In the late 1990s, Dr. Epstein and his coworkers implemented a curriculum reform process at URMC, and his particular charge was to assess the competence of medical students. To accomplish this, he did two things. First, he reviewed the literature on the assessment and definitions of special competence. Second, he turned the magnifying glass on himself. “I thought that it might be a useful exercise to try to understand what made me practice at my best and what barriers there were to doing so.”
The resulting article from this self-monitoring and evaluation was published in JAMA in 1999, before the review article on defining and assessing professional competence appeared in that same journal.3,4 Exploring the nature of his own mindful practice reacquainted him with two areas in which he had participated as a teenager: music and the study of mind—particularly the use of meditation to enhance mental capacities. Those inquiries led him to explore the psychology of a number of qualities of mind: attentiveness, curiosity, decision-making, and the use of cognitive knowledge. The literature was convergent in a number of ways, he says, and “seemed to point to the fact that a lot of competence is not a matter of book knowledge or the kind of knowledge we can explain but tacit knowledge, things we do semi-automatically that really take some effort to deconstruct.”
He realized that “what distinguished an excellent clinician from someone who wasn’t quite so excellent had to do with some of those same qualities that one sees in accomplished musicians, athletes, and meditators, which is the ability to make fine distinctions, lower one’s own level of reactivity, respond in a more conscious way, and pay attention to the unexpected—the surprises that are part of everyday work but that we often ignore.”
All of this rather radicalized his view of what medical education should be doing. He came to believe that—on top of a foundation of knowledge and skills—physicians need to be attentive to their own mental processes and alert to the effects of bias or prior experience.
Writing about excellent clinical practice in this way drew a crescendo of response from readers of the JAMA. The JAMA editors had thoroughly engaged in helping him refine and present the ideas in a way that would really speak to clinical practitioners and educators.3 After publication, he was amazed to receive hundreds of letters from all over the world from physicians in different specialties expressing their appreciation “for having articulated something that was really at the heart of medicine,” he says. “For me, that was incredibly gratifying.”
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Hospitalist Qualities of Mind
What qualities of mind are important for a hospitalist to have?
“You have to be enthusiastic, fast-paced individuals,” says Yousaf Ali, MD, hospitalist at URMC and assistant professor of medicine in the Hospital Medicine Division. You also have to be able to immediately connect with patients and families and to have the knowledge and passion that makes that possible. Further, he says, you need to quickly access knowledge pertaining to caring for patients with multiple problems.
Traci Ferguson, MD, is a hospitalist at Boca Raton Community Hospital in Florida, which, by affiliating with Florida Atlantic University (the regional campus for the University of Miami School of Medicine), is moving from community hospital to teaching hospital. Dr. Ferguson believes the qualities of mind necessary to be a good hospitalist are the capacity to be aware of reactions and biases toward patients in order to avoid being judgmental.
“I think the major thing is being present and being attentive when you are caring for patients,” she says, “and that occurs when you’re writing a chart, when you’re talking to family members, [and] when you’re talking to nurses, just as it does when you’re at the bedside.”