In case you’re thinking that video games are mindless and far removed from clinical practice, think again. They aren’t. Computer programs now use avatars as virtual doctors and even psychotherapists—quite effectively.14 Patients become emotionally attached to the computer figure in the same way that they might connect with a psychotherapist. Like Harry Harlow’s monkeys, who, in captivity, bonded to an inanimate “mother” made of wire and cloth, humans naturally bond with other people, or what they imagine to be people, even when they know that they’re not real. It’s because our brains are wired to promote attachment and relationship.15
Social presence—or shared presence—is critical for health care. The ability of doctors to see each patient as a complete human being (and vice versa), in my view, is the basis for the trust and understanding that help the patient through the hard times. It is a learned skill, a habit of mind. It reminds me of how I’d prepare for concerts. Performing well in the rehearsal room was only part of it. I’d get the technique down and would let the music speak. Yet, I’d need additional practice to prepare for when I’d be onstage, in relationship with people who I imagined might be approving or critical, being moved or watching my every move. Similarly, clinicians have to prepare for those relationships that place them outside their comfort zone—when there is suffering, conflict, uncertainty, or loss.
It might seem straightforward how humans come to be present with and understand one another. After all, we have language and can communicate what is important to us. Yet shared presence goes beyond language. Philosophers and cognitive scientists have explored how we come to understand the minds and intentions of others, even though it’s hard enough to read our own minds, much less those of other people. They emphasize that, as social beings, we need to understand others’ internal experiences in order to cooperate, collaborate, communicate—and survive. Until recently, human understanding was thought to involve “theory of mind,” that we constantly theorize about what might be going on in others’ minds—what they’re aware of and what they’re thinking and feeling. Sometimes we try to verify whether our “theory of mind” is correct; but more often we do not. Those who lacked theory of mind were particularly impaired, such as patients with autism and schizophrenia.
A competing theory about how we understand each other is called embodied simulation, which proposes that we relive in our own bodies and minds the actions and presumed intentions of the other. For example, when I used to do deliveries, I would find myself holding my breath and straining when women were experiencing contractions; I would do this without being aware of it, then it would filter into my consciousness. I entered the raw sensuality of the experience (albeit vicariously). At the same time I could also be aware of my “doctorly” frame of reference; I’d say to myself, “When you’re holding your breath and straining, perhaps it’s because you know that the patient is entering the second stage of labor.”
More recently, social neuroscientists, psychologists, and philosophers have taken another step further. Theory of mind and embodied simulation suggest that we are separate entities, that it is one mind understanding the completely distinct mind of another. This is only partially true. Research suggests that our minds are intertwined, so much so that it seems that our minds are not completely our own. Some part of our cognitive and emotional lives—and our identities—is shared with others.16 I am not merely an aloof observer of a patient’s experience; I am, to some extent, a participant. In that way, presence is intersubjective; it blurs the boundaries between that which is me and that which is you.17 Intuitively this makes sense. We engage in shared mental processes all the time; married couples commonly complete each other’s sentences, and doctors and patients might both recognize in the same moment that something is wrong.18 The premise of the field of “team science”—how teams work together—is that teams have shared mental models.19 Science has only begun to describe how shared mind happens, psychologically and neurobiologically, and the implications are profound.20 I believe that we are at the cusp of understanding how presence happens—when shared mind is revealed to both parties.21
LIKE ME, NOT LIKE ME
Presence—unfortunately—is not naturally democratic. Humans are not only social organisms, we are also tribal—for better and for worse. We connect more easily with people we perceive to be similar to ourselves. “Tribe” can be whatever we define it to be—the tribe of white people, the tribe of those who speak Portuguese, the tribe of the sick, or the tribe of the poor. You might consider yourself a member of several tribes at once. As a result of their—often unconscious—tribal affiliation, people tend to see the world through a particular lens, consciously and unconsciously dividing the world into those whom they perceive as being “like me” and others who are “not like me.”
Physicians are tribal too. Perhaps that’s why doctors are poorly prepared to be patients when they themselves become ill. When physicians become ill, they really don’t like it. Doctors don’t only feel more vulnerable because of what they know (. . . and now they’re going to do that to me?), they literally become strangers to themselves.22 It’s as if doctors and patients belong to different tribes, and when doctors become ill, they become involuntary members of both.
While the positive side of tribalism is a sense of belonging and communion, the dark side is bias—a set of unverified and preconceived assumptions about someone, often simply because we think that they belong to a particular group. Everyone harbors biases, whether it be about race, ethnicity, gender, body habitus, sexual behaviors, or something else.23 Physicians, like everyone else, make different assumptions about people depending on whether they are obese or thin, male or female, black or white, Spanish-speaking or English-speaking, and a myriad of clinically relevant and clinically irrelevant factors. These biases usually are implicit—below the level of awareness.
