Dr. Ron Epstein - A Perspective On Medicine, Mindfulness

Dr. Epstein is a family physician, palliative care Dr., author, researcher, and teacher of communication and mindful practice in medicine. His book, Attending, Medicine, Mindfulness, and Humanity explores how the foundations of mindfulness can help clinicians expand their capacity to provide high-quality care, and how doctors, patients, and their families can more collaboratively and mindfully approach medical decisions.

He shares how the practice of mindfulness in medicine helps support.

Transcript

Welcome to Untangle.

I'm Patricia Karpis.

Today's guest is Dr.

Ron Epstein,

A family physician,

Palliative care doctor,

Author,

Researcher and teacher of communication and mindful practice in medicine.

He shares how the practice of mindfulness in medicine helps support a deeper understanding and connection between clinicians and patients,

How we can flourish and be more resilient in the midst of uncertain situations,

And how healthcare professionals can more skillfully cope with the discomfort of ambiguity,

Something we can all learn.

He also discusses his hope that the human aspects of medicine can become at least as important as the technical aspects.

I love that his life's work has been discovering that mindfulness might just be the quality that creates a wholehearted master clinician.

Now,

Here's Ron Epstein.

Dr.

Ron Epstein,

It is so great to have you on Untangle today.

Thanks so much for being here.

Oh,

It's a real pleasure to be with you.

I just want to read some of the quotes that are in the beginning of your book,

Because they really struck me.

Jon Kabat-Zinn says,

This book will be phenomenally useful to all of us who are desperately in need of true health care and caring.

Dan Siegel says,

The book is a beautiful synthesis of inner wisdom and hard-earned empirical findings.

And you start the book by saying that you believe the practice of medicine depends on a deep understanding between clinicians and patients,

And that human understanding starts with the understanding of oneself.

And I would just like to start with this question,

Where did you begin with this understanding of oneself?

It's probably in my genes to some degree,

Because I remember even as a young child being interested not only in the world outside,

But also in the world inside.

And I was interested in what a thought was,

And I was interested in breathing.

I was asthmatic as a child,

So in a way I had to learn how to breathe and not cough.

So I was kind of interested in how the body worked,

How the mind worked,

How ideas got into your mind,

Things like that from a pretty young age.

I guess it's the upside of being somewhat introverted,

That dual view of the world,

Just that interior view and that observer view.

When did you first recognize that in yourself?

Were you 10 years old?

Did you have some influences?

It sounds like you were a seeker,

That you were asking a lot of questions.

I was.

I remember it certainly started before high school.

I was really interested in reading,

And I would read things that were beyond the point where my world experience would allow me to truly understand.

And I was reading Camus when I was in junior high school,

And obviously you can't really get what he's talking about.

I mean,

I knew the words.

But I kind of had this sense that he was really trying to understand the world,

And so was I,

And discovered Hermann Hesse fairly early on also.

That actually resonated with me because all of his novels basically have the same plot of two people who start out life,

And one becomes a contemplative and spends their lives in a monastic search for wisdom,

And the other goes out in the world and becomes a wanderer and tries to understand the universe through experiencing the world in a deeper way.

And I saw both of those in myself,

And from quite a young age thought was drawn to that.

I think it was sometime in high school that I learned about Maslow's hierarchy of human needs.

The bottom is just like there's survival,

And at the top was self-actualization.

And I wanted the express train to self-actualization.

That's where I want to be.

I can't say that there's—Walt Whitman did the same thing for me.

I discovered his poetry.

We had to read some of his poetry at like a junior high school or something,

But I really discovered it as a personal manifesto,

Probably when I was like 14 or 15.

And his degree of connection to the world,

To everything that the world could offer,

And an intimate connection,

Wasn't just I see this,

I observe that,

But I immerse myself in this.

I jumped into the water in the deep end and swim through it.

So that for me was the place I started,

And that's how I ultimately got interested in meditation and thought I was actually at age 19,

Thought I would become a Zen monk.

I made a very serious attempt at it.

Yeah.

You spent a few months at the Zen San Francisco Center.

