Mindfulness

Mindfulness is sometimes referred to as being conscious of the present moment. It is an irony of the training of health care professionals that we are constantly being directed towards a future focus. We readily don the blinders of a professional life that keeps us focusing on what lies ahead. Although some element of this is essential for professional success, we run the risk of missing out on the richness of our everyday experiences.

We offer an exercise that each of you can try to help understand this point. Obtain a piece of chocolate, or other small treat that you commonly consume by the dozen in a matter of minutes. Take that one piece, and commit to having the experience of it. Remove the foil wrap, since we will presume that you have chosen a Hershey’s Kiss^®, or similar confection. Lift the chocolate to your nose, close your eyes, and breathe in the aroma of the chocolate. Does it bring back any memories? Does it evoke any feelings such as hunger, desire, or happiness? Now, do something you may have never done before. With your eyes still closed, take a tiny bite of this small piece of candy. Avoid your patterned response of putting the entire piece in your mouth and chewing once before you swallow it. This time, take that small bite and let it slowly dissolve in your mouth. Pay attention to the texture of the candy on your tongue. Concentrate on what the chocolate tastes like. If you are not a chocolate fan, try this with something else that is easy for you to crave. Let the taste linger for several moments with your eyes still closed. How long does the taste remain? How does the intensity diminish? Do you miss that intensity, or is the experience of ebbing “chocolate ness” a nice experience itself? Do you wish to have another bite? If so, then go ahead. Can you feel satisfied with this single piece of chocolate? Have you enjoyed this chocolate as much as when you would go through a dozen pieces in the same time frame? Have you enjoyed it more? What if we approached life like this? Each moment is an experience around which we can choose to be mindful. Are there delicious moments in your life that you would like to be able to savour and extend? Connect to those because they are meaningful. It is so often said that life is short just like a single piece of candy is small. Why are we in such a hurry to get to the next piece?

Another useful exercise you can each do everyday to practice mindfulness is to sit quietly and spend some time with yourself. Remember that time with yourself is very different than time by yourself. With your eyes closed, become aware of how nice it is to breathe. With each breath, feel the life giving lusciousness of air. Now, say to yourself: “May I be happy.” Think about how wonderful it feels to wish that for yourself. After you have spent some time with that thought, breathe in a second thought: “May I be healthy and strong.” Think about how everything you do each day is a gift made possible by your health. Connect to your wish for health and strength. What part of your body are you drawn to? Can you connect to that wish for health as you proceed through your day? Next, say to yourself: “May I be safe and free from danger.” Connect to what it feels like to be safe. Are there people or places with whom or where you feel most safe? Can you bring that awareness of what it is like to feel safe with you to everywhere you will be spending your day? Be mindful of that feeling and how your breathing becomes deeper and slower when you give yourself permission to wish for happiness, safety and health. Finally, say to yourself: “May I be at ease in the world around me.” Be mindful of the thoughts that accompany easiness. George Daicoff created that feeling for one of us (RU) when he was so welcoming in an environment that otherwise seemed intimidating. What is it like to feel confident, present to yourself and at ease? Can you bring that feeling with you throughout your day, and embrace it when you need it to be present in you?

Healthcare is so externally focused. We would encourage you to find ways to be aware of what happens for you in the moments of your life as a healthcare professional. Only by experiencing each moment of our lives can we experience all the moments of our life.

Intentionality

In our work with busy professionals, we have found that so many have drifted into the automaticity of patterned responses. This gets us in so much trouble because we forget that we always have choice. The problem is reflected by us choosing what others might demand or expect from us, rather than finding a way to honour and value our own needs.Reference Dickey, Damiano and Ungerleider^2–Reference Satir, Banmen, Gerber and Gomori⁶ The consequence of automatic living is that we lose connection with what we truly wish for ourselves. We begin to feel controlled and overwhelmed by the responsibilities to our professional life. David Whyte, who is often referred to as the poet for corporate America, writes in his exquisite book, The Heart Aroused:

We were once asked to give a talk to a large group of surgeons on how to create a balanced life. We followed an expert in time-management. His talk was comprised of an informative sequence of slides that provided advice on how to be organized and efficient from the time you got up in the morning until you went to bed at night. The audience was busy writing notes on every bulleted point. So were we. Here was a lecture full of useful information. We would never again have an excuse for failing to gets our tasks done. And we would be able to expect the same efficiency from others. What a wonderful prescription for success. With the audience now fully cognizant of how much more productive we could all be, we began our talk with a story about time management as we see it. If you take a large jar and fill it with some big river rocks, is it full? “Of course not,” replied this now well attuned audience. All right then, what if we then took scoops of pebbles and poured them into the jar to fill those spaces between the rocks. Is the jar full? “No,” replied the audience. There is still space. So, what if we then sifted in a bunch of sand and gently shook the jar to make certain it invaded whatever space is left. Is it full? “No.” Apparently the previous speaker had made quite an impression. Well, what if we now fill the jar with water. Is it full? “Yes,” sighed the audience. “We believe you have now filled the jar.” So, we asked, what is the point of all this. Our time management guru, who was still in the audience, blurted out the obvious: “Just what I was mentioning. You can get a lot more into your day than you imagine.” Well, we replied, that would seem to be the case. We offer another thought that we would like you to consider: If you don’t get those big rocks in first, you’ll never get them in later. Those big rocks are the secret for being intentional. They are the core elements of your life. If you lose touch with them, you will lose your foothold on the foundation that can support and balance your life.

