Latest / Off the Chart: A Business of Medicine Podcast / S1 Ep121: Attending to patients and ourselves, with Melissa Lucarelli, M.D., FAAFP, and Ronald M. Epstein, M.D., FAAHPM
Transcript
- 0:00 When you ask patients what they really want in a visit with a doctor, uniformly, the thing that rises to the top is to feel understood and to understand so they're really looking for a relationship as well as as well as a prescription. You 0:20 Austin, welcome to off the chart of this 0:23 is a medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Luttrell. I'm the associate editor of medical economics, and I'd like to thank you for joining us today before we get started with quick note, physicians practice will be hosting a practice Academy event on March 19. The practice management track is a virtual learning experience designed for physicians and practice administrators who want to build stronger, more efficient and more resilient practices focused on real world, practical strategies that you can apply right away from optimizing operations to adapting to an evolving healthcare landscape. You can register now by clicking the link in the show notes or by visiting registration.physicianspractice.com, 1:03 but in today's episode, Dr Melissa Lucarelli, a family physician and owner of Randolph Community Clinic in rural Wisconsin and longtime editorial advisor for medical economics, sat down with Dr Ronald Epstein, a professor of family medicine and palliative care at the University of Rochester, and the author of attending medicine mindfulness and humanity. Their conversation explores how mindfulness shows up in real clinical practice, not as another task to add to an already full to do list, but as a way of paying closer attention, communicating more clearly and staying grounded in the exam room. Epstein reflects on physician burnout, presence, curiosity in beginner's mind, and how small moments of awareness can shape patient care, teamwork and professional satisfaction. So Dr Lucarelli, thank you so much for leading the conversation. Dr Epstein, thank you for joining us. Take it away. Dr Lucarelli, 1:53 every day across the United States, physicians do their best to lead teams of clinicians who care for patients, but physician burnout remains at troubling levels. Patients are dissatisfied with the health care system, and this frustration adds to the ill health of our nation. Could mindfulness be the cure? 2:12 I'm Dr Melissa Lucarelli, a family physician, clinic owner and editorial advisor to medical Economics. Today we'll discuss these issues with Dr Ronald Epstein, professor of family medicine and palliative care at the University of Rochester, his JAMA article, mindful practice was a landmark in 1999 2:30 and he's the author of attending medicine, mindfulness and humanity, currently available in paperback and written for a physician audience, about how patient treatment depends on physician perception and communication. Dr Epstein, thank you for joining us today. A pleasure to be here with you. I am so honored to be able to speak with you because I'm a big fan of your book, whose title attending evokes both the role of an attending physician as well as the practice of being present and paying attention. It's one of those inspirational books with which I have to keep re buying, because I've given them so many copies away to friends and colleagues. So for those who are unfamiliar, would you please describe what your book calls the four foundations of mindfulness, attention, curiosity, beginner's mind and presence? Yeah, so attention refers to how we can actually regulate what we pay attention to and how we pay attention. And in the book, and I can give some examples as we talk, 3:30 we're trained to pay attention to certain things and not to others. And also sometimes we're more open to surprise than other times. And often it's in those lapses of attention, that errors happen, and also misunderstandings happen 3:45 when you ask patients what they really want in a visit with a doctor, uniformly, the thing that rises to the top is to feel understood and to understand, and then secondarily, to get a treatment that will help them with their condition. So they're really looking for a relationship as well as as well as a prescription. And so attention to that, to those two aspects of medicine is particularly important. Curiosity is an important ingredient in paying attention and being present. Because if you're really not interested in what you're doing, and the patient who's in front of them, in front of you, the patient will know that they'll kind of get a sense that you're just phoning it in. 4:25 Curiosity drives good medical judgment, asking yourself a question of, well, what am I assuming about this person or this situation? That might not be true. 4:35 That's a curiosity kind of question that really opens the door to considering other possibilities. I was in primary care practice for 35 years, and I had some of the same patients for 35 years with some of the same complaints for 35 years. And this sounds familiar, I'm sure, 4:53 and so I had to find a way of remaining interested in that person with diabetes. You know, I had a lot of. 5:00 People with diabetes in my practice, but none of them were really the same, right? They all had their own quirks, their own individual circumstances, and somehow developing a curiosity about what you know, what their life is like, and how going to the grocery store is for them, as opposed to, for me, going to the grocery store 5:20 