These biases affect the care that patients receive.24 When physicians’ tribal associations prevail, the seeds of bias are sewn. Witness the early days of the AIDS epidemic, when people who superficially were very much like their treating physicians—well educated, predominantly white, generally healthy males—were “othered”; they were blamed for their illness and sometimes treated as if they were less than human. Staff left hospital food trays at their door, afraid to enter the room. Physicians avoided touching them—even long after everyone knew that HIV was only spread through intimate contact and blood products. They were made into outcasts, in part driven by clinicians’ fears—of stigmatization by association, of contagion, of talking about sexual and drug use behavior, and of death.25 While now—fortunately—the horror stories about clinicians’ refusal to care for patients who were HIV infected are well behind us in most communities in the United States, this dynamic persists in large parts of the world.
Tribalism is hardwired in particular parts of the brain—the dorsomedial prefrontal cortex in particular—which respond differently if we feel that the other person is a member of our tribe. Tribalism is expressed through our hormones. Oxytocin, the hormone that promotes labor and milk production, also promotes love and nurturance within one’s tribe. However, for those outside one’s tribe, oxytocin has the opposite effect—it promotes aggression (think of why it’s not a good idea to get between a mother bear and her cub).26 In case you were wondering, men have oxytocin too, with the same psychological effects. Our tribal tendencies are to some extent a survival strategy—evolutionarily, we’ve always needed to be able to assess quickly who was friend and who was foe.27
The discovery of mirror neurons in the 1990s revolutionized neuroscience by providing a mechanism for human understanding. Mirror neurons fire when we observe others engaging in goal-directed tasks such as reaching for an object (the early experiments used monkeys witnessing other monkeys reaching for food). These nerve cells are located near our motor cortex—the part of the brain that controls our movements—and when they are activated, our brains simulate what it is like for the other person (or monkey) to engage i
n that action and thus draw conclusions about the other’s intentions and goals. More recently, scientists have speculated that some areas of the brain interpret not only the physical actions of others but also their associated emotions. These emotional resonance systems are thought to be the basis of emotional intelligence and social intelligence. One such area—the anterior cingulate—seems to grow and develop in response to mindfulness training.28
Being present with a patient (or anyone for that matter) whom I perceive as “not like me” initially feels less natural than with others with whom I share aspects of my identity. I will admit that—initially—I relate more effortlessly to a fellow professional than to someone who is mentally ill or to a recent refugee from an embattled third-world country. It takes effort and imagination to resonate with the other person’s experience. I have to ask, “What’s it like?”—and hearing the answer usually connects me with a more basic and shared human experience. My brain needs to shift gears to bridge the gap between my life and his.29
A PRACTICE OF STILLNESS
Practicing presence, for me, is practicing becoming available (to myself and others) and practicing quieting the mind. Being available means showing up and letting patients know—through words and gestures—that there is space. Patients can recognize presence when they don’t feel that they have to say, “I know you are busy, but . . .” or “Sorry to bother you with . . .” Clinicians are afraid of being too available—myself included. They’re afraid that patients will call them at all hours of the day and night and invade their personal lives relentlessly. Even though I know that’s a real risk, I have to remind myself that being more available often saves time. At the end of a visit, I’ll say that usually I’d schedule a follow-up visit in a month, but that they can come back sooner; they usually say no but appreciate knowing that space is there. Sometimes I give out my home phone number to patients who are worried or are seriously ill. Patients rarely call, and in thirty years of practice, I can count on one hand the patients who called inappropriately. Knowing that they can reach me makes them feel that I’m present. I find that they call the practice less often; they don’t feel a need to repeat and amplify their concerns.
Quieting the mind makes space within the clinician; it promotes openness. For those who are drawn to it, sitting practice offers one way to quiet the mind, and the presence that is achieved while alone can translate into presence with others. Among doctors who take the time for stillness, nearly all feel that the time one makes for contemplative practices—meditation, reflection, awareness—is soon recaptured in increased clarity. The goal of presence is not necessarily efficiency, but efficiency often arises from presence.
All contemplative practices offer ways of practicing stillness. Yet these practices do not confer immunity to strong emotion; quite the opposite. Even those who’ve spent thousands of hours meditating have the same kinds of reactions to stress as anyone else.30 Their hearts race, they feel anxiety and dread, and they experience moral outrage. Research shows that these immediate emotional reactions are at least as robust in experienced practitioners as in those who’ve never done any contemplative practice. So why bother? The difference is that in experienced practitioners, those stress reactions abate sooner—they don’t keep on reverberating. Rather, experienced practitioners discern more rapidly which emotions and experiences are “theirs,” and which belong to other people—in other words, they’re good at self-other differentiation.31 They have the skill to “decenter”—they can feel their own emotions and at the same time observe them as if they were standing outside themselves. They develop a capacity for what psychologists call mentalization—they understand their own mental states rather than being oblivious of or mystified by why they feel the way they do. They have learned to see their mental states as something they can control rather than the other way around; they know that these states are transitory and not enduring, that they ebb and flow. For example, they more readily distinguish between I am feeling angry—an emotion that they can control—and I am angry—a person whose anger is part of their identity. They learn to set aside their immediate reactions so that they can respond more mindfully.32 All of these skills open up space for presence. Physiologically, meditators learn to regulate the expression of certain genes that affect the number and type of receptors to the stress hormones (such as epinephrine, cortisol) that course through our systems when we’re aroused and anxious, as well as the neurotransmitters (such as serotonin, dopamine, neuropeptide Y) that play a role in regulating emotion.33 It’s not that you don’t have strong and sometimes-distressing feelings; while feeling their immediacy, you learn how not to be consumed or paralyzed by them.34
WHERE ARE MY FEET?
