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living in the moment (Korones / JCO novembre 2010) [19/12/2010]

Living in the Moment

David N. Korones

From the University of Rochester,
Rochester, NY.

Corresponding author: David N.
Korones, MD, University of Rochester
Medical Center, 601 Elmwood Ave,
Box 777, Rochester, NY 14642; e-mail:
© 2010 by American Society of Clinical
DOI: 10.1200/JCO.2010.30.7835

As an oncologist and palliative care physician, I was
vaguely aware of the concept of mindfulness, “the
quality of being fully present and attentive in the
moment during everyday activities.Originally a
Buddhist practice, its purpose was “to alleviate suffering
and cultivate compassion. Hence, it is not
surprising that this discipline might have application
in medicine for our patients as well as ourselves.
Mindfulness techniques appear to be effective in
helping patients cope with pain, disability, and
stress, and, similarly,mayreduce stress in health care
providers and enhance their ability to care for their
patients. Physicians and patients can learn mindfulness
techniques in a series of sessions devoted to
gaining an understanding of this discipline and how
to practice it. But until recently, whenever I heard
the word, “mindfulness,” and heard others extol its
virtues, I did not really understand what it meant, or
what relevance it had to me or the work I do
. In fact,
the whole concept of mindfulness confused me,
even intimidated me. It just seemed sort of “out
there,” abstract, even a bit weird.
Then a few years ago, at my medical school at
the University of Rochester, I was asked if I would be
interested in teaching mindfulness to our residents. I
am not certain why I was asked; perhaps it was because
I am a relatively senior clinician, perhaps because
I practice oncology and palliative care, or
perhaps because they took one look at me and felt
that I could use a good dose of mindfulness. They
went on to explain that if I was interested, I would be
required to take a course in mindfulness-based
stress reduction to get a better sense of what it was
all about, and be able to more effectively teach
the residents.
I am not sure why I signed up, but I did. I told
myself (and others) that I was doing it not for myself,
not to helpmewith the stress ofmywork, but rather,
so I could qualify to teach the concept to others. But,
in retrospect, I do not think it would take a rocket
scientist or a psychiatrist’s in-depth probing to find
that I was doing this because I was stressed, and this
was my own obtuse way of reaching out for help.
So with considerable trepidation, I signed up,
and when I rushed across town from a particularly
intense day of work and walked intomyfirst evening
class, I was not at all sure what I was getting myself
into. There was our instructor (a physician himself)
sitting cross-legged, barefoot, in jeans, ringing a
gentle-sounding, high-pitched gong to get our attention.
I remember thinking, “Oh, my God, get me
out of here!” But I stayed and listened to the 20 or so
people from various walks of health care explain
why they were there. They were good people, and
like me, they felt that the weight of their work was
sometimes so crushing it could interfere with their
ability to do that work effectively, and live their
lives well.
The next thing I knew, I, too, was sitting crosslegged,
listening to the ring of the bell, closing my
eyes, quieting my beleaguered brain, and just being
there. And as the weeks rolled by, and I would rush
over to class after hectic days of work, and sit, eyes
closed, legs crossed, I began to feel this wave of
something that is hard to explain: a sort of combination
of relaxation, relief, rest, rejuvenation, a
feeling of being unfettered, uncluttered. It felt
good. This class that I had so dreaded gradually
grew to be one I cherished.
But other than serving as the spiritual equivalent
to a good glass of wine (which also works quite
well), how has mindfulness helped me on a day-today
basis with my patients, with coping with my
work and with my life? While there are many intangible
ways, I can think of three very specific ways it
has made a difference.
Focus. I will never forget the time, about 20
years ago, that I brought my son to the pediatrician
for a regular well-child visit. As is so often the case for
pediatricians’ offices, the place was a zoo; a lot of
noise, bedlam, and utter chaos. I rememberhowour
pediatrician found us in the waiting room, ushered
us back to an examination room, closed the door,
and the noise and the chaos quickly fell away. I will
never forget how focused he was onmyboy; I would
guess that he did not spend more than 5 minutes
with us, but it seemed like all the time in the world.
In retrospect, I think my pediatrician was practicing
mindfulness. We might not have called it that at the
time, but I believe that is what it was. He was so
focused, so free of distraction, so totally in the
present. I walked out of that office feeling good
about my son and the care he received; all my questions
had been answered and all issues addressed.