beginner's mind is a concept that's borrowed from a Zen teacher named Shimura Suzuki and and the idea here is that our expertise is liberating as well as constraining. I'll just give you an example. When I was doing my dermatology rotation in medical school, I was taking public transport in Boston, and I stopped seeing people's faces. All I saw were zits and bowls and and rashes and and, you know, I found myself worrying, you know, like, let's say I thought saw something I was sure was a melanoma. You know, what would I do? But, but it's really this difference in perception that we develop as and, and so other things can just fly right past us, because it's really not part of the fee our professional field of vision. Michelle Foucault calls it the clinical gaze. We 6:15 and it's and, and then presence is really the hardest thing to define, but we all know when it's there and when it isn't. Just think about, you know, 6:25 think about how you feel present during a movie or a play or a musical performance, and how you can tell, especially if it's something that's live, how you can tell that person is really present there and with you. And I think all of us who have been Ill remember these moments of presence, and they really are, if you have time, I'll just give you a very brief example. I was in the emergency room with abdominal pain several years ago, and the doctors did everything correctly, all the right tests, all the you know, and and the information they gave me was correct. But the one moment that I remember that kind of made me feel like I was in good hands was the transport guy who was taking me from the emergency room to the CT scanner. 7:13 And he stopped at one point during this long trajectory down the labyrinth 7:18 and just looked me in the eye and said, How are you doing? And that suddenly I felt myself relax. I just, I just, it kind of changed the whole tenor of the of the encounter. I never knew his name, 7:33 but I can see his face clearly now. And it's, you know, it's maybe 10 years ago that this happened. So, so those kinds of things are really important. With screens, with computer screens being present is a bit more challenging. So how do you navigate that relationship? So those things, they're very pragmatic and and so we can talk more about each of them as we go along. 7:58 In your book, you describe your experience as a young physician noticing differences in how doctors operate, literally in surgery, as well as various examples of physicians unintentionally overlooking important medical details without betraying any patient confidentiality. Would you describe one of these examples for us and perhaps share some of your own mindfulness breakthroughs that led to better patient care during your years of medical practice. Great. Yeah. I mean, I towards the beginning of my book, I recount the stories, but it really sits with me still, because it was an incredible learning experience for me. I was a medical student, a third year student on my surgery rotation, and this was an open procedure. They didn't have robots back then, and it was a retroperitoneal lymph node dissection for a young adult with with a secure cancer. And they did that in order to stage the disease. And 8:56 he the surgeon, first dissected around one kidney, then switched sides of the table to table to dissect the other kidney. And so I was standing across the table from the surgeon, looking right at the kidney he had just worked on, and I noticed it was beginning to turn blue. And as a medical student, I didn't know very much, but I generally knew that pink was good and blue is bad. So so I tried to mention this to the surgeon, and I broke this Cardinal. I was first of all getting really anxious, because you're not supposed to speak unless spoken to in the operating room. I mean, that was, I think things have loosened up a little bit since then, but that was kind of an unspoken rule and but I did, and I said, you know, I think there's something going on here. I think, you know, the kidneys looking blue, and the surgeon basically ignored me, and kind of said something like, you know, shut up kid, or as the equivalent, and and then after a while, I noticed the kidney was beginning to turn a dusky purple, and I was the person who had the best view of it. So I mentioned it to the nurse who was standing next to me, who mentioned it to the resident who was standing next to the surgeon, who mentioned. 10:00 The surgeon. At that moment, the surgeon panicked. He tried to untwist the kidney the blood supply had gotten, got cut off, unsuccessful. Had to call in a vascular surgeon, and it took a while, actually, to restore blood flow and 10:14 and I know a few days later, this young adult's kidney function was not quite normal, so, but it was really interesting to me, because I was on rounds the next day with the surgeon, and he said an unavoidable, unavoidable problem occurred in the operating room. And so the kidney getting twisted may have been unavoidable, but his lack of attention and the subsequent delay in acting wasn't. And so, you know, I think it, and this was a very reputable surgeon at a major Boston hospital, teaching hospital, and and I just realized any of us could fall into that trap. 10:56 Just another quick example we had on our service, someone with a very rare and interesting disease because the genetic basis of it was known, and this was the 1980s and not much was known about genetics. It was hairy cell leukemia, which is now better understood, but and everyone was so fascinated with this fascinoma that they failed to see that there was this woman lying alone in the bed, never having visitors, and in pain, 11:26 right? So that completely went by them. And I said, you know, well, on rounds, I said, Well, what about a little bit of, you know, pain medication for her and and they, you know, very happily did that. But it was stunning to me how they saw the disease and didn't see the person. 