View From the Other Side of the Stethoscope
As an internist and cancer survivor, Wendy S. Harpham, MD, FACP, offers a unique perspective on oncology practices.

Monday, March 27, 2017

The Healing Power of Attending

​​My ongoing search for insights about improving patient care and holding on to the joy of medicine just hit pay dirt. Here's the scoop in one word: attending. I mean both the verb—being fully present with your patient—and the book, Attending, by Ronald Epstein, MD, a must-read about mindful medicine.

Before you roll your eyes, the book is not new-agey nonsense. Epstein, a Clinical Professor at the University of Rochester School of Medicine & Dentistry, grounds his work in the respected literatures of neurobiology, sociology, and psychology. With the discipline of a scientist and the artistry of a journalist, Epstein blends engaging patient stories with provocative insights and practical advice that just might fulfill the flap jacket's promise to inoculate you against burnout.

Epstein offers a fresh view of high-profile topics, such as compassion, suffering, medical errors, and the wounded healer. Without whining, he addresses the challenges to providing comprehensive care. Without patronizing, he suggests ways to overcome them. For a taste of what Attending offers, let's look at the link between certainty and curiosity.

As clinicians, you strive for certainty about patients' diagnoses and best treatment options. That desire is adaptive, motivating you to keep learning and honing your skills. A rewarding sense of certainty breeds confidence. It's a pleasurable feeling that offsets the frustrations and sadness of patient care and helps you let go of tough cases to focus on your next patient. Clinicians' desire for certainty is a good thing.

Except when it's not. In clinics where the clock is ticking and patients are waiting, the desire for certainty can grease the wheels for over-testing and cognitive errors. Academics who address medical errors often recommend adding checks in the system and training clinicians to self-monitor for biases, anchoring, and such. Epstein suggests you manage the desire for certainty by fostering another desire: curiosity—a deep desire to understand something.

To illustrate with an anecdote, Epstein describes his frustration with a patient who didn't take her meds. His annoyance grows when she refuses an exam. He doesn't care why she's acting this way and just wants the visit to be over. In a mindful moment, he becomes aware of his negative emotions and responds by engaging curiosity about what's going on with this difficult patient. As you already guessed, his next questions quickly uncover the problem. I can almost hear the violins crescendo in the background as the curtain comes down on a satisfied patient committed to following medical advice and a satisfied physician enjoying a triumph. Conclusion: curiosity leads to good care.

So, what's the story with clinicians' curiosity these days? Sometimes curiosity is squelched by the fear of asking patients, "What else can you tell me?"—an open-ended question that risks opening a Pandora's box of complaints. Epstein reassures you the added minutes will likely be fewer than you expect and investing upfront will save hours in the long run. Nothing new here.

The heart of Epstein's discussion begins with his belief that "Curiosity is sidelined by what Jerome Kassirer, former editor of the New England Journal of Medicine, called a 'stubborn quest for certainty.'" To explain how this happens, Epstein builds on material presented earlier in the chapter, such as how the brain responds to interruptions and information overload by ignoring novel, unpleasant, or unexpected data. (If not convinced, check out the "Monkey Business Illusion" on YouTube, a classic illustration of selective attention.)

Knowing this, now think about the fact that when you're curious you open your mind to the possibility that things with your patients are not what they seem. You believe that anything you think you know is "provisional, incomplete, or evolving." You accept living with the paradox of multiple equally legitimate ways of viewing a patient's situation, such as a patient who is both stubbornly non-adherent and struggling to comply. For some clinicians, embracing all that ambiguity feels like letting go of the expertise you worked so hard to achieve. Maintaining a sense of "unfinishedness" stirs feelings of being inefficient and unproductive or out of control.

Here's where Epstein makes a strong case for the benefits of curiosity outweighing the costs. For one, curiosity is an intrinsically rewarding drive. Constantly looking for something new, unexpected, or interesting—in other words, "preparing to be unprepared"—puts you in a state of "relaxed awareness" that is energizing, in contrast to hypervigilance, which is exhausting. For another, under stressful circumstances, increasing curiosity triggers a feedback loop of decreasing anxiety, rigidity, and defensiveness, all of which help you uncover the truth of the matter.

Taking curiosity to another level, Epstein claims you have a moral responsibility to be curious. He argues that curiosity drives you to pay attention to what matters to patients. Doing so makes their concerns important, which, in and of itself, helps relieve patients' suffering.

Thus, curiosity fills your tank by tapping into your sense of purpose and serving your mission, no matter the patient's medical outcome.

Epstein inspires you to nurture curiosity by getting in the habit of asking, "What's interesting about this patient? What's not known? What's important to this patient?" At first it may take a little extra effort for curiosity to coexist with the healthy desire for certainty, a balance that depends on accepting the increased uncertainty while letting go of the associated negative emotions. With practice, the curiosity of your youth can become second nature, enriching your connections with your patients, enhancing your proficiency, and infusing your noble work with vitality and joy.

"Curiosity" is just one of a dozen equally fascinating chapters, each supported by plentiful notes in the index. Put together, Attending describes a modern approach to mindful medicine. The goal of attending—being fully present with your patients—is not efficiency, yet efficiency often arises from such presence. More important, mindful medicine is good for your patients, for our profession, and for you.