In San Francisco,

Yeah,

I was the youngest person there,

And wide-eyed,

And I can't imagine what some of the older Zen students were thinking about this young kid who was there.

And I just needed to do that.

It was the next step for me.

It sounds like you could have gone down this path of being a spiritual monastic or a philosopher.

How did you take what you were learning from meditation and from studying at the Zen Center and then decide to be a doctor?

The subtitle of your book is Medicine,

Mindfulness,

And Humanity,

And I think that so perfectly represents the essence of who you are as a human being,

But when did this and how did this all come together for you?

As a child,

I was interested in things medical,

And I remember even when we first got an encyclopedia,

Paper encyclopedia,

Nothing was electronic.

And I would look up,

I was first interested in asthma,

I was an asthmatic,

And then started reading about other illnesses and aspects of human experience,

And that coupled with a fair degree of family,

I wouldn't call it pressure,

I guess,

Some expectation or hope or aspiration that the family would somehow produce a doctor.

You were the chosen one.

I was the chosen one,

Right.

My grandmother,

My mother's mother was very explicit about it.

She was somewhat of a controlling figure and had everyone's life figured out for them,

You're going to be this,

You're going to be that.

And so I was going to be the doctor.

And so I embraced it for a little while,

But as soon as I began to experience any sense of autonomy,

I really said,

No,

That's not going to be living out my life to fulfill someone else's dreams.

So I really parked it for quite a while.

And it was a difficult decision for me to change course.

This is after I'd already graduated from college to go back and take premed courses and become a doctor.

But it wasn't after having tried a number of other things and realized a few things.

One is that although I liked reading books about philosophy,

I didn't really want to spend my time in libraries and writing books as my exclusive connection to the world.

It needed something to be physically immersive,

Not just intellectually immersive.

And the second is that I had a few illness experiences myself that I think tipped the balance and said,

Okay,

I saw and experienced suffering in a way that I hadn't really understood in a personal way before.

And I actually ultimately had to come to peace with the fact that I would never be able to fully untangle my family expectations from my own aspirations,

That there would always be some ambiguity of intention there.

That was okay.

I subsequently feel that there are no pure choices.

We're conditioned by our prior experiences,

Whatever they are.

And so that illusion of total autonomy is just that,

It's an illusion.

It's a gift to the medical world and to patients that someone like you is in the healthcare profession and is treating us.

There are a lot of contemplative people in medicine that discovered that first.

And that's one glorious thing about writing is that when I first started writing about mindful practice over 20 years ago,

The correspondence I got was extraordinary.

Hollywood email was just nascent then,

So I'd get letters and phone calls.

You wrote an article in,

I think it was 1999,

And you said that it just struck a chord.

Tell me a little bit about what chord were you striking?

I wrote it coming from a few perspectives.

One is that trying to understand what reflection really meant in practice.

And it meant for me more than just Monday morning quarterbacking,

Not more than sitting around a table figuring out what happened and how you might do it differently later.

There needs to be some immediacy to the reflection.

You need to be able to observe yourself and be immersed in your work at the same time.

And I didn't see a model for that.

There were two models that came to me.

One was meditation.

My view of these familiar people doing meditation,

It's practice.

You write it's practice,

And then you bring what you learn from that practice out into the world.

You bring it into your relationships with people,

Into the work you do.

My second attempt at a career after I decided I didn't want to become a monk was to become a musician.

And if you're playing,

You can't hear what the listener is hearing,

Not just what you playing want to hear,

But if you can put yourself in the shoes of the listener and understand the received effect of what you're doing,

Then you're not really a good artist.

You need to have that reflective capacity,

That imaginative capacity in the moment.

And how do you develop that?

For me,

The most powerful experience I had in developing that was meditation and everything that went along with it.

That's where the dots connect for me.

AMY to talk about in the book as a doctor being a guardian for your patient's health,

But also you talk about,

You call it your inner operating system in each moment.

And this I'm assuming is what you are talking about with this reflective capacity when you're with a patient.

How does that work?

What do you think about that?

JIM I use that metaphor just because it may strike a chord with people.

I have a friend who's an engineer and designs what you might call intelligent machines,

Machines that can tell when they're malfunctioning and then fix that malfunction.