11:43 So I could go on and on about this, so that 11:47 I think the 11:49 awakening for me there, there's one event that 11:54 stands I had a patient who I'd been caring for for more than 10 years, and knew him. Really liked each other. We shared a lot of interests, and 12:04 he came into the office one day and said, You know, it's kind of hard to say, but ever since you got this new computer system, I mean, I really like you as a doctor, and part of what I like is that you're a really good listener, but ever since you got this new computer system, I just kind of feel like you haven't been listening in the same way, and thought I should tell you. And, and my first feeling was kind of this sense of someone's kind of stabbing me through the heart. Because my professional identity is, I teach communication skills and, and this, this kind of mindless lapse is it was just and then I was just like, suddenly really grateful, because he actually pointed out something that was really true. And so my fix in that moment was to say, Okay, I'm going to try this little experiment for the first minute or minute and a half of every visit. I'm not going to turn on the computer. I'm not going to do anything but look this person in the eye and just listen to what they have to say, and, you know, interrupt if I need to after a minute or so, but 13:07 and I discovered several things. One is that I actually remembered what patients said better. The second is that 13:15 the visits were no longer, 13:17 and the third was I felt a lot better at the end of the day, I felt less. I felt it felt a sense of lightness, and like I was really doing the job I was supposed to be doing. And and that sense of gratitude, really, kind of, 13:31 I don't know, it kind of cut through a lot of the you know, for lack of a better word, crap that one has to do when, when, 13:39 when interacting with the healthcare system and everything else. So, so, so I continue doing that that's just became a became a habit. You just don't, I don't. 13:50 I think of it as a like a little mini rebellion, because we were taught, you know, in the E record training, that the first thing you do when you go into the room is you turn on the computer and you log in. And I thought, Wait a second. I can you know they're not going to send me to jail if I don't do that. So, and let's just see what happens. So for me, that was a mindfulness exercise, right? It was deciding to be present, attentive, curious, with a beginner's mind, and doing that intentionally, and that, for me, is the most important step, is that intention. Now I have kind of a confession to make. I first read your book when it was sent to me as a free gift from my malpractice insurance carrier. How do you think your book is relevant to medical risk management, and why did they send that to 14:41 me? Well, I can tell you a couple of things. One is that we do workshops for physicians either anything from half a day to three days, 14:50 and just helping them find ways of being more mindful in clinical practice. And our risk management department has arranged that for anyone taking one of these workshops. 15:00 Ops of three hours or more, they get a 15% discount on their medical malpractice. That could be quite substantial, right. 15:08 And the reason they're doing that is the the 15:12 argument is, is that if physicians are more present, if they communicate better, 15:18 even if errors do occur, they're less likely to get sued and they're less likely to get sued for as much. And there's some good data on looking through malpractice claims. Colleague of mine, Howie Beckman, did that a number of years ago, and embedded in almost all of the complaints is a failure of communication. 15:37 And so errors happen all the time in medicine, and only a very small part, small percentage of them ever end up in court and so, or even with a complaint. And so improving that level of attentiveness, presence and communication is really foundational. 15:55 That does make sense? Yeah, there's a lot of time pressure on practicing physicians as we do our work in the clinic or in the hospital, and yet you describe circumstances in which just a few seconds of preparation or awareness might lead to better patient care now and save time later. How do you respond when someone suggests that increased mindfulness requires hours of meditation every day, or that it sounds like yet another thing on their to do list? I think it's possible to develop some pretty simple practices that take virtually no time in your practice, if you're willing to. I mean learning anything new, first of all, feels awkward, and second of all, there's a learning curve. So one thing that I suggest people just try out is pausing for a moment when you touch the doorknob or door handle, when you're going from one patient encounter to another, whether in the hospital or in an outpatient setting, and when you do that in that pause, just take a breath and then imagine what it is that you want to carry into that room and what you want to leave outside. So as a family doctor, I could, in a typical day, see an 80 year old with advanced lung cancer as one patient, and the next patient could be a healthy six month old coming in for a well child check. No, I don't want to, I don't want to bring in that, 17:22 that 80 year old. I don't want to carry that person, that and that mood and that, 17:29 that that event, with me. So I kind of imagine there's a little shelf outside every room, and I just kind of put that, the 80 year old and his problems on that little shelf. I can come back and retrieve it, right? And if I and I do, because when I write my notes, but just that little mental exercise of saying what, what do I need to be, what do I need to bring with me to this next encounter? 