In healthcare professions, we get caught up by our responsibilities to others. The path that we are told to follow is such that, eventually, we may lose contact with the solid footing we need from the big rocks that would allow this path to run parallel with our personal hopes and dreams. The haunting words in the song, 100 Years, by Five for Fighting remind us that the path we take in life needs to be our path.

• I’m 15 for a moment

• Caught in between 10 and 20

• And I’m just dreaming

• Counting the ways to where you are

• I’m 22 for a moment

• She feels better than ever

• And we’re on fire

• Making our way back from Mars

• 15…there’s still time for you

• Time to buy and time to lose

• 15…there’s never a wish better than this

• When you only got 100 years to live…

• I’m 33 for a moment

• Still the man but you see I’m a they

• A kid on the way

• A family on my mind

• I’m 45 for a moment

• The sea is high

• And I’m heading into a crisis

• Chasing the years of my life

• Half time goes by

• Suddenly you’re wise

• Another blink of an eye

• 67 is gone

• The sun is getting high

• We’re moving on…

• I’m 99 for a moment

• Dying for just another moment

Achieving balance in professional life has been a hot topic in the past few years at many medical meetings. We are frequently asked to speak about this, and we are often in the audience as others give their views on the subject. Balance, contrary to the opinions of some, is not about creating equal parts of work and time with the family. Balance is about choice.Reference Dickey and Ungerleider³ “Who are you and what do you want?” These seem like such simple questions, but many of us go our entire life and never answer either. The numbing and insatiable addiction to the external validation that comes from performance recognition can have us lose sight of ourselves. Begin to believe that you are defined by your performance and at some point in your life, you may, having travelled far from who you are and the dreams that you held for yourself, become focused solely on the performance required for the next award. It’s as if you set out to be some thing, and you forgot how to be some one.⁸ There is a classic scene in the movie City Slickers, with Billy Crystal and Jack Palance. Palance plays the part of Curly, a wizened cowboy who takes middle-aged business men on cattle drives to help them get away from the crises of their lives. Billy Crystal (Mitch) is struggling with how to handle numerous stresses in his life and he is riding alongside Curly when he gets a famous dose of Curly’s wisdom.

Curly:

“Mitch, How old are you? 38?”

Mitch:

“39.”

Curly:

“Yeah, you all come up here about the same age. Same problems. Spend about 50 weeks a year getting knots in your rope and then you think two weeks up here will untie them for you. None of you get it. (Pause. They stop riding and just look at each other. CURLY continues). You know what the secret of life is?

Mitch:

“No. What?”

Curly:

“This.” (he holds up his index finger)

Mitch:

(trying to be funny, and dismissive of his feelings) “Your finger?”

Curly:

“One thing. Just one thing. You stick to that, everything else don’t mean s**t.

Mitch:

“That’s great, but what’s the one thing?”

Curly:

“That’s what you gotta figure out.”

That “one thing” might be to figure out your big rocks, those things that give your life a meaningfulness that you feel somewhere in the middle of you. And make choices with them in mind.

Mindsight

MindsightReference Seigel⁹ is about empathy, and the ability to connect to the experiences of others. At the beginning of this tribute to George Daicoff, we mentioned that we all have similarities. Mindsight is about connecting to our differences.

Mindsight is about knowing and understanding another in a way that allows us to hold an accurate representation of them within ourselves. It is as if we know them in a way that allows us to see the world through their lens. Many of us have people in our lives with whom we have had this experience, such as a parent, child, teacher, or friend. When we experience mindsight with another we each feel known. We feel “gotten.” If you have ever felt “gotten” by someone, then you understand the power or mindsight. Mindsight comes easily for us in some relationships, and can be extremely difficult in others. This difficulty seems to be most pronounced with others who we perceive as having an unfamiliar or different experience of the world than our own.