So machines are programmed with that capacity.

And I thought as a crude approximation of what we're doing by exploring the inner world,

That's kind of what we're doing.

We're having a bit of a window into how our own minds work and hopefully enough clarity to be able to discern when the mind is working well and when it isn't,

And then hopefully the tools to recalibrate.

AMY And you talk about medical training.

I think you said it largely ignores the development of these capacities of an inner life in general.

Do you still feel that that is true?

Or do you think that there are some changes?

JIM I think it's gotten better.

When I was a med student,

In the formal curriculum,

There was some lip service to being reflective.

And I had some fabulous teachers and role models,

But they all were kind of on the periphery of this locomotive that was biotechnical medicine.

It was not part of the core of medical education.

Now,

Certainly in word,

It's different.

The buzzword these days in medical education is what they call professional identity formation,

Which intrinsically is a reflective practice.

It's how does this human that you are want to be in the world as a professional,

As a healing professional?

And what practices and attitudes and values do you need to embody in order to do that?

And how do you acquire those?

Obviously,

Some places are responding to that imperative better than others,

But just the fact that it's part of how medical schools are now evaluated.

Do they attend to professional identity formation?

I think it's better.

It's not where it should be,

But it's certainly on the radar screen.

RISA GOLUBOFF You talk about having found some really great mentors early in your career,

Which I feel is great for anyone in any career.

When you talk about being drawn to qualities like insightfulness,

Thoughtfulness,

Curiosity about the human condition,

You saw doctors that said,

Help me understand,

Like stepping into someone's situation versus just trying to diagnose it based on cognitive information.

JIM GILMORE And this is not just in the emotional realm,

Even in the technical realm.

I started out the book describing two different surgeons that I worked with as a third year college student,

And one was clearly responsive and reflective and the other one wasn't.

And if you looked at them from the outside,

The one who was responsive and reflective was very extroverted,

Loud,

Fast,

Funny.

He didn't strike you like as being monkish or anything like that.

I mean,

He wasn't stopping,

Calling for a moment of meditation in the beginning of the operation.

But he certainly had that capacity of being in the moment and being attentive and being curious and recognizing errors before they really got to be big errors.

And what mindfulness actually looks like is not about still pons and lotus flowers.

Mindfulness happened in this chaotic,

Fast-moving world of technologically driven medicine as well.

SONIA DARA.

.

.

You have this model for mindful practice.

Do you remember the one that I'm talking about where there are three bubbles?

One is quality of care.

One is quality of caring.

And the other is clinical resilience.

Let's talk about how you do define mindful presence and where you see that in the ecosystem of healthcare right now.

JIM KEEFE.

.

.

You're asking two different questions.

One is,

I was just trying to make the point that being mindful isn't always helping yourself feel better or stronger.

In fact,

The ripples of that mindfulness touch the lives of patients,

Both in a biotechnical sense.

That is,

I think if you're being mindful,

You're more likely to make the right diagnosis,

Prescribe the right treatment,

Not make surgical errors,

Not stick yourself with a needle,

Things that go bad in healthcare settings.

So I think it's safer,

More effective,

More patient-centered care.

The second is relational.

That is,

If you're able to be more self-aware,

You're more likely to make strong relationships with patients and also with colleagues.

The third bubble,

I've really changed the nomenclature a few times because it's not just about resilience and it's not just about well-being.

Now what I would put in that bubble is flourishing,

That it's a sense that you're doing the job that you're meant to do and you're doing it well and you have a sense of wholeness about it.

It doesn't mean you're happy all the time.

It doesn't mean you're content,

But there's a certain wholeness to the work that you're doing.

So that's what I would put in that bubble.

RISA GOLUBOFF.

.

.

I don't know how you feel about this now,

But medicine being in crisis.

Do you feel that way now?

Is it healthcare that's in crisis?

Is it the whole spectrum from patient to doctor to payers?

DR.

JIM BEREN.

.

.

Yeah,

I do.

I don't want to be overdramatic,

But there is a confluence of factors that are concerning for at least the last 50 years,

Or actually more than that.