17:54 During the dark days of covid, I was on the palliative care service at a time when relatives couldn't visit their or people who could not visit their dying relatives in the hospital 18:07 and relied on Zoom calls that, you know, I mean, it was, it was awful. The halls were empty. It was incredibly bleak. So just as a way to, I guess, maybe maintain my sanity and able to be attentive in this kind of circumstance, I just decided that every day there would be one moment of exquisite beauty, and I never knew when that moment would happen. And I'm not pollyannish, I don't I don't think everything's beautiful and all that, but there always is one moment. It could be someone's face, a smile. Could be a flower. It could be the snowstorm outside. 18:46 It could be anything and but just knowing that that moment would happen somehow shifted the way that I paid attention to the world. 18:57 So when I when I do longer workshops to help clinicians be more mindful. We just talk about these little things. When you wash your hands, you know, surgeons wash their hands. What I asked them, what they think about, you know, what's going through their mind? And some say that it's actually incredibly relaxing. It's just, they just are there in the present moment. Some kind of mentally go through the operation that's going to happen. 19:24 There are some surgeons that 19:27 there's a video of a surgical, a neurosurgical group in New York, that have intentional, mindful moments in the beginning of an operation, you know, they first make sure there's the right patient and the right side and the right limb and the right you know, and all of that stuff. They've got the right equipment, and then they just have a mindful moment and just ask to imagine that this person lying, maybe now unconscious on the gurney in the operating room, 19:54 just just to take a moment to take in that this is a human being. 19:58 That's it, and that. 20:00 Mindful moment lasts for maybe 30 seconds. It seems like a very long 30 seconds, but it's a way of bringing a team together around common purpose and really setting the stage for paying attention to one another. 20:14 I actually apply your strategy every day now pausing at the patient's door to clear my mind. I actually read your book during covid, and in 2020 there were all kinds of things, you know, going on a million a million thoughts all the time. But when I was seeing a patient, I and I still do this. I'll stop for a moment, and I just try to just be blank and think I'm entering into 20:39 be with this person. And then it really has made a difference. It's really helped as far as 20:45 the connectedness, feeling connected to the person as I'm walking in I, you know, we were taught to shake hands or touch the person, so I always do that and naturally, but, but I really feel like I'm there. I'm not thinking about now I need to type my computer. Now I need to do this other thing. I'm really I'm really there. So that was super helpful. I just wanted to thank you in person for that, because that's been a great strategy for me. 21:09 I guess I want to add to that 21:12 in the book, I talk a fair bit about meditation, because for me, that's something that's been quite helpful, and it's something that I did long before I went to medical school, so it was a tool that it kind of brought with me, and but I think that many of us enter that same state of mind in various other activities we might engage in. And so, you know, sitting on a cushion for some people is part of the answer, but other people really do have ways of of helping themselves, kind of be present and attentive. And I don't want to limit the idea of mindfulness to just having a meditation practice. Having said that we in workshops that we do, we often have people who've never done any kind of contemplative practice, 21:55 and they find that that even just a small introduction to that opens the door to possibility that one could observe oneself, one's own thoughts and feelings 22:08 during everyday work, not only just when they're doing some kind of meditation practice, so and especially when the emotional tone gets really high, when patients get angry with you, when something unexpected and bad happens. Just that ability to say yes, I'm angry, or yes I'm sad or yes, I'm upset, 22:30 and just observe how that is playing out with you without reacting immediately, sometimes produces a much more intelligent response to difficult situations. Mindfulness isn't just applicable to individual physicians in clinical care, right? You? You've done some training with inpatient teams or consultants, haven't you? Yeah? Yeah. Actually, one of the first ones we did with that with a with an intact team was a 23:01 transplant surgery group. And we had a workshop of about 40 people, ranging from, you know, anyone who actually sees a patient in their department. So the secretaries, the nursing staff, 23:14 the physician assistants, the surgeons, 23:17 um, 23:19 and it was just incredibly powerful, because they knew each other quite well, and kind of worked pretty well as a team, but just the idea that they could actually align and engage in what I what I call shared mind, that is a shared perspective on what's going on and understanding each other's role and thinking processes. 