Acknowledgments
Attending could never have been realized without the efforts of a few key people. Most notable is Rebecca Gradinger, who through her confidence in me led me to find my voice and sustain the passion and energy for the book. She is an agent extraordinaire, passionate advocate, and tough critic, who never stopped believing in this book even when I was mired in doubt. She answered e-mails at noon and midnight and kept me focused on who I am and what I could give. She and her team at Fletcher & Company, including Jennifer Herrera and Veronica Goldstein, were incredibly supportive. Rebecca introduced me to my editor, Shannon Welch, whose passion for the topic, thoughtful editorial guidance, and commitment helped to make Attending the best it could be. Along with her remarkable team at Scribner, including her associate editor, John Glynn, and editor-in-chief, Colin Harrison, she shaped the manuscript so that it spoke with greater clarity and coherence. For their efforts and commitment I’ll be forever grateful.
I want to thank Gail Gazelle, Tula Karras, and Paula Derrow, who coached me early on, as I was just conceiving the book. My friend and medical school classmate Dan Siegel and my palliative care colleague Ira Byock gave me important advice about the publishing world, and my friend and college classmate Ron Siegel gave me the real skinny on books and editors and agents. He read, and hated, my first draft of a proposal, advising me that readers want the richness of stories, not merely sterile ideas. As I was drafting the book proposal, Arthur Frank, Jon Kabat-Zinn, Tim Quill, and Marc Lesser also offered support, enthusiasm, and helpful critiques through the eyes of those who’d been through it all before. Steven Henry Boldt, Mahala Ruppel, Esther Brown, Maria Milella, Betsy Frarey, and Deborah Fox all read the manuscript in its entirety and provided invaluable editorial suggestions for style, grammar, and sense. Thanks to you all.
I was amazed and grateful when friends and colleagues came out of the woodwork offering to read the manuscript in its entirety and provide specific critiques and impressions, most notably Andy Elliot and Bill Ventres, accomplished writers and busy people. Andy brought a reader’s eye to each sentence and reminded me that I was writing to reach out to others as well as to understand myself. Bill provided inspiration, thoughtful critiques, and gentle prods to “get real” when my thinking became too abstract and academic. Saskia Hendriks, a fellow researcher at the Brocher Foundation, provided insightful comments that led to important changes in the first two chapters of the manuscript.
I am a physician and not a neuroscientist, and although I had read hundreds of articles about the neurobiology of attention, resilience, attachment, compassion, and curiosity, I needed help reconciling competing ways of understanding how the brain and the mind work. Al Kaszniak and Jud Brewer read the portions of the manuscript about neuroscience research, correcting my misconceptions and getting me as up-to-date as one can be in a field that is evolving rapidly. Olga Klimecki was kind enough to explain the procedures and limitations of functional-imaging research, including her research on empathy, compassion, and conflict. Conversations with Amishi Jha helped me to understand more deeply the mechanisms of attention, Eric Nestler and Stephen Southwick helped interpret research on resilience, and Jean Decety and Beth Lown helped me to understand better the neurobiology and psychology of empathy and compassion. Anthropologist and Zen teacher Roshi Joan Halifax introduced me to the work of Carl Batson and Nancy Eisenberg, whose theories of empathy, sympathy, and compassion deeply influenced my thinking. Evan Thompson, a philosopher of mind and cognitive scientist, expanded my notion of what minds could do and be, and my Rochester colleague Paul Duberstein introduced me to the idea of collaborative cognition, which informed my ideas about shared mind. Chris Lyddy and Darren Good helped me to develop ideas about organizational mindfulness and sent me literature from the world of business and organizational management that might be applied to medicine. Yishai Mintzker brought to my attention the shared etymologies of meditation and medicine.
Several chapters represent a shared inspiration. I owe a debt of gratitude to Larry Dyche, who badgered me for months to respond to his offer to cowrite an article on curiosity just as I was beginning to think about writing this book, and the article we wrote together in 2011 influenced chapter 3. Similarly, Tony Back’s imprint on chapter 7 and my understanding of suffering is profound, as represented in a 2015 article we coauthored. Jordan Silberman and Dan Siegel helped me develop ideas about self-monitoring, which influenced much of how I frame mindfulness for clinical audiences. The focus on difficult decisions (chapter 6), suffering (chapter 7), compassion (chapter 8), errors and grief (chapter 9), and burnout and resilience (chapter 10) closely parallels the curriculum that Mick Krasner and I developed collaboratively for educational programs for students, residents, and practicing clinicians. I am grateful to all these colleagues for their generosity in sharing their ideas and letting me bring them from the academic realm to the public eye.