I read essays from the early part of the 20th century,

So 100 years ago,

Bemoaning the excessive attention to the technical aspects of medicine and insufficient attention to the human aspects of medicine.

And that's one area of tension.

And part of it is the technical aspects are more concrete.

They're easier to grasp.

It's easier to know if you've mastered them.

It's easier to know if you're doing it well or not.

And the human aspects are by nature more intersubjective,

And some things kind of slip through your fingers.

It's easy not to notice.

The nefarious aspects,

I think,

Are a few.

One is what I call the hegemony of coding,

Which is now the international classification of diseases now lists 71,

000 different diagnostic categories,

But not one of them is called suffering.

There's a category for rare tumors of the left index finger,

But there's this imperative to categorize.

And even with 71,

000 categories,

They don't account for the uniqueness of each individual.

So it's thinking digitally as opposed to analog thinking.

And that coding is driven by economics to some degree.

That is,

Depending upon the code you give,

You can charge different amounts of money for caring for people.

And the second is the corporatization of healthcare.

So despite people's aspirations to provide high quality care,

And I think even the chief financial officers of most healthcare enterprises are committed to high quality care,

It's just that the process of increasing productivity,

Throughput,

Profit hijacks discussions about quality.

And I just think about I've attended faculty meetings in my own department and many other departments,

And the amount of time spent on quality of care as opposed to quantity of care is just out of balance.

It's very much out of balance.

The other areas of concern,

I think,

Are professional isolation of clinicians.

This is an untoward effect of electronic health records where people are now sitting in front of computer screens rather than talking with one another.

And I think there's a collective sense of alienation in healthcare that the camaraderie that could be there isn't.

And I don't mean to extol any good old days because they had their problems too.

But one thing that was present for a very long time was a sense of community among dealers.

And this is very,

Very hard work that we do.

It's emotionally taxing,

It's physically taxing,

And it just becomes so much more possible when you feel you're part of a community.

And in fact,

In the work that even though I didn't talk much about community in the article in 1999,

That's really come to the forefront as one important quality of practicing mindfully is a support for that is having a feeling that you're not doing this alone,

That you're part of a larger effort.

As I was reading your book,

I felt so much compassion for doctors who are often made out to be the bad guys or women.

And this idea that what you talk about is the lack of community,

But also like cognitive loads drive them to be on autopilot.

And this expertise is so important and the need to redefine expertise to create an opening for other ways of being that may be more possible or other ways of healing that may be more possible.

And you talk about the emotional distress that many doctors go through and this idea you were used an example of patients saying to the doctor,

What would you do if this were you?

And how difficult these questions really are for a human being to answer.

And how much of your emotional life you may have to cut off sometimes to be able to be with the kind of suffering that you're with.

Yeah,

So you're touching on a number of things.

I want to respond to the last one.

I think part of the task,

You have to be on autopilot some of the time.

You couldn't get through the day without that.

Again,

I kind of go back to my musical training.

If I had to think about how to play a C major scale every time I played one,

I would never be able to learn a piece of music.

There's something that just has to be just through repetition and experience that becomes lubricated to the point that it becomes effortless.

And that's really important in order to get through the day.

Equally important is to recognize when that effortless,

Automatic work has its limitations and you need to step into a more deliberate and reflective moment.

So it's really,

It's a both and.

And I would say that the mindfulness piece is knowing the difference.

Is knowing that you're on autopilot and knowing that you need to slow down or stop.

And by knowing,

Often that comes before you can actually articulate it.

So again,

The examples of the surgeons that I gave,

And this comes from work of a colleague of mine in Toronto,

Carolyn Walton.

She talks about slowing down when you should as a quality of good surgeons.

But the surgeon isn't saying to themselves,

I'm encountering a difficulty,

I'm going to slow down.

They just kind of do it.

It's this tacit knowledge that they have.

They do recognize that it does register and they do slow down,

But they don't even go through the mental process of deciding to slow down.

That in and of itself,

That capacity to slow down,

To take a pause,

To take a moment is also a learned capacity.

So I would say that stepping out of autopilot itself may involve some kind of autopilot.

And an internal alert system saying,

Gee,

What I normally do is working,

Stop,

Do something different,

But it's not even at that verbal level.

