Just being

The secret of the care of the patient is caring for the patient

Care of the Patient
F Peabody, 1927¹

The secret of the care of the patient is caring for oneself while caring for the patient.

Medicine and the Family: A Feminist Perspective
L Candib, 1995²

SELF-CARING AND SELF-KNOWLEDGE

Caring for oneself, like caring for others, is not always a simple matter. this is because caring always involves knowing.^2,3 I am not speaking of knowing about, the accumulation of details that constitute medical records and life stories; these descriptors do not necessarily lead to caring. However, knowing does, through a deep appreciation of how experiences, desires, and dispositions contribute to daily actions.

For me, the most fruitful means for self-knowledge have been music and meditation. I hesitate to subsume either under the category of self-care or well-being, as I believe that neither discipline should be limited by having to have an end result. Not that end results are unimportant—Plato and the neo-Platonists regarded music, for example, as having aspects that were essential for moral education and reflection as well as entertainment, and the Pythagoreans regarded mathematics and physics as subdisciplines of music.⁴ More recently, studies indicate that music education alters brain structure and function,^5,6 and may enhance learning.^7,8 But I do not—and should not—learn to play a Bach fugue just because it improves my problem-solving skills or makes me feel well. There is more—an element of dedication, engrossment, and relationship with the task that is part of the purpose. So, when I learn a Bach fugue, I transmit both the beauty and structure of musical expression while creating relationships among the music, the audience, and myself.

MEDITATION

In 1971, I took a daylong course in Transcendental Meditation. The turmoils of adolescence during a turbulent era made advertisements promising inner peace very appealing. Although some of the exotic trappings were a bit much for me, the inner process was engaging. I started a meditation practice to begin each day. I left college temporarily to become a student of Zen Buddhism. Part of the reason I chose Harvard Medical School several years later was to explore the current research on the medical benefits of meditation. Promising studies suggested that meditation could help control blood pressure,^9,10 chronic pain,^11,12,13 psoriasis,¹⁴ and anxiety.¹⁵ I also sought out other clinicians who would validate my own experiences and help me translate them into a medical culture. This proved less obvious and more difficult then I had hoped. With the exception of some aspects of psychiatric training and Balint groups,¹⁶ I did not see much explicit attention to the self of the practitioner.

Imperceptibly, meditation has become a habit. Like brushing my teeth each morning, the day feels incomplete without it. It is a habit of practicing presence, just presence—no more, no less. It has been years since I have attended an intensive meditation retreat. For me now, it is a solitary, quiet endeavor. In fact, only some of my friends and a few of my colleagues know about my daily practice. Like many habits, it seems perfectly ordinary. I had always considered it part of my private life. I do have some trepidation about going public, though, in that I do not want to promote one method, especially one that may have religious connotations for some. Nor do I consider myself an expert or a teacher of meditation. There are many other quiet meditators in medicine—I am far from alone.

MINDFULNESS

Mindfulness means paying attention, on purpose, to one's own thoughts, feelings, and judgments¹⁷—“observing the observer, observing the observed.”¹⁸ Buddhist meditation is the practice of mindfulness and requires only the belief that knowing oneself can foster compassion.¹⁹ There is no other requirement, including adherence to any particular cosmology; many people practice meditation and continue to observe Judaism, Christianity, or Islam.

The simplest mindfulness practice involves finding a place free from distractions. With eyes either closed or partially open (depending on the tradition) while in an upright sitting posture, the practitioner pays attention to thoughts and feelings as they arise without trying to change, judge, or categorize them. Some traditions use the breath to focus attention, others use imagery, and some use nothing at all. Buddhist teachers call this “just sitting.”^17,19,20

Rather than a practice of well-being, I prefer to call mindfulness a practice of “just being.” That is, as soon as another purpose is assigned (feeling good, lowering blood pressure, and so on), it somehow limits the process. I have to practice just being because it does not come naturally, and my efforts are always imperfect. There are also difficult moments, when insights are neither pretty nor desired. At those moments, and others, a teacher and a community of others involved in similar activities can be very helpful to provide insight, support, and encouragement.