23:38 And so I think that and and then subsequently, I came across an article that was really interesting that looked at nursing units, and they did some kind of survey just that, assessing how mind field, how mindful people were, how observant and attentive, etc, and 23:58 the nursing units that scored higher as a collective on those mindfulness scales also had fewer patients who fell, had fewer medication errors, fewer needlestick injuries. 24:10 So this kind of collective vigilance, 24:15 this collective mindfulness, 24:19 I think, is really powerful, and it's an important ingredient. You know, when you think about clinical medicine, it's not like a Toyota car factory, right? You know, we're we, we produce things, if you will. You know, we have procedures and prescriptions. But it's also a relational 24:39 task. I mean, it's, we're actually relating to one another as humans, and that relational piece 24:47 is often not taught in medical training, and it's not necessarily valued when it comes to even 24:57 the way that physicians are evaluated. So. 25:00 So just thinking of those two elements of clinical care, the the 25:04 transactional, the task focused, and also the relational. 25:10 Switching gears here a bit, if I may, artificial intelligence seems to be on everyone's mind these days. In the book chapter being present, you wrote back in 2017 about people's sense of shared presence and bonding with video game avatars, and you said in the same way that they might connect with the psychotherapist. Well, now that we actually have aI chat bots acting as psychotherapists, how can we get how can we use that past research about presence and use that to inform our safer use of AI in mental health care, right? I would extend it beyond mental health care, but 25:48 first of all, I have to say parenthetically, these days, I'm much more concerned about human intelligence than artificial intelligence, but 26:00 I'm involved in a project that to train clinicians who take care of seriously ill patients how to communicate more effectively about things like prognosis, treatment choices, hospice, palliative care, uncertainty. I mean, these are kind of the big things, death and dying, 26:19 and to help them, help clinicians. This is a training program for clinicians, for 26:25 to help them help their patients navigate those difficult times more effectively. So to do that, we created an on screen avatar. The The prototype was named Sophie, and so this is someone you could have a conversation with on screen. She looked kind of humanoid, act a little acted a little bit robotic, 26:46 but was able to listen, if you will, to what you said, and respond more or less appropriately. And also, while you were doing this, was monitoring your own response, that is how fast the physician speaks, whether they use jargon words, whether they forget to address a concern that a patient has brought up, whether they use what we call hedge words, things that 27:13 make them make patients not understand what the doctor is quite saying. You know, maybe possibly this might be associated with such and such, the patient walks out of the office saying, What did the doctor say? And we also know that patients remember on a good day, about half of what we say to them, and the rest goes elsewhere. So so the the avatar is imperfect, 27:38 but the feedback that the avatar is able to give is stunning. It will say the patient is worried about diet, said they were dying, and you change the conversation here to talk about their cholesterol level 27:53 and, and I've heard this, I've heard this in real life because you know my research and, and it'll say, here are five ways you could have addressed their concern 28:03 and 28:06 or you used a lot of words that your reading level, your speech level, is at the level of a graduate student in one of the Biomedical Sciences, 28:16 and most patients, you have to tailor their reading level to maybe an eighth grade level. 28:24 And here are ways you could do that, and saying, you know, you use this, this word, 28:30 and these are other words that might have been more understandable. So the 28:37 so that after just a half an hour interaction with Sophie and getting feedback 28:44 positions performance with a human actor that we train to portray somewhat similar situation, improved substantially, whereas those who didn't have that online training. So so, you know, the area of AI that I'm involved in is really in education is using because standardized patients are expensive. They're hard to get. You know, once you finish medical school, they're not usually available. And here's a way that you can improve your communication skills. 29:13 It also can track your eye movements, see if you're looking where you're looking. I mean, there are all sorts of sophisticated things it can do and it, I think it's, in a peculiar way, a mindfulness tool, because it has you aware of stuff that you would otherwise completely be unaware of. You think, we all think we're clear. We all think we're explaining things clearly. 