In the words of Virginia SatirReference Satir, Banmen, Gerber and Gomori^{6, 10} “It is in our similarities that we connect, but it is in our differences that we grow.” In our medical culture we have tried so hard to homogenize each other. We teach our students to see things as we do, and get perturbed when they don’t. Charles BoskReference Bosk¹¹ wrote an enlightening field study, Forgive and Remember, after following a surgical team for several months to try and understand the nature of errors that occur on a surgical service. Among these, he described an unconventional category of errors that he termed “quasi normative”. These errors were felt by the attending surgeons to be egregious mistakes committed by a resident who didn’t remember precisely the way the attending liked things done, as opposed to how another attending on the service wished to deal with similar problems. Are these errors? Or simply differences? In the culture we have created in health care, we tend to handle differences with an approach that resembles interrogating, judging and fixing. People who have authority commonly adopt a style of coercing and telling in order to make sure they get things done “their way.”^{4, 12,} Reference Quinn¹³ This form of connecting obliterates the potential for magnificent contributions that could come from the innovation of others who see a different perspective.¹⁰

Mindsight is the key to developing nurturing relationships with others that bring out the best that the relationship can offer. This is important for all relationships, be they professional or personal. There is now a lot of research into the neurobiology of the brain indicating that, as you develop understanding of others, which we call empathy, the brain is “rewired.” It undergoes a chemical transformation such that neurons become linked in ways that they were not previously.Reference Seigel⁹ The result is that we begin to find sustenance in relationships through the process of exploring to understand an “other.” In this approach, we stay open to the wonderment of trying to understand one another in a way that connects and appreciates, rather than one that judges and criticizes.

In order to do this, it is important to spend time learning about what is important to people. In the movie, Phenomenon, George (John Travolta) has an attraction for a young woman, Lacey (Kyra Sedgwick), and he sells, at the gas station where he works, the handmade chairs she crafts. He appears to be selling the chairs as fast as she can make them, and she is pleasantly surprised by this, since it is providing her the income she needs to support her children. One evening, she happens to go by George’s house, and is astounded to see her chairs stacked everywhere – on the porch and cluttering up the entire first floor of the house. When Lacey confronts George about this, he shrugs his shoulders and says: “I love those chairs. You made them, Lacey.” We offer this story as a reminder that we all make chairs of some kind. We are all passionate about, and invested in, something. What does it feel like when someone recognizes your chairs and buys them? Successful relationships, whether at work or at home, require some ability to buy someone’s chairs. It is through our ability to influence one another that we form bonds of appreciation and connection.

Forgiveness and shared meanings

It is important to practice forgiveness, and to create shared meanings in relationships. These processes allow us to reconnect to people who have hurt, disappointed, or angered us. When we don’t forgive, we create toxic relationships, both with ourselves and with others. It is the heaviness of resentment that prevents us from being at ease.

Most of us understand this, and yet when we get angry or hurt, we get so swept up with the emotions of the experience that it takes on an inexorable energy that we can’t contain. This energy prevents us from relating to that part of us that can remain open to understanding and connecting to others – the piece that we mentioned earlier that is so important to cultivating mindsight.

We suggest that there is something you can do the next time you get so frustrated or irritated with someone that you feel you cannot forgive them. It is the process for creating shared meaning. First, take a deep breath, if necessary, several deep breaths. See if you can connect to some part of yourself that allows for different experiences of the same situation and try to stay open to listening to another. You may need some time to calm down a bit, and if so, ask for it, or grant it to the other if they need it. Then, when you both feel you are ready, sit down with that other person and face each other. Make a commitment that you want simply to understand each other’s perspective, not judge or condemn the other or their perspective. Then, try to explain the other person’s point of view in words where they finally say: “yes, that is what I feel or yes, you understand my experience of the situation.” Then, have them do the same with you, until you feel that they have articulated your feelings and thoughts in a way that you can agree that they “get you.” This is hard, and takes practice. Even though we know it is extremely helpful, we each have trouble doing this because we are human, and get so caught up in the emotions of the experience and in our need to control events to create the outcomes we prefer. This is an exercise that you need to practice. As you become more skilled at it, you will create renewed appreciation for others as you begin to understand them as simply having a different perspective than you, not one that is more right or more wrong. In many cases, the problem is not the problem, coping is the problem.Reference Satir⁵ There is much written on this topic of relationships, and we would recommend reading more as you learn to explore to understand and connect to others in your life.^4, Reference Satir, Banmen, Gerber and Gomori^6, Reference Arbinger^14–Reference Wile²⁰

As you practice this tool, try not to interrogate to reach judgment. Remember, none of us have the authority to forgive another. Just listen and explore truly to understand the other. If it is hard to listen without feeling criticized or blamed, try breathing deeply, and keep your hands centered around your heart. Have gentle compassion for how much courage it takes the other to tell you their truth, and let them know you appreciate them for doing that. It may be difficult for you to articulate someone else’s perspective, but if you listen carefully, they will give you the words. You don’t have to agree, just try to understand them. They then will do the same for you, and you will have every opportunity to express yourself so that they can try to understand you. They, too, should refrain from criticizing or judging and only try to make sure that they get the information they need to articulate your feelings in a perspective that conveys understanding. They, too, do not have power to forgive you, but we all have the power to give the gift of forgiveness to ourselves. And the pathway to attaining this gift is to appreciate and cultivate shared meaning with others. At the end, you don’t have to come to a decision about who is most “right.” You will have accomplished something far more meaningful, namely a shared meaning to describe how you each see the problem. Most importantly, you have learned how to turn conflict into conversation. Without this, the conflict just comes out in some other way, later. Without conflict, there is false harmony.Reference Lencioni²¹ With congruent dialogue,⁴ there is potential for growth, understanding, and trusting relationships which enhance teamwork.