I am grateful for the gift of time. My department chair in the Department of Family Medicine at the University of Rochester, Tom Campbell, and Vice-Chair Susan McDaniel, advocated for my 2014 sabbatical—supported by the University of Rochester—during which I monkishly developed the book proposal. I am also grateful for the gift of space. The Brocher Foundation, just outside Geneva, Switzerland, is devoted to the social aspects of medicine, and enthusiastically supported my writing by providing a room and a tranquil study overlooking Lac Léman to complete the first draft of this book in February 2016. Several foundations supported the background work for the book through their funding of my time to develop, implement, and evaluate the educational programs that demonstrated effectiveness of mindful practice training on clinician well-being, resilience, and quality of care they could provide. I am particularly grateful to the Arthur Vining Davis Foundations, the Arnold P. Gold Foundation, the Maria Tussi Kluge and John W. Kluge Foundation, the Mannix Fund, and the Physicians Foundation for Health Systems Excellence.
Several teachers have had an enduring influence. My fifth-grade teacher, Marguerite Britton, ran her classroom as a democratic organization focused on identifying individuals’ learning needs and taught me about presence amid chaos, much to my enrichment and the school principal’s dismay. In college, my main influences were Randy Huntsberry, who introduced me to emptiness and mindfulness, and how mindfulness and stillness can happen in movement; Ken Maue, music and philosophical visionary; and the late Jon Barlow, who could make connections among anything, including baseball, Charles Ives, and John Ford, and between sixteenth-century English keyboard music and southern-Indian mridangam drumming. They all taught me that the way you see the world is limited only by your expectations and imagination. In medical school, my inspirations were psychiatrists Peter Reich and Les Havens, both humanists bucking the tides of psychoanalytic rigidity and biological reductionism, and later, in Rochester, George Engel, who taught me how to observe and ask. I wish they were still of this world so that I could thank them.
After I finished my medical training, my colleagues became my teachers. The late Ian McWhinney, family physician and philosopher, lived and breathed patient-centered care. My Catalan colleague Francesc Borrell-Carrió has been one of my most treasured intellectual partners and critics. He introduced me to pragmatist philosophers in my own backyard—John Dewey and William James—and has a way of gently questioning and challenging me to be as clear as I can be. David Leach, another Aristotelian, showed me the logic behind breaking rules in the name of wisdom, an idea dear to my anarchist heart, and how organizations themselves could become more mindful in the process. Conversations with Stuart and Hubert Dreyfus, Kevin Eva, Brian Hodges, and Carol-Anne Moulton strongly shaped my concept of expertise in medicine and how to know when you have it. While he was the senior associate dean for medical education at the University of Rochester, Ed Hundert provided the opportunities for me to lay the intellectual groundwork about how we understand and assess competence. Lucy Candib helped me understand the meaning of suffering and oppression and what
doctors can do about them. From Susan McDaniel, Dave Seaburn, and Pieter LeRoux I learned a family-systems orientation and family-of-origin awareness that suffuses every moment of my practice, teaching me that there is never just one patient in the room. Peter Franks taught me to adopt healthy skepticism about my own senses and convictions, especially those I hold most strongly. My greatest teachers have often been my patients, who, for confidentiality, must remain unnamed, yet I am grateful for their generosity, tolerance, and patience with me when I was off the mark.
The mindful practice programs that I describe in this book were the collective brainchild of my colleague Mick Krasner and me, with considerable input from Fred Marshall, Tim Quill, Scott McDonald, Stephen Liben, Patricia Lück, Shauna Shapiro, Tony Back, and Heidi Schwarz. Mick, the intuitive, spontaneous extrovert, offers the perfect complement to my analytical, conceptual way of seeing the world, and our educational programming is truly an example of shared mind. I am grateful for intellectual leadership, inspiration, and guidance from Jon Kabat-Zinn and Saki Santorelli and their colleagues at the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts; from Rita Charon and Tom Inui, who helped me develop the narrative medicine components of the mindful practice programs; and from Penny Williamson, who shared her wisdom about appreciative inquiry. I thank Michael Zimler, Ed Brown, Reb Anderson, Richard Baker, Joseph Goldstein, and Christopher Titmuss for their generosity in helping me develop a meditation practice. I have been deeply influenced by many other conversations with teachers, mentors, friends, and colleagues over the past forty years, and to name them all would be impossible. Sometimes I may have forgotten the source of an idea, but that makes me no less grateful.
By far my deepest thanks go to my wife, Deborah. Her clarity about what is important, her insistence that I speak from the heart—my heart and no one else’s—her frank critiques, her bullshit detector, her ability to size up people, her willingness to drop everything to help me think of just the right word, and her ability to channel me even when we are continents apart are extraordinary. She is my best editor and most loving critic. She tolerated my grouchiness, brought me tea and ripe pears, and even took over cooking dinner, normally my task, so I could write uninterrupted. My children, Eli and Malka, have helped me see the world through new eyes, and I am moved to tears by their emulation of those parts of me that give me joy, and by their tolerance of those parts that I’m not always proud of. And my parents, Joan and the late Jules Epstein, were totally mystified when my first-semester college transcript listed a course called Emptiness, but kept paying the tuition, trusting that I was doing something valuable even if they couldn’t understand it, and didn’t flinch when I announced I’d be a harpsichordist, then a Zen student, then a musicologist, then a chef, then an acupuncturist, and then a doctor. Their confidence in me was unwavering, and they knew it would all work out somehow.
