Focus on Metacognition
Dr. Epstein, director of The Rochester Center to Improve Communication in Health Care, says metacognition builds on other approaches, such as the Healer’s Art, a course designed by Rachel Remen, MD, and colleagues, which a number of medical centers are incorporating into their curricula.7
“We are building on Dr. Remen’s wonderful work,” he says. Both curricula include self-awareness, humanism, caring, compassion, meaningful experiences, and physician well being. Both address the “informal curriculum”—a term used to refer to the social environment in which medical trainees adopt values, expectations, and clinical habits. In addition, Dr. Epstein and his colleagues focus on quality of clinical care, including medical decision-making and preventing errors.
“Importantly, our initiative is part of the required curriculum,” says Dr. Epstein. “It targets students and residents working in clinical settings at an advanced level, and it also has a faculty component. … We are trying to transform and heal the informal curriculum, not just immunize students against its toxicity.”
In the Thick of It
All this sounds as if it might benefit hospital practice, according to the hospitalists interviewed for this story. All three believe that mindfulness can be cultivated. Dr. Ali believes the aforementioned forces acting on hospitalists require that hospitalists work at their top capacities, but prioritizing remains essential. He believes one way a hospitalist can cultivate mindfulness in the patient-physician relationship is to avoid burnout in any way that works. Having been a hospitalist for almost 10 years, he discