They are:
Present moment awareness, or contact between awareness and ones embodied experience of the present without controlling or avoiding any aspect of the experience.
Clarity and contact with values, or those ways of being
in the world that bring a sense of vitality and aliveness to
ones human existence.
Committed actions or movements of the hands, feet, and
mouth in the service of ones deepest values.
Self as context or a sense of self as the witness or observer.
Cognitive defusion, or holding thoughts lightly, recognizing them as products of the mind, without accepting that
they refer to present moment reality in any way.
Acceptance and willingness, a kind of whole-heartedness
in which one consciously chooses to not just be aware,
but to stay aware and from moment to moment drop the
urges to struggle with experience, to analyze, fix, or make
it be other than what it is.

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_20,

Springer International Publishing Switzerland 2015


K. Sogge


















Fig. 20.1 The acceptance and commitment therapy model. This figure, also known as the Hexaflex reflects the major dimensions of the
psychological flexibility model developed by Stephen Hayes etal. as
part of relational frame theoretical foundations of acceptance and com-

mitment therapy, a third-wave therapeutic approach that is researched

and practiced by the worldwide contextual behavioral science community (see for more information)

The session: I am seated in my worn leather chair in my office in a spacious, formerly grand home renovated to a dozen
offices, in Ottawa, Canada. I am between patients savoring
those precious minutes between psychotherapy sessions
where I spend a few moments reconnecting with my breath
and body in the present. I let go of all that has come before,
and with a few deep breaths and maybe a few stretches on
the floor, ready the earth of my body and mind to receive the
new seeds of the patient who will be settling in across from
me in the coming session. I notice there is a slight draft from
the sharp Canadian winter wind moving through the old window with distorted panes to my right. I wonder if I should
block it, and then decide that it is having the helpful effect
of keeping me alert and fresh and I decide to leave it alone.
Relaxing into the chair, I intentionally place my feet on the
floor. I feel the thick, old carpet beneath my feet. I draw a
long in breath and feel the oxygen fill my lungs, expand my
rib cage, lift my chest. My fingertips sense the coolness of
the arms of my chair. The room smells like wood smoke,
a remnant from the ancient fireplace behind me. I drop my
shoulders, rolling them ever so slightly outward and sliding
my scapula down my back. Extending the crown of my head

slightly upward, I notice a light hold at the top of the breath,

then I let my attention slide down the long exhale as I press
my feet into the floor, open my eyes, and stand up in the big
consultation room. As drafty and creaky as it is, the walls of
the room are warm; the room is a refuge to me, and many
patients have told me they experience it in the same way.
I sense that the space is now prepared for my patient, both
within and without. An image passes through my mind of an
otter joyfully sliding down a riverbank as my attention rides
the full exhale of my breath. My mind thinks the thought
OK sweetheart, next patient. I walk across the room and
place my hand on the cold brass doorknob.
As I open the door, a woman startles and looks up from
her cell phone (expectantly? worriedly?) in the waiting area.
There is a moment of recognition. Oh yes, I have met her
before. It is our first parent-only session after her teen fired
me. The initial call some months ago had been frantic, I remember. It had been a call for assistance with a family member suffering from a suspected eating disorder. I get many
such referral telephone calls every year from our geographic
area, as I practice a form of family-based treatment for eating
disorders that is not widely available in our region. As I see

20 The Good Mother

my patients face, my mind quickly provides a picture of her

daughter, a younger version of her. I have a foggy memory
of the entire intake session with her daughter, but I do recall
that her daughter had not been ready or perhaps was thoroughly uninterested in the services we offered at our clinic,
thus we had not continued beyond the first intake, perhaps
making some referrals to more traditional providers. After
years of clinical practice, I still feel the sting when not allowed to help when I am confident that I have the proper
diagnosis and intervention protocol that could ease suffering.
However, as most clinicians eventually realize, an excess of
professional ego is a luxury not conducive to effective treatment and patient progress. I remember now that I had not
pushed my agenda with her daughter in that one and only
session. There must have been a good reason. Now I wonder,
why her mother is here? I wish I had made the connection
when she called so that I could have reviewed the chart for
family history rather than thinking she was new. I feel my
mind anticipating questions, anticipating requests for professional opinions, and reminding me that I like to be fully
prepared. Smiling, and internally thanking my overeager
problem-solving mind for its Sisyphean efforts, I decide to
drop the internal dialogue and simply be curious. I hold out
my hand and my patient approaches and grasps it.
I am so incredibly glad you agreed to see me, she declares.
She is tall; I notice that we have this in common. Moreover, we appear about the same age. She is quick with her
movements and her smile. As we move through the ritual of
entering the consultation room, winter coats are hung and
pleasantries exchanged about the weather, the neighborhood
traffic, the convenience of the booking system, etc. In the
meantime, I am noticing that she is quick to apologize and
to make light of any inconveniences en route to getting to
the session.
Mindfully attuned to any discrepancies between what is
happening in the world of the five senses and the world of
language, I file my fleeting footnote about my patient away
for future reference. Mindfulness of these things could be
helpful, or it could hinder action on more important issues.
Reflection: After years of teaching mindfulness in stress
reduction classes, I had noticed myself, and my patients, occasionally becoming caught up in the view of the practice
of insight meditation as a panacea. Being naturally skeptical
and committed to evidence, I began looking deeply into the
causes and conditions behind why my patients and I would
get stuck in the midst of such a beautiful and rich practice
as mindfulness. In this self inquiry, I saw that we needed
to expand our definition of mindfulness beyond open, nonjudgmental awareness in informal or formal mindfulness
practice, to mindfulness in psychotherapy that was an embodied way of being, a way of experiencing the painful and
stuck places of humanity and responding with compassion,


skillfulness, and vitality. After this moment of awakening

as a psychotherapist 7 years ago, I found myself seeking a
way to practice psychotherapy that allowed me to truly integrate what Buddhists refer to as right view and right
speech with the classic mindfulness meditation practices I
had been teaching in my mindfulness-based stress reduction
and mindfulness-based cognitive therapy. My intention for
this way of being as a psychotherapist was to move beyond
the superimposition of classical meditation practices on an
old agenda of assessing, diagnosing, intervening, and eliminating symptoms, to a form of psychotherapy that would
modify the fundamental stances of both therapist and patient
regarding thoughts, emotions, sensations, desires to avoid or
control, stuck habitual patterns, concepts of self, and outmoded habitual behaviors and finally, pain.
I found the form of psychotherapy that was most consistent with my mindfulness practice was called ACT. I travelled to the Association for Contextual Behavioral Science
conference in Parma, Italy and learned more. I was exhilarated that I had found at this conference clinicians and researchers who were interested in integrating mindfulness deeply
into the process of change in psychotherapy, as well continuing to support the formal practice of mindfulness.
The session: Back in the session with my patient, I decide
after a few minutes to point out to my patient that in the
space of as many minutes she has apologized to me, or minimized the inconvenience of the terrible construction work at
the entrance to the street on which our practice is situated,
not less than four times.
Totally OK with me if you are irritated by the long lines
and the frenzied traffic cop at the entrance to our street! Are
you worried I will think ill of you if you complain? I query
with kindness.
Unexpectedly I note the telltale flush and downcast eyes
of an emotional response in this articulate and apparently
confident professional woman.
Ha-ha well yes, of course that is true, she says, and
quickly deflects by noting, All that aside, what I am really
seeking is your professional advice about my daughter, who
is refusing to see anyone right now. We dont know what
to do about her. She has quit all therapy. Family therapy
makes us all feel like shit. The psychiatrists say she is not
sick enough to be admitted to an inpatient unit. The outpatient program has a two year waiting list. Her school says
they dont have the resources to deal with her. What have we
done wrong?
I remember from the initial intake with her daughter that
this mom has advanced academic training. I entertain the
thought that she is likely as skilled at analysis and problem
resolution as any exemplary clinician. I remember that she
is surrounded by others in her work environment who may
have given her myriad reasons, both valid and invalid, for the
current agonizing situation with her daughter. I feel compas-


sion for her, her family, and her daughter welling up in me.
Perhaps analysis and reason giving are not what is needed
here? However, my problem-solving mind is already at work
in the consultation room. She quickly produces the latest
stack of test results, psychiatric evaluations and assessments,
seeking professional advice to solve the pressing problem of
her daughter. I feel terror in the room. I listen carefully to the
litany of diagnoses, case formulations, and failed treatments.
Understanding the need to know and the felt pressure to
explain and analyze pain, while noting ruefully to myself that
my mind shares the human bent towards fixing and explaining, was I not doing exactly the same thing to myself just a
few minutes ago when this patient entered to the room? I
listen intently for some time, modeling presence and holding
of all this thinking with some lightness, questioning perhaps,
with this stance of not reacting to the daunting list of clinical
problems to be addressed, both the existence of diagnoses
as real entities, and the necessity of being stuck in suffering because of a diagnosis. When my lovely patient pauses
to breathe while in the story of fear, frustration, and agony
left in the wake of serious mental health symptoms, I say, I
think I am getting the picture. So I am hearing that you have
tried everything. I hear how much you want your daughter to
have a good life, and I both hear and see that you are feeling
terrified at the thought that a good quality of life and hopeful
future does not seem possible for your daughter with her current symptoms, the confusing messages about medication,
about diagnoses, about best treatment options, about school.
You are concerned for her, as any good parent would be. As
a parent I identify with your terror! We will discuss your
daughter, and I am confident that I have some ideas on how
to be with this difficult situation in a more workable way.
However, can we just back up for a second and have you
describe what happened right there a few moments ago?
Right where? she asks.
When I noted that you were apologizing and minimizing
all the inconvenience just to find my building. I noticed your
eyes changed or something crossed your face and I was curious about what was going on with you. Then when I noted it
you quickly moved to the next topic. What did you experience there? I respond.
Reflection: In the mindful practice of change in psychotherapy, we clinicians and our patients endeavor to drop our
habits of avoiding or controlling our experience, and seek to
just explore what is, without judgment. In this way, together
we may discover new information that we may have been
pushing out of our awareness, and we may tap into previously ignored resources to expand our range of options for
skillful response to challenges that initially may have seemed
overwhelming or intractable.
The session: She takes a sharp inhalation. Ah yes, I feel
so selfish. This is supposed to be about my daughter. Hmm
(tearing up) right there I felt a surge of grief. I feel like I am

K. Sogge

drowning in failure. We are a nice family. But we cant seem

to get it right. We have been to the ER three times this month.
My daughter has been out of school for most of a year. She is
cutting. If we say no to her she screams and tells us we dont
love her and threatens suicide. Her medication is constantly
changing. We see treatment teams, and I have to tell you it
is embarrassing because many of them we know socially or
professionally, and after all this they see us in an entirely different light. Once upon a time we were great parents. Now,
we meet with people who once liked and respected us, and
because our daughter has been in the ER, they are talking to
us about what we must have done wrong as parents, about
flaws in our attachment processes. I feel like the worst person, the worst mother, in the world. A pariah. Is this all we
can hope for, for ourselves, for our daughter? And sometimes, it is so insane at home (tearing up again) I feel
like you hate her? I ask softly.
And her tears flow unabated.
There is a dull pain in my chest as I hear her story. I lean
in and breathe. We let the tears run down her face. In a few
breaths I say, I am so sorry. Lets try to do something new
here and then I hand her our economy size box of tissues.
She laughs at the ridiculously big box, then smiles a bit
through her tears, saying,
God I hate this.
I know, I say, I hate that it happens this way too.
Reflection: How often does dominance of past or future
experiences keep us caught up in suffering? We look to the
past, amplify the wounds we experienced there, or perhaps
we seek explanations of our current pain in order to feel in
control of it. Sometimes we project our pain into the future,
and create hopeless scenarios as a way to avoid actually staying in full contact with the pain of the present moment. One
of the scenarios we create lead to intense suffering is when
we say, This cant be happening to me. We get caught up
in the words we have told ourselves about who we are. When
the reality of our experience does not match those words,
we either deny our reality, or we fall into predictable stories
about who we are. I must be the worlds worst mother. I
am a pariah; I have failed therefore I am a failure. In psychotherapy, I hope we can identify these stories about who
we are, who we are supposed to be, as conceptualized self.
Conceptualized self fails to recognize that we are in a constant state of change. The problem is, if our contexts constantly change, to be healthy, our self-concept must be imminently flexible, ready to mold as Bruce Lee said like water
to the cup. Anything less and suffering occurs.
The session: In the next session I ask, Could we start by
turning that big scary thought on its head?
Which one? she asks.
The thought that I am the worst mother in the world and
that is terrible, I respond.

20 The Good Mother

We tread through her memories of the day her daughter

was born fully contacting how deeply she feels love for her
daughter, and establish that this profound connection of love
does not exclude hate. She remembers vividly how she held
her daughter naked on her chest only moments after birth.
She remembers how both parents stayed up late at night with
their colicky baby daughter, how they had frequent cuddle
sessions that have continued to this day. How her daughter
had been a gifted student, artist, leader. Her face glows with
the love and pride of a mother.
Then she shares this secret: When I see my daughter experience so much pain that she has to cut herself, it kills me.
I think why? I think if only I could take all that on for her. I
could die if it would take it all away from her.
You resonate with her, I reflect.
If attachment is, as Siegel describes, the exchange of energy and information between two people [6] like the sound
waves coming from my voice to your ears, and not a static
quality or trait of either individual, then it sounds to me like
you are attuned with your daughter. You feel what she feels
and that is incredibly difficult for you.
Yes, I am totally connected to her. I can feel that. So
maybe I am not the worst mother in the world, she concedes.
It may also be helpful to know that Mary Main, the
founder of attachment theory, and her research team, when
they observed good enough caregivers, saw that there was
not one constant state of energy and information exchange
between good enough caregivers and their children. The
types of interactions were about equally divided in the research between mis-attunement/distress, repair from misattunement, and attunement. Does that help you see mothering and attachment more as a process than as a static quality
attributable to either you or your daughter? I inquire.
Yes, she answers. Her skin flushing, I witness emotions
I feel so angry. I am angry with the system. Everyone in
the hospital made me feel like the most horrible person. They
kept saying that with these symptoms our daughter there had
to have unresolved attachment issues. My husband and I
couldnt figure out where we might have gone wrong.
I hold my right hand out like it is cradling something precious. Or I say, could we hold all that anger, all that frustration, with gentleness, without knowing.
With my left hand, I put my hand to my eyes as if I am
an explorer looking out to sea, searching for my destination.
We look so hard for answers. We are sure there must be
one right answer. We analyze. We dissect. We search. We
long for the security of knowing something for sure.
She nods.
I continue, dropping the left hand to place it next to the
right, making a bowl. Yet maybe we can never know. Maybe
the challenge is to drop the need to know. This searching
and searching for the best analysis, the best answer, in itself


becomes suffering on top of the pain that initially prompted

the desire to search. Maybe we can hold the mystery, along
with all of the anger, fear, sadness that goes with it. We can
hold it in awareness.
She looks reflective. That feels like something I can
work with. I am just so tired of struggling.
Feeling our presence in the room with one another, the
connection between us, I say You know, it could also happen here, that we become mis-attuned or I make you angry
or vice versa. I hope that you will tell me when I make you
angry or when we are mis-attuned. I will be honest with you
if it happens with me. It is no big deal, but could be a problem if we dont put it right out there and talk about it. This
room is a laboratory for testing out things that you do later
out in the rest of the world.
I have no problem with doing that. Believe me I have
learned from an expert (my daughter), we laugh.
Good. I benefit from her training. Thank you, I say.
Then, pausing Can I suggest something? I say,
There is another way that we can be with this thought that
you are the worlds worst mother, besides challenging the
distortion. In my experience this way is even more powerful
than turning the thought on its head.
She assents, so I suggest Imagine your hands are
We both place our hands on our eyes.
What do you see?
Um, darkness. The inside of my hands.
OK, now place your hands two inches from your face.
Now what do you see?
The outlines of fingers. I see light glowing pinky-red between my fingers. A little bit of you.
OK now lets stretch out our arms. Now what do you see?
My bright, caring, angry patient laughs out loud.
I see two crazy people sitting in a room holding their
hands out in the air.
She is funny. I laugh with her.
What might it be like to relate to your painful thoughts
with this kind of freedom, with this kind of room in which to
move around them rather than being trapped inside them?
I query.
We end the session with her shaking her head.
Reflection: On some days, I struggle with fusion with
thoughts as much as my patients do. In mindful practice, I
intend to shift myself and my patient from a position of believing the thoughts that pass through our minds, to seeing
thoughts as events in the mind, weather in the climate system
of our being. Just as weather requires the right conditions to
form, so thoughts are conditional and require the right conditions to form. It is transformational when one realizes this
new relationship to the contents of the mind.
In another session, my patient is confused by our demonstration of cognitive defusion in which hands are thoughts.


But this blows my mind. This is what I do to myself.

This is what I am GOOD at doing! This is how I earn my living damn it! What am I supposed to do if it is not to take my
thoughts too seriously? What else is there?
Excellent points. Excellent question, I agree.
And what about when my daughter says she is thinking about killing herself? Are we supposed to just ignore
that? What if we are wrong? This is terrible! I observe that
she is getting angry at me and my therapeutic absurdities.
Let me suggest that perhaps rather than treating everything that is happening in the mind, even your daughters
mind, as a reality, we treat it as the conditioned arising of a
certain pattern of neuronal firing. We dont dismiss it, but we
can respond to it rather than react to it.
Reflection: Compassion, living from my heart as I sit with
experience, is so important to me in responding skillfully to
thinking, both my own and my patients. Too often, I see that
my first reaction to realizing ones fusion with unhelpful or
unworkable thinking is to say, What an idiot I am! I cant
believe I am doing that! Over the years, I have learned to
shift my motivational strategy, to speak to myself and the
areas of myself that my mind considers a little behind, a little
less on program with the rest of my being, with kindness
and encouragement rather than criticism. By doing this, I am
more able to encourage clients in recognizing and shifting
their own motivational strategy to one that includes a little
more kindness with their stuck areas.
I intend to also see these stuck areas as perfectly sensible
responses given the context in which they originated. We all
do, think, and feel things that perhaps made perfect sense
earlier in our lives, or in some cases earlier in our parents
lives or our grandparents lives.
Instead of abusing ourselves for participating in our
human inheritance, I intend to invite my patients to tap
into the evolutionarily older tend-and-befriend responses
rather than persisting in energy draining or futile fight-andflight responses.
The session: Several sessions later, my patient arrives
eager to tell two stories.
Here is the first one:
So we were about to take a big risk. We were to go out to a
friends house for dinner without our teenaged daughter. This
is always a hard time, because we need to make sure a) that our
daughter doesnt bolt with an unsavory character (this has happened in the past), and b) that she doesnt find some self harming
strategy or tool that we have missed and kill herself while we
are gone. We were understandably apprehensive, but you have
been encouraging us to hold our thoughts lightly, and to stop
avoiding doing things that are important to us. Community is
really important to us, and this past year we have been really
isolated due to her illness and everything. So, we planned and
talked about this a lot before we decided we were ready to do it
and we felt that our daughter was ready for us to try it. We set up
everything as best we could so that she was calm and comfortable, so she was safe, so people were checking in on her, and had

K. Sogge
a pretty good day. We came downstairs all dressed and ready to
go. Then it happened. I could see her breathing pick up. I could
see her starting to pace.

That clinician mind inherent in me, always eager to anticipate, mistakenly chimes in, and before I can stop, my lips
mouth Uh oh.
Ah ha! crows my patient victoriously, jumping from her
chair mischievously and pointing at her hypocritical clinician, you did the same thing I USED to do!
Nailed me, I admit with a secret smile of delight. She
is finding freedom I think to myself, What did you do instead? I ask out loud, genuinely curious.
Well I noticed that when she starts to pace my mind
starts to race. I start anticipating another big fight. This time
I didnt do that. Instead of anticipating what I felt was coming, I focused on breathing. I used that 4-4-8 breath. And I
said to myselfI can see she is going down the rabbit hole.
I am not going with her today.
Wow! I clap my hands, again without thinking about it.
You are NOT going down the rabbit hole today.
Thats exactly it. So I didnt go there, she exclaimed. I
said to her Honey I can see this brings up anxiety. I promise
you we are not gone for long. This is a sign that we trust you.
You know that if you really need us we will come home.
Lets do this hon. She didnt like it. The yelling and accusations started, but I didnt react with anger or with hurt like I
have in the past. I could actually feel some more compassion
for her, but at the same time I felt weird, like I was being
more distant.
Hmm thats a thought, I reflect.
Yes and I also had the thought there that maybe this is
being a really bad mother. It is so hard not to believe that
kind of thing, particularly when people who are supposed
to know better than I do imply that I am. She laughs with
sadness. It is a different kind of mothering for sure. It isnt
the same kind of compassion I had for her when she was
a toddler and she skinned her knee and I could scoop her
up in my lap and comfort her and make it all better. It is a
cooler more distant kind of compassion, that lets her know
I can trust her, that she can trust me, and that we are in this
together but
Unable to resist the thoughts going through my mind, I
say Ah, and it includes you doesnt it? You get to be there
but be separate, to be with her but not join her in the rabbit
Yes that is it! I am here too. I am a mother and a person
That is brilliant. How did it feel? I question.
And what actually happened?
Well we went out. Just got in the car and went. And yes,
it was hard to be there knowing she might need us. I was
checking my phone all the time; there were a lot of texts. I

20 The Good Mother

had her older sister check in on her. I had to hand the phone
to her father because the texts like I hate you dont get to
him the way they do to me. But we made it through most of
the night and we were home by ten.
And what did you notice?
I noticed that when we got home she hadnt cut. She
took a while to fly by, and then she came and joined me on
the sofa. She cuddled up with me and I noticed she actually
made ME a cup of tea when she made some for herself this
time, which just floored me. I think I can see way through
Reflection: Within me I ask myself: how do we get our
hands, feet and mouths to serve what our hearts contain?
For myself and for my patients, I notice that impulsivity or
inaction are both ways that we get stuck. I intend to support patients in reconnecting to important values, and finding
ways to embody them even in very difficult circumstances is
a way to create vitality and mindful engagement even in the
midst of pain. If engagement is bringing the best in oneself
to a situation, then I intend to help my patient shift from inaction or impulsivity to full engagement, compassion, and
committed values-based action in the face of her painful habitual interactions with her daughter and herself.
The session: Here is my patients second story.
So in my work I get to see a lot of people who are very knowledgeable. They have to solve a lot of problems. They are the top
in their field. This week was pretty tough, because my daughter
has started back to school, so I have been on call basically every
minute of the day. Some days she has made it and some days she
hasnt, but we are doing our best to balance compassion with
this whole skillfulness thing and letting her know that thoughts
are not facts, that emotions are not harmful. So I am exhausted
from doing this all week, staying out of the rabbit hole so to
Then I am asked to come in and consult with a situation where
all the top brass are there, all in 100% agreement on what must
be done, but the business client doesnt want to follow the recommendations. They are all bringing in articles, studies, the best
arguments to convince the business client that it is absolutely
essential that he follow our recommendations. They are starting
to get angry, are talking about calling in lawyers to force the client to follow their recommendations. Im sitting there listening,
and I realize that it happens to everyone. I am sitting here after
dealing with a major blowout with my daughter this morning,
and I realize it. They are all going down the rabbit hole too.
They have their ideas, their plans, their expertise, their knowledge about what is what, and it doesnt work. It doesnt work,
because they cant see through all of their expertise to who this
person really is. The pattern they are all caught in is the same
pattern I used to get caught in, and still sometimes get caught in,
but I recognize it and get off the train a little earlier now.
So I ask if I can talk to the client independently. I go in, and
all I see is fear. The thing they are asking him to do is contrary to
the way he sees himself, his world, his way of doing things. He
is trying to tell them that and they are not listening. When they
attack and judge him for his view he knows they are attacking
and judging him. Hes not stupid. So he just pulls back. So I sat
with him, listened to him, and then I said, You know, you are
absolutely right. You are the one who has to decide for yourself.

You deserve all the information you need in order to make the
right decision for yourself. What do you need? He wanted to
talk to someone else who wasnt part of our organization. So I
arranged it.

And this is the story about how you taught others about not
going down the rabbit hole, I lean back and grin.
Yes. No wonder all of those professionals implied I was
a bad mother, that there was something wrong with our family. It was the only thing they could think of given that they
needed to eliminate symptoms and only had that story to tell
about us. I have just decided that our family cant do that.
My daughter is a human. We are humans. We are good people. This is terrible what has happened, but we dont need to
go down the rabbit hole with everyone else. We can just be
with it in this kind of limbo and respond in a way that admits
that we are not in control of what happens. We are only in
control of how we respond to what happens, and to what we
believe is important. So that is my story for you, yes, about
not joining everyone in going down the rabbit hole.
Reflection: I feel such joy when I see my patients find
a way to vitality. I feel sympathetic joy, when I see this patient, or any patient, find a pathway to contact what will
bring them vitality, even if we cannot solve or eliminate the
problem that initially brought them to call a psychologist and
enter psychotherapy. The story my patient and I are writing
together is not empty of pain, or even of suffering, but as I
see her letting go of thoughts, having compassion, contacting
the present moment, reconnecting to her values, I can sense
the vitality in her growing. Her story, our story, becomes a
story of movement from numbness and disconnection from
the deepest longings of the heart in the presence of pain, to
a story of heart-filled active engagement, compassion, and
committed actions towards values even while pain is present. Together we are in a state of vitality. Together we enter a
moment of wholeness.
The session: In one of our last sessions, my patient arrived to announce
My daughter has fired her mental health team.
I am in good company there, I think and then I decide
to say it, which makes my patient laugh.
And she has returned to classes full time, and is painting
again. Unfortunately she kept me up late last night freaking
outbut the freak out was a good thing. She was freaking
out about getting all her credits in time for applying for university.
It is a bit miraculous for me to imagine that this could be
happening. It makes me a bit anxious to tell you the truth,
she admits.
What is the anxiety about? I query.
That it is too good to be true. Something terrible must be
about to happen, my patient laughs.


I smile and remark, Everything changes, that is true. I

wonder if we can hold that thought the way we would hold
anything else that has barbs and prickles.
I just returned home after taking a big risk for the first
time in years. I thought you were absolutely crazy to support
me on this idea, but I decided to attend a professional meeting
across the ocean, without my daughter. I was terrified how my
family would manage. Particularly since my daughter and her
dad can really push each others buttons and I am there mediating. But this other miraculous thing happened. They had
a great time together when I was out of the picture! I thought
I would be getting calls from the police on another continent,
but I heard nothing. Nothing! They managed with aplomb!
Not only that, I knocked it out of the park at my professional
meeting. I remembered there is this other self inside me.
Reflection: The symptoms are still present, but as I used
to remind my Advanced Psychopathology class students frequently, it is not the presence of symptoms that defines a
diagnosis, it is the degree of impairment that the symptoms
cause. If an individual is fully engaged in a life that has an
abundance of meaning and vitality, then this is the embodiment of mindfulness. What were her last words to me as we
parted at the same doorway through which she had entered
months before?
Thank you for not believing I was a horrible person.

1. Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance
and commitment therapy: model, processes and outcomes. Behav
Res Ther. 2006;44(1):125.

K. Sogge
2. Ost LG. Efficacy of the third wave of behavioral therapies: a systematic review and meta-analysis. Behav Res Ther. 2008;46(3):296321.
3. Powers MB, Zum Vorde Sive Vording MB, Emmelkamp PMG.
Acceptance and commitment therapy: a meta-analytic review. Psychother Psychosom. 2009;78(2):7380.
4. Ruiz FJ. A review of acceptance and commitment therapy (ACT)
empirical evidence: correlational, experimental psychopathology, component and outcome studies. Int J Psychol Psychol Ther.
5. Hayes S, Strosahl K, Wilson K. Acceptance and commitment therapy: the process and practice of mindful change. New York: Guilford; 2012.
6. Seigel D. The developing mind. New York: Guilford; 2012.
Kimberly Sogge Ph.D., C.Psych. is a clinical health psychologist in
private practice in Ottawa, Canada, where she offers third-wave psychological interventions (acceptance and commitment therapy (ACT),
mindfulness-based cognitive therapy (MBCT), dialectical behavior
therapy (DBT), and mindfulness-based relapse prevention (MBRP)),
and mindful self compassion (MSC) specializing in work with physicians and other high-performing professionals. She is a Class of 2016
member of the Mindfulness Yoga and Meditation Teacher training program at the Spirit Rock Vipassana meditation in California. Dr. Sogge
has designed and facilitated mindfulness-based interventions since
2004, when she co-taught the first mindfulness-based stress reduction
(MBSR) course offered in the primary care clinics at Student Health
Service of the University of Texas at Austin. She has taught MBSR
to Desert Storm veterans arts-based mindfulness courses to pediatric
patients and families and most recently mini-MBSR courses to faculty and residents at the University of Ottawa, Faculty of Medicine. Her
current mindfulness practice includes sculling on the Ottawa River and
trail running in the Gatineau hills of Quebec.

I Am My Brothers Keeper


Dennis L. Dobkin

Seven years ago, I saw a new patient in the hospital. Maurice

was a 36-year-old unemployed male with a serious drinking problem. He was admitted with high blood pressures of
220/120 and heart failure with cardiomyopathya greatly
weakened heart muscle, probably due to untreated hypertension and years of excessive alcohol consumption. He lived
in a public housing unit and it became obvious that had little
or no family support as he had no visitors. He was ill kempt
and had trouble maintaining eye contact. He seemed to care
little about his personal hygiene or his health for that matter.
His nails were uncut and he was poorly dressed. Of course I
had taken care of many such patients and I did wonder what
had led him down this miserable road. Time was limited and
I did not inquire into the details of his life. I felt badly for
him but did not dwell on his sorry plight. He was just another
unfortunate member of a society that rarely cares for its own.
As a cardiologist, I could address his cardiac issues but the
social problems were not my responsibility. I did not possess
the skills nor did I have the time to explore this aspect of
his life. He responded to medical therapy; his blood pressure
normalized, his heart failure cleared, and he was discharged
on medications. He seemed to understand the rationale for
medications and that he needed to lower his salt intake. I
arranged for follow-up with me in 2 weeks in our private
He showed up 2 weeks later in my office as it is our policy to see all patients regardless of their ability to pay for
services. He was feeling better but had not filled any of his
medication prescriptions. His blood pressure was high but
he was not in any heart failure. His physical appearance was
unchanged and I noted that he seemed detached from the
systemfrom the plan I had outlined to improve his health.
I could not tell if he just did not care about his health, did not

Waterbury Hospital Health Center, Waterbury, CT, USA

trust us, or simply did not have the skills to become part of
his own solution.
As I talked to him, another story was percolating in the
background of my mind. My story of Maurices behavior
was drowning out his story. As he told me that he could not
afford the medications and was still drinking, I could not help
but think that his ultimate prognosis was quite poor because
of his attitude. I reasoned that if he could find the money for
alcohol, he could afford medications as I had referred him to
a clinic where medications were quite inexpensive. As I saw
it then, he had not even bothered to obtain these medications.
I was polite but frank. I unconsciously got into my lecture
mode. I told him that if he did not make the effort to take
care of himself, then he would be unlikely to get better and
faced a life of recurrent hospital admissions and poor health.
I thought that his failure to try to care for himself was his
obstacle and that there was little I could do. I could advise
him but I could not force him to care for himself. I silently
blamed him for his circumstances which allowed me to abolish my responsibilities and, for that matter, any remnants of
empathy that remained. I experienced an element of pity but
as far as I could see, it was not my fault and there was little
I could do. I would fulfill my obligations by going through
the motions and leave it up to him to be accountable for his
As predicted, the next several years were punctuated by
recurrent admissions for heart failure with poorly controlled
blood pressures due to non-compliance. I saw him many
times thereafter despite that he was a no pay and hoped the
best for him with little belief that he might get better. I have
dealt for many years with alcoholics and others with drug
problems and did not have much faith in their ability to help
themselves or in my ability to change their course.
I had grown up in a secular Jewish family where compassion for all people was part of our cultural heritage. From an
early age, I knew that being a physician was my aspiration.
I believed that being a physician afforded one the opportunity to heal the sick and change lives. As a young doctor
many years ago, I promised myself to care for people from

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_21,

Springer International Publishing Switzerland 2015



all walks of life and to never allow socioeconomic issues

to interfere with providing service. I was an understanding
person, cared deeply about my helping profession, and maintained this perspective for many years. I started a private
practice cardiology group and we have, for the past 30 years,
taken care of anyone regardless of compensation.
As the decades passed, I began to notice an insidious
change in my colleagues as well as in myself. America
seemed to have changed, or perhaps, I just noticed it more.
I often encountered patients who did not seem to take care
of themselves. I was surrounded by physicians who became
bored with their practices and found myself in a medical
system and society where polarization between the haves
and the have nots became more pronounced. The poor and
desperate became more prevalent and financial constraints
in our practice became more pressing. Many physicians
complained of government regulations and decreasing reimbursements but that is not what bothered me.
I began to notice that I tried less to help these people. It is
not that I did not care; I did my job but left it to them to help
themselves more. There were elements of boredom, less belief that I could help all people, and less satisfaction in treating these poor, needy people. Burnout was commonly selfdiagnosed among us. Somehow, I had bought into the notion
that if they were not contributing members of our society
(whatever that means) and did not make an effort to care for
themselves, then I could forfeit my obligations to them.
For a variety of reasons, including this feeling of separation from my own patients, I became interested in mindfulness. I began to explore Buddhism as mindfulness stems
from both the Hindu and Buddhist traditions. Mindfulness is
one of the basic tenets of Buddhism but the tradition is much
broader and helped me find an approach to life which clarified our relationship to each other. I started to incorporate
some of the main practices into my life: compassion, loving
kindness, appreciative joy, and tranquility. This helped me
not only change my approach to life as a person but also as
a physician. I did not need to become a Buddhist per se to
appreciate this viewpoint and I came to value human interactions more deeply.
I also studied the Buddhas eightfold path which helped
me organize my approach to interacting with the people in
my world. Relevant to my medical practice were such principles as right action, right livelihood, right speech, right
effort, right concentration, right view and, of course, mindfulness. The latter seems best defined as the awareness that
emerges from purposeful paying attention, moment to moment, without judgment, and with acceptance. As I tried to
incorporate these precepts into my daily life, I also attempted
to apply them to my interactions with my patients.
I came to understand that part of the problem was the Judeo-Christian notion of good and bad. Like most in the West,
we tend to judge all behavior subconsciously in these basic

D. L. Dobkin

terms. I realized that a more enlightened way to address

this was to interpret behavior as skilled or not skilled. This
diminishes blame and judgment. It is not for me to judge.
Buddhist teachings suggest that peoples behaviors stemmed
from their ignorance, desires, and aversions rather than from
intrinsic malevolence or, especially, sin. When I saw bad
behavior in the substance abuser or one who failed to care
for themselves, I began to judge less and care even more as
I understood that their behavior was lack of skill rather than
due to a volitional act.
I began to reformulate my former aspirations once again
in the context of right action and right livelihood along with
the concept of skillfulness. I came to appreciate that helping
all of my patients should not be limited by their personal
problemsI still remained their caregiver. I had to redouble
my efforts and actively concentrate as I spent time with these
patients. I focused on my intentions to help them despite
their own limitations. The right view became clearer.
As part of the development of mindfulness, I started daily
meditation every morning. This provided a point of focus
and served to orient myself towards the day ahead. I learned
how to spend more time in, and being more aware of, each
moment. Gradually, I was able to translate this into my daily
routine. The mind needs training just like the body. Meditation, a form of mental exercise, channels one towards being
more mindful. It is an invaluable tool that complimented
more traditional ways of staying in tune.
As I personally interacted with patients, I slowly developed the ability to pay attention to the moment more. I
practiced becoming more aware of some of the subtle interactions that are easily ignored between the doctor and the
patient. I became more aware of the cadence of their speech,
any unstated anxiety, and their ability to sustain eye contact.
I still noticed my inner stories but tried to test them for accuracy. Maybe there were reasons that they did not take their
medications. Perhaps I did not have their trust and needed
to establish their confidence. But I also learned to hear their
stories in the context of their lives and in the context of their
medical setting. I learned to listen more and talk less. When
I approached the patient, I paused and remembered to make
the right effort and remind myself to concentrate on the interaction. I began to move beyond the intellectual considerations and explore how I felt about these people. I started to
listen to my heart as well as my head. It took practice and
vigilance before it became routine.
As a result, I have also developed more compassion and
more loving kindness. Awareness, effort, and concentration
helped me to interact more circumspectly than in the past.
Most importantly, I learned to become less judgmental. No
one really knows the underpinning of another persons situation. I realized that my role as a physician was not to discover why someone acted as they do: it was to take care of
them no matter why they acted in such a way.

21 I Am My Brothers Keeper

One last concept guided me as well. The teaching of noself is a difficult notion to comprehend, especially in the
West where the liberal democratic ideal is focused on the individual. This tends to separate people and ignores the basic
connections that we all share as humans. One of the meditations that enabled me to overcome this was the practice of
exchange of self. One mentally identifies with the other
and notices how he feels as a way of developing empathy.
Incorporating this particular sitting meditation practice allowed me to apply it in everyday life.
Recently, I saw Maurice again after a several-year hiatus.
He had just gotten out of jail and was in mild heart failure,
quite hypertensive, and not taking any medications. He was
with his brother who seemed to care about him. He physically looked the same but my view was now quite different.
Being more mindful, I listened to his travails about jail, his
struggles with alcohol and how he was searching for a path
to recover. I activated my meditation skills and applied them
to the clinic setting. I shared his disappointment in himself. I
felt compassion for this young man whose life was not going
well. I could not tell if he had changed or I had changedbut
it did not seem to matter. I felt more involved and somehow
more hopeful. I was able to exchange places with him and
subsequently I viewed him differently.
I no longer thought that he did not care for himself or
that there was little I could do. I did not focus on his bad


behavior. I observed his lack of skill and felt sympathy for

his plight no matter what the causes were. It was clear what
the right action was and how my choice of this profession
gave me the opportunity to redouble my efforts and steer him
towards better health. I saw myself in a new role: I was more
a brother rather than father to this young man. I was employing a mindful attitude and I felt this allowed me to become a
more humane doctor.
Making a commitment to the practice of mindfulness is a
choice that demands vigilance, patience, effort, and concentration. It is a journey that never ends as there is no end to
human interactions. It has allowed me to return to my younger, more idealistic self but in a more mature way. I would
advocate any caregiver (all humans actually) to explore this
viewpoint as a means towards self-insight, and moreover, as
a path to providing more compassionate care to all of their
Dennis L. Dobkin MD is a cardiologist affiliated with Yale Medical
School who works full time in private practice in Waterbury, Connecticut, USA. He teaches residents in the practice of cardiology with a
special interest in palliative care and the emerging students needs to
address whole patient care in todays technology-oriented health-care
system. Using the basic tenets of Buddhism, especially mindfulness,
he is integrating mindful medical practice as a complement to technology and paradigms that emphasize the biomedical model of patient care


The Mindful Shift

Tara Coles

At first glance, the emergency department might seem like

the least opportune environment for mindfulness practice.
Unlike the cocooning silence of a Buddhist Zendo or the
focused peacefulness of a guided meditation, the emergency
room (ER) is a constant cacophony of human and mechanical sounds, an enclosed space lit by bright lights and defined
by the nonstop movement of patients and providers. It is by
its nature and mission not a relaxing atmosphere. Anyone
who arrives for care is experiencing some perceived version of urgency or threat to their healthwhether emotional,
psychological, or physical and sometimes all three at once.
Just by arriving at our doorstep, a person is transformed into
a patient, and the health and well-being of she/he and their
family become our responsibility.
It may seem that the stereotypical person who chooses
emergency medicine as their specialty may be ill suited for
mindfulness practices. Media has mythologized the ER doctor as an adrenaline junky with a savior complex, the kind of
physician who loves the diagnostic puzzle but has no time
for the therapeutic relationship. The caricature of the rushed,
frantic, distracted but heroic doctor running around, cracking a chest open in room 3, performing a rapid drug detox
in room 12, and saving an abused baby in room 9, has been
nourished and sustained by a popular culture that misunderstands the true role and mission of emergency medicine.
I fell in love with emergency medicine during the 1sthour
of my very first shift in the ER. As a 4th-year medical student, this was my last clinical rotation before I needed to
decide on my future specialty. Up until that moment, I had
rotated through my other clerkships: internal medicine, pediatrics, obstetrics and gynecology, family medicine, psychiatry, neurologywith an interest in everything but a passion
for nothing. In the ER, unlike other rotations, I had patients
Medical Emergency Professionals, 11140 Rockville Pike, Suite 100,
# 232, Rockville, MD 20852, USA
University of Maryland, Baltimore, MD, USA

in front of me without a known diagnosis, with no prior records to review, just a person with a story and symptoms
and vital signs and clues. I walked into each room with a
stethoscope around my neck, and these strangers trusted me
to ask intimate questions, to lay hands on their bodies, to
discern the source of their pain, and to plan the course of
their treatment. Suddenly, all the pieces of my educational
path clicked into placeall the basic science and pathology
lectures and physical exam techniquesthis is where I could
see putting it all together. I loved the mystery of it all, the
problem solving, the teamwork, the energy and pace, and the
lulls of broken ankles and toothaches punctuated by the heart
attacks and traumas.
And 15 years later, I still love italthough like all longterm love affairs, the nature and dynamics of the relationship
have changed. In a common scenario, my professional evolution was jump-started and cemented by a personal crisis.
Unlike other personal experiences, this event was so fraught
with life-lesson metaphors that it, in retrospect, is almost
laughable. This touchstone occurred at the end of my second
year of residency. Following the absolutely correct advice to
attend the most rigorous residency program possible, I was
training at a level 1 trauma center, seeing the sickest of the
sick, treating the worst injuries imaginable, and learning from
the best clinical doctors and physician mentors in the world
of emergency medicine. Having attended a medical school
that valued humanism in medicine, championed service as
a calling, and taught empathetic communication skills, I felt
comfortable developing quick rapport with patients. My time
and energy in those early years were dedicated to mastering
procedural and diagnostic skills. I was also focused on learning the art of using all my senses, knowledge, and intuition
to answer the most fundamental and difficult question of any
clinical encounter in the ERis the patient sick or not
sick? The irony is that I had lost the ability to know this
about myself.
I completed my 2nd year of residency with a 12-hour
night shift for the record booksmultiple traumas, critical
patients with pneumonias and strokes, and hours spent quiet-

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_22,

Springer International Publishing Switzerland 2015



ly sewing stellate and jagged lacerations back into unbroken

skin. A year spent as a procedure person had given me confidence and muscle memory that allowed suturing to occur
in an almost effortless rhythm. The tying of the last stitch
coincided with a call into the trauma room where I was initiated into my next role as a trauma resident. My first time
at the head of the bed, heart pounding, in charge of airway,
breathing, and circulation. The sounds distant and echoing
as if in a long tunnel, I looked into the mouth of this stranger
to find the beautiful pyramid-shaped vocal cords and passed
the breathing tube through it. Then I went to break the news
of the young mans serious injuries to his stunned parents. I
looked them in the eyes and spoke gently of what I knew and
did not know, sat with them in the silence of their unanswerable questions, and walked them to see their son as we tried
to save his life. On my way home when dawn arrived, I felt
reconnected to my calling as a healerone that most doctors
will tell you came to them as a child in some way or another.
Trust me when I say physicians started out with the sense
that they have been healers all their lives. It may be buried
under many layers, but it is always there. I drove home basking in the glow of having survived 2 sleepless years, with
a sense that finally my life of white knuckling it through
might be coming to an end.
Just 1 week later, I woke up with a sore throat, slight chills,
and the Oh no, I am getting sick and need to be at work
today feeling. In my day as a medical resident, there was
a self-imposed shared ethos of not calling in sick, not needing to activate backup, and not inconveniencing your fellow
residents. So I went to work and then during the next 3 days
at home proceeded to get sicker. Fevers of 104 that would
not break, vomiting that turned to unrelenting coughing fits,
and whole body shakes. Then, on day 5, waking up to fingers
turning blue, counting my respirations at 40breaths/min, and
attempting to listen to my own lungs with my stethoscope to
see if one had collapsed from coughing. My husband drove
me to my own ER where my friends and mentors cared for
me, where the simple pneumonia spread to both lungs, and
septic shock rendered me mercifully delirious. I do not remember much from this time other than the feeling of drowning, suffocation, and powerlessness. I do recall asking one of
my mentors through my oxygen mask if I was going to die. I
remember his silence as he held my hand.
Through a combination of excellent care and random luck,
I survived. While I recovered, as the coughing lessened, as I
could speak again in full sentences, I lay in the hushed darkness of our apartment and literally caught my breath. Slowly
filling my lungs with air filled me with gratitude. The ability
to exhale with unconscious ease was magical. I felt a mindful
shift settle over me. I was awake.
Our bodily design is amazing when it holds itself in health
and balance. The state of illness is a signal of disease. This is
not to lay any blame or fault on a person for being sick, nor

T. Coles

to claim any understanding of the randomness of tragedy.

And it is not a call to arms against the natural process of
aging and dying. I respect and honor both the incomprehensible fact that we are here right now in this lifetime together
and the inevitability of each and every one of us leaving
someday through death. In between these moments is living.
I speak only as one person, as a doctor and a patient, a daughter and now a mother, that my ability to relieve suffering
has become a privileged opportunity to slow down and listen, to attend to the needs of those placed in my care, and to
observe the world with an openness to whatever may occur
and unfold before me. My mindfulness practice started out
as a self-preservation strategy but has evolved into a way of
moving through life with kind intention, focused attention,
and positive attitude.
There is a paradox in modern medicine and particularly
in the ER: To be an effective doctor, one must be both thorough and fast-paced, simultaneously patient centered, and
clinically efficient. Emergency medicine clinicians rely on a
balance of routine skills, advanced decision rules, evidencebased medicine, and diagnostic intuition to make decisions
and coordinate treatment. Advanced practitioners are able to
synthesize information quickly, incorporate new data, and
redirect hypotheses and actions accordingly. Leading a team
demands consistent calm presence in the midst of constant
pressure to divide attention and multitask. And here lies the
conundrumundivided attention is the secret to the flourishing of any relationship, but is particularly critical to the
therapeutic relationship between healer and patient. How in
this busy, stressful, and high-stakes life and death environment can mindfulness find a practical and sustainable relevance?
The common thread among anyone who has ever visited
an ER is a prevailing and usually unspoken sense of vulnerability, a turning over of the suffering self to a random
stranger, an unknown physician who must gain trust in an instant in order to provide the best care within a limited frame
of time, space, and reference. The briefness of the encounter makes the need for mindfulness even more critical. The
scaffolding supports and provides structure to all the other
competencies. Mindfulness in clinical settings and in personal practice can improve intuition, reduce medical errors,
bolster teamwork, combat cynicism, and inform professional
growth. At its most powerful, it can provide a sense of meaning and connection that fosters healing long after the clinical
encounter has ended.
Like all ER doctors, I work in shifts. The start of each
shift is like the opening curtain of an improvised play. I do
not know any of the characters or the script. The details of the
drama unfold in real time. My heart beats slightly faster as I
put on my white coat then slows as I take full deep breaths
and consciously set my healing intentions. Before a professional chef begins to cook, she/he practices a ritual called

22 The Mindful Shift

Mise En Placethe setting up of the cooking station and the

putting all things in place. I find that doing a similar ritual in
the ER focuses my attention and awakens my clinical mind.
I clean my workstation, check the code room for supplies,
note the people on the team, and take the pulse of the room.
Are there new nurses today? Is the hospital full? Do people
seem stressed? I meet my scribe for the shifta great asset
to mindful practice. The medical scribe will accompany me
while I see patients, writing down their stories, documenting
the physician exams, following up on diagnostic tests, and
drafting the medical charts. This frees up my mind to the
task of listening with full attention to my patients without
multitasking in the moment.
My aim when I walk into a space is to create a calm and
safe energy. This requires a commitment to emotional awareness, nonjudgment, and openness to honest feedback in real
time. Mindfulness lowers my own reactivity to stress, improves my ability to notice and observe, and allows me to
focus on the actual full sensory experience of the present
situation. The resiliency, intuition, and joy that mindfulness
provides allows excellent patient care even when a shift unfolds likes this: sign in, take care of toothache, broken bones,
pneumonia, heart attack, stroke, sepsis, appendicitis, ectopic
pregnancy, new cancer diagnosis, domestic violence, suicidality, syncope, dehydration, back pain, headache, blood clot,
diarrhea, earache, fever, rash, corneal abrasion, end-of-life
comfort care, psychosis, urinary tract infection, miscarriage,
asthma, accident fatality, near drowning, sudden cardiac
death, clean up, sign out, go home, feel the pounding adrenaline drain away, and fall into a deep dreamless sleep.
The ER is a microcosm of any high-intensity, high-stress,
and high-stakes environment. Personalities, problems and
misunderstandings can rise up and threaten the flow at any
moment. Mindfulness has improved my capacity to greet
pain, anger, frustration, and confusion with grace and unattachment. I can recognize frustration, stress, anger, and
disappointment as it arises in myself and let these feelings
wash through me with dispassion. When the ER turns into
a hurricane, I anchor back into the breath and maintain the
calm eye of the storm.
The ER physician is witness to countless intimate moments of pain, fear, stress, and vulnerability. We see the dark
side of life, the subcultures of abuse and neglect, the realities
of poverty and loneliness, and the consequences of ignoring
the body and spirits true needs. We also bear witness to moments of inexplicable beauty, compassion, and tenderness.
The best-kept secret in the field of medicine is thishealers
want the very best life for their patients even if they cannot
always cure or save them. They serve with a dedication that
threatens to devour them. The flip side of that intense caring
is the pain that comes with opening our hearts to our patients
suffering and with knowing that it could be us, our kids, our
family or friends, and that one day it inevitably will be. Al-


though we do not like to think of it, we all walk daily just a

few steps away from the edge of the cliff. Mindfulness helps
maintain the vigilance to stay on solid ground.
Here are a few things that patients might not know about
their ER doctors. They think about you on their ride home.
If something has gone wrong for you while under their care,
they will agonize about it and for your suffering for a long,
long time. They will call the intensive care unit (ICU) to see
how you are. They will learn from your story. They will be
better healers in the future because they took care of you
today. They will hold on to their faith that their presence for
you in your time of need was healing. They will treasure the
note you sent thanking them for their care and compassion.
They will save it tucked behind the frame that holds their
medical degree.
Our job in the ER is to make every patient feel like our
full care, expertise, attention, and focus is on them during
their entire stay. Despite taking care of multiple patients at
the same time, the ability to completely focus on one situation in all its complexity is a critical skill. During the brief
moment of a doctorpatient interaction, all the white noise
and competing demands fade into the background leaving
space for an empathetic connection. Mindful practice is a
chance to provide kindness, attention, and a gentle touch
given unconditionally to whoever is placed into our care.
With no chance for in-depth histories and with no expectation of an ongoing therapeutic relationship, the ER encounter
unfolds entirely in the present. At the end of the day, everyone is anonymous. No one will remember anyones name.
Faces and stories and bodies and X-rays blur together and
become scattered fragments. We know that our patients will
probably not remember our name or face either. Despite this,
we hope that the faint memory of our care elicits feelings of
safety and compassion.

Patient Encounters
Mr. Y was brought in by the police, his wrists in handcuffs,
one hand wrapped in gauze. A cut to the palm during his
arrest had demanded a pit stop to the ER. I examined his
hand, determined that the injury was superficial without injury to the tendons or nerves or blood vessels. The wound
was cleaned and I placed his palm under a sterile blue towel.
His now uncuffed hand lay still under the bright light as I
numbed the area around the laceration, which was long but
relatively straight. I took a moment and imagined the movement of my hand, piercing of the skin with the needle, pulling, and knotting the suture. He followed my instructions to
stay completely still. As I began stitching, I had a fleeting
thought about the violence that this hand might have done,
the crimes it may have committed. Then the quiet monotony
of suturing took over. When I was finished, 15 even stitches


appeared on his palm, a new sliver of black crossed over his

lifeline. He thanked me as I cleaned up and went to see the
new patient in the next bed.
Ms. S was an 80-year-old woman brought in by ambulance. She was lethargic and ill, appearing with her dry lips
pursed into an O shape. I looked at the stack of papers detailing her previous multiple hospitalizations in the past year
for a stroke, chronic emphysema, and Parkinsons disease.
As the nurse and I examined her, the patients daughter and
son arrived. Her daughter seemed confused as to what had
happenedI was just there yesterday, she seemed fine. Just
yesterday she was sitting up in her chair, eating, talking to
me. I listened to her without interruption. The patients son
was quiet. The monitors were beeping denoting fast heart
rate, low blood pressure, and low oxygen levels. We began
intravenous fluids and, as the tests came back, it was obvious that Ms. S was in septic shock and impending respiratory
failure. The paperwork designated her daughter as next of
kin, and there was no advance directive in the chart. Your
mother is very ill. There is a very real chance she will not
live through this illness. If she gets any worse we may have
to think about putting her on a ventilator and starting medications to bring up her blood pressure. Her daughter started
to cry. Her son looked dazed. I looked at Ms. S. Her eyes
were closed, mouth open, and I imagined her as a baby, her
own mother cradling her in her arms. I saw her as child
her clear smooth face smiling and unafraid. Will she ever
come off the machines? her son asked. I sat with him at his
mothers bedside, a woman I had just met moments before.
He held her hand, the hand that had nurtured him throughout his life. Is she in pain? I dont think so, I answered,
but if she is in any distress we can give her medications to
help. If we decide to have a breathing tube what will happen? She will go the Intensive Care Unit for antibiotics
and fluids. She will be sedated on the ventilator. Then you
will have to decide if she gets worse and her heart stops what
you want us to do. Next, I was asked the one question that
I knew was comingWhat would you do if this was your
mom? I cant answer that for you, but I can tell you that
CPR on a frail elderly woman will likely break her ribs and
in all likelihood would not be successful. It is not a peaceful
way to die. The word peaceful hung in the air like an echo.
The son and daughter looked at each other and their mother,
an oxygen mask misting up with each shallow breath. This
year has been so hard, whispered her daughter. We lost
our father at the beginning of the year and mom just went
downhill so quickly. She has really suffered. She wouldnt
talk about any of this stuff with us, but no machines, no CPR,
please just make sure she is not suffering. We decided together to admit her to the hospital with continuation of the
fluids, antibiotics, oxygen, and morphine for discomfort. I
heard later that she died the next morning with her children
and grandchildren at her bedside.

T. Coles

After I was starting to wrap up the day, I was called to see

Mr. W who had been admitted hours earlier. He had passed
out at home, and an electrocardiogram (EKG) had revealed
a dangerous heart blockhe needed a pacemaker and was
on the schedule for the afternoon. Impatient with the long
wait, agitated at not being able to eat, and uncomfortable on
the hard stretcher, Mr. W. was demanding to leave. As his
wife was arguing with him, I approached his room, sat down,
and listened. I remained completely silent. I felt his anger
wash over me like a wavenothing personal, just his fear
and hunger and impatience and craving for a cigarette. His
tearful wife asked me to tell him what could happen. Well,
you could have a sudden cardiac death or you could pass out
while driving and crash your car or faint during a bath and
drown. Your wife told me your sons college graduation is
next monthTheyd like you to be there. But you know all
this.How can I help right now? A warm blanket, nicotine
patch, pain medication, and dimmed lights and all was calm
once again. Just one person helping one other person in one
moment. No public performance, just another small drama in
a million other stories playing out in ERs all over the world.
As I walked towards the ER exit, the hospital chaplain
and a pastoral care student were entering the ER. The chaplain asked if I wanted a Blessing of the Hands. The student
placed a drop of oil in my palm and took my hands in hers
Healer of all, give Dr. Coles the courage to touch the world
every day using her unique life and gifts. May the fragrance
of compassion fill her, free her, and bring comfort to others.
Bless the work of these hands and this heart. As I walked
slowly in the darkness out to my car, my pulse slowing down
to civilian rate, I thought of my four sleeping children in
their beds waiting for me. I imagined their soft breath on
my face as I kissed them in their slumber. I would make the
mindful shift from doctor to mother, giving them what I gave
my patients, what we all need at the end of the day, at the end
of our lifeattention, understanding, care, dignity, freedom
from fear, pain, and loneliness. We all just want someone to
hear us, to feel sacred, and to be remembered:
Compassion is that which makes the heart of the good move
at the pain of others. It crushes and destroys the pain of others;
thus, it is called compassion. It is called compassion because it
shelters and embraces the distressed.Buddha
Tara Coles MD FACEPis a practicing board-certified emergency
medicine physician. She graduated from the George Washington University School of Medicine and Health Sciences and completed her
residency in emergency medicine at Boston Medical Center where
she served as Chief Resident. She has been faculty at the University of
Maryland School of Medicine and currently practices in a community
hospital setting. She is passionate about injury prevention and safety
education, geriatric and palliative care, health literacy, nutrition, and
mindfulness practice. She is an avid reader, student of narrative medicine, and public speaker on maintaining healthy families and career
family balance. She is also an advocate for womens leadership in
healthcare and creative entrepreneurship in the healing professions.


Carol Gonsalves

I still can remember the feelings of panic after having been

assigned a complicated pediatric patient on the mandatory
ward rotation. It was early on in my first clerkship year as
a third-year medical student. The preceding 2 weeks of the
rotation had quashed my initial assuredness that treating sick
children was my lifes calling. I had uncovered a number of
doubts about clinical medicine leading up to that day, stemming from an uninterrupted flow of anxiety, an emotion foreign to my usually self-confident state. I had not anticipated
the challenges of pediatric medicine in having two sets of
patientsthe child and their parentsnor the heartache I
felt at seeing them suffer. My love for kids clearly was not
translating into a love of being responsible for their medical care. I felt anxious, incompetent, and frankly scared that
I would do something wrong nearly all the time. Outward
appearances were perhaps deceiving as I could not tell that
anyone else was experiencing similar anxieties, despite the
overwhelmingly busy clinical service.

An Uncomfortable Question
Probably not unlike most students accepted to medical
school, I rarely had cause to question my knowledge of myself and the workings of my mind until my clerkship year.
I was academically successful, had strong social supports,
and considered myself to be a well-rounded individual. If
asked who I was I could answer easily with a litany of
roles and extracurricular activities that I believed made me,
me. I had encountered some hardships during my young life,
but nothing that made me question who I was or my roles.
With the advent of clinical care, my very definition of what
I was, who I was, was being challenged as I encountered for

Department of Medicine, Division of Hematology, Ottawa Blood
Disease Centre, Ottawa Hospital, 501 Smyth Road, Box 201A,
Ottawa, ON K1H 8L6, Canada

the first time regular feelings of self-doubt and a consequent

uncertainty of the future.

An Unexpected Mindful Moment

John was a 10-year-old boy who was admitted with recurrent
pericarditis. He had a congenital heart condition but had been
generally well until the past few months. He maintained an
outer stoicism typical of boys at that age and seemed much
less nervous than I was in our first encounter. I completed the
required history and physical, and told him I would be back
to review the laboratory work results with him and his parents later on. He shrugged, seemingly indifferent to whether
I returned or not. I felt utterly useless and peripheral.
The next few days carried on like this: me going in to assess John, he paying scant attention as he played with toys
meant to keep his mind off the upcoming pericardial tap.
My case load and previous weeks of unexpected angst were
catching up with me. My sleep patterns were erratic. I found
it difficult to concentrate while these unpleasant emotions
persisted and even followed me out of the hospital.
On the morning of the planned procedure, I walked into
Johns room with the intention of doing the requisite cardiac
assessment as quickly as possible and getting on with the
myriad of other tasks and patients on my list. I was functioning in survival mode. And then an unexpected moment of
awareness, something I had not been experiencing the preceding stressful weeks, emerged. I do not know what brought
it on, perhaps a deep breath taken as a means to bolster my
self-confidence before I entered the room. Instead of seeing
John as just another task to get done, I saw him. I really
saw him, for the first time since his admission. He was not
another patient on my list, he was a scared child. A wave of
shame at putting my own anxieties first washed over me.
Then I realized that I was still putting my emotions first by
wallowing in yet another painful emotion!
I took another breath. I looked at John closely, this time
with direct eye contact. He had the most striking, wide, blue

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_23,

Springer International Publishing Switzerland 2015


C. Gonsalves


eyes that I had not noticed in the 3 days I had been caring for him. I softened the previously perfunctory tone of
my voice, sat down beside him on his bed, and offered an
encouraging smile as I spoke with him about the steps involved in preparing him for the procedure. Time seemed to
slow down, and the anxiety I had been feeling about past
and future dissipated in that moment. Johns body seemed to
unclench from the knot it was in when I first arrived in the
room. His mother, always present, also seemed to relax. The
change in the dynamics of the interaction between us precipitated by the purposeful attention I was now paying to him,
allowed John to disclose for the first time his fears of how
painful the procedure may be and about not being able to
have his parents with him. I listened, as his caregiver on the
medical team, but also as a fellow human being, understanding of fear and anxiety. Before I left, John asked if I could be
with him during the procedure. He let out a heartfelt sigh of
relief when I told him I could. For the first time during his
admission, a real connection had been established.
After they had wheeled his stretcher into the procedure
room, a nurse and the anesthetist started hooking up various
monitors to John. I stood out of the way but within his line of
vision. I made a conscious effort to pay attention to his nonverbal cues. I had no specific knowledge of the procedure itself; this would have made me exceedingly anxious and selfcritical only a couple of days earlier. I could not change what
I did not know at that moment. The cardiologists and other
professionals in the room were fully in charge of the situation anyway. What I could do however as an inexperienced
third year clerk was equally important. We maintained eye
contact. I smiled at him as the sedation started to take effect.
He was quiet, somewhat relaxed and offered a reassured, if
slightly nervous smile back to me.
The procedure went well. John had the fluid drained from
around his heart without complications. When the sedation
wore off he searched the room anxiously with his eyes and
found me. I held his hand, again, consciously making the effort
to be present and aware at that moment. He visibly relaxed. He
thanked me in a small, relieved voice. He went home a couple
of days later and his parents thanked me for the care.
While I did not choose pediatrics, the experience with
John was a turning point in how I saw my patients. Pediatrics
was better suited to physicians with other dispositionswe
are fortunate that in any given medical school class, there
are a variety of strengths and interests among the group and
everyone usually ends up where they should. I was awarded the prize for best student in the pediatric rotation for my
class which seemed ironic to me at the time given those first
weeks filled with anxiety. But what changed after John was
my awareness of my role on that service, of what I could
and could not do, of the need to mitigate difficult emotions
in order to be fully present and effective in caring for my

The experience with John was the first I had with the
power of mindfulness. By becoming aware of the present
moment and not merely going through the motions I was
fully and completely engaged and therefore more effective. I continued to experience feelings of stress and doubt,
but instead of feeling overcome by these emotions, I consciously recognized and acknowledged them as being part
of my experience, which allowed me to act from a center of
awareness. Feelings of stress no longer indicated that I was
an incompetent person; they alerted me to the fact that the
situation called for something else (e.g., more information
or preparation). I was able to appreciate the learning issues
gleaned from the clinical cases I later encountered.

Developing a Regular Mindful Practice

I never forgot that lesson or John. However, at that time I did
not recognize what happened between us as being the product of mindfulness. In retrospect, I see that I had an aha
moment; clearly being mindful is an inherent human skill.
However, like any skill, it requires practice training the mind
to be aware of the present moment, fully and nonjudgmentally on a regular basis. I finished medical school with this
new tool in my armamentarium to deal with the present moment; however, I was not engaged in any systematic practice
to strengthen this skillI simply did not know how. While I
had made a conscious effort in every clinical rotation going
forward from that experience with John to engage deliberately with my patients, later when I went into an arduous
internal medicine residency there were many more anxious
moments, periods when stress seemed unbearable especially when combined with lack of sleep and general lack of
self-care. During that time, I worked diligently and oftentimes seemingly in vain, to return to that state of presence
and compassionate awareness. It was a challenge to sustain
nonjudgmental attention on the present moment in such conditions with no outward guidance or systematic practice. I
once again found myself questioning my career in medicine.
I slipped into a pattern of cynical indifference, a state that is
unfortunately predictable and well documented in the literature on stress and burnout in medical trainees.
I spoke to a faculty academic advisor about my uncertainties midway through that first year and broke down crying in
her office. She was sympathetic, kind, and offered examples
of people she knew that had similar doubts and anxieties
and went on to have fulfilling medical careers. While she
was trying to be helpful, knowing that other people have
gone through this too did not offer a solution to my particular dilemma. My parents and newlywed husband were
doing everything they could to support me. I felt like I was in
the waiting place in Dr. Seuss book Oh the places youll
go! [1]just waiting to get through this stressful, difficult


part of my life. I repeatedly recalled what had happened with

John. How could I find that place of compassion, attention,
and awareness on a regular basis under these new and challenging circumstances of increasing clinical responsibilities?
I started to make trips to the local bookstore and found Buddhist philosophy books on mindfulness. I learned what this
term meant. It became apparent I had to develop a systematic
approach to mindful awareness in all facets of my life.
While I believed that the ability to be mindful was an inherent human skill, it was, apparently, a fragile one. There
are multiple distractions at any given moment that draw us
away from this way of being. To begin a regular practice,
I started by simply noting the feeling of the wind on my
face walking at an even and deliberate pace to and from my
apartment and the hospital each morning. I looked up and
noticed the color of the sky and the shape of the clouds; I
heard the sounds of birds and traffic. A walk previously filled
with distracting anxieties and a to-do list for the upcoming
day was transformed into a peaceful, enjoyable experience.
I noted I was okay in that moment. I was able to carry this
feeling into the clinical setting. I was becoming more focused and consequently more efficient. Incorporating mindful practices into my daily routineseating, showering, an
evening walkchanged the previously stressful clinical encounters into ones that could be managed with more clarity
and compassion towards the human beings I was caring for.
I reconnected with the empathy I held in my heart when I
entered medical school. I could bring the appropriate compassionate, focused energy into an encounter, whether it was
a counseling session with a patient on diabetes, an ICU line
procedure, or a difficult conversation about death and dying.
At the end of my internal medicine residency, I was awarded
Outstanding Resident by the Faculty of Medicine despite
my struggles, or maybe thanks to them. A friend emailed me
the announcement as I had missed the awards ceremony after
being admitted to hospital for the birth of my first son. I was
surprised and humbled.
The years since my graduation from residency have
brought many developments: I went on to complete a hematology and thrombosis fellowship, a Masters of Medical Education, and had three children with my spouse of 15 years.
I have made time to renew old friendships and forge strong
new ones. While my life is wonderfully busy, it is not a perfect picture of calm and happiness bolstered by continuous
mindful practice. Mixed with blessings and hard-earned successes, there have been failures, family crises, and the runoff-my-feet feeling. I have cried at patients bedsides. I have
experienced frustration and anger. Being mindful does not
eliminate emotions or situations that provoke them. It does,
nonetheless, allow me to put all situations into context and
to be less reactive. I can experience anger without letting it
overtake me. Instead, I acknowledge it, respect its presence,
then put it aside, and subsequently act from awareness of the


situation or person that has contributed to that emotion. Attempting to live mindfullyeven if not always successful
at least gives me a chance to be effective and fully present in
my life on a more regular basis. Understanding that, living
that, has allowed me to appreciate the full catastrophe living, a phrase I have embraced from Kabat-Zinns seminal
book on mindfulness [2]. Mindfulness has taught me not to
take moments for granted, to let myself off the hook once in
a while, to respect the human condition just as it is.
In my clinical practice, I encounter people from all age
groups and comorbid states. I treat patients with terminal
and chronic illness as well as those with acute conditions.
I see patients with varying degrees of insight into their
own health and wellness and consequently varying degrees
of frustration or peace. I try to be aware of these differences and approach each patient with respect. I have had
the opportunity to reinforce my practice by taking part in a
faculty-offered program in mindfulness-based stress reduction (MBSR) for physiciansa full 15 years after that first
life-changing encounter with John. Dr. Kim Sogge [author
of Chap.20], a psychologist trained in MBSR along with
her experienced colleague Gail McEachern, a social worker,
gave that course over a 4-week period to a diverse group of
physicians. Each of us had our own reasons for signing up
for the course, however, the essence of our intentions was
the samewe were seeking to live more fully, and to find
systematic ways to support ourselves and consequently our
patients in that goal. While the activities and homework assignments were familiar from my years of personal study
and practice, it was a gift to have this guidance. I relished
returning to beginners mind and learning from different
perspectives. My instructors and peers taught me about our
similar humanity as well as unique journey. My daily mindful practices were renewed and I brought this energy back
into my clinical practice.
Now, my clinical mindful encounters are less of aha
moments than that with John 15 years ago. They have become a cornerstone of how I practice on a regular basis.
Being mindful in a clinical encounter means engaging with
my patient in language they can understand, in an emotional
tone that is responsive to their concerns and anxieties, with
clear eye contact. I make a conscious effort to sit facing them
as opposed to turning to the computer terminal or standing
which can make it seem as though I am ready to leave any
moment. This allows me to be empathic, without being emotionally drained at the end of the day. Moreover, the communication experience between us is enhanced.
When I am less focused, my body language transmits information that I am distracted either by checking the time
or being anxious about how off-schedule I am, or when I
am writing prescriptions or requisitions while trying to listen to the patients questions. Patients perceive our multitasking; reports reveal that communication breakdown (or

C. Gonsalves


patient perception of it) leads to adverse patient outcomes

or dissatisfaction. Given the specialized field I practice in,
the door is not readily open to offer suggestions to my patients for employing mindfulness practice in their own lives.
However, there have been particular encounters, where I
have taken this extra step to promote wholeness and healing
with my patients by introducing the concept of mindfulness
to them and suggesting that they review it further on their
own if it resonates with them. One such encounter involved
a young male patient diagnosed with a deep vein thrombosis
that hindered his academic and work activities to the point
he was spending most of his time playing video games alone
at home. He had such a difficult emotional time reconciling himself to his diagnosis and forced change in lifestyle
causing him to be unhappily unproductive. These feelings
were described on all of our preceding encounters. During
one clinical encounter, I brought up the topic of mindfulness
and suggested some reading material. He eagerly took down
the information. He thanked me wholeheartedly for this additional material that may impact his healing. A few months
later, he relayed to our clinic that he had found productive
work and was getting on with his life. How much did mindfulness have to do with that transition? I am not surehe relocated for work and is not seen in my practice anymore. But
the transformation from that last clinical encounter just a few
months later made me glad to have discussed it with him.

A Comfortable Answer
So who am I? I am human. No more, no less. No single role
I play defines me more than this simple noun. I am subject
to all that a human experience can entailfrom sadness,
uncertainty, frustration, and anger, to pleasure, excitement,
and blissful happinesssometimes all in one dayand I am
accepting and grateful of that. How often do I employ mindfulness in my practice? Every day. By being mindful, I can
recognize the humanity in my role as a physician. I aim to act
with compassion and ensure nonjudgment in my interactions
with patients and families. I do not get as regularly stuck in
unpleasant states or in assuming that my thinking represents the true reality at all times. In almost 20 years since
I embarked on my chosen career in medicine, this is what I
have learned: that life is a gift, every moment is worthy of

thoughtful attention, the good and the bad. And I am learning

every day. That includes in my mindful practice.
It is a privilege to be a part of another persons experience
when they are most vulnerable, i.e., when they are in need
of medical attention. I continue to carry in my mind, a quote
on the possibilities of medical practice from Hippocrates to
cure sometimes, relieve often, and comfort always. Curing
is based on knowledge and evidence, and considering our
patient in the context of a similar patient population. Healing and comfort involve taking into account the particular
social, psychological, and emotional factors of our patient to
develop a therapeutic relationship. Patients can experience
healing without necessarily being cured of their disease.
Conversely, they can be cured, without necessarily feeling
healed. Mindful practice offers a way to bridge this chasm.
My mindfulness journey has sculpted the person I am today
and saved my career in medicine. It is a constant lifeline,
professionally and personally. In bringing awareness of this
skill to our students early in their training, they may also
experience less stress, burnout, and be able to sustain empathy throughout their careers. This ordinary, extraordinary life
we are all living and helping our patients live deserves that,
and more. Mindfulness makes me aware of mine and my patients humanity on a daily basis, and the humbling privilege
of being part of this healing profession.

1. Seuss Dr. Oh, the places youll go! New York: Random House;
2. Kabat-Zinn J. Full catastrophe living. Using the wisdom of your
body and mind to face stress, pain, and illness. New York: Random
House; 1990.
Carol Gonsalves MD, FRCPC, MMEd is a clinician educator in the
Department of Medicine, Division of Hematology, The Ottawa Hospital. Her academic focus is on medical education, specifically in the
areas of needs assessment and curriculum development. She has held
a committee position in Faculty Wellness at the University of Ottawa
since 2008, supporting a specific personal and professional interest in
the benefits of mindfulness on student and physician health since her
own residency training. She holds a committee position on the Mindfulness Curriculum Working Group at the University of Ottawas Faculty
of Medicine, has assisted in editing the course material for this longitudinal curriculum, and is an investigator in research involving a mindfulness curriculum in undergraduate medical education

Medical Students Voices: Reflections

on Mindfulness During Clinical


Mark Smilovitch

The transition from classroom to the clinical setting is an
exciting and challenging time for medical students as they
begin to apply knowledge and develop clinical judgment
skills. However, many students experience or witness some
degree of disconnect between what is taught during their preclinical studies regarding patient care, and what is observed
during clinical rotations. Empathic patient care and efficient
work habits are often perceived as mutually exclusive, and
this may contribute to student frustration and distress.
The following narratives represent reflections on mindfulness during clinical encounters as experienced by students
during clerkship.
Mindful clinical encounters were more likely to involve
attentive listening, and the ability to focus while limiting
distractions. Mindful clinicians demonstrated an awareness
of self and others, while acknowledging their own thoughts,
feelings, and emotions. Comfort with silence was often described in these encounters, inviting patients an opportunity
to pause as well, reflect, and express their concerns. Mindful
clinicians were noted for being present in the moment, and
establishing a sense of connection with their patients and colleagues. Curiosity and enquiry about patients lives beyond
their illness was often reported in these encounters as well.
Common to many clinical encounters was the observation
that the attitudes demonstrated by clinicians were contagious
in nature. Nursing staff, medical students, and residents were
influenced by the behaviors of both positive and negative
role models. Mindful behaviors elicited more caring in other
team members, while less-mindful behaviors contributed to
increased levels of tension and stress.
Robertson Davies, in a lecture to medical students, describes the characteristics of the mindful medical practitioner
Cardiology Division, Faculty of Medicine, McGill Programs in Whole
Person Care, Strathcona Anatomy & Dentistry Building, Room M/5
3640 University Street, Montreal, QC H3A OCA, Canada

[1]. On the subject of knowledge and wisdom in medicine,

Davies comments that knowledge is an external element acquired during education which may be directed at treating
disease, whereas wisdom is an internal element that allows
the doctor to look at the person with the disease and enables
the healing connection between the doctor and the patient.
In writing these narratives, the students benefited from
the experience of self-reflection and developed a deeper
appreciation of patients perspectives. This shared wisdom
helps to differentiate the experience of illness from the biology of disease, and facilitates the recognition of opportunities for healing.

Unmindful Clinical Encounters

Operating Room Tension
As a medical student, I greatly enjoy being in the operating room (OR). In such an environment, where stress can
be overwhelming, emotions run high, and self-awareness is
essential, it is particularly important, yet also most difficult,
to engage in the practice of mindful medicine. During senior
clerkship, I was witness to a less-than-ideal case.
Similar to many major university hospitals across the
country, the hospital in which I worked had its constant
flow of trainees in various health-care professions. On that
particular OR day, I was with a staff surgeon, a fellow, a
scrub nurse trainee, a circulating nurse, an anesthetist, and
his student. I was very excited to scrub-in on the case as it
was a highly technical, minimally invasive surgery, and the
surgeon was a world-renown specialist who had just moved
to Canada from a world-class hospital in another country.
The day began with introductions, as many of the professionals in the OR had never worked with the surgeon, and
coincidentally the scrub nurse was on her first ever solo
surgical case. Everyone started the case in high spirits; the
anesthetist demonstrated enthusiastically intubation techniques to his student, the nurses hurried about, and the sur-

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_24,

Springer International Publishing Switzerland 2015



geon patiently guided his fellow through the intricacies of

the surgery. However, it soon became evident that our patient had a distorted anatomy and the surgery was going to
be more complex than expected. As the case got more difficult, the surgeon started requesting very specific instruments
that unfortunately were not available. Evidently frustrated,
he repeatedly described the instruments he needed, stating
that he would not be able to work without them. The new
scrub nurse, already seemingly nervous, looked increasingly
frazzled as she rummaged through her tray looking for instruments fitting the surgeons description. Meanwhile, the
head nurse called, wanting to cancel the surgeons next surgery due to time constraints. I watched his frown deepen as
he continued with the increasingly difficult case. Although
both the nurses and the fellow gave suggestions on improving the efficiency of the case, he was deaf to all. Although he
was physically present in the room, I doubted that he was really fully aware of that moment. His tone was impatient; his
words were curt and authoritarian; and his body language revealed uneasiness. His rigid posture, stern facial expression,
and brisk movements with the instruments only added to the
glacial environment already omnipresent in that OR. As I felt
the tension rise, I was increasingly stressed. I became fidgety
and my heart pounded. I noticed racing thoughts regarding
the communication breakdown, feelings of frustrations and
anger at the failings of the health-care system, and sadness
at my own incapacity to contribute. Thankfully, the surgery
progressed smoothly thereafter, diffusing the ticking bomb
that I had been dreading.
I wondered what caused his behavior. Was it the altruistic sense of duty to his patient? The severe time constraints
imposed by the head nurse? Or the code of professionalism
to which he abided for so many years? I realized that it was
probably a combination of these. Although I empathized
with the frustrations of the various participants, at the end
of the day, I was tremendously relieved to be out of that OR.
The surgeon, as well as the other health-care professionals
in that OR, myself included, could have been more mindful
in opening a dialogue and taking responsibility by engaging
in that dialogue. What if he had had more awareness of the
situation? What if there had been some time-out activities?
What if he had sought help from more experienced nurses?
I learned that as a physician, it is important to apply knowledge and carry out procedures; but, equally fundamental to
remain sensitive to our colleagues responses.

Night Shift Multitasking

Multitasking is an inherent part of day-to-day physicians
work. Medicolegal and administrative responsibilities combined with simultaneous medical acts and communications
as part of a multidisciplinary team all contribute to it. I will

M. Smilovitch

describe herein what it was like to work on a night shift as

a 3rd-year medical student on obstetrical service under the
supervision of Dr. OB (fictive name) and will show the negative impact multitasking can have on team work, supervision, and general work environment, as I experienced it.
It was a busy night on the obstetrical service on one summer night. Many women were expected to deliver shortly
and numerous patients had to be taken care of on the postpartum ward. Two or three C-sections had been required and we
had reached full triage capacity. As a medical student, I was
under supervision of my staff, Dr. OB, and my senior resident. Dr. OB put strong emphasis on getting the job done and
working as a team. He distributed tasks to my resident and
me. However, he did so in a very rapid way, limiting communication as if he wanted to save time and kept shifting back
and forth between the different points on the task list. I remember he appeared to be stressed, somewhat overwhelmed
and not in full control of the situation. I remember feeling
stressed and disoriented due to the numerous unclear directives for which I had unanswered questions, due to time constraints. Among a list of things to do, he asked me to consult
neonatology for a twin pregnancy that might have resulted in
preterm delivery. After paging three times the local hospital
neonatologist on call, I finally got a hold of him and was able
to see him in person at the nearby intermediate care unit. He
explained me that I would need to consult the NICU staff at
an affiliated larger hospital for a possible transfer as the case
would likely require more specialized care, in his opinion.
With no time to waste, I took the initiative to call the NICU
staff at the other hospital and explained the situation so they
would be aware in case of a transfer. Later, when I met my
supervisor and explained to him what I had accomplished,
he became furious and made it clear that I should not have
contacted the other hospital even though I explained him the
local neonatologist told me he would not take the babies at
our hospital. He called the NICU staff at the other hospital
and said to ignore what the medical student had said. I
apologized but I recall that I was surprised, confused, and
frustrated that Dr. OB did not give me clear enough instructions about what my duties were initially. I had taken the
initiative based on my best clinical judgment to get the job
done as required with the limited information I had.
Although Dr. OB takes very good care of his patients and
is known to be nice with medical students and other personnel, I believe what I experienced that night shift might have
been prevented by a mindful practice. In the context of a
busy night shift, Dr. OB had taken the get the job done
traditional stance, which implied multitasking, distribution
of tasks, and team work. I believe the stress and the confusion I felt were at least partly derived from what my supervisor experienced and modeled. I decided to get the job done,
even though I did lack clear information about what my tasks
were exactly, which turned out to be different from what was

24 Medical Students Voices: Reflections on Mindfulness During Clinical Encounters

expected from me. In my opinion, the shifts in ideas, task explanations and brief, rapid and insufficient communication,
all reflected non-mindful multitasking. I wonder, is it possible to multitask mindfully? What if my supervisor had
taken an extra 20 s to better explain what he expected from
us and to clarify what was still imprecise for me? What if he
had focused on one task at a time? Being mindful in multitasking involves the complementary abilities of focusing and
shifting attention, one task at a time to better perform each
of them. Also, Dr. OB was frustrated about the situation, but
I do not think he realized until later that I had done what I
thought would be best for patients with limited directives.
One point I would like to emphasize is that Dr. OB is a
professional and trusted physician whom patients and medical students appreciate. I share this consideration completely.
Unfortunately, I believe that, during this particularly stressful night, part of his practice was not mindful and I suffered
from it, as a medical junior clerk.

Laboring Alone
Clerkship obstetrics and gynecology: A surprisingly interesting and rewarding couple of months! There is one encounter,
however, that I will always remember for all the wrong reasons. I entered the room of one of the patients and noticed
several things right away: first that she was laboring alone.
A closer look at her garments and head covering told me she
was of a modest Jewish sect, in which men are not present
during labor and delivery. I felt so sad that she had not a
single person by her side!
Second, I noticed that her nurse was not paying much attention to her; instead she was busying herself with the organization of the room, rearranging things here and there,
instead of coaching her through her contractions. I was
shocked because I had otherwise been thoroughly awed and
inspired with the compassion, dedication, and almost motherly protective instinct that the obstetrical nurses dotted on
and accompanied their patients through the process of giving
Lastly, I noted the senior staff accompanied by a junior
resident, chatting amicably among themselves, while leaning between the bare, propped up legs of the patient, ignoring her completely but for the occasional glance to track the
progression of the babys head.
A multitude of emotions rushed through me at that time:
anger, sadness, frustration, disbelief, disgust, and contempt. I wondered if they realized what they were doing.
The impact it had on me was huge, perhaps because they
were both male physicians? I do not know. Although a certain degree of habituation can be expected from performing
the same task over and over, as a seasoned physician would,
giving birth is never mundane for the mother in the room. I


promised myself never to be this mindless when caring for a

patient and her family. This experience has created a greater
awareness of the ways in which I conduct myself in front of
patients and my team, including verbal and nonverbal communication. I make an effort to be conscious of my facial
expression and stance when interacting at work, taking care
to make eye contact, and to sit at eye level as often as possible. I want to be professional at all times, even when faced
with people who are disrespectful or rude. I understand that
I can only control my own behavior in response to theirs;
nonetheless, I hope I can affect change by modeling how I
would wish to be treated.
I can only speculate as to how it must have made the patient feel to be disregarded so blatantly. Perhaps she lost trust
in the doctor, nurse, and medical system as a whole. It may
have sullied her birthing experience, making her feel small
and insignificant. This is not the first time I have witnessed
patients tolerating behaviors from health professionals that
they may not have ignored coming from anyone else. If she
were standing at the cash at the grocery store being ignored,
would she have spoken up? Probably. There seems to be immense tolerability when it comes to doctors. Why? Doctors
are tremendously respected, perhaps even a little feared, and
maybe they have gotten a little accustomed to being idolized.
Our level of education should not be used as a premise to
excuse bad behavior. Watching that scene unfold was a bit
like being told Santa Claus does not exist: crude and disappointing.

Mistaken Diagnosis
In medicine, time restraints can influence our interaction with
patients and may impede us from being mindful. In order
to properly diagnose and treat a patients current illness, we
need to know the patient as a whole and understand their
psychosocial and past medical history. One incident where I
witnessed a physician not practicing medicine mindfully was
in a hectic surgical rotation where assumptions were made
and a diagnosis was missed.
Morning rounds in surgery begin at 5:45 a.m. There were
approximately 30 patients to see before making our way to
the operating room for a long day of surgery. We visited each
patient as a group: one resident entered the room to ask a few
questions and perform a brief physical exam, while another
wrote orders for labs and medication, and at the same time
someone wrote a brief note. One patient encounter in this
rotation that marked me was a 65-year-old woman postoperative bypass surgery. When we passed by her room as a
group, we noticed that she was moaning and talking to herself. The resident immediately dismissed her complaints and
labeled her as having delirium. No tests were ordered and
we continued on with the other patients. The following day,


the endocrinology team was consulted for management of

the same patients diabetes. I overheard the team discussing
that this patient was not delirious; in fact she was experiencing diabetic ketoacidosis. Although it was documented
somewhere in her chart, the residents had missed that she
had a history of type I diabetes. The endocrinologists were
fuming that the surgeons had diagnosed this patient with delirium without performing a complete workup. When returning to see the patient, her neurological exam was abnormal,
and numerous tests were ordered, including imaging, to rule
out the possibility of a stroke. Her neurological deficits had
been overlooked because someone attributed her bizarre behavior to confusion. As a consequence, the patient did not do
very well but thankfully improved with the proper treatment.
I remember feeling upset that the resident had missed an
important diagnosis because he did not spend the needed
time to examine the patients medical history or perform a
full neurologic examination. What if she had had a stroke
and was permanently disabled because someone mistook her
symptom? What does it take for someone to spend a few
minutes speaking with the patient or her family to determine
why she is hallucinating? After the anger came fear. I was
terrified by the thought of how easy it was for medical errors
to occur. I looked at the resident, who had just been in the
operating room for 12h straight, and still responsible for all
the patients on the ward, and I was worried. When a resident
does not even have time to stop what he is doing to eat or to
go to the washroom all day, how is he expected to function
fully and be mindful of each patient? Will patients suffer because we are overwhelmed with responsibilities and stress?
On a surgical ward, or in the emergency room, there are
many patients to see with little time and it is easy to become
distracted and unaware of the environment. When pressed
for time, we can make assumptions without taking the time
to explore a problem further. Being mindful in medicine with
every patient interaction can help us avoid potentially fatal
medical errors in the future.

Mindful Clinical Encounters

How Are the Crops?
During my Family Medicine rotation, I encountered a physician who I thought embodied perfectly the principle of
mindful medical practice. He ran a Family Medicine clinic
in rural Quebec. It was a practice of some 30 years old, and
he knew most of his patients for just about that long. We
had busy days; the mornings were filled with walk-ins, and
the afternoons with follow-up appointments. He listened
attentively to each patient, answered all of their questions,
proposed plans fitting each persons needs, and always left
time to chat with patients about their daily lives. As such,

M. Smilovitch

most of his patients saw him as an old friend, whom they

could trust and confide in. Despite having a very busy clinic,
I sensed that he was never rushed. He seemed to go into each
patients room with the same intensity and the same kindness, never frazzled, never fatigued. I truly felt that he was
there for his patients. Over time, as I watched him calm the
anxieties of a young mother-to-be, address the concerns of a
patient gripped with chronic pain, and grieve alongside a recent widower, I developed a great admiration for his person.
I could not help but wonder how he did it. How could he be
there for each and every one of his patients? How was he not
emotionally drained or physically fatigued at the end of the
day? What was the origin of his motivation? Was he driven
by the altruistic sense of duty to his patient, or by the code of
conduct dictated by medical professionalism? Maybe he was
motivated by social and financial gratification.
One morning, we saw an elderly gentleman with chronic
back pain. At the end of visit, the patient asked: How are
the crops? The physician smiled and to my great surprise he
started discussing fervently about farming with the patient.
A little while later the patient left, but not before making
the physician promise to discuss fertilizer choices at his next
visit. As we walked back to our offices, the physician smiled
at the puzzled look on my face. He then related to me that he
was, in fact, also an avid farmer, owner of just about 8acres
of land. He said that working on his land kept him grounded over the years. He enjoyed soaking in the warmth of the
sun, the feeling of raw earth between his fingers, and driving
around in his old tractor. I could sense his excitement as he
spoke of his farm; how he aspired to expand his land, to build
a mill, and to acquire some more animals. Before I could
help myself, I asked: But why? Arent you busy enough as
a doctor? What he replied would change my perception of
the medical profession. He taught me that as physicians, it is
extremely easy to be immersed by our work. Though gratifying, medicine can take over our lives if we do not make
an active effort in making space for ourselves. Hence, it is
vital to find our own happy place, where we can let go of the
worries of the day, and enjoy that moment with ourselves. In
his case, his farm was where he was most aware, and most
I thought that his medical practice was the perfect embodiment of mindfulness. Not only was he addressing the
physical and psychological concerns of his patients, he did
so with full awareness of their individual socioeconomic and
cultural circumstances, all the while being attentive to his
own needs and capabilities. Through self-care strategies, he
also became present, grounded, and more in touch with each
moment spent with his patients.
As medical students, we learn of the importance of patient care. We are expected to be compassionate and caring,
to absorb our patients pain and help them with full focus
and composure. Now I know that self-compassion is equally

24 Medical Students Voices: Reflections on Mindfulness During Clinical Encounters

important: taking care of the self to take care of others. Only

then will we become more present for our patients; to recognize their subtle expressions of anxiety and suffering, and
to provide them with the best care possible (composed by
Clara Wu).

Staff Magic in the ER

The experience I would like to relate was in the emergency
room. This was my first rotation, so I had not yet matured
clinically. I was seeing a 90 something female patient as a
consultant for the internal medicine team at approximately
11p.m. She had come in for shortness of breath and appeared to suffer from some amount of memory loss, likely
mild cognitive impairment. I did as much as I could with the
patient, but at some point she became annoyed with me and
refused to participate any further in the medical interview
and refused to allow me to examine her, saying, Go away!
I was dumbfounded. Realizing that there was not much
else to do, I gathered myself up to find my staff. I recall the
muscle tension, dry mouth, and awkwardness with which I
approached him knowing I had done an incomplete job. I
related as much information as I could and apologized for
my inability to complete the consultation. All the while he
listened and nodded without interruption. When I finished
my case presentation, he smiled and said, Lets go see her.
As we came up to the patient, I noticed that my attending
approached the situation differently in two particular ways.
The first was that he called her dear. The second is that he
held her hand and comforted her. Being the good medical
student, I followed suit and held her other hand while my
staff completed the interview. She immediately opened up,
smiled, and was very much interested in participating in the
medical interview process once again.
I believe that this was an example of mindful medical
practice for several reasons. The first is that my staff likely
saw that I was upset and could sense the shame I felt. Ordinarily this staff person engages students in a playful and fun
manner to show them where their knowledge is weak, but on
this occasion he merely listened. In short: he was mindful
with me. Then, without ever having met the patient, he must
have surmised what she needed emotionally. He delivered a
kindness and gentleness that was natural and authentic simply by smiling and holding her hand. I was utterly astounded.
When I related the story to some colleagues, they smiled and
said staff magic.
The impact that this had on me was profound. First, it
reminded me that the personal touch is extremely important.
This was something I knew in a very intellectual, cognitive
kind of way. I did not know how to do it spontaneously,
at least not with someone 65 years my senior. I recall also
feeling the shame melt away when the patient responded so


warmly to us the second time around. I realized that my inexperience and nervousness were barriers to being authentic
with this person in the moment. I felt relieved that this was
not a failure that would define me, but rather a very important lesson.
In terms of the effect this had on the patient, I believe that
at first she was probably irritated by me: annoyed with my
questions, annoyed with seeing another student doctor late at
night in the emergency room. Perhaps she was angry that the
system was not taking good care of her. However, I believe
that we quickly turned the situation around and that she felt
listened to and cared for. All she wanted was someone to hold
her hand and say it was going to be okay. Just a few more
questions and then we had all the information we needed for
that night. All it took was a smile and some reassurance. So
simple. I hope that after our encounter she had renewed faith
in the medical system, realizing there are some doctors and
nurses who are capable of taking the time to pause and make
a human-to-human connection (composed by Eric Lenza).

No Need to Translate Compassion

During a rotation in hematology and oncology, I had the
privilege to care for a young boy suffering from chronic
granulomatous disease. Because he had already previously
failed an attempted bone marrow transplant, the childs parents were now on edge and very anxious about his future
or lack thereof. Due to his immunosuppressed state, the boy
was perpetually confined to an isolated chamber with advanced filtration systems. Any visitor entering the room had
to gown himself appropriately and don a mask and gloves.
His condition being chronic, there was admittedly not
much change in my day-to-day morning visits. Every day,
I could witness the parents suffering as they watched their
child play innocently all the while being shrouded in a constant veil of uncertainty about his chances of being cured.
The young child was evidently unaware of his prognosis and
had seemingly become accustomed to the strange, yet familiar daily routine where medical personnel would frequently
visit him in his filtered prison.
Eventually, the monotony of this routine had to come to
an end as the child was to receive a second attempt at curative bone marrow transplantation. Before receiving the actual transplant, he needed to undergo a thorough immunosuppressive protocol to optimize chances of success and prevent
reactivity. Like any other procedure, this needed to be fully
discussed with the parents as their consent was required to
proceed. Given that the childs family had a poor mastery of
the English language, the attending oncologist brought me
along as I spoke their language and felt that I would be an
asset in ensuring that the situation be conveyed effectively.
Upon initially approaching the family for this serious meet-

M. Smilovitch


ing, I was surprised to observe the warmth displayed by the

staff oncologist as he was usually more distant and slightly
domineering. He proceeded to empathize effectively with
the family and acknowledge the suffering that they had experienced thus far given that the previous transplant had
failed. He confidently reassured them that he made every arrangement possible to optimize the chances for success this
time. As I was translating between both parties, I could feel
first-hand the parents hope growing and their hearts opening up to the oncologist once more after this display of professionalism and competence. The oncologist, ordinarily an
extremely busy man with multiple academic and administrative commitments, had temporarily completely set aside his
other duties to personally discuss therapy with the patients
family. He had immersed himself fully in their world and
wanted to answer every single question that they could possibly think of. Even when the parents had exhausted their
inquiries, he encouraged them to think of more. At the meetings conclusion, I can safely state that the mood of everyone
in the room had been lifted and their worries cleared by the
oncologists impeccable display of physicianship.
In retrospect, after having now learned about mindfulness, I can appreciate how the oncologist was able to fully
immerse himself in his patients circumstances, temporarily disregarding doubts, limitations, and the flow of outside
time, to provide the best quality of care possible at that crucial moment. By connecting briefly, yet effectively and professionally with his patient and his family, he was able to
assume a congruent stance and practice medicine mindfully
(composed by Simon Sun).

The Power of Silence

Neurosurgery is recognized as one of the most competitive
and busy specialties in medicine. I undertook my neurosurgery rotation not knowing really what to expect, except for
the amount of work involved. I quickly realized how sick
some patients admitted on the ward were, some of them disabled with severe neurological conditions. Dr. N. was my
staff on the ward. Although I had not seen him often in my
day-to-day work, I had observed a few of surgeries he had
performed with my resident. During one of the staff rounds,
we entered the room of a patient suffering from a malignant
brain tumor with a very poor prognosis. I realized I had seen
and interviewed the patient during my emergency rotation
couple of months earlier. An emergency doctor had told me
at that time he was on a special chemotherapy for this type
of cancer which effectively prolongs his life expectancy but
also causes him to come repetitively to the emergency room
with complications requiring other interventions. The patient
was deeply sleeping and his wife was sitting at his bedside.

I remember the staff talking to her very gently, honestly,

and with kindness. The conversation about her husband was
marked by many long silences during which Dr. N. and the
wife would look at the patient sleeping. My resident and I
moved to the door entrance, answering nurse questions and
signing orders for other patients, but I observed attentively
the interaction between Dr. N. and the patients wife. At one
point, she cried and the doctor looked at her, then he touched
her shoulder while keeping silent. She had been present all
the time since her husband had been diagnosed, accompanying him to ER visits, follow-ups, and admissions. I recall
thinking she must be exhausted physically and emotionally
in the face of the very poor prognosis of her beloved husband. I felt very sad at that time. I also felt amazed, perhaps
a little bit surprised, that such a busy neurosurgeon, which I
knew only from the operating room with his mask on, was
so humane and empathetic. He took all the time needed to
make sure that the wife would feel understood and supported
through this difficult time.
I believe this interaction had a positive impact on the wife
and the family of the patient. The wife was suffering and
alone. Dr. N. recognized and addressed her suffering as a
healer with an open mind, time, and mindful approach. What
I witnessed during this round proved to me that any physician, whatever his or her specialty, can have an important
impact not only on patients but also on their family. I recognized that healing often involves more than the patient alone;
the family, close friends also need to be treated. Listening
in a mindful way, allowing for silences, pauses, and emotions
to be expressed is a powerful way to engage with the core of
the problem and to address hidden profound dynamics.
I will remember this clerkship experience in my future career as an example of a mindful medical practice and healing
for the patients family. One important element of mindfulness consists of exploring the deeper issues which require to
be addressed instead of being ignored. One very useful tool
to achieve this is silence, listening, and acknowledging our
own thoughts, gut feelings, and emotions. The context and
circumstances are certainly very different from one patient to
another and from one family to another but the goal is always
the same: healing.

Kindness is Contagious
On the hematology/oncology ward, many of the patients
were seriously ill; some had received bad news on too many
occasions. The ward was full and there was not an empty
bed. This made for hectic days and many patients to be seen.
Each day, the doctor in charge would venture from room to
room and visit patients, answering their questions, and alleviating some of their fears. It was difficult to allocate enough

24 Medical Students Voices: Reflections on Mindfulness During Clinical Encounters

time to each patient but somehow this staff managed it and

made it seem easy.
I remember being struck by his behavior and his words.
He was soft spoken and took his time before speaking. As a
result of his deliberately slow speech and his ability to allow
for comfortable silences, his patients felt that he was not
rushing them. They did not feel the need to have pre-written
lists of questions; they were not nervous about possibly forgetting some of their questions, or taking too long to formulate them. At times, he only spent 5min with a patient, but he
always left them feeling reassured and less stressed than they
were before he arrived. I remember a certain patient who was
very anxious; one might call her and her family difficult.
Most of the team felt impatient, even exasperated when
working with them. Although this staff acknowledged that
they were challenging to deal with, he never let this show
when in their presence. He was patient and explained, again
and again, what the course of action was and what the options were. If the patient needed more reassurance in order to
feel good about the decisions she was making, he offered this
to her without forcing her to apologize or feel guilty about
her fears.
He often sat on the bed next to his patients, sometimes
having physical contact with them. This seemed natural,
especially when he had very difficult and negative news to
share with them. During our 2 weeks together, I never heard
his pager go off during his visits with patients (perhaps he
had set it to silence before his rounds). He did not fall victim
to the many barriers to mindfulness; he was rarely distracted
by tasks we had to yet complete and did not attempt to multitask. No distractions seemed to exist during these protected
visits with his patients, no matter how long or short they
were. It is easy to forget that mindfulness can occur despite
time constraints, and his skills with patients inspired me to
be better during my own patient encounters.
Thanks to observing his interactions with patients, I also
learned that curiosity is important. He often asked the patients what they had done for work; he queried about their
family, and posed questions regarding their life prior to their
illness and hospitalization. He made sincere attempts to get to


know his patients on a personal level and they clearly sensed

this. He put them at ease. Receiving difficult news was made
easier for them; they began to trust and know this bearer of
bad (or good) news. In hindsight, I realize that he was an exceptionally mindful and present physician, regardless of the
duration of his patient encounters. This staff clearly had the
ability to not only cure or treat in the medical sense, but he
also alleviated a great deal of suffering with his compassion,
kind words, and gestures.
The empathy he showed his patients was inspiring and
made me proud to be a part of that team. His attitude was
contagious. During his time as staff, it was clear that the
nurses, students, and residents all felt the need to live up to
his example. Everyone seemed to be just a little more patient, a little more empathetic, a little more willing to extend
kindness. One persons attitude causes a cycle; sometimes
vicious, sometimes kind. The multiple encounters I had with
this staff and his patients were very educational in a personal
and professional sense. Remembering these encounters helps
me to realize that being fully present with patients assists
them during their healing process but also allows members
of the medical team to feel positive and valuable with regard
to their work and contributions to patient care (composed by
Rachel Tessier).
Students whose names appear herein have provided written

Robertson D (Editor). The merry heart: reflections on reading,
writing, and the world of books. Selections 19801995. In: Can a
doctor be a humanist? (chap.5). New York: Penguin Books; 1998.
Mark Smilovitch MD is a cardiologist and associate professor in the
Department of Medicine at McGill University, Montreal, Canada, as
well as on the Faculty of McGill Programs in Whole Person Care. He is
interested in medical education, and is involved in physicianship teaching, with an emphasis on simulation-based learning

Growth and Freedom in Five Chapters


Stephen Liben

Growth. Freedom. The words resonate. But what is meant by

growth and by freedom? One definition of freedom is
to be able to choose how to consciously respond, rather than
unconsciously react, to events. Something happens and our
biology and conditioning invoke an almost instantaneous,
cognitive, and emotional reaction. Without mindful awareness, we then act on this conditioned reaction. With mindful awareness, there is a pause created between stimulus and
response/action. During that pause or gap, between stimulus
and response/action, an awareness emerges that can observe
both the external context and internal preprogrammed reactions. Awareness of external context and internal reactive
behavior patterns allows for a reassessment: What will likely
happen if I react this way and is this what I really want?
When in reactive mode, we act on stimuli in preprogrammed ways because in that moment it feels like there are
no other options available. With mindful awareness, the gap
between stimulus and response allows for questions to be
asked about previously unexamined aspects of the situation.
Asking these questions (e.g., What am I assuming? What
am I not seeing? What am I not questioning?) often results
in many choices being made available when previously there
was only one. To react is to act out of unconscious unawareness. To respond is to act from conscious awareness. Reacting unconsciously in preconditioned ways is to be a slave
to each stimulus that sets off predictable preconditioned and
often harmful actions. Responding means the ability to see
the likely possible outcome(s) and then discern which action
would reflect the kind of person we endeavor to be. Developing the capacity, in the moment, to choose how to respond
out of mindful awareness is a movement towards self-actual-

ization, to our deepest aspirations of who we might become.

In a word, growth.
There is much written on mindfulness, its definition, how
to cultivate it, and different practices that are helpful in its
development. If you want to learn swimming you need to
get wet, to get into the waterit is not enough to read a
book on how to swim; similarly, reading about mindfulness
is unlikely enough to help a person develop mindful awareness in the moment. This chapter will not teach you about
mindful medical practice; rather, it uses a poem written by
Portia Nelson, An autobiography in 5 chapters as scaffolding onto which examples are shown of the reactive mind
in action. Awareness practice often arises, as it did for me,
out of a profound dissatisfaction from seeing my reactive
self repeat the same unhelpful actions over and over. Once
these reactive patterns of stimulus-reaction-unhelpful-action
are known, there is simultaneously disappointment (Is this
how I really am so much of the time?) and the possibility
for change, to move towards freedom by choosing responses rather than be driven by unconscious harmful reactions.
The kind of person I aspire to be, i.e., more responsive and
less reactive, less judgmental while having better judgment,
more patient kind and loving towards self and others, is, if
not wished for universally, is likely shared, in particular, by
readers of this book.
Because personal growth does not necessarily follow a
linear narrative of things getting better and better over time,
the vignettes likewise take steps forward and then back over
the years. If at the end of this chapter you find yourself thinking, If a mindful practice can help someone as reactive as he
seems to be then imagine how much potential it has for me
then what I had hoped will have been achieved.

McGill Programs in Whole Person Care, Faculty of Medicine,
Paediatric Palliative Medicine, Montreal Childrens Hospital,
McGill University, Montreal, QC, Canada

Chapter I

4469 deMaisonneuve O, Westmount, QC H3Z1 L8, Canada

I walk down the street.

There is a deep hole in the sidewalk.

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_25,

Springer International Publishing Switzerland 2015


S. Liben

I fall in.
I am lostI am helpless.
It isnt my fault.
It takes me forever to find a way out.

I am a 28-year-old, second-year pediatric resident, doing a

pediatric emergency room rotation on hour 5 out of my 7-h
shift. My role is to first see patients on my own and then,
when I am ready and have thought through what I want to do,
review the case with the staff doctor. In practice, this means
that I typically have four patients at a time in various stages
of being worked up with tests or in observing their response
to medication, all waiting for me to review their cases with
the staff doctor. This means that when I enter the room of
a new patient (most commonly a small child with a fever
brought in by her mother), I always have several patients at
various stages of workup and treatment going on simultaneously. Working in the emergency room is stressful for meI
am not that good at focusing on what is in front of me as I
walk into the examination room of a new patient and their
parentsmy mind keeps jumping from one thing to another:
all the patients and parents waiting in the crowded waiting room (I cant possibly work fast enough to make a
the three other patients that are waiting for me to check their
labs before they can either go home or be admitted (Did I
remember to order the urine sample?; How long has it been
since I went back to re-examine that baby with a fever?: Have
I forgotten all about the 9 year old with asthma in the back
the teaching presentation I did yesterday that did not go so
well (I should have prepared more so that I would have known
the answer to more of the questions); the presentation that
I have to prepare for next week (Maybe I should present on
how hard it is to keep focused when working in the emergency
my emotional state, that I am barely, if at all, aware of, that
feeds my anxious thoughts (Am I anxious, or just tired, or
my physical state, that I am also mostly unaware of (tense
muscles, frowning face, hungry, thirsty, need for the bathroom).

I carry all that (thoughts, feelings, physical sensations) with

me as I walk into the room of a new patient (who has been
waiting for 4h) where I see a concerned looking mother
holding her 14-month-old son:
What I say: Whats happening with your son, why did you
bring him in today?
What she says and what I hear: Well, since yesterday he has
felt warm and he has just not been himself. I tried giving him
some Tylenol but he just wont eat and he is drinking less and

At this point, what she says and what I hear become two
separate streams, and I am left only with the confused jumble
of thoughts going on inside me, as I am no longer able to
hear her spoken words.
What follows are phrases of my fragmented inner dialogue
that have now completely replaced what is actually being told

to me by this concerned mother (that I am no longer hearing):

I hope the urine on that 1-month-old comes back negative
cause if not then he needs an L. P. and I so dont want to
do one right nowmaybe I can take a break from this place
after this patient and get something to eat. I wonder if I
have time to run across the street as a warm burger and fries
sure sounds good right nowbefore that I would just like to
have like 2min in the bathroom to wash my face.
After 5 or 10min of this mother telling me what is wrong
with her child and of me not listening to a word she has said
(has it been 5min of her talking and my not listening or even
longer?), I then think to myself, What is wrong with me?
How can I do this to her and her child? How can I save face
without admitting that I have not heard anything she said?
I ask her (for the second time now), So you brought in
your son today because.?
I am just so ashamed of myself and give myself the poorest listening skills ever award.

Chapter II
I walk down the same street.
There is a deep hole in the sidewalk.
I pretend I dont see it.
I fall in again.
I cant believe I am in the same place.
But it isnt my fault.
It still takes a long time to get out.

I am a fourth-year pediatric resident doing a neonatal intensive care unit rotation on hour 18 of my 24-h shift. It is 2
oclock in the morning, the hour when bad things that happen in hospitals tend to happen, when the sickest kids tend
to arrive in the newborn nursery. I am lying down in the on
call room when my pager goes off and I am told to get to the
delivery room, stat, for a baby that is going to be born prematurely (7 weeks before her full-term date). I arrive sleepy and
irritable and accompanied by one of my increasingly common migraine headaches as my unwanted companion. The
baby is born and it becomes obvious within minutes that she
will not be able to breathe on her own. I begin to bag/mask
breath for her and ask for the staff doctor to be called while
we prepare to place a breathing tube into her (intubation) in
order to be able to place her on a ventilator. I am nervous
about the intubation and have never tried before in so young
and small an infant. The staff doctor arrives and she is also
tired but I can feel the calmness and confidence emanating
from her that I know I do not have. I am tired and my head
hurts and I have no confidence and my thoughts are all negative and self-pitying (Why me?) and I am not even aware
of my negative thoughts, my depressed emotional state, and
my tense muscles. I try to intubate and cannot see where to
place the tube. With encouragement from the kind and pa-

25 Growth and Freedom in Five Chapters

tient staff doctor I try again. I fail again. The baby is safe as
we try, but it must hurt to have these tubes stuck in her throat
over and over again. I am asked if I want to try to intubate
again (I know that the staff doctor can easily do this procedure herself at any time and she is only being kind in offering
me the opportunity to improve my skills.). I answer her back
by saying, No I cant try again, I have a headache and I need
to lie down. I walk away before hearing what she has to say
and I shuffle back to the call room and fall into bed. I am
beyond tired and am fed up. I hate the baby for being born. I
hate the staff doctor for being so kind. I hate myself. Why is
the world so unfair?

Chapter III
I walk down the same street.
There is a deep hole in the sidewalk.
I see it is there.
I still fall inits a habit.
My eyes are open.
I know where I am.
It is my fault.
I get out immediately.