You can practice presence. One way is a practice called “Where are my feet?” At first glance, it seems almost too simple. Ask yourself, “Where are my feet?” Give yourself a moment to feel your feet. Are they flat on the floor? Is your weight equally on both feet? Is there any discomfort? Do you feel them inside your shoes? Do they feel strong and reliable? Pay attention to any sensations you might experience. You can do this while standing or sitting. Once you get the hang of it, see if you can ask “Where are my feet?” in a stressful situation. Use it as a way to stay present. Feet are our foundations, our sources of stability, and our engines of mobility; they maintain balance, allow us to be still, and impel us forward. By assuming a physical attitude of stability, strength, and balance, you simultaneously draw attention to and stabilize your thoughts, feelings, and emotions.35 Your physical presence stabilizes your presence of mind.36
Shared presence is cultivated through deep listening. In workshops, I frequently ask participants to write about meaningful experiences in their work settings, moments of connection and times when things did not go well. Participants pair off, and each is given time to read her story or tell it in her own words. However, this is not a social conversation; it’s an exercise in listening deeply, with attention, curiosity, and beginner’s mind. While it’s okay to ask clarifying questions about what happened and how the other person felt, and also to express understanding or empathy when appropriate, I caution listeners to be aware of their impulses to interpret, criticize, judge, or elaborate upon their colleague’s emerging story—and to deliberately set those thoughts aside for the moment so that they can be present. To help them respond more mindfully, I’ll suggest that listeners have some way of slowing down. For example, if they feel that they have something brilliant or insightful to say, rather than saying it right away, they might count slowly from one to five, and only then share that insight if it still seems as urgent and relevant after the short wait. Deep listening can be remarkably difficult. It feels awkward. We’re so used to thinking about our responses before the other person has finished speaking—we feel we have to be doing something and not just be there. With practice, though, most people feel gratified when listening deeply, knowing that the other person feels heard and understood in a space of shared presence.
Yet another way of practicing shared presence was described by Chade-Meng Tan, who created the Search Inside Yourself “mindfulness for engineers” program at Google. In a deceptively simple exercise that he calls Just Like Me,37 you visualize somebody in your mind and then consider—and even gently speak to yourself—phrases such as “This person has a body and a mind, just like me. This person has feelings, emotions, and thoughts, just like me. This person has, at some point in his or her life, been sad, disappointed, angry, hurt, or confused, just like me. This person has, in his or her life, experienced physical and emotional pain and suffering, just like me. This person wishes to be free from pain and suffering, just like me. This person wishes to be happy, just like me,” and so on. You can easily carry this contemplative practice with you into the workplace with colleagues; it’s particularly useful with people with whom you don’t see eye to eye.
With this and other practices of presence, you open the door to dialogue and understanding, and you build the mental mu
scles to prepare for the moments when you feel the least prepared. Practicing presence helps clinicians slow down, listen more deeply, think more deliberately, shift from doing to being and from activity to stillness. Practicing presence, even for a moment, can be long enough to avoid a potential error, long enough for a patient to feel acknowledged, heard, and known.
6
Navigating Without a Map
Richard Grayson was a retired professor of epidemiology. He had been a patient of mine for the previous ten years, and I was one of his sole supports during a messy divorce. He was a lover of good food and wine and now had no appetite and couldn’t tolerate alcohol. He looked gaunt and tired. He had lost twenty pounds, his skin color was a pasty white, and his eyes were slightly jaundiced. I ordered a CT scan of his abdomen, knowing that the news would not be good. He had a stage IV cancer in his liver—which likely originated in his bile ducts—aggressive and incurable.
Richard wanted to know the facts. The cancer surgeon advised him that surgery would be risky and unlikely to improve survival or quality of life. Richard said that he would never consider chemotherapy, but I encouraged him to see an oncologist, just to find out. This muddied the waters. Richard learned that chemotherapy offered a 20 percent chance of extending his life by an average of a few months while possibly improving his energy and appetite. No one could know whether he would be one of the lucky ones whose cancer would respond—or one of the 80 percent who just had side effects with no benefits at all. He consulted another oncologist, searched the Internet, and wrote to friends and colleagues, including some of the most highly regarded oncologists in the world. The options were dizzying, including a “promising” experimental treatment. Richard knew well that only 5 to 10 percent of experimental cancer drugs prove effective, and no one knew what the side effects might be.
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