29:38 But this little bot can tell you, wait a second. No, you're not the key word. The most important word in your discussion was a word that most people don't understand. And 29:49 and so 29:52 now about 29:54 and I've seen studies where for like mechanical aspects of health care, like 29:59 in. 30:00 Know, where is the, where is the dialysis suite in the hospital? You know, it will give you really clear directions. How did which elevator to take, and how many yards to walk. And those directions will be better than human directions. But if you, 30:15 if, if you type into AI, I know, gee, I'm a 71 year old male with blood pressure of 120 over 70 and a HDL of 95 and an LDL of 66 should I be taking statins? There you get into trouble, because that that's a total gray zone. I picked that example because it's me and and it's right on the borderline of you know, I would be recommended for a lipid in the United States, but it wouldn't be recommended if I was in England or Canada or Switzerland or Norway. So, so it's kind of in this huge gray zone. This is a place where I don't think AI could really help you very much. I think you need to have 31:02 a shared conversation with a human who is willing to listen. Just last week, medical economics guest article, I think it was a blog argued that when the system is broken, no amount of mindfulness can fix it. That's a direct quote. Since you wrote about imagining a mindful healthcare system, would you? How would you respond, and particularly around the idea of organizational mindfulness? 31:29 Yeah, I, you know, and I would give slightly different answers now than I wrote. It's now. I actually wrote the book about 10 years ago. And so the landscape has changed, and also I've changed. 31:43 One thing is the role of leaders, and I had really underestimated that for most of my career, until I really started meeting with leaders and also seeing how they work and visiting a lot of different institutions around the world and and 32:00 if leaders are aligned to what really matters in medicine, then that can create an organizational culture that that would permit that kind of collective mindfulness to emerge. 32:13 However, if you're in a situation, I've been in situations where I've been asked to give a you know, keynote lecture in a health system that clearly is not only dysfunctional, but toxic, expecting that my whatever hour long talk would fix things, and it can't. I mean, it's just completely impossible. And 32:34 I think that organizational mindfulness, that if you think of an organization as an organism 32:40 with the same kind of capacities for self awareness and repair and self monitoring, 32:49 then you can really see how, how some organizations themselves are more mindful than others 32:56 and and I'm working very closely with some organizations that seem to be more on that more mindful spectrum, and what they can accomplish in terms of staff well being, I think is much more meaningful. I'm having a hard time picturing that. What do you mean by an organism? And maybe the jargon went over my head. I'm sorry. I'm sorry I don't mean to be oblique 33:23 that people within the organization are attentive to one another, that they're vigilant towards one another's behavior and their own, that they're willing to accept feedback that sometimes is and give feedback in a psychologically safe environment 33:42 that reduces defensiveness and actually promotes that there's a sufficient amount of autonomy and even anarchy, because we know that overly controlled systems tend to become rigid. So so we I call it informed flexibility, that the organization itself, the team, has some inherent flexibility, so that when circumstances change, that they can adapt readily. 34:12 And 34:14 some of the early work on organizational mindfulness was done by by people observing aircraft carriers where the risk level is extremely high, you know, the plane landing on an aircraft carrier is off by a few feet. That's disaster, right? And so they started observing what really, what really contributes to a mindful organization, and part of it is, is a preoccupation with failure, just knowing that anything, even if you've done it a million times, could fail, 34:46 a kind of attentive observation to oneself and one's team, 34:53 the ability to listen to people who don't have authority. So for example, if you want, if you're concerned. 35:00 Concerned about infection control in your institution, you might want to talk to the chief of infection control, but you also might want to talk to the people who sweep the floors 35:10 and and you might get a very, very different answer 35:15 from those two people. And so being being attentive to those processes, 35:22 there have been organization. Most organizations now have done burnout surveys, but I also see how they different organizations handle them. Some will do the surveys, and only the CEO will see the results and they'll be kept in a drawer somewhere. 35:37 Some they distribute the survey results to the department chairs. And of course, 35:43 once you do that, you have very little control about what each department chair does. One department chair might want to fire people who score high on the burnout level, and other department chairs might want to help them. And another way is to actually have a dialog with those people who actually filled out the surveys and asked them, saying, we're noticing that there are some areas of distress. Can you help us move forward with that? 36:12 There's a place for all of those, but I just observe those differences, and the organizations that seem to be healthier have access to 36:22 a richer way of handling clinician distress, but But having said that, if any if one clinician goes to one mindfulness workshop and returns to their health system that has 90,000 employees, it's not going to have a huge influence on the organization. 