Appendix: Attention Practice
In the beginning, meditation—like any new habit—takes practice. First, the effort is in just doing it—making time and being consistent. Frequently, the next challenge is stabilizing one’s attention, learning how to be in the present moment and how not to drift into mind-wandering or rumination. After sustained practice, meditation becomes effortless. The hard-won focus and awareness feel natural and simple. For me (and although I’ve practiced for decades, I make no claim to being an advanced practitioner), meditation is a habit, like brushing my teeth, so much so that the day would feel incomplete without it.
The instructions for both focused attention practice and open awareness practice start with posture; it should be comfortable and “dignified.” If sitting in a chair, you should be upright with feet on the floor; if on a cushion, you can be cross-legged or kneeling. Training need not be done sitting; practices can be done while walking, standing, or even lying down (a bit trickier because of the tendency to fall asleep!).
In Zen training, focused attention practice comes first, whereas in Vipassana training (otherwise called mindfulness meditation), both focused attention and open awareness are introduced early on. Focused attention starts with an awareness of the breath. In the Zen tradition, trainees are taught to count breaths—one, two, three, and up to ten, restarting at one and continuing to ten, then back to one, and so forth. In the Vipassana tradition, the focus is on awareness of the breath, and counting is not emphasized; instead attention is directed toward watching its rhythm, depth, and speed. You don’t try to control the breath in any way, but rather just notice how it is deep or shallow, fast or slow, regular or irregular.
For open awareness practice, the instructions are a bit different. You don’t necessarily focus on the breath, a mantra, or anything else. Rather, you assume an open, receptive, nonjudgmental awareness of all physical sensations, thoughts, and feelings that may be transpiring—whether they arise from within the body or from the external world—without any attempt to alter them in any way. It’s like watching a movie and being the main character at the same time—it’s observing the observer observing the observed.1 Open awareness involves naming those sensations: “Oh, I’m feeling my foot itch” or “Oh, there was just a loud noise.” Similarly, one can name emotions as they arise: “I’m noticing that I’m feeling angry”—or sad or frustrated. Naming emotions helps us engage in first-person inquiry, be curious, and respond to emotions intelligently, even if our first reactions are avoidance or annoyance.
If you’re starting on your own, choose one practice and stick with it. Get any of the dozens of audio-recordings, apps, or books, or go to a workshop.2 Your choice of practice may depend on whether you can find a partner or a group with whom you can practice—just as with exercise or any other lifestyle change. You may want to dive right in with twenty to forty minutes a day or start more slowly and increase as you can; even five minutes in the morning can make a difference. Importantly, be gentle with yourself—if you’re counting breaths and you can never get beyond three or find yourself at 142, gently bring yourself back to the task. A kind smile always helps.
You may remember two other practices mentioned earlier in the book—the body scan (chapter 3) and metta meditation (chapter 8). For these practices a guide can be helpful—either in person, or via one of the innumerable guided meditations available on the Web.
© STEPHEN S. REARDON PHOTOGRAPHY
DR. RONALD EPSTEIN, a practicing family physician, is a professor of family medicine, psychiatry, and oncology at the University of Rochester School of Medicine and Dentistry, where he directs the Center for Communication and Disparities Research and codirects Mindful Practice programs. He is an internationally recognized educator, writer, and researcher whose landmark article, “Mindful Practice,” published in the Journal of the American Medical Association in 1999, has revolutionized physicians’ view of their work. Dr. Epstein has been named one of America’s Best Doctors every year since 1998 by U.S. News & World Report. Visit Dr. Epstein at www.ronaldepstein.com.
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Notes
1. BEING MINDFUL
1 Even if one kidney had sustained permanent damage, given Jake’s young age, the other kidney would be highly likely to assume greater functioning over time and his kidney function would normalize—just as it does in people who donate a kidney for transplantation.
2 For descriptions of cognitive traps, see articles by emergency-room physician and decision scientist Patrick Croskerry: P. Croskerry, “The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them,�
� Academic Medicine 78(8) (2003): 775–80; P. Croskerry and G. Norman, “Overconfidence in Clinical Decision Making,” American Journal of Medicine 121(5) (2008): S24–S29; P. Croskerry, “A Universal Model of Diagnostic Reasoning,” Academic Medicine 84(8) (2009): 1022–28; P. Croskerry, “Context Is Everything or How Could I Have Been That Stupid?,” Healthcare Quarterly 12 (2009): e171–e176; P. Croskerry, “From Mindless to Mindful Practice—Cognitive Bias and Clinical Decision Making,” New England Journal of Medicine 368(26) (2013): 2445–48; and descriptions of Croskerry’s practice in J. E. Groopman, How Doctors Think (New York: Houghton Mifflin, 2007).
3 For a detailed discussion of the holistic and multifaceted nature of professional competence of clinicians, see R. M. Epstein and E. M. Hundert, “Defining and Assessing Professional Competence,” JAMA 287(2) (2002): 226–35; and R. M. Epstein, “Mindful Practice,” JAMA 282(9) (1999): 833–39.
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