You're talking about intuition,

Right?

Is deconstructing this vague thing that people call intuition?

Because intuitions can be right on and intuitions can also just confirm stereotypes and biases.

That looks like a dishonest person.

Well,

What about it?

Is it the color of their skin?

Is it their gender?

Is their age?

Is it the fact that they speak with a certain accent?

I don't know.

If you can deconstruct it,

Then you can use your intuition intelligently.

How do you think mindfulness or your meditation practice helps you get to that place?

Because it seems like such a unique place,

Right?

This like intersection of expertise and heartfulness and some vague knowing.

The way I put it together,

And this is not an original idea,

There's a psychologist named Eugene Gendler,

Who I read a little bit of,

Who talks about experiencing as a primary learning modality.

There's a difference between having experience and engaging in experiencing.

It's a way of getting around having to explain what you're doing.

This experiencing thing is a source of learning,

But it's a source of learning in a process mode.

It's not a checklist kind of learning.

It's a familiarity with a process that allows you to understand its landscape.

I think about the way surfers describe waves.

But yeah,

They use all these words to,

But still,

I can't imagine that that's the way it actually feels.

That the words somehow are a common language,

But there's also this feeling of what a wave is and how you're intersecting and interacting with it.

I think of mindfulness more in that process sense,

And I don't mean to be obscure or mysterious,

But really good clinicians can say there's something not right about the situation or there's something,

Their lab tests look good,

But they just don't look healthy.

And so it's that capacity for seeing dissonance and not discarding it.

I love the way you just said that.

Yes,

Seeing dissonance.

Right.

And that dissonance provokes curiosity as opposed to ignoring or discarding.

This is reminding me,

I just watched the new Oliver Sacks documentary.

This idea you talk about in your book that he perfected the art and joy of observation.

And he had this curiosity,

This realization that there's always more.

And he had this deep seeking to know,

Which was so,

Wasn't he criticized so much in the early days?

He just didn't want to accept his way of seeing the world.

But he was always really so unique and so curious and had such keen observational skills.

And also so persistent.

He got fired from here and there and had a crazy life.

But he kept doing the one thing he knew how to do,

Which was to be an amazing observer,

Not only of others,

But also of himself.

So you talk a lot about curiosity.

And I feel like this is interesting for doctors and for all of us,

This idea of transforming discomfort into curiosity.

I don't think this curiosity,

Discomfort to curiosity transition is masochistic.

It's just a form of practice in service of being who you are.

You sort of in the book invite doctors to embrace or even tolerate ambiguity sometimes.

And ambiguity is so uncomfortable.

This idea that to be a good diagnostician,

You may need to see things from different perspectives.

And this is true,

But this is also true to hold something lightly enough to be able to see it from different perspectives.

As soon as you become too wedded to an idea,

Then your thinking begins to shut down.

But if you're not wedded enough to an idea,

Then you can't move forward because you need to,

If someone's there short of breath,

There's this ambiguity,

Maybe it's heart failure,

Maybe it's pneumonia,

Maybe it's a collapse,

But you've got to do something to act.

One way to approach that is with absolute certainty.

Oh yes,

This looks just like that,

I'm going to do this,

Which will work a certain percentage of the time.

But then if that certainty remains too rigid,

Then you won't be able to navigate if your first supposition didn't work out.

So I think it's having enough certainty to act or enough confidence to act and enough ambiguity to remain curious.

It's remarkable the degree to which humans can actually learn this.

On the positive side there,

This is a pretty nuanced skill to be able to see the world in different ways.

And young children can do that because they've got great imaginations,

But they don't have that sense of focus and discipline quite yet to be able to carry their curiosity through to some kind of meaningful action.

You have a quote from William James in your book,

Defining Practical Wisdom.

You say,

All human thinking is essentially of two kinds,

Reasoning on the one hand and narrative,

Descriptive,

Contemplative thinking on the other.

Are you teaching other students now?

Are you mentoring young medical professionals?

How are you sharing all of this amazing wisdom that you've amassed throughout your career?

How are you planting the seeds for the next generation?

I see this as collective inquiry.

Collective inquiry?