36:43 So when I when I'm invited to do workshops elsewhere, I'll often ask to meet with someone from the leadership to say, this is what I'm doing. And just want to know one thing from you, which is, if what I'm doing is successful, what change would you see in the organization? 37:01 And then I try to address that as directly as I can in what I can do, and also say, Well, I can do this piece, but this is another piece that the organization might have, might consider doing in order to have it really have a greater impact. During a recent medical economics panel, I brought up value based care as an alternative for independent practices like mine, who are struggling to remain viable in a fee for service market. What are your thoughts about productivity based compensation for medical care? 37:35 It depends what you mean by productivity. If you mean its throughput. That is how many patients you can see in a day. I guess that would be one metric. 37:47 If the ultimate product of healthcare is health, 37:52 then that raises a different set of questions. So for example, in some value based care systems, they might reward you for ordering hemoglobin a 1c levels more frequently, 38:05 either in people with or without diabetes. 38:08 But what I've seen, both locally as well as elsewhere, is that 38:14 people who perform well on that metric may not actually follow up on those a 1c levels, and may have patients whose diabetic control is no different than it was before that metric was in place. 38:27 So 38:29 now holding physicians individually accountable for someone's health 38:35 in some sense, is unfair, right? Because I can give advice to someone with diabetes, and they can go out and, you know, buy whatever they want in the grocery store. So some of that, I think, really, some of those metrics really need to be collective 38:53 and and really, and if 38:57 so, it's a complex answer, but I suspect that the throughput answer is not really going to generate health. In fact, I have no evidence that that will improve the health of the population, and perhaps there's some evidence that it might worsen it. If mindfulness is a skill that can be cultivated, what changes would you like to see in medical education, if you could change medical education in the US so that physicians don't lose that beginner's mind curiosity, I'll answer in several ways. One is, 39:32 apparently firefighters are taught two things when they're being trained. They're taught how to fight fires, and they're also taught how to survive a fire. 39:43 And in medical education, we're teaching doctors how to fight fires, but we're not teaching them how to survive a fire. 39:52 And so part of that survive a fire is being aware of danger, both danger coming from within yourself, as. 40:00 Well as danger from the outside. So danger from within yourself are your emotional reactions are, and 40:07 especially negative emotion unrecognized, negative emotion 40:12 being overly concrete, being too sure of oneself, arrogance. So there may be a number of factors within ourselves that are that are dangerous spots, and I believe that early recognition of those dangerous spots will make doctors happier and healthier. 40:32 My son used to work at Google, and the orientation at Google included 40:39 learning how to work in teams, recognizing when you need to be in a quiet place to do some some some thinking or work that you would do better alone. And it actually, they actually, I toured hit the place where he worked in Los Angeles, and they did have quiet spots, and they did have team spots where teams could talk with one another. 41:00 Now obviously the stakes are a little bit lower, but I will tell you, the onboarding process of almost all healthcare facilities I visited consists of days and days of of regulatory talk and training, doing electronic health records, and no attention to the physical or mental health of the workforce. 41:19 So that's something that really that's a leadership issue. 41:24 And you probably are well aware a stunning percentage of physicians in this country are over age 60, and those who are under age 60 are often talking about quitting before they get to 60. 41:37 And as that lack of attention to the health of the healthcare workforce that I think is going to become very expensive and also erode the quality of healthcare that we can provide. Several of the ideas in your book seem almost prescient to me now, such as you were talking about the advent of AI therapists and the concept of tribalism and mirror neurons on medical biases, but I thought you might be amused to learn that there's a 2025, best selling mystery thriller novel called secretive secrets, which uses the metaphysical idea of shared mind as a plot device. I think you'd be a great technical advisor if they decide to make it into a movie someday. 42:18 If you were updating your book attending today, what new ideas or research would you be most excited to add? 42:27 Yeah, so I think I mentioned leadership before. That's that's something that I think is really important, and also the sense of community. I think those two things. 