Meditation is visceral learning and feedback. The visceral lessons are transferable to clinical and teaching settings. My habit of pausing before I enter a patient's room is a momentary state of repose and stillness, usually invisible to others. I give myself the gift of being present with myself while trying to give my patients my attentive presence. I often experience moments of quiet in the midst of action. By allowing me to be more present and less distracted, I believe these moments contribute both to the patient's feelings of having been heard, as well as to my own feelings of satisfaction at the end of the day. These moments also contribute to creative thought and writing. In administrative meetings, mindful practice is more difficult for me to achieve. Perhaps it is because the purpose of such meetings is not always to foster healing, satisfaction, or presence. But I do believe that it is possible and especially necessary to cultivate mindfulness in such settings.

Table 1.

Organizations that offer instruction in mindfulness, meditation, well being, and self-care
The Center for Mindfulness in Medicine University of Massachusetts Phone: (508)856-2656; www.umassed.edu\cfm
Offers programs for professionals, patients, and the lay public
The Omega Institute Rhinebeck, NY Phone: (845) 266-4444; www.eomega.org
Offers seminars, workshops, and intensive courses for health professionals and the lay public
The National Association for the Clinical Application of Behavioral Medicine Mansfield Center, CT Phone: (860) 456-1153; www.nicabm.com
Offers conferences several times per year that include lectures and workshops
The San Francisco Zen Center San Francisco, CA Phone: (415) 863-3136; www.sfzc.com
Provides opportunities for training in meditation and is engaged in community and healthcare projects
Insight Meditation Society Barre, MA Phone (978) 355-4378; www.iharma.org
Offers training and retreats in Vipassana Buddhist meditation
John Christensen, PhD Portland, OR Phone: (503) 413-7544; christej@ohsu.edu and
Penny Williamson, ScD Baltimore, MD Phone: (410) 235-0344
Offer workshops to enhance physician effectiveness and well-being

MUSIC

Musical practice has had a different influence. Because I trained first as a musician, then later as a physician. I was surprised in my otherwise excellent medical education by a striking lack of attention to the self of the practitioner. In contrast, in music study, which can be as theoretically and technically complex as any medical specialty, the self of the performer is an object of constant study and reflection. While the performer must experience inner stillness, the music must move and speak to a listener. There is little room for error; even the inattentive mind catches wrong notes. Music requires observation-in-action and the ability to hear the sound—in one's mind—before it is produced. The performer's presence creates a relationship with the listener. In that way, musical performance is a bit more like being with patients, and meditation is more like the silences in between.

BEING WELL

There are many ways for health professionals to enhance well-being, to reflect, and to be mindful. A recent study indicates that mindfulness meditation training for medical students improved their psychological and spiritual well-being and also improved their capacity for empathy.²¹ Meditation is not for everybody, however, nor is studying music. The Greeks advocated that music study be balanced with gymnastics. They felt that too much music softens the soul and too much wrestling hardens it. This seems like good advice, not only because of the medical benefits of exercise, but because it is useful to develop mindful practice in more than one sphere of life. There are many other means to become more present, reflective, and caring. These include keeping a journal, exercising, creating art, spending time in nature, and gardening.

What will it take for medicine to become a more reflective, mindful practice? In my view, more important than developing reflection groups in medical school and residency will be the collective work of individuals who are willing to let themselves be known. The commitment to develop and use self-knowledge may be as important in promoting self-caring and compassion as the insights gained. I am impressed by the number of physicians who do practice mindfully, but do so in isolation. Perhaps they feel that to reveal their inner lives would threaten their credibility as professionals. Mindfulness underlies all efforts to be with, to know, and to care. We have something to learn from musicians in that regard, for whom public demonstration and performance of a mindful activity is at the core of their profession.

Figure 1.

A peaceful place helps mindfulness practice…© Hank Christensen