Wednesday, January 26, 2011

Deviant Skill: Mindful Practice Part 2


In the last post, we covered the types of knowledge relevant to clinical practice. Now, we're going to delve into exactly what mindful practice entails.

Mindfulness is an extension of reflection. Mindful practice involves being mentally aware of action, thoughts, sensations, images, and emotions.

A quote from the cited article that explains the theory of the practice so well:

"mindfulness leads the mind back from theories, attitudes, and abstractions. . .to the situation of experience itself, which prevents us from falling prey to our own prejudices, opinions, projections, expectations and enables us to free ourselves from the straightjacket of unconsciousness."

Wow, deep stuff! I love the mental image of the straightjacket of the unconsciousness. Mindful practice may derive from a philosophical basis but in practice is just active reflection on mental processes.

The goal then is to become aware of your mental processes. To do this you must:

-Listen more attentively

-Become more flexible

-Recognize bias and judgement

-Act with principles and compassion

-Have curiosity about the unknown

-Be humble about the imperfect understanding of another's suffering

Consider the following: a resident is having difficulty with an intubation that you are supervising. What options does he have? He has to weigh the humiliation of admitted incompetence, the loss of self esteem related to said admission, and the pride of knowing when to ask for help. If he isn't a student of mindful practice then he will learn little and will probably blame himself or the patient for his failure. If instead, he is mindful, he will reflect on the factors that influenced his failure, such as technique, patient factors, choice of position, choice of tools, etc, and will be mentally and technically ready for the next intubation.

Mindlessness, on the other hand, is responsible for many of the negative deviations in clinical practice. This behavior seems to pervade the more emotionally involved or high pressure situations. In emergency medicine, this may be due to attempts at efficient flow, feeling of being overwhelmed, or a desire to avoid admitting incompetence.

There are a variety of ways to become mindful.

-Keep a journal of reflection

-Practice meditation

-Review videotapes of sessions of yourself with patients

-Create personal learning contracts when deficiencies are discovered

-Evaluations, both self and peer created

-Critical incident reports after an error

Ultimately, becoming mindful takes time and practice which is why it is probably viewed as an expert skill. As educators, we can begin to teach these skills. We can ask our students questions to make the unconscious conscious. How do feel about this patient? What are you uncertain about in this case? How will address your feelings of revulsion about this particular case?

Barriers to mindfulness are many. In emergency medicine, we are victims of mental and physical fatigue, pressure to do more with less, patient anger and unreasonable expectations, and more. All of these can lead to close mindedness and resentment of practice.

As you can see, becoming a mindful practitioner is within reach of all of us. Despite the many challenges, simple awareness and practice of this skill will lead you toward better patient care and becoming the ultimate "positive deviant."

As mindful practice is easier with guidance, has anyone out there practiced this in any form? I would love to hear insights from active practitioners who could provide tips and tricks to accelerate learning these skills. Leave a comment!

Epstein RM. Mindful Practice. JAMA. 1999 Sep 1; 282(9): 833-9. PMID: 1047868


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