42:37 I mean, going back to ancient times, people who practice meditation did not do it alone. Generally. They generally did it in groups and and it provides and it that's not just meditation, it's also medical practice, all these things that are really difficult people often do in groups. So, and we are 42:56 a social animal, and so just thinking about ways to promote team mindfulness, Team function. And so I probably 43:05 focus and in some of my more recent writings, there's a book that came out called distracted doctoring by a colleague of mine. I've got a chapter in there where I talk about mindful teams and mindful organizations. And so that's really my thinking is going is that medicine is not a bunch of individuals medicine as a social network. 43:24 And so how do we strengthen that social network? And 43:28 when I think about shared mind, I think about things like schools of fish or flocks of geese or ant hills or beehives, where, 43:39 where the individual creatures all have an individual intelligence, but in order to survive, they need some kind of collective intelligence in order to avoid predators. And I 43:49 mean, it's hard to know if an ant is happy or not, but, 43:54 but, but they survive. They need they. And I think as humans, we need that too. So there's the sense of collectivity is something I'd add. There's some really fascinating research done by Lisa Feldman Barrett on how emotions are made and and her thesis, which is really gaining a lot of traction, is that 44:15 we have kind of general feeling tones of feeling positive, feeling neutral, feeling negative. 44:22 But then we make choices as to how to name those, fear, anger, anxiety, what have you, because those are constructed by our own minds, that as our mind is a predictive organism, we try to predict what's going to happen in the future. 44:38 We hear a news report, and then we kind of make assumptions about how it's going to affect us, and then we generate some kind of anxiety. 44:48 And so what it means is that emotions aren't something that just happened to us. There are events that happen to us that then we construct as either helpful or. 45:00 Helpful emotions 45:02 and 45:03 just a personal experience. I've had a number of kidney stones, but the first one was by far the worst, because I didn't know what it was, right? So it was this anxiety about dying is the end of my life. They're very, very painful, 45:18 and subsequently, I'm sure the kidney stones were just as painful, but just this knowledge that I could navigate my way through these and it wasn't going to kill me. And so I just say, I just say that in the sense that 45:33 we we have more autonomy in terms of how we feel than often we lead ourselves to believe 45:43 real an extreme example of that is Viktor Frankl, who wrote about his experiences in concentration camps during the Second World War, but was still able to maintain some sense of self and sense of purpose. We're not all Viktor Frankl, but I think that we're all facing some pretty extraordinary stresses in healthcare. And, you know, have ideas about how some of those stresses might 46:07 be improved, but whatever improvement organizations make, those improvements will be slow and coming. I mean, it's hard. It's like, you know, it's trying to steer a cruise ship. And if you read Plato, actually, some 2500 years ago, wrote a bit about medical practice in one of his books, the laws, and he describes very well a burned out physician 46:31 and and also describes a physician who is really curious and attentive and present. And so 46:38 part of this 46:40 distress is intrinsic in the work we do. I mean, people, we didn't invent burnout, huh? No. And in fact, the earliest work on professional burnout in medicine was in the 1970s 46:53 when people were more worried about how Medicare was going to destroy medicine, even before the the era of managed care. So so I would say that 47:05 some of the burnout 47:08 is obviously systemic and needs to change, but there also is this residual that always is part of medical practice 47:16 and and that's we need to have some more intelligent way of 47:23 because it's very predictable. It's you know it we know it happens. 47:27 And we know it happens to many of us, probably most of us, at some point in our careers. 47:34 And so this needs to be part of medical education, medical culture and medical leadership. Wow. This has been a great conversation, and in the interest of time again, I'm Dr Melissa Lucarelli, an editorial advisor for medical economics, and my guest today has been Dr Ronald Epstein, a family physician, professor and the author of attending medicine, mindfulness and humanity. Dr Epstein, thank you so much for joining us. Thank you once 48:05 again. 48:08 That was Dr Melissa Lucarelli speaking with Dr Ronald Epstein, professor of family medicine and palliative care at the University of Rochester, and author of attending medicine, mindfulness and humanity. My name is Austin Luttrell, and on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss the next episode, and don't forget physicians practice will be hosting a practice Academy event on March 19, featuring a practice management track with practical, actionable education for physicians and practice administrators. You can register today by clicking the link in the show notes or going to registration.physicianspractice.com 48:40 be sure to check back on Monday and Thursday mornings for the latest conversations with experts, sharing strategies, stories and solutions for your practice. 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