I am a 52-year-old staff pediatrician now on day 12 out of

12 (having worked through the weekend) on a busy inpatient
pediatric hospital ward. It is, finally, my last day and as I
enter the ward in the morning, I vow to myself to be careful as I can sense my inner state is conductive to me losing
it. What that means is that conditions are just right for me
to lose my temper and start my reactive process of blaming
myself and others that I seem to default to when I am under
stress. I have learned, the hard way (Is there any other way to
learn the most important things?) that for me the conditions
that make me prone to reactive outbursts of blame are being
tired and not having enough of a balance between work and
time off. So it comes to be that on this Friday morning, I am
simultaneously tired/drained and also hopeful of the possibility that I can end the rotation on a positive note. During
morning report, I hear the updated medically stable status
of an adolescent boy with psychiatric/behavioral problems
that was admitted to the ward 2 days ago, and as per protocol, was to be transferred to the psychiatry service once
he was stable. We had counted on this now medically stable psychiatry patient being transferred this Friday, before
the weekend, and we had come to that agreement with the
psychiatry staff when he was admitted a few days ago. On
Friday at 2p.m., the psychiatry resident tells us that, The
patient will not be transferred to our service today, but we
will reconsider taking him onto our service on Monday. The
time between my hearing those words that Friday afternoon
at 2p.m. (only three more hours before I was about to finish
for the weekend!); getting reactive/angry was triggered in


me in less than 1s. By 2s I was sure I was right based on

my interior monologue that, They were never ever going
to take this patient and they purposively waited until Friday
to tell us so that we would have no options! This is just like
them, always making promises that they etc Propelled by
this inner monologue, I then proceeded to lash out at both the
psychiatry resident and psychiatry staff person accusing and
blaming them both for being manipulative. All the while, I
am blaming and raising my voice at them a part of me wonders: just maybe, is it possible I am not being either rationale
nor helpful? What keeps coming up in a corner of my mind,
first as a whisper that is easy to suppress and then louder and
louder are the questions What am I taking for granted here?
What am I assuming and not questioning? What else might
be going on here? What am I not seeing? This feels familiar
and just like so many other times where I at first was so sure
I was right and others were wrong.
Three hours later, I apologize to all and go home exhausted and embarrassed. Will I never learn?

Chapter IV
I walk down the same street.
There is a deep hole in the sidewalk.
I walk around it.

I am a 44-year-old staff doctor about to leave for an intensive mindfulness retreat in California. I have never been
on a silent retreat before for more than 1 day. I have looked
forward to this retreat for over a year. It is going to be great.
California in the winter (compared to Montreal, Canada).
Nine days of minimal need to interact socially. Good food,
all prepared by others, and just waiting three times a day
to eat it. Walks in the mountains. Face time with world-renowned mindfulness teachers. What could be bad?
Day three of the retreat: I am going crazy. This is madness. It is their fault. What they have set up here is a mental
pressure cooker. Take people out of their usual life, change
the rules of social engagement (i.e., there are none) and have
us sit still from morning to night every day for day after
day! Of course, I am feeling overwhelmed with thoughts
and emotions. I ask to meet with one of the teachers (this
is arranged by leaving a written note asking for a personal
meeting on a posted board). I am going to tell her that I see
through their manipulative set up and I will show them the
error of their ways. I meet the first teacher and tell her everything I am thinking and feeling. She asks, Who do you think
you are to ask to change the way these retreats are run?! I
leave the meeting as angry and self-involved as ever. I then
decide to request a meeting with the intimidating and wellknown head of the whole program. I leave him a note that
morning saying Are you sure you know what you are doing

S. Liben


here and are not creating harm with a purposively manipulative brainwashing environment? At lunch, I spy on him
as he eats a few tables away from me. Of course, no eye
contact is allowed so it is hard to know if he even sees me.
Did he see my note from this morning? He gets up and walks
over to where I am sitting and without breaking his stride nor
making any eye or other contact he leaves a note next to my
fork. The note says Meet me at 2:30 in room 1. Room 1,
his room! My ego is simultaneously gratified at the personal
attention (Was that what I was really looking for in all this
fuss I have created, the feeling of being special?) and terrified at now actually going one on one with this intimidating
teacher. We meet and he seems more confused than upset.
What is your problem Stephen, everyone else is grateful for
the quiet and the setting? He does not get what I am angry
aboutDoes not he understand that the reason I am feeling
so angry and agitated is because of what he did in setting up
this retreat the way it is? Why cannot he understand?
I decide that I will (probably? maybe?) leave the retreat
tonight but before I do I ask to see the third teacher. I want
someone to validate that what I am thinking and feeling is
not my fault and that it is because of what they have done
here. I want them to know that I am leaving and it is their
fault for creating such a psychologically unhealthy situation.
My meeting with the third teacher is very different compared
with my previous meetings. This teacher is less well known
than the other two. He hears me out (my speech is now well
practised from having been given to myself hundreds of
times and now twice with the two other teachers). He seems
truly confused and, like the other two teachers, cannot understand what I am so upset about. What is wrong with these
teachers here anyways? Are they so deluded that they cannot
see what is right in front of them? Except the difference with
this teacher is not in what he says, which was essentially the
same thing the other two teachers said, I cannot understand
what you are so upset about Stephen. Rather, it is not what
he says, but how he says it. He was simply concerned and
bothered that I was not OK. His voice transmitted a concern
that I had not heard before. I felt cared for. He said, I understand you may leave the retreat and you should do what you
need to do. I want to tell you that I do hope you will find a
way to stay as your questioning is good and I think you have
something to offer the group.
I walk out of the meeting room and look down the hill at
the gate where I could hail a taxi and just leave. In that moment, I know that if I leave it will be because of me. It will
be because I cannot bear being with myself. There is nothing
happening here other than what I do or do not make of it. If
I leave I will be walking away from what is difficult within
me. I will be walking away from myself. I decide to stay and
see what happens. There is no great awakening. No epiphany.
Just a gradual settling down of my mind. By the end of 9 days,
I wish the retreat and the silence could go on even longer.

Chapter V
I walk down another street.

I am 52 years old. It is a few weeks before these words were

written. We are on rounds in the morning on the pediatric
ward. We form a group of six people as we walk from patient
room to room, three residents, two students, and myself. We
enter the room of a 16-year-old girl who has been in the hospital, bedbound, for over a month with a chronic debilitating
neurological disease that has left her profoundly weak. She
has been having panic attacks at night that are difficult to differentiate from troubled breathing that can happen as a result
of her muscle weakness. The six of us squeeze into the small
room where she is on her laptop, in bed, with her mother and
father sitting in chairs next to her. So much information is
transmitted before a word of greeting is said. The way she is
lying in bed focused on her laptop, the way she tries to fully
lift her head to greet us, and her parents who leap up out
of their chairs as we walk in. The anxious/expectant looks
on her parents faces. We introduce ourselves as the medical
team that will be looking after her for the next 2 weeks. I explain that we have reviewed her chart and know many of the
details of the failed treatments, the persistent panic attacks
that are hard to differentiate from breathing crises and the
inability to get her stable enough to be sent home. I explain
that, as this is our first day meeting them that we will need a
bit more time before we can make any new suggestions for
treatment. She says little. Her parents ask us about increasing
the dose of one of her medications and we respond by saying
we will ask the neurologists involved for their opinion. I feel
the pain of her parents and their frustration that No one has
answers on how to make our daughter better. I tell them that
their frustration is understandable and that we will do the
very best we can to see what is possible. I am aware of my
own desire to leave the room because of unwanted feelings
of uselessness and sadness that I myself am feeling that may
be a reflection of what they are feeling (what Freud called
counter-transference). I am aware of my own thoughts,
feelings, and physical sensations in the moment that all point
me towards saying good-bye and leaving the room to see the
next patient. I see and feel so much pain for all involved and
so little answers. I ask her, When you are well what is something that you love to do? She answers, something that I
love to do? incredulously, as this is an atypical question that
likely she has not been asked before during team rounds. She
answers, very softly so that we strain to hear her, I love to
sing. I exclaim, How wonderful! she replies, I have a
video of me singing with a famous singer that was done by
the make a wish come true foundation, would you like to
see it? I am heartened by her enthusiasm and she begins to
play the video to all of us in the room as we gather around
her and her laptop. The video (

25 Growth and Freedom in Five Chapters

watch?v=oLiyYcOkV64) shows her being driven in a limousine with her sister and her parents to a music studio where a
recording session has been set up. She then sings a duo with
her recording idol. After we watch the 5-min video, the feeling in the room has been transformed. Her mother is teary
eyed, one of the medical students is crying, two of the residents and myself are holding back tears. Tears of joy, tears
of sorrow, tears of hope, tears of recognition of the beauty
that is this adolescent girl in front of us. Nothing has really
changed in terms of what treatments we can offer her. But in
another sense, everything has changed. We see her. She sees
us. Both she and her parents know we will do everything we
can to see how she can be helped. As we leave the room, the
mood is soulful, touching, and sweet. This is what medicine
can be. This is what life can be. This is another street.


Stephen Liben MDis the director of pediatric palliative

care at the Montreal Childrens Hospital and professor of
medicine at McGill Medical School in Montreal, Canada.
He is affiliated with McGill Programs in Whole Person Care.

A Wounded Healers Reflections on



Cory Ingram

We are not human beings having a spiritual experience, but

rather spiritual beings having a human experience [1].

I invite you to share my experience as a wounded healer as I

reflect on the depth and meaning of mindfulness in my clinical work. Dr. Carl Jung, decades ago, described the wounded
healer as a person called to relieve the suffering of others
because of their own healing wounds. In my personal experience, wounding is perpetual grief from a life of estrangementa life of distanced from what most people long for,
i.e., connectedness with those we love the most. My story
may be similar to yours. I, however, rarely hear such stories being shared in professional circles. I imagine people
feel shame and embarrassment. While writing this chapter,
I became concerned that people may question my abilities
to care for others if I am unable to set right all that is out of
kilter in my own family life. Nevertheless, I have comes to
terms with my own imperfect life.
I remember sitting in a jam-packed room at the 2012 Annual Assembly of the American Academy of Hospice and
Palliative care as two colleagues shared their stories. Stories
I wished I could tell. Stories of how they were invited to
tenderly care for their seriously ill and dying parents. Stories hallmarked by love, intimacy, and legacy. Stories of
grief from loss and not from distance and separation. My
friend and mentor, Ira Byock, published his first book with
the first chapter dedicated to how he and his family cared
for his dying father [2]. Ira learned what he needed to know
about caring for others by watching his parents care for his
grandmother when he was just a child.
I remember during the 2012 Annual Assembly wanting
to stand and ask the audience if they had experienced such
a picture perfect intimacy with their loved ones prior to or
during the phase of life called dying. Certainly, I was not
Family and Palliative Medicine, Mayo Clinic, College of Medicine,
200 1st St SW Rochester, Mankato, MN 55905, USA

the only person in that crowd that felt inadequacy as a son,

brother and wannabe healer. It definitely made me question myself and the field. Why do we only share the feel
good stories? Dr. Balfour Mount in his masterful book,
Sightings in the Valley of the Shadow, told the story of
his mothers illness and death. He wrote that a shortcoming
of his book was the inability to convey the rich texture of
the relationships that each of the family members had with
Mother and with the others in the family. I too, wish that I
could share the same, but I cannot.
That said, I have come to accept my situation. I have
recognized the value lodged in this entrenched voyage of
my longings. My story may be a photographic negative of
learning how to care for others that contrasts with the ideal
familial and personal experiences. There are equally powerful lessons embedded in the imperfectness, separation, and
distance that I live with. Perhaps this is a sort of coming out
for palliative care clinicians. My deduction is that wounded
healers who do not enjoy wished for familial loving and
care-full relationships are nonetheless able to assist others
heal their wounds.
This work takes a personal toll on me and I am not referring only to the aggregate toll. I mean the toll of the moment.
Mindfulness is hardly a day-by-day event, or a during-anannual-retreat event, but rather a breath-by-breath and heartbeat-by-heartbeat affair. My work requires me to be an attentive listener, a skilled communicator with attention to: healing, quality of life, dignity, human development, spirituality,
while maintaining my status as expert clinician [3]. This juggling act is difficult as this calls for me to approach each patient with a fully present, open, and curious mind [4, 5]. My
breath-by-breath work shows up in my attention to the spoken and unspoken of the patient and their loved ones while
simultaneously attending to my own thoughts, feelings, and
lived experience. This is my definition of mindfulness.
Metaphorically, I view mindfulness like a fire scorched
tree high upon a granite cliff overlooking a mirrored lake
at dusk. Mindfulness is my attention to the details of the
trees scars (the patient) and how I experience that which is

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_26,

Springer International Publishing Switzerland 2015


C. Ingram


reflected in the water (me). Herein I relate the foundational

principles of mindfulness as I live them in the setting of palliative medicine.

Healing and Quality of Life

An environment for healing has been illustrated in the context of goals of care conversations; it serves as a visual representation of the relationship between health care professionals and patients with the aim to foster shared decision
making [6]. Healing is a movement away from wounding
and a discovery of wholeness in a person whose integrity has
been threatened by serious illness or injury [7]. Healing has
also been defined as an improvement in quality of life for
persons living with one or more illnesses in which the treatments are not having the desired effect, function is declining,
symptoms are worsening, treatments are burdensome and
they live with the knowledge that life is fragile and possibly
drawing near to its end [8]. Quality of life shifts along this
continuum between healing and wounding [9]. Healing is a
relational process involving movement towards and experience of integrity and wholeness, which may be facilitated
by a caregivers interventions but is dependent on an innate
capacity within the patient. I serve to create a space for discovery of that innate ability. In that process, I discover my
own innate abilities to move toward integrity and wholeness.
Clearly, healing is not dependent on physical well-being [9].
A wounded healer, while treating another person, welcomes the unexpected and sometimes the unwanted. For
me, mindfulness involves being authentically present while
being vulnerable. The vulnerability I am describing is not
one of countertransference or sharing personal experiences.
While I do not speak of my own experience, it is present
in me and in the encounter. Vulnerability itself conveys my
own openness to the suffering of the other without overtly
revealing my own. This characterizes compassion in my
practice. I have been yearning to share my thoughts with a
broader audience for some time and I am grateful to have this
opportunity via this chapter. This book creates a community
of physicians and others who tend to the ill where it is safe
to tell ones truth.

Dignity Conserving Therapy

I like to keep things simple. When Dr. Chochinov published
his paper on dignity therapy in the British Medical Journal, it
resonated with me. Even though his paper is on dignity conserving therapy, I view and use the ABCD framework as a
foundational outline for mindful practice. ABCD stands for
attitude, behavior, compassion, and dialogue [10]. The way I
translate this into teaching and clinical work is to view these

four components as means for personal perpetual preparation for caregiving. Not only preparation prior to meeting a
patient but also an ongoing exploration during patient and
family encounters, tempered by mindfulness. I consider this
model as representing a perpetual preparation of mind, body,
and soulone that influences ones spoken and unspoken
exchanges with patients and their families.

In cultivating my attitude or mindset for seeing patients, I
center my attention on the patient and create awareness for
myself of thoughts that are competing for my attention. In a
busy medical practice, using check points to slow the mind
can be helpful. Examples are: while washing of your hands,
just before knocking on the door, or when reviewing their
chart outside the room.
Mind preparation also requires an awareness of bias, attitudes, and feelings about the patient, their disease, and their
family situation. For example, recognition of how you feel
about a long lost family member placing a dying incapacitated elder through medical tests and procedures that you
thought were fruitless and harmful. Or, how you feel towards
the family member you perceived to be inducing suffering
without hope of improvement. How do you reconcile what
you know to be true of the patients previously stated wishes
to avoid suffering near lifes end and others disrespect for
that? How do you recognize that moral distress and address
it prior to meeting with and during your clinical encounter?
I typically hold mixed emotions when preparing to meet
with families in different phases of setting things right
amongst themselves near lifes end. I certainly am not living
with my own bags packed and ready for departure. There are
a lot of loose ends. I question myself, how would I be in a
similar situation? Will I adhere to the recommendations that
I offer these people? Can I create the space that allows the
healing potential to be fulfilled? Will someone do that for me
when my time to go comes?
OK, am I ready to see this patient? In the time-pressured
work environment of modern medicine this process of mind
preparation happens in the moment and continues during the
encounter. It is not a question of time, or another thing on my
list to check off as done; I believe mind preparation is a key
ingredient of being fully present to the patient and family
and creating a space for healing.

Preparation of the body is about attention to practical details.
Given that I have mostly an inpatient clinical practice, conveying respect for patients living situation in the hospital

26 A Wounded Healers Reflections on Healing

is important. I start by asking permission to enter into their

private space. I typically sit down when meeting with patients and their families. I introduce myself and any learners
or colleagues I may have with me. I rarely wear a watch, and
when I do I am careful not to look at it. I silence my pager or
give it to someone else to answer. I try to convey a sense of
time and attention to their personal situation by being physically present, comfortable and not reaching for the door. I
use silence to convey that not every second has to be filled
with sound. We have time simply to be in the company of
one another. Sometimes, I reflect openly with the patient and
family members that, all roles aside, we are just people who
have been brought together to care for one another.

Preparation of the soul is for me is an opening of myself,
my soul, to the suffering of another person coupled with the
intent to relieve their suffering. This is hard work. How do
you prepare your soul with openness to your own suffering?
How do you do this with every patient? There are times that
this is inherently difficult. Preparation of the mind and soul
are unique but not separable. The interwoven nature I experience between mind and soul is exemplified in Dr. Balfour
Mounts article, The 10 Commandments of Healing. In it
he lists: be truly present to this moment, trust, attend to your
whole person needs, be open to deeper relating, listen to your
intuition, create, develop your self-reflective skills, be gentle
with yourself, think small, and celebrate [5].
Earlier I mentioned the scorched tree reflected in the
water. Attention to the other and to the self is inherent in
compassionate care. There is a desire not only to bear witness to the suffering of another human being but also to
alleviate that suffering. In its simplest form, being compassionate requires me to suffer with the other. There is a
moment-to-moment emotional toll that requires a simultaneous inward exploration of my soul. The tree reflected in
the water: breath by breath, heartbeat by heartbeat, word for
word, silence by silence.

The Narrative: Life Completion

The narrative often is a reflection of human relationships
and a yearning for meaning. Serious illness has an immediate quality about it that forces one to take care of things now.
It is a very present tense experience. The future is almost
always uncertain and at times obscure. Many people I treat
live 1 day at a time. Some live hour by hour.
Most people live with imperfect and strained relationships. Some families have suffered transgressions that have
separated loved ones for lengthy spans of their lives. The


patients I care for reflect on these relationships and their desire to attain resolution. I understand from my personal experience how difficult these situations can be. They want to
make things right and they want to do it quickly.
In the moment of caring for them, I return to mind, body,
and soul with alert attention to how I might experience their
situation given my longings and losses. I am keenly aware
of my feelings and I temper my presence to allow for space
and time for revealing the innate healing capacity within the
patient. Dosing supportive counseling is something not typically taught in medical school. I await an opening or invitation from the patient to offer suggestions. I am continually
aware, breath by breath, moment by moment, that the same
supportive counseling would apply to myself as the wounded healer. I catch myself wondering how the immediacy of
serious illness and the approaching end of life will affect me
and my family.
I may suggest to the patient a new way of looking at one
key topic such as forgiveness. I share approaches to life completion that I learned from my mentor, Ira Byock. I suggest
that forgiveness may be nothing more or less than simply
giving up hope for a better past. It may involve deleting the
details pertaining to the transgressions and ping on the here
and now. Often I share with people the four things that most
people value having said before they are forced to say goodbye. These are: Please forgive me. I forgive you. Thank you.
I love you [14]. I understand the yearning for those four short
sentences to alleviate suffering.
Mindfulness of the suffering of the patient and family and
me in regard to imperfect relationships, love, and forgiveness fosters attunement between us that is authentic in my
experience. Roles and titles fall by the wayside and human
beings are simply caring for one another.
The life completion narrative is at risk of having an ending that many may describe as inadequate. A good ending to
this narrative is typically one whereby people can declare
that there is nothing left unsaid or undone. They desire a positive legacy. They long to die well. How then does human
development factor into the life completion narrative?
Human development and growth continue throughout life
from birth until death [15]. Tasks of development, life review and generatively become more significant for persons
living with a life threatening illness [16, 17]. Physical decline can be accompanied by emotional, psychological, and
spiritual growth [18]. Fostering tasks of life completion require attention to completion of relationships, expressions of
regret, forgiveness, acceptance, gratitude, finding a sense of
meaning, telling ones story, life review and transmission of
knowledge or wisdom to others [19].
Dying well is often thought of in the context of the process
of dying. However, foundational to human development and
the care we all provide, it is more accurate and challenging to
think of dying well with well-being used as an adjective. The

C. Ingram


person was not only healed but they also achieved a sense of
wellness fostered by attention to the tasks of life completion
and developmental milestones [20].

The Narrative: A Premature Goodbye

This year I will turn 45 years old. I feel young. My wife, Lilian, and I have four children 10 years and younger. I often
care for seriously ill people that are very similar to me in
age or family stage of life. The perpetual awareness of mind,
body, and soul transports me into new emotional realms
when caring for people experiencing a premature goodbye
from their spouses and young children.
The narrative of a premature goodbye is one of the themes
in meaning finding, preparation, and legacy. It reminds me
of why I am reluctant to refer to the seriously ill or the
dying as these statements imply that these people are different from me. However, the line between health, illness
and the end of life can blur in an instant. We are all mortal.
Often the appointments and the business of our lives that we
consider so important while healthy fade away when serious
illness interrupts our plans. At such times, what is most important becomes more evident. Relationships and ultimately
love moves, almost immediately, to the forefront of our lives.
Dying patients identify family, pleasure, caring, a sense of
accomplishment, true friendship, and rich experiences as
their most common values [21]. Dr. Victor Frankl reminds
us, The salvation of man is through love and in love [22].
Practically, patients ask me how to prepare their children
for a future without them. The narrative is one inherently
tied to legacy and how they want to be remembered. Most
narratives of the premature goodbye effect people who have
been working hard to juggle a young family and life with
many competing priorities where they often perceive little
choice in how to prioritize their time. They feel as though
they have to do everything. As I write this, I consider of how
my children will remember me. Will they remember me as
the dad who was busy writing a chapter instead of playing
with them? Serious illness typically forces patients professional lives to a halt. Treatments consume much family time
and resources. I find myself offering advice to them to speak
about their emotions with their children and I offer to serve
as an interpreter and translator of their truths.
I employ several strategies to provide parents an opportunity for memory making, legacy, creation, and projection
of themselves into a future that they will not be present for.
Together we craft letters to children to be opened at future
moments at times like graduations and weddings. I have
made hand molds with parents and children. I am privileged
to have videotaped their narratives for their family.
I often am asked to communicate on their behalf to their
family their values and preferences for end of life medical

care. I am sometimes asked to communicate their desires regarding their relationships. These are topics so difficult to
talk about that they entrust them to me to convey. The situation is one most families never forget. I approach it not as
transference of information, but rather a therapeutic intervention. I am present mind, body, and soul: moment by moment and breath by breath. The situation could be mine. The
people I am speaking to could be my broken family. I have
been privy to broken families that finally heal. I wonder why
it takes serious illness and approaching end of life to jettison
people to a healing space where forgiveness simply happens
and relationships are well and complete.
I have accompanied parents reaching out for someone
else to love their children as much as they do. I have experienced this selfless act on numerous occasions: a parent, who
in the midst of the grief and loss, is searching for a surrogate;
finding hope in a new way. A way distinct from hope for
cure, hope for a gentle death, instead, it is a hope for a love
filled and safe life for their children to have without them. I
never can fully imagine what that is like. I do, nonetheless,
sit very close to the raging emotions of parents dealing with
saying goodbye to their children.
In the midst of being with dying parents, I mentally associate colors to the emotions that arise in our midst: deep
unending matte black captures the emptiness I experience
them expressing as they prepare to say goodbye. It is difficult to celebrate a life well lived when life is ending prematurely. There is a plenty of raw sadness and I experience that
too. I often say, If I am not doing this work who is? It
is not attractive in many ways I suppose, but for me, as the
wounded healer, I cannot imagine doing anything else other
than providing human to human tender loving care for seriously ill and dying patients and their families.