Yeah.

And part of what I really love about teaching is learning and watching others learn.

I mean,

Learning myself and watching others learn.

So I see this as just a choice of what kinds of questions you want to ask.

I could ask a medical student,

Please explain to me the biochemical basis of diabetes or something like that.

Okay.

That's a question I know the answer to.

It's not,

I think the students should know that.

But other questions that I might ask are,

The moment you met this patient,

What did you think was going on?

And how did your thinking change as you got to know this patient better and as you did the exam and as you looked at their lab tests?

And what dead ends did you find in your reasoning?

And how did you get out of those dead ends?

And what do you feel most certain about?

What do you feel uncertain about?

If there's something that you might have missed,

What would that be?

And those kinds of reflective questions just jiggle people's thinking and say,

Okay.

And then I try to be transparent about my own mental processes.

And if I end up in a blind alley or a rabbit hole,

I'll tell a student that.

I say,

Gee,

You went this direction.

I thought it was going to show this,

But in fact it did not.

And it's a big surprise,

So now what do we do?

Well,

I liked your kayaking when you learned how to kayak and there was this sense of being off balance,

But stable and safe at the same time,

Knowing that you're never completely in balance and that that's okay.

Yeah,

So I'm not a fabulous kayaker.

I just enjoy doing kayak on lakes and things.

I'm not a really great water meteor and the ocean and all that.

But I went to buy a kayak a few years ago and the guys selling me the kayak talked to me about what they call primary and secondary stability of the kayak.

So primary stability or instability is how maneuverable the kayak is,

But also how tippy it is.

So a kayak that's more maneuverable by its very nature will feel tippier.

It'll feel wobbleder.

And if I got this right,

Then secondary stability really refers to how easy it is for the kayak to actually tip over.

If you want to have a kayak that really can round the corners well,

But not get wet,

You'd want a kayak that has a lot of primary instability and a lot of secondary stability.

It's supple,

It feels tippy,

But you're not going to get wet.

And of course it's a matter of taste because people who need an extreme of maneuverability may have to sacrifice some of that capsize ability for it,

I guess.

If you want to go in a straight line in the ocean for a long distance,

You want a kayak that's super stable.

But I think medicine is somewhere in the middle.

You need your mind in a way to be prepared for a few waves and obstacles,

And you need to be able to be pretty quick about maneuvering around them.

But also you don't want to drown.

You don't want to get wet.

You don't want to abandon your patients.

So you want a kayak that's just not going to tip over.

And I use that as a metaphor for the mental state that you might want to be in when you're doing clinical work.

Yeah,

I really like that because you also talk about stress can be a really good thing.

And it's finding this balance of things that may seem like they're opposite,

But finding a place of stability for yourself.

The other thing I want to talk about before we close is,

And we talked a little bit about suffering,

This idea of suffering and compassion for both doctors and patients.

How can we make sense of certain things that happen?

I think you use these words,

The brutality and unpredictability of a disease.

I personally have a friend who has a genetic degenerative disease,

And she's very young and she will likely die within maybe a few years.

And it's this idea that doctors have to face this patient,

Patients have to face this brutal condition and living with chronic pain.

This question is really about how do we suffer together as doctor and patient?

What helps us to deal with these things?

And how does a doctor wake up every day over and over again to face these kinds of things in the world?

I think we all navigate that conundrum differently.

One is just,

For me,

At least in my role as a doctor,

Knowledge that even human understanding often relieves suffering.

The last time I was on service in the hospital a few weeks ago,

We had a patient who's been repeatedly admitted for intractable pain related to a complication of cancer and a young woman and has been on every medicine known,

Including some experimental ones and has had a number of procedures on the pain process.

So everyone has this sense of helplessness and sometimes hopelessness,

Including the patient and her family.

And there's this real temptation of wishing that she would go away or wishing that we didn't have to walk into the room.

And I know I would never say that in a professional context,

But the feeling is there.

It's undeniable.

It's just on the other side,

There's a contrasting feeling of saying that you can make some difference just by helping the patient feel that they're not alone and accompanied and listened to.

And that in the broader scheme of things,

Even if the pain doesn't get better,

The suffering might.

