The ongoing COVID crisis in the U.S. has highlighted our broken heath care system. And with it, has come an opportunity to begin to fix the system. Some touted mindfulness as a panacea pre-COVID – suggesting that if clinicians reframed the situations around them, they could better cope and continue. This backward argument echoes the idea that clinicians should redouble their resilience rather than address the core drivers of their distress. But perhaps there is a role for mindfulness.
What would happen if clinicians flipped the script on mindfulness, and instead of using it to tolerate a broken system, used it to sharpen awareness of the challenges? Like mindfulness jujitsu, clinicians could use the training being offered by many institutions not to accept the status quo but to fix it. Sharpening the ability to be present to better recognize moral injury, identify its drivers embedded in the corporate framework of healthcare, and to advocate powerfully for change.
Both authors use mindfulness. One (WD) since medical school at the University of Massachusetts, when Jon Kabat Zinn was first advocating for the practice in clinicians; the other (ST) since an early career recommendation from a coach. Both authors see mindfulness as an essential technique in high-tempo, high-stress settings for self-management, and emotion regulation. It is a remarkably useful tool for being in the moment and present for our patients, our colleagues, and our families. It allows those who practice it to deftly step aside from the intensity of a moment, to develop fuller awareness of the challenges in situations, and to appreciate others’ perspectives. It allows one the mental “space” to find alternate approaches to a situation, and the opportunity to deliberately choose one’s response from a variety of options rather than simply reacting with a triggered emotion. It is a practice of self-regulatory awareness and flexibility.
But we are critical of how it is being used with clinicians presently. Hettie O’Brien described the use of mindfulness to discount the very real concerns of tenants being forcibly displaced from their homes, suggesting the approach was privatizing a social problem. Ronald Purser has written and spoken about the perversion of mindfulness in the corporate world, too. Both perspectives are applicable to medicine. Mindfulness programs have been implemented by many healthcare facilities as a low-cost, easily implemented solution to clinician distress. However, it shifts responsibility for resolving the distress from the organization to the individual, and it fails to address the underlying causes. The unspoken message is that mindfulness will lessen distress by offering a path to acceptance. Acceptance then leads to wellness and happiness. But the beauty of mindfulness is in accepting a stream of thoughts without judgment, not in accepting situations as fated and undeserving of change. And this nuance makes all the difference.
Right now in medicine, our days are crisscrossed with challenging situations resulting from how the corporate framework of care is engineered. But many stakeholders have vested interests in perpetuating the belief that the healthcare landscape is inherently treacherous, and individuals are simply maladapted to its rough terrain. This approach is inaccurate—in fact, physicians are acknowledged to be significantly more resilient than the general public—and it does not serve the clinicians on the front lines of care. It is time to reject the notion that mindful acceptance is the cure. We can do better than accepting the status quo – we can change it.
Instead of using mindfulness techniques as treatment, we can and should use them as a diagnostic tool for the systems issues causing our distress. We can use mindfulness to notice the moments when we feel caught in double binds, wanting to take the best care of our patients but stymied in some way by the corporatization of care. Those isolated moments, if consistently attended to, will coalesce into patterns of distress. The most frequent or most disruptive drivers of distress will become clearer: constant prior authorizations; inaccessibility of colleagues for questions or quick consultations; narrow networks; narrower formularies; electronic medical records that distract during patient encounters; poorly interpreted patient satisfaction surveys; constantly trying to be in two places at once; too little time with patients; understaffing, or something else entirely. Each institution has a unique set of drivers, depending on its corporate structure and culture. But whatever the unique challenge is, we can use mindful attention to learn the patterns well, and to understand why that particular challenge is most problematic.
When the most pressing challenge is clear, focus on a solution. First, find allies. Pay attention—again, being mindful—to who else is having the same problems. Who knows how this sector of the system is designed? Who has the responsibility for making sure this part of care runs well? How are incentives structured to perpetuate the pattern, and who has a vested interest in those incentives?
Secondly, become the informal expert in that problem. Learn what regulation, legislation, or policy drives the requirements, what healthcare sectors it impacts, how finances are structured around it, and when and how the internal framework supporting the problematic pattern was established. Gather all of the publicly available information about the challenge. Just ten minutes of exploring each day mean 60 hours committed to the problem by the end of a year. That is a substantial amount of wisdom.
Finally, implementing change is more successful if there is a clear, well-communicated vision for the desired end state, and a comprehensive action plan backed by an energized coalition. Each of these can be scaled to the size of the change. Changing a department policy might involve three months of effort and a handful of supporters, but would still benefit from a deliberate, organized approach.
Mindfulness is a useful technique to optimize performance in high stress, hard-charging environments, but on its own, the practice is insufficient to address moral injury or burnout. Rather than deploying mindfulness as a solution, it is more effective to use mindfulness practice as a diagnostic tool to identify the drivers of distress in medicine and to inform potential changes. Let’s approach mindfulness like Picasso: “Learn the rules like a pro, so you can break them like an artist.”
Wendy Dean is a psychiatrist. Simon G. Talbot is a plastic surgeon. They are founders, Moral Injury of Healthcare.
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