The Narrative: Spiritual Distress

In the midst of serious illness and end-of-life care sometimes
the most pressing issues triggering suffering are existential
and spiritual distress. Surprisingly, in light of the previous
section on premature death, I have experienced people dying
young that were less concerned with dying young and more
uneasy with the fact they have not been baptized.
Spirituality has dimensions of the essence, meaning,
transcendence, relationship, and values [23]. Serious illness
often leads people to search for meaning, explore their values
and their very essence. I maintain that there are three common aspects of spiritual care. First, people are just trying to
get through the day, others are trying to set some things right,
and sometimes people are wrestling with transcendental issues of putting things right with their maker. The interprofessional spiritual care model recommends that spiritual care is
integral in any patient-centered care model and should honor

26 A Wounded Healers Reflections on Healing

each individuals dignity. The model promotes attention to a

spiritual diagnosis by trained professionals elevating spiritual
care to routine care. Disease and illness disrupts much of the
core of the lives and relationships of patients and their families and threatens the integrity of their personhood [23]. Is it
a surprise that spirituality may be the definitive vital sign?
Often the narrative goes something like this: I used to
be, fill in the blank religion, but I have not attended church
in a long time. People express a distancing from a community of people that gave them and their family meaning at
a time prior to their illness. Like the other narratives, the
themes of relationships, legacy, love, and connectedness are
all spiritual in some way. Spiritual in the way they extend
into an open-ended future, provide meaning, and transcend
the person themselves. There may be less of an expression
of religious issues. Their pain is real. The transgressions underlying the pain are genuine and often part of the secret life
of their personhood.
While little to none of my formal medical training having
prepared me for this, I see my role in this aspect of care to
be present and to bear witness to their suffering. There are
no particular answers I can offer. I am mindful to my own
narrative of imperfection and spiritual struggle and growth
as a wounded healer. My daily contemplative practice helps
prepare me to be with their spiritual suffering. Fortunately, I
work in a team and connect patients and families with other
professionals who can help them. From a theoretical standpoint, I recognize that spiritual screening and assessment are
within the bailiwick of the doctor while spiritual history and
diagnosis are more for chaplaincy. However, seriously ill
people often do not present their spiritual distress in neatly
defined medical constructs thus I do what seems best in the

In conclusion, reflecting on the foundations of my mindfulness practice in relation to the narrative of the patient and
my own personal lived experience as a wounded healer has
given me more insight into the therapeutic relationship.
Mindfulness enhances the quality of patient care and furthers
my ability to continue to provide care. Mindfulness supports
our respective healing processes by opening a therapeutic
space for our inherent capacity work through pain. The presence is the key to the therapeutic relationship and therapeutic
I am convinced that there are other people like me with
strained and broken familial relationships that live with those
scars while providing excellent care for people dealing with
the same. I believe we should share these experiences in an
open forum, like this book. Writing this has been arduous.
Having written this has been a healing experience. I long


for richly textured family relationships. I guess this too is a

lesson in being well in the midst of personal loss and grief.
This chapter has served as the task of life completion for me.
I will continue to live with my bags packed as well as I can,
as I am heedful of the narrow line between health, illness,
and the time of life we call dying.

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C. Ingram
Dr. Ingramis a Senior Associate Consultant Palliative Medicine,
Assistant Professor of Palliative Medicine Assistant, Professor of Family, Medicine Director of Palliative Medicine Mayo Clinic Health System, and Director of Palliative Medicine Office of Population Health

Mindfulness, Presence, and Whole

Person Care


Tom A. Hutchinson

Jacob Needleman is correct. Ideas are radically different

from and more powerful than concepts. Concepts are closed
definitions fully encompassed by words, while ideas are
open-ended and include an experiential element [1]. Which
is why I have found even the best definitions of mindfulness
[2] unexciting and unhelpful, while the underlying idea of
being fully present has changed my life.
And it goes back a long way. When I was 5 years old, I
destroyed the flowers in our neighbours garden by beating
them with a stick. I was immediately horrified at the destruction that I had caused and terrified that I would be identified as the culprit, which happened later that day. My mother
spoke to me, clarifying that I knew what I had done was
wrong, and that I would have to apologize. I remember the
horror with which I greeted this instruction Anything but
that! And yet, trusting my mother that it would somehow
work out, I walked that long solitary walk up the neighbours
path and knocked on the door. I do not remember what happened next except the walk back down that path. The world
appeared to be a light and airy place and everything smelled,
looked, and sounded clear and vibrant. Was that mindfulness? I do not know but it is certainly that potential which
interests me in this topic. Because I do think that what I experienced at the age of 5 is key to the practice of medicine.
The next time that I experienced something as intense
was 35 years later during a workshop for physicians led by
pioneering family therapist Virginia Satir [3]. At first, I did
not understand Virginia and found some of what she did
frightening and possibly harmful. She seemed to be encouraging people to take risks with their lives and relationships
that seemed unwise. I am not sure exactly when it changed
but one experience appeared pivotal. The workshop involved
a lot of role-playing, and I had decided early on that I would
rather die than play a role in front of the group. And then, one
McGill Programs in Whole Person Care, Faculty of Medicine, McGill
University, 546 Pine Avenue West, Montreal, QC H2W 1S6, Canada

of the participants was picking someone to play Gary Larson, a cartoonist about whom I knew nothing. I sank into my
seat, adopted a blank look and literally almost fainted when
she asked Tom would you be willing to play this role? And
despite what felt like my better judgement, I stood up and
said yes. I played the role and participated increasingly in the
workshop until after 4 days I felt more alive than I had for
years. I decided that I would do whatever it took to bring this
experience into my life and work.
What did these two experiences have in common? It
seems to me that they shared the key components of love,
facing risk, and trust. In the first case, my mothers love for
me and my love for her and in the second Virginia Satirs
love for human beings and our love for her and the process
that she was leading. They both had an element of pushing
me forward towards what felt like a risky experience. And
there was a trust that somehow things would work out if I
faced what I most feared. It seems to me, that is exactly what
happens when our clinical presence and focus on curing our
patients begins to move into a healing relationship.
Recently, I saw a woman who was dying of a metastatic
cancer at the age of 35. I saw her with her mother. We were
at the point of discussing transfer to the palliative care unit.
The main difficulty for me was being able to face fully that
this young woman was dying and to accept that in a certain
sense this was OK. Despite all of the sadness, it was OK with
her and her mother. The patient explained that it had taken a
lot of work to get to this point. Her mother indicated that she
knew what was happening, and she accepted it without resentment. At one point in the interview, they looked for what
seemed like an eternity into each others eyes. The mother
slowly rose, took a step forward, and they hugged each other.
At that instant, the only feeling in the room was love. It felt
like a profoundly healing moment. The patient was transferred to the palliative care unit the next day.
But how could this be OK? A young woman of 35 with
an abdomen so full of tumour that it was hard to the touch,
a face daily growing more thin and cachectic, frightened
eyes with a staring quality that often seems to accompany

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_27,

Springer International Publishing Switzerland 2015


T. A. Hutchinson


cachexia, and strong negative emotions of fear and sadness.

Did they not see these things, feel these things? Did I not
think and feel these things? Yes, and, at the same time, we
were able to allow these thoughts and feelings to be as we
faced what was happening with love and trust. I was back
as a child of 5 or an attendant at Virginia Satirs workshop
except that now the stakes were much higher, the importance
of being present even greater, and the trust was not in a person like my mother, or in the process of a workshop with an
expert like Virginia Satir.
When I teach mindful medical practice to healthcare
workers or medical students, it is this awareness of what
is going on internally and the choice to respond rather than
react, the willingness to face what needs to be faced, and the
potential for healing to occur if we can be open to that possibility and remain fully loving and present, that I attempt to
get across. Perhaps influenced by my experience with Virginia Satir, we explore these possibilities in role-plays that
are based on real situations and are made as true to life as
possible [4]. We re-enact that tendency that we all share to
do anything to avoid facing the risk of being fully present in
difficult situations and yet encourage participants to step into
that space of risk and see what opens up.
Are we teaching mindfulness in Kabat-Zinns sense of
moment-to-moment, non-judgmental awareness, cultivated
by paying attention in a specific way, that is, in the present moment, and as non-reactively, as non-judgmentally, as
openheartedly as possible [2]. Yes, but with a larger goal
in which mindfulness is a way of being which serves our
ultimate purposethe promotion of healing [5]. And for
that purpose, we also need love, a willingness to face risks,
and trust, sometimes the kind of ultimate trust in life that
involves accepting what we cannot fully understand. That is
what is necessary for us to be what a colleague calls radically
present [6], the kind of presence necessary to catalyse the
transformation in suffering that we refer to as healing.
But that is not the end of the story or the complete explanation of my current perspective on medicine and mindfulness. There was a third pivotal moment, more powerful than
my 5-year-old apology or my participation in a Virginia Satir
workshop. I changed my clinical practice from nephrology
to palliative care. After the workshop, I went on sabbatical,
did a 4-year course in family therapy, brought out a book of
100 stories of patients with kidney failure [7], and continued working in nephrology feeling increasingly isolated and
unconnected to myself, my patients, and my colleagues for
reasons I could not completely articulate. There did not seem
to be space for what I thought medicine, and life, was really
about in that work context. I flirted over a 10-year period
with changing from nephrology to palliative care but each
time I got close to switching the fear of death, what I saw
as a relentless onslaught of death represented by palliative
care, made me back off. Until two things changed: I saw a

colleague whom I trusted make the change and report his

happiness and satisfaction; and I realized that time was moving on, and it was now or never. At age 55, I made the change
and found that the confrontation with death in palliative care
was anxiety provoking and, at the same time, satisfying and
rewarding beyond my expectations. On a daily basis, in the
practice of palliative care, I experienced a new sense of
being fully present and alive as I spoke with and engaged
with patients who were dying. What a paradox, that dying
and being in the presence of dying should be the necessary
catalyst to feel fully alive, which appeared to be true for both
me and my patients. And yet, not so strange, from a Buddhist
perspective, the origin of mindfulness includes awareness of,
and meditation on, death as the key ingredient to being fully
present [8].
Where does that leave me with regard to the role of mindfulness in medicine across the spectrum of practice and not
just in palliative care? Am I suggesting that everyone, like
me, will need to take up palliative care in order for medicine
to experience the full benefits of presence and mindfulness.
Obviously not, but neither do I believe that the necessary
changes will occur by having physicians en masse take up
a regular mindful meditation practice. We need a paradigm
shift as radical as that represented by the change in our stance
towards death and dying represented by palliative care to
produce the kind of transformation needed in clinical practice. We will need to alter our attitude towards patients (from
various degrees of detachment to love), to risk and suffering
(from avoidance to acknowledgement and turning towards),
and to the future (from fear to trust) in a way well represented by the mother in the clinical story I related earlier. As this
paradigm begins to take hold in medicine, mindfulness will
start making its full contribution to the revolution in medical
practice known as whole person care [9].

1. Needleman J. The heart of philosophy. New York: Alfred A Knopf;
1982. p.4556.
2. Kabat-Zinn J. Coming to our senses. New York: Hyperion; 2005.
3. Satir V. The new people making. Mountain View: Science and
Behavior Books; 1988.
4. Hutchinson TA, Brawer JR. The challenge of medical dichotomies and congruent physician-patient relationship in medicine. In:
Hutchinson TA, editor. Whole person care: a new paradigm for the
21st century. New York: Springer; 2011. p.3143.
5. Hutchinson TA, Mount BM, Kearney M. The healing journey. In:
Hutchinson TA, editor. Whole person care: a new paradigm for the
21st century. New York: Springer; 2011. p.2130.
6. Mount BM. Radical presence. McGill University: Montreal. Lecture given to first year medical class, 2014 March 4.
7. Philips D, editor. Heroes: 100 stories of living with kidney failure.
Montreal: Grosvenor; 1998.
8. Rosenberg L. Living in the light of death: on the art of being truly
alive. Boston: Shambala; 2000.

27 Mindfulness, Presence, and Whole Person Care

9. Mount BM. Foreword. In: Hutchinson TA, editor. Whole person
care: a new paradigm for the 21st century. New York: Springer;
2011. p.viixiii.
Tom A. Hutchinson MB is a nephrologist, palliative care physician,
and professor in the Departments of Medicine and Oncology, Faculty

of Medicine, McGill University and director of McGill Programes in
Whole Person Care, Montreal, Canada. He is the editor of
A new paradigm for the twenty-first century (Springer Press,
2011) and chaired the First International Congress on Whole Person
Care in Montreal, October, 2013

Mindful Attitudes Open Hearts

in Clinical Practice


Patricia Lynn Dobkin

Loaves and Fishes

This is not
the age of information.
This is not
the age of information.
Forget the news,
and the radio,
and the blurred screen.
This is the time
of loaves
and fishes.
People are hungry,
and one good word is bread
for a thousand.

up to edit a book entitled, Mindfulness and the Therapeutic

Relationship [8]. There is a consensus that clinicians benefit personally and professionally when they integrate mindfulness into their lives and clinical work [9].
Qualitative studies using various methods (e.g., focus
groups, audio diaries, interviews) have documented clinicians views regarding the processes underlying the effect
mindfulness has on their work. A sampling of these studies
is used herein to examine whether the intentions, attention,
and attitudes proposed to be mechanisms of mindfulness by
Shapiro, Carlson, Astin, and Freedman [10] emerge in clinicians descriptions of how mindfulness matters in their clinical encounters. Their hypothesis is relevant, especially since
Irving et al.s [11] grounded theory model provided empirical support for it in a study of 27 (of the 110) health care professionals who took the mindfulness-based medical practice
course and participated in focus groups.

David Whyte [1]

Mindful clinicians feed their patients with kind words and

quench their thirst with hope.

Qualitative Studies: Underlying Processes

as Described by Clinicians in Various Settings
Case reports (e.g., [24]) have described how physicians
are integrating mindfulness into patient care. Cohort studies with medical students and health care professionals have
shown how the mindfulness-based stress reduction program
contributed to patient-centered practice [5, 6]. Siegel, a child
psychiatrist, published The Mindful Therapist [7] in which
he explored how mindsight enhances the therapeutic relationship. Similarly, a social worker and psychologist teamed
Department of Medicine, McGill Programs in Whole Person Care,
McGill University, Strathcona Dentistry and Anatomy Building,
Room: M/5, 3640 University Street, Montreal, QC, H3A 0C7, Canada

Irving etal. [11] noted that 68% of the 110 participants in
the mindfulness-based medical practice program indicated
that their goal was to enhance their clinical practice, be more
present, attentive, and compassionate with their patients.
Bruce and Davies [12], in a study of nine hospice workers
with an average of 16 years of meditation practice, found that
the participants intentions were to face suffering (in others
and themselves), to be open and present to all that transpired
in their interactions with patients. Counselors interviewed by
Rothaupt and Morgan [13] spoke of intentional living, i.e.,
there was no boundary between being aware in and out of the
clinical setting. Connelly [2] wrote:
Practicing mindfulness, I recognized my discomfort and my
habitual pattern. I realized a decision point. I could assume control and make arrangements for his transfer today. But I also saw
that the patients contributions to the decision were lacking. So
before I entered the room, I decided to let go of my control of the
situation and be open to all the possibilities that might arise in
our conversation. I promised myself to listen. (p.89)

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1_28,

Springer International Publishing Switzerland 2015


P. L. Dobkin


Enhanced attention was reported by clinicians in two studies [11, 14]. One family physician interviewed by Beckman
etal. [15] stated:
I am much more attuned to listening. I put a mental stopwatch
in my head. I [now] have a heightened awareness and sensitivity
to peoples conversation. I look at my own communication and
pay much more attention to that. I pay much more attention in
general. (p.817)

Beckman etal. [15] found that 50% of the family physicians
were able to respond nonjudgmentally; they were open, curious, and stayed present in the moment. Irving etal. [11]
and Keane [14] reported that compassion was enhanced.
Non-striving was noted by Irving etal. [11]; clinicians saw
the importance of moving from the practice of doing/fixing
to being when working with patients. Keanes [14] psychotherapists internalized the qualities of acceptance, calm, and
compassion such that who they were as people impacted
how they were with their clients. Nonjudgment and nonreactivity in particular were related to therapist empathy.
Clinicians audio diaries in Nugent etal. [16] revealed that
mindfulness provided the space to stop, reflect, and then
respond (i.e., nonreactivity). The hospice workers in Bruce
and Davis [12] described using the beginners mind (e.g.,
You start to appreciate beauty in places you never saw it
before. p.1337), letting be and trusting the therapeutic process. They described this as, leaning into stillness. There
was a spiritual quality to their responses, especially regarding the Buddhist concept of no self/no separation. For
example, one clinician said:
Our lives are interconnectedyour suffering is my suffering
youre dying and Im going to die. I dont assume that I am independent from the person in the bed. Or in a peculiar way, I dont
assume that I am better off. (p.1337)

Feeling connected with others and having a deep sense of

gratitude was expressed by counselors interviewed by Rothaupt and Morgan [13] as well.

Siegel [7] purports that when one is open and truly present
for another person, one can be attuned to them. Some clinicians interviewed claimed that mindfulness helped them to
be more present to patients [17]. Keanes psychotherapists
mentioned that deeper listening, attunement, and the ability to be present were corollaries of being mindful while
working. Similarly, Beckman etal. [15] in a study with fam-

ily physicians found that 60% of those who took the mindful
practice course increased their capacity to listen attentively
and respond more effectively to others at work (and home).
Nugent et al.s [16] health care professionals echoed this
finding. The hospice workers in Bruce and Davies study
[12] viewed engaged presence not as something brought into
a situation but, rather, as a letting go into a presence that is
always there. Kearsley [4], a radiation oncologist (the author of Chap.8), wrote a narrative that reflected on presence
consistent with mindfulness. His open orientation invited a
patient to tell his story in such a way that it was healing for
both the patient and the doctor.