That she may be able to function better despite the pain,

That she may feel that she's that much less alone,

And that her life has a greater sense of meaning and purpose just by virtue of having been listened to in a deep way and a human to human contact.

That's the part that tells me,

Okay,

I'm going to go in the room because even if I can't do anything technically to change her medical condition,

There's something that I can do just by being present.

Now,

How do we deal with our own distress around those kinds of circumstances?

I think that's where community comes in,

Knowing that you're not the only physician or healthcare professional taking care of someone who presents problems that are intractable and being able to talk about it and also being able to turn towards that and saying,

Well,

If there was one way that I could see the situation differently,

That would be more energizing and enabling,

What would that be?

And so actually taking on this issue of suffering as the issue of approaching suffering itself as an opportunity for learning.

Yeah.

So you talk about why some people don't burn out and there are several resilience factors that you point to.

I guess let's talk about doctors.

Do you think doctors can learn to be more resilient?

Do they become more resilient as time goes on and they face more and more of these really difficult situations or what is that capacity that allows us to be more resilient?

Yeah.

Here,

I think that medicine has done a really bad job.

But yes,

It's true.

Some people do become more resilient.

Some people burn out.

But I don't think there's any or there's not enough concerted effort in terms of building the capacity for resilience in an individual and collective way as in other professions.

For example,

I know in the aviation industry,

After you've had a nearness,

If you're the pilot,

You're not allowed to fly again until you have a chance to talk with someone about your experience and how you manage that emotionally as well as cognitively.

And there are procedures in place to help people deal with traumatic events.

And even in the military,

In training for special forces,

For example,

They know that they're going to be sending these people into very,

Very dangerous circumstances.

And they don't just throw them in at the deep end.

They do some progressive conditioning so that they are able to navigate a mildly difficult situation,

Then moderately difficult situation,

Then a severely difficult situation.

And so it's just this progressive training.

I think musicians do that also.

Good musicians don't wake up and one day are playing in Carnegie Hall.

They play for a small class and then they play for a larger group.

But I think in medicine,

Students can spend two years essentially in the classroom.

Yes,

They do have some pretty early clinical experiences,

But essentially they're doing classroom learning.

And then they're just thrust into these environments in which raw human suffering is unfiltered and often without enough opportunity to debrief and to build their capacity for resilience in those circumstances.

And the culture of medicine,

As we spoke about before,

Doesn't acknowledge and reinforce that to the degree that it should.

I really feel that there's a lot to be learned and a lot that needs to be changed about the culture of medicine to make it recognized that not only patients,

But healers are human as well.

And it would certainly help the high levels of burnout among physicians.

One would hope,

Yes.

What is your meditation practice?

What do you do every day?

Yeah,

I wake up every morning,

Either do meditation first or do some exercise first and then do meditation.

I would say some days it's 25 minutes,

Some days it's 15 minutes in the morning.

I was trained initially in Zen meditation and there are two forms.

One is more focused attention meditation.

The second is what's called Shikantaza,

Which just means just sitting.

And it's kind of a more open awareness meditation.

So that's what I do.

I'm aware of the breath,

But I'm not counting breaths.

I'm not trying to control it.

It's somewhat similar to some Vipassana meditation techniques.

So that's what I do.

And then in the afternoon,

I usually do something much briefer and do it lying down at the end of my work data,

Punctuate the transition between work and home.

And for me,

I've done that,

Both of those,

Well,

Since I started in medicine.

Yeah.

Do you teach any of the doctors or residents that you work with now,

Or do you pretty much keep your practice as your practice?

Well,

I do that in the context of workshops and mindful practice for health professionals,

But it's not just meditation.

We also do a lot of narrative work and deep listening exercises and other things,

But meditation does form an important container for all of those other activities.

I am so grateful that you're doing this work.

It will have such an impact and already has had such an impact on so many people.

I loved this book and I highly recommend it to patients,

Potential patients,

Healthcare professionals.

Thank you so much for writing it.

Thank you for being on Untangled today and so happy you could be with us.

And thank you.

Thanks so much to Ron Epstein for being with us today.

As always,

We'll see you next week.