As you try some of these exercises, practise making friends with yourself and treat yourself the way you would like to be treated by a friend. This is especially helpful for the stressful and often seemingly unforgiving career we have chosen for ourselves.

Management of stress

We should learn to recognize when we are stressed. We cannot manage what we don’t know. The first four tools for managing the demands of your life, discussed in our previous sections, wouldn’t be so hard if it weren’t for stress. It is when stress enters our life that we lose control, and begin to react with familiar patterns for coping that may serve us well in the moment, meaning they temporarily reduce stress, but eventually create more stress over time. For example, a surgical case may not be going well. The surgeon yells, and blames his team members in the moment. He immediately feels better and experiences a reduction in stress. Unfortunately, he has transferred his stress to members of his team, and may have impacted on their ability to be effective. In the long haul, his momentary reduction of stress will create more stress for him, as he will have to manage the consequences of a poorly functioning and non-trusting surgical team. We finish with a suggestion as to how it is possible to break that “habit” of reaction, and create possibility for growth and change.

When I (RU) was training in paediatric heart surgery with Paul Ebert at the University of California in San Francisco, I think it was one of my jobs to get him stressed by introducing him to problems in the operating room he had never seen before – a job I did particularly well! I recall one such occasion. Instead of responding in the way I was accustomed to, he stepped back from the table and took a deep breath, maybe a few deep breaths, and then returned to the work at hand. He seemed calm and poised, and prepared to meet the challenge created by his young resident. I remember that day very well, and I learned that response to stress does not need to be reactive and patterned. We have control over our behaviours and our performance, but only if we choose. That choice is made possible by the recognition that we need to take a moment to acknowledge the stress, by our mindfulness, and choose intentionally to respond in a way that can serve well us and others. In so doing, we create mindsight and shared meanings. In order to help you do this, we offer you another tool.

Take a moment to think about your favourite place. We have had people tell us of many kinds of favourite places, spots where they feel at peace and at home with themselves. It could be a geographical place. For one person, in one of our workshops, it was in the arms of their spouse. For another, it was home. For each of us, there is a place that is a gift.

Think of that place. Close your eyes and feel what it is like to be in that place. Connect to the sounds, the smells, the sensations. Place your hand over your heart, and feel how your heart slows into the rhythm of that space where you feel at peace. Imagine the caressing joy of being in that place, and stay with that feeling for several moments while you breathe in and out the serenity of your favorite place. Then slowly open your eyes and return to the place you are in at this time, only bring with you the feeling that you had while in your favourite place. You can go to your favourite place anytime, and collect some of the tranquility that you need to bring back to the immediate moment in your life. With practice, you can do this in almost any moment of stress. It will surprise you how your heart will slow down, and you will see other options available for you to choose as you select a response.Reference Childre and Rozman²² You will have learned a way to manage the demands of your professional life.

Finally, we want to offer one more enchanting thought about your favorite place. It comes from the mesmerizing words of John O’Donohue, a very spiritual Irish poet.Reference O’Donohue²³

• Our difficulty with the earth is that we are usually so busy

• And so taken up with our lives,

• That we rarely seem to acknowledge that we are actually here at all.

• And we rarely wonder, and hardly ever ask ourselves,

• How the earth actually sees us.

• And it’s a very interesting question, you know.

• When you think of the place you live,

• or you think of your own favorite place,

• is it not possible that that place could have a huge affection for you.

• And it could see you in a very special way

• And indeed be very proud of you.

• That it might love to see you coming

• And miss you while you’re away.

• Maybe when you die, your own place will be immensely lonesome for you.

• And that its huge affection for you will be incredibly sad and sorrowful.

• That it will miss your presence.

• The way that you walked upon it.

• The bright waves of your thoughts.

• The story and news that you brought of other places

• That it could never go.

• And the whole aura and light and luminosity of your soul.

• And to make you wonder you know,

• That when the funeral cortege passes a person’s home and native place

• Is it the person that’s getting one last look at their own place,

• Or is it the place getting a last look at the person

• Or indeed, is it both.

• We are wombed to the earth in a very intimate and secret way

• And the memories of nature are within us.