Mindful Attitudes Manifested in the

Contributing Authors Narratives
Bugenthal [18] describes three aspects of therapeutic presence: (1) being completely open to the patients experience,
(2) being completely open to ones own experience, and (3)
being able to respond in a salutary manner in the present moment. Note the word being which transcends techniques.
The whole person of the professional is engaged as she/he
balances compassion and equanimity such that the heart and
mind are receptive and nonreactive, respectively. KabatZinn [19] listed attitudes (elaborated upon herein) that are
the foundation for mindfulness meditation practice; these
can be extended to the therapeutic relationship.
In the next section, I have taken words verbatim from the
contributors narratives and embedded them in the attitudes
listed below to show how their interactions with their patients embodied these attributes.
Nonjudging Mindfulness is cultivated by assuming a stance
of impartial witness to our and the others experience. With
a nonjudging mind, things are seen as neither good nor
bad, but simply present or absent.
Dr. D. Dobkin: Recently, I saw Maurice W again after a
several year hiatus. He had just gotten out of jail and was
in mild heart failure, quite hypertensive and not taking any
medications. He was with his brother who seemed to care
about him. He physically looked the same but my view was
now quite different. Being more mindful, I listened to his
travails about jail, his struggles with alcohol and how he
was searching for a path to get better. I applied my meditation skills to the clinic setting. I shared his disappointment
in himself. I felt compassion for this young man whose life
was not going well. I couldnt tell if he had changed or I had
changedbut it didnt seem to matter. I felt more involved
and somehow more hopeful. I was able to exchange places
with him and subsequently viewed him differently.
Dr. Hassed: Well Peter, I said, whether or not you have
practiced mindfulness meditation, you have made some very
useful discoveries about the cost of unmindfulness this week

28 Mindful Attitudes Open Hearts in Clinical Practice

which is great. You have noticed that being unmindful impedes learning, reduces enjoyment, gets in the way of connecting with people, wastes time, and leaves us vulnerable to
frustration and worry. If being unmindful works for us then
we should practice it but if unmindfulness isnt so useful
then perhaps we might want to cultivate mindfulness instead.
Thanks Peter for being brave and sharing that. I dare say that
others in the group recognized what you were talking about
and I value that you said exactly how it was for you. I encourage you and the whole class to just say it as it is and not
to just say what you think I want to hear.
Patience Patience demonstrates that we understand and
accept that things have their own time for unfolding. This
allows us to simply observe the unfolding of the mind and
body within ourselves, the context in which we are with
other people, and our and others reactions.
Dr. Schachter: We engaged in a brief conversation on
the prevalence of these problems and I mentioned available treatments including doing nothing. Then I paused and
checked in again. Too much detail about any particular modality would leave behind her emotional reaction and with it
any therapeutic engagement. In elective gynecological surgery we have the luxury of a mindful surgical pause. When
the patient cries, becomes indignant, refuses treatment,
challenges my expertise, or repeats questions previously answered, she is overwhelmed and its time to rest and let the
situation simmer.
Dr. Bailey: There was a long period of silence filled with
tension so thick you could slice through it. We waited for
what felt like hours. In these moments of silence, I became
aware of how loudly my heart was pounding. I wondered if
she could hear it. I found my breath and allowed my attention to follow the natural rhythm of my body breathing. I
knew I didnt need to do anything in this moment. I simply
needed to give her time and space. I felt my body relax as I
joined her right where she was. I no longer felt the need to
bite my tongue to avoid breaking the silence. Just then she
Beginners Mind In order to be able to see the richness of
the present moment, it helps to cultivate a mind that is willing to see everything as if for the very first time.
Dr. Kearsley: I felt a sense of anticipation, almost excitement, at the prospect of meeting a totally unknown person,
and the prospect of making a difference in whatever opportunities presented themselves. I enjoy the not knowing about
who the next person might be.
Dr. Gold: After the dawn, Richard realized: I am not my
illness, and began to let go of over-identifyingone of the
barriers to self-compassion. He recognized his arrogance and
the pitfalls of comparisons; he knew he was as worthy as others, no more and no less. I noticed that Richard and I were


different each time we met, that each visit was the first visit
in a way. I set the intention to let go of expectations and look
and listen in a fresh way.
Trust It is far better to trust your own feelings and intuition
than to get caught up in the authority of experts. If at any
time, something does not feel right to you, pay attention,
examine your feelings, and trust your own basic wisdom
and that of the other.
Dr. Gonsalves: I took another breath. I looked at John
closely, this time with certain eye contact. He had the most
striking wide, blue eyes, I hadnt noticed in the three days
I had been caring for him. I softened the previously perfunctory tone of my voice, sat beside him, and offered an
encouraging smile as I spoke with him about the steps involved in preparing him for the procedure. His body seemed
to unclench from the knot it was in when I first came in the
room. His mother, always present, also seemed to relax her
shoulders and facial muscles. The change in my approach
and the consequent change in the energy of the interaction
we were having seemed to register on a nonverbal level. He
let me in on his fears of how painful the procedure may be,
about not being able to have his mom or dad with him. I
listened, as his caregiver on the medical team, but also as a
fellow human being, understanding fear and anxiety. Before
I left, John asked if I could be with him during the procedure.
He let out a sigh of relief, so innocent and heartfelt, when I
told him I could. For the first time during his admission, a
real connection had been established.
Dr. Lucena: Throughout the first year of the follow-up, a
relationship of trust was built on a weekly basis (fifty minute
sessions). I compare this period of relationship-building to
that described in Saint-Exuperys book, The Little Prince,
where the little prince carefully tames the suspicious fox.
First they meet from a distance, as the fox requires. Then
they get closer, little by little every day. With Emilio the
work required space and time as well. In building trust with
him, two basic rules helped: (1) to be honest always with
Emilio whether or not he liked it and (2) to choose carefully
my words at the moment of truth.
Non-striving There is no objective other than to be conscious of yourself as you are, while inviting the other person
to do the same.
Dr. Kearsley: But, in bearing uncertainty and staying
present, I am continually mindful of attempting to make
a difference despite the unfamiliar seaways of uncertainty through which I navigate. That challenge gives me
strength and reassurance in situations like Carmens, every
time. It means that I also have to believe in mystery, and to
develop a sense of nonattachment to outcomes over which I
have little or no control; on most occasions, I have no idea as
to what type of difference I make.


Dr. Frolic: At the outset of the case, I am very anxious

about my role and how I can help and worried about the fact
that this case doesnt fit the mold of the usual NICU ethical
dilemma. Gradually, I am able to open to the unknown, trusting that showing up and listening carefully will be helpful
in itself.
Acceptance Acceptance involves seeing things as they
actually are in the present. We may not like it, but if that is
the way things are, so be it. Acceptance allows us to cease
struggling to change things that are beyond our ability to
control and is the first step in any genuine process of change.
Dr. Hassed: You also said that you were trying to accept
the anxiety. Why?
I wanted it to go away.
Is wanting something to go away actually acceptance, or
is it non-acceptance masquerading as acceptance?
I guess its not really acceptance if youre trying to make
it go away.
I suspect you are right. Non-acceptance makes it worse.
It seems to.
So, can we be thinking we are practicing acceptance
when we are in reality practicing non-acceptance?
Yes, were probably doing it all the time.
Acceptance is exactly what is says; acceptance. If something is there its there. Were just practicing being at peace
with whatever is there, even if its anxiety. It may change but
from a mindfulness perspective, we are just watching without trying to do something to make it change.
I keep falling into the same habits.
Youre not alone. Were all a work in progress.
Dr. Rappaport: We were alone, and I heard myself asking
Jeannie if she knew she was dying?
Jeannie looked at me, bewildered.
Oh, what have I just done? I searched through my mind
for a way to fix things, because in my mind I had erred in my
care for this patient in so many ways.
Are you afraid? I asked, trying to see if she understood
Oh, not so much, but I just want to get the dying part
over with.
Letting BeIn our minds, there are often things we want
to hold on to (pleasant thoughts, feelings) or push away
(unpleasant experiences). With letting be, we put aside
the tendency to elevate some parts of our experience and
reject otherssimply allowing our experience be what it is,
accepting things as they are without judging, and realizing
the impermanence of all experience.
Dr. Liben: I see and feel so much pain for all involved and
so little answers. I ask her, When you are well what is something that you love to do? She answers something that I
love to do? incredulously, as this is an atypical question that

P. L. Dobkin

likely she has not been asked before during team rounds. She
answers, very softly so that we strain to hear her, I love to
sing. I say, How wonderful!
She replies, I have a video of me singing with a famous
singer that was done by the make a wish come true foundation, would you like to see it?
After we watch the 5-minute video the feeling in the room
has changed. Her mother is teary eyed, one of the medical
students is crying, two of the residents and myself are holding back tears. Tears of joy, tears of sorrow, tears of hope,
tears of recognition of the beauty that is this adolescent girl
in front of us. Nothing has really changed in terms of what
treatments we can offer her. But in another sense everything
has changed. We see her. She sees us.
Dr. Sogge: And her tears flow unabated.
There is a dull pain in my chest as I hear her story. I lean
in and breathe. I am with her. We let the tears run down her
face. In a few breaths I say, I am so sorry. Lets try to do
something new here. and then I hand her our economy size
box of tissues.
She laughs at the ridiculously big box, then smiles a bit
through her tears, saying,
God I hate this.
I know I say. I hate that it happens this way too.
Gratitude The quality of reverence, appreciating and being
thankful for the present moment.
Ms. Osorio: Then I feel it, familiar, as I have felt it beforein other situations, with other peoplelike a fresh
breeze entering the room, as the confusion of our words is
gently blown away and the quality of presence fills the space,
drawing us both into the room, into this moment, effortlessly.
Now, there is no trying to practice, no need to explain, no
words piling up. Now, there is simply an opening into what
is happening, guided by words, by silence, by breathand
yes, even by confusionand allowing it all to settle on its
own. Now, we are ready to begin the session, with the time
that we have, meeting one another in the moment. Thats all
that matters.
Dr. Baron: I rang the doorbell. Her husband opened the door
while she was waiting for me in a chair in her living room.
She looked at me and I looked back at her in complete silence.
It was a comfortable silence. Time stood still. I felt peaceful,
appreciating each moment of this simple and powerful encounter. My body was released of tension and my heart was
free of discomfort. I felt in harmony, despite the gravity of the
situation, while attending to her needs and to mine.
Gentleness This attitude is characterized by soft, considerate, and tender quality; soothing, however, not passive,
undisciplined, or indulgent.
Dr. Bailey: Im not sure what happened but Im sensing
some discomfort in the room. Do you feel it too?

28 Mindful Attitudes Open Hearts in Clinical Practice

Mom maintained her defensive posture and without looking up nodded her head.
I would like to talk about it before we end the visit today.
Id like to understand what happened.
Mom agreed. She asked if we could talk alone. I nodded and invited her to step out into the hall with me while
the kids played in the room. Once outside the room, mom
seemed less angry. Her body language had softened and yet
there was still discomfort there; a kind of nervous energy.
She struggled to find the words to describe what she was
feeling internally. I could tell she was providing me with
hints, hoping I would figure it out and she wouldnt have to
say what seemed so difficult for her to say. I reached out and
took her hand in a gesture of support.
I can see this is difficult for you. Its okay. You can say
whatever you need to say without worrying about how it
sounds. Itll give us a place to start and we can figure it out
as we go along.
This seemed to give her permission to speak from the
Ms. Osorio: I think my mind is falling in, he says to me.
Please hold me close,
Before I fall,
So I can feel before I fall
I hold him close,
Beside my arm
His tears so warm,
Upon my arm
His hands so withered, dry and cold
He seems so tired, lost and old.

Generosity Giving within a context of love and compassion, without attachment to gain or thought of return.
Dr. Coles: The ER physician is witness to countless intimate moments of pain, fear, stress, and vulnerability. We see
the dark side of life, the subcultures of abuse and neglect, the
realities of poverty and loneliness, the consequences of ignoring the body and spirits true needs. We also bear witness
to moments of inexplicable beauty, compassion, and tenderness. The best kept secret in the field of medicine is this
healers want the very best life for their patients even if they
cant always cure or save them. They serve with a dedication
that threatens to devour them.
Dr. Krasner: Eventually she moved from her apartment in
the Mother House to the memory unit, still within the Mother
House. And I began to make nearly weekly visits to her, each
time finding Norma always at her bedside, always attending
to Sisters personal, emotional, and spiritual needs. I would
sometimes just sit with the two of them, holding conversations about music, speaking of composers and vocal artists,
and learning much more of Sisters own musical performance career. I brought to her recorded talks of a contemplative nature for her and Norma to enjoy, and I during my
visits I listened to old recordings of Sister Josepha singing


in choral groups and solo some if the very arias I had grown
up listening to.
Empathy The quality of feeling and understanding another
persons situationtheir perspectives, emotions, actions
(reactions)and communicating this to the person.
Dr. Phillips: Beneath her suffering I had had a glimpse
of a fellow human being who cared deeplyabout her children, her husband, and her connection with others. While I
had found her degree of suffering and desperation for relief
from this to be almost unbearable, I had liked this woman.
Dr. DeKoven: I am worried about her safety and her future fertility. I am well aware that what had initially catapulted her into her unfortunate circumstances was her desire
to have a second child. I understand her desire to have two
children. I am forever grateful that I managed to swing having two healthy kids by age forty. I feel like I just slipped
under the wire.
Loving Kindness This is a quality embodying benevolence,
compassion, and cherishing, all filled with forgiveness and
unconditional love.
Dr. Krasner: But in the end, it is more than simply medical care and connections with the past. It is the continued
unfolding of birth, aging, illness and death that draw us together, within which the lines between healer and patient
blur slightly, at times merging into simple human connection
and kindness.
Dr. Bailey: I took a breath. How would I feel if I had been
abandoned by my mother who still lives locally? Perhaps I
would be angry too. I made space for both my irritation for
their blatant disrespect of their grandmother with any accompanying judgmental thoughts and my appreciation for
the childhood trauma theyve experienced through abandonment. It was from this place that I could respond to the developing chaos in the room with fierce compassion.

Final Reflections
When I reflect on my clinical work, it is clear that being
an MBSR and mindful medical practice instructor makes
a difference, in that each time I teach another course, be it
to patients, medical students, or clinicians, being present in
the moment and responding rather than reacting to events
becomes more natural to me. I feel attuned to the people in
my courses as well as to my patients in individual psychotherapy. Often, before a session begins I simply sit still for
a few minutes to let go of what is going on in my day. This
transitional use of mindfulness was noted by therapists interviewed by Horst etal. [20] as well. Meditation practices can
be transformative, and mindfulness applied to the therapeutic relationship goes beyond cognitive restructuring, stress


management, or behavioural changes [21]. My orientation in

therapy is not solely focused on outcome; rather than try to
mend patients, I trust the therapeutic process. My experience
is echoed by another psychotherapist who stated,
Real therapy is the capacity not just to heal or to deal with what
are the most current symptoms a persons feeling but also to help
them recover a sense of their potential and what they want and
I think that requires a depth of appreciation for human beings.
This recovery model were talking about is really driven by
something quite deep. And I think mindfulness may help us to
get back to that [11].

Closing Remarks
What these narratives offer with open-hearted generosity is a
behind-the-scenes view of clinicians commitment to compassionate patient care. Despite being faced with budget cuts
and restructured health care systems, clinicians continue to
respond in exemplary ways. Just as patients seek cure and
care from their clinicians, this book offers hope that kindness
can prevail in the midst of a demanding medical practice.

1. Whyte D. The house of belonging. Langley: Many Rivers; 1997.
Part IV. Belonging to those I know, LOAVES AND FISHES. p.88.
2. Connelly JE. Narrative possibilities: using mindfulness in clinical
practice. Perspect Biol Med. 2005;48(1):8494.
3. Dobie S. Viewpoint: reflections on a well-traveled path: selfawareness, mindful practice, and relationship-centered care as
foundations for medical education. Acad Med. 2007;82(4):4227.
4. Kearsley JH. Wals story: reflections on presence. J Clin Oncol.
5. Irving JA, Dobkin PL, Park J. Cultivating mindfulness in health
care professionals: a review of empirical studies of mindfulnessbased stress reduction (MBSR). Complement Ther Clin Pract.
6. Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B,
Mooney CJ, etal. Association of an educational program in mindful communication with burnout, empathy, and attitudes among
primary care physicians. JAMA. 2009;302(12):128493.
7. Siegel DJ. The mindful therapist: a clinicians guide to mindsight
and neural integration. New York: W. W. Norton & Company;

P. L. Dobkin
8. Hick SF, Bien T. Mindfulness and the therapeutic relationship.
New York: Guilford; 2008.
9. Escuriex BF, Labb EE. Health care providers mindfulness and
treatment outcomes: a critical review of the research literature.
Mindfulness. 2011;2(4):24253.
10. Shapiro SL, Carlson LE, Astin JA, Freedman B. Mechanisms of
mindfulness. J Clin Psychol. 2006;62(3):37386.
11. Irving J, Park J, Fitzpatrick M, Dobkin PL, Chen A, Hutchinson T.
Experiences of health care professionals enrolled in mindfulnessbased medical practice: a grounded theory model. Mindfulness.
12. Bruce A, Davies B. Mindfulness in hospice care: practicing meditation-in-action. Qual Health Res. 2005;15(10):132944.
13. Rothaupt JW, Morgan MM. Counselors and counselor educators practice of mindfulness: a qualitative inquiry. Couns Values.
14. Keane A. The influence of therapist mindfulness practice on psychotherapeutic work: a mixed-methods study. Mindfulness. 2014:
15. Beckman HB, Wendland M, Mooney C, Krasner MS, Quill TE,
Suchman AL, etal. The impact of a program in mindful communication on primary care physicians. Acad Med. 2012;87(6):8159.
16. Nugent P, Moss D, Barnes R, Wilks J. Clear(ing) space: mindfulness-based reflective practice. Reflective Prac. 2011;12(1):113.
17. Cohen-Katz J, Wiley S, Capuano T, Baker DM, Deitrick L, Shapiro S. The effects of mindfulness-based stress reduction on nurse
stress and burnout: a qualitative and quantitative study. Part III.
Holist Nurs Pract. 2005;19(2):7886.
18. Bugenthal JFT. The art of the psychotherapist: how to develop the
skills that take psychotherapy beyond science. New York: W.W.
Norton & Company; 1987.
19. Kabat-Zinn J. Full catastrophe living: using the wisdom of your
body and mind to face stress, pain, and illness. New York: Delacorte; 1990.
20. Horst K, Newsom K, Stith S. Client and therapist initial experience
of using mindfulness in therapy. Psychother Res. 2013;23(4):369
21. Brito G. Rethinking mindfulness in the therapeutic relationship.
Mindfulness 2014: 5:351359.
Assoc. Prof. Patricia Lynn Dobkin PhDis a clinical psychologist
specializing in chronic illness and chronic pain. She is an associate
professor in the Department of Medicine at McGill University. As a
certified mindfulness-based stress reduction (MBSR) instructor, she
spearheaded the mindfulness programs for patients, medical students,
residents, physicians, and allied health care professionals at McGill
programs in Whole Person Care. Dr. Dobkin collaborates closely with
Drs. Hutchinson, Liben, and Smilovitch to ensure the quality and integrity of the mindfulness courses and workshops offered at McGill University and other venues (e.g., conference workshops, weekend training


Acceptance, 1, 15, 21, 23, 24, 34, 111, 120, 158

Acceptance and Commitment Therapy (ACT), 111, 113
Addiction, 79, 82, 83
Adherence, 92, 97, 102
Anesthesia, 76, 77
Art of medicine, 33
Attention, 1, 3, 14, 100, 101, 107, 147, 156
Awareness, 1, 68, 3234

Body-mind, 16, 108, 109

Breath, 6, 7, 22, 34, 39, 49, 50, 57, 58, 62, 68, 126, 127, 135,
157, 159
Buddhism, 5, 120
Burnout, 1, 26, 97, 130

Death, 9, 10, 13, 25, 26, 37, 38, 7173, 85, 101, 124, 125, 152
and dying, 71, 129, 152
anticipation of, 64
Decision making womens health, 109
cognitive, 111, 115
Depression, 1, 30, 49, 50, 71, 72, 90, 96, 101
history of, 72
Dialectical Behavior Therapy (DBT), 79
Dialectic therapy, 21

Cardiology, 54, 120

Clerkship, 123, 127, 136
Clinical challenges and mindfulness, 1
Communication, 31, 67, 91, 92, 132, 133
analogic form of, 2
styles of, 84
Compassion, 1, 6, 13, 31, 3335, 52, 60, 88, 91, 102, 105,
109, 113, 117, 120, 125, 137
defination of, 59
Compassionate care, 121, 147
Connectedness, 145, 149
Connection, 6, 9, 14, 20, 26, 29, 43, 50, 60, 121, 125, 135
mind-body, 15, 54
Counselling, 89, 129

Eightfold path, 89, 91, 92

Elder-hostel, 25, 26
Emergency Medicine, 123, 124
Empathic communication, 123, 129
Empathy, 13, 7, 32, 44, 45, 88, 105, 121, 137, 159
End of Life, 147, 148
ER, 92, 114, 123126
staff magic in the, 135
ER Doctor, 124, 125
Ethics, 62, 89
Experience of illness, 2, 131

Facing Risk, 151

Faith, 38, 67, 100
Fertility, 76, 159

Healing, 2, 14, 15, 26, 39, 71, 124, 130, 146, 152
foster, 1, 87

P. L. Dobkin (ed.), Mindful Medical Practice, DOI 10.1007/978-3-319-15777-1,

Springer International Publishing Switzerland 2015



source of, 88
House calls, 8, 100

Integrative, 15, 50, 55

Intention, 1, 3, 19, 32, 52, 62, 63, 67, 87, 8992, 101, 102,
124, 129, 155
setting an, 68, 69
skilful, 90, 91

Journey, 2, 21, 30, 37, 38, 67

towards change, 7982

Loss, 10, 25, 27, 106, 109

Love, 5, 6, 8, 9, 16, 25, 52, 67, 77, 101, 145, 147, 151
abundance of, 52
Lymphoma, 71, 72
symptoms of, 72

Making, 8, 9, 14, 27, 39, 65, 88, 113, 133, 137

Massage, 42, 58, 67
Medical education, 7, 19, 50, 95
Medical students, 3, 5, 15, 19, 20, 41, 56, 131, 133, 134, 152,
155, 159
Meditation, 1, 6, 15, 19, 21, 30, 74, 120, 123
Mental health, 2, 30, 32, 71, 117
Mindful attitudes, 3, 156
Mindful attunement and suffering, 33
Mindful doctor, 2
Mindful health care, 1, 30, 56, 109
Mindful inquiry, 23, 24
dialectic approach, 2123
Mindful medical practice, 13, 134136, 139, 152, 159
Mindfulness, 13, 14, 16, 20, 21, 30, 34, 50, 68, 83, 87, 92,
95, 97, 99, 101, 105, 108, 128, 129, 134, 155


benefits of, 74
in action, 53, 54
in medicine, 1
meditation, 20, 21, 26, 33, 34, 88, 156
Mindfulness-based psychotherapy, 111
Mindfulness-Based Stress Reduction (MBSR), 1, 15, 26, 33,
51, 95, 129
Mindful practice, 5, 7, 78, 114, 115, 125, 129, 130, 132, 146
developing a regular, 128, 129
Mindful psychiatrist, 10, 29, 155
Mindful surgical practice, 109

Narrative, 111, 131, 147, 148

life completion, 147, 148
medicine, 1, 3, 5
spiritual distress, 148, 149
Neonatal care, 68, 140
Nephrology, 95, 152

Obsessive-Compulsive Disorder (OCD), 72

Oncology, 41, 73, 135
radiation, 45, 85
Opera, 25, 26
Overeating, 99, 100

Pain, 15, 17, 24, 29, 30, 33, 59, 60, 65, 67, 72, 114, 117, 125,
Palliative care, 10, 27, 41, 145, 152
Patient-centered decision, 2
Personal growth, 139
Physician burnout, 1
quality of, 1
Physician self-care, 55
Physician well-being, 1, 146
Poetry and medicine, 7, 50
Presence, 1, 1315, 31, 60, 137, 152, 156
practicing, 50, 51
Psychotherapy, 1, 13, 16, 82, 99, 109, 111114, 117



Qualitative research, 26

Reconstructive pelvic surgery, 105

Reflection, 1, 3, 15, 30
Callums, 45, 46
Carmens, 46, 47
Doctors, 41, 42
Katherines, 44, 45
Reflective writing, 3
Residency, 25, 71, 85, 86, 105, 123
Role models

Self as context, 111
Self-reflection, 7, 73, 92, 131
Speech, 14, 29, 30, 33, 71, 91, 92, 120
skilful, 90, 91
Stress management, 19, 160

Therapeutic alliance, 30, 33, 95

Trauma, 30, 123
Treating suffering in therapy, 13, 33
Trust, 1, 60, 80, 100, 109, 151, 152, 157

Values, 63, 66, 67, 71, 109, 117


Wholeness, 2, 59, 130, 146

Whole person care, 1, 3, 44
Women in Medicine, 2, 3
Womens health, 108110
decision making, 109, 110
Wounded Healer, 33, 145149

Yoga, 15, 16, 73, 87, 102