Mindfulness techniques have helped me bring some of this focus
to my patients. Just as in class, when we are taught to focus on our
breathing, and when our minds wander to bring it back to the breathing,
so, too, with my patients, when my mind wanders to the person I
just saw, or the particularly challenging one whom I will see next, I try
to reel it back in to the person who is right in front of me. My practice
of this is not perfect and it does not work all the time, but my sense is
that my patients appreciate this focus.
Time.  A second way mindfulness has helped is awareness of time.
I am sure that all busy clinicians struggle daily with the constant
tension of trying to find a balance between giving our patients all the
time they need, and at the same time, not keeping a waiting room full
of people sitting for hours. In a desperate attempt to remain on
schedule, I used to constantly steal a glimpse at the clock on the
computer in the examination room, or subtly tug atmysleeve and take
a quick look atmywatch. It was not that I wanted the time to go by, but
simply that I needed to know what time it was, so I could pace
myself for the rest of the visit. In retrospect, I think that every time
I did that, I would lose a little focus, and I suspect my patients would
attest that my glimpses were not so subtle as I imagined. Now I do not
do that any more (or, at least, not as often). I think we all have a better
sense of time than we credit ourselves as having. I find that if I keepmy
focus on my patient and the tasks we need to accomplish in the time
allotted to us, the time will usually take care of itself.
Getting away. This last is a more personal aspect of mindfulness:
getting away. It used to be that when I went on vacation for a week, I
would spend the first 2 or 3 days coming down, and then a few days
before the vacation’s end, “patient care stuff” would trickle into my
consciousness. By a day or two before my return, that trickle would
become a torrent, and by the time I returned home, I was already
anxious again. Now, for reasons I think are related to mindfulness
(although I cannot say this for sure), as soon as I hit the road, as soon
as the wheels of that plane lift up off the runway, Iamout of here! Iam
disconnected from the Web, the cell phone, the e-mails, the text
messages and the electronic laboratory reports, notes, and images.
I am on the road, I am on vacation, I am not in the hospital; I am
where I am.
I must confess that I still do not completely understand mindfulness.
It is somewhat heavy and abstract, and for someone like myself,
who considers himself forever mired in the stage of concrete operations,
that can be a challenge. But there are things about mindfulness
that I now better understand and appreciate. I understand that mindfulness
is, quite simply, a way of being present for my patients and for
myself. I also understand that mindfulness is a discipline. It is a way of
thinking (or perhaps more accurately, a way of being), and, like any
discipline or new approach, it requires training and ongoing practice.
It is not as simple as a sip of wine in the evening, which may serve to
dissipate the tension that has built during the day. It is better; it is a
disciplined, practiced approach that enables us to deal with tension as
it arises.
And now, armed with this better understanding of mindfulness,
I try to incorporate it into my practice and into my own life. I also try
to impart its value to our trainees, whoseownstressesmaybe different,
but are considerable. I explain to them my initial skepticism, and how
even though on the surface, it might seem that it is just one more thing
they have to do, it may help them cope with all those other things that
overwhelm them. Somehow, as I tell them, it works. It helps me keep
the focus on my patients, it helps keep the satisfaction in my work, it
helps me to rejuvenate, and it keeps me sane.

1. Krasner MS, Epstein RM, Beckman H, et al: Association of an educational
program in mindful communication with burnout, empathy, and attitudes among
primary care physicians. JAMA 302:1284-1293, 2009
2. Ludwig DS, Kabat-Zinn J: Mindfulness in medicine. JAMA 300:1350-1352,
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The Art of Oncology

::::::    Creato il : 19/12/2010 da Magarotto Roberto    ::::::    modificato il : 19/12/2010 da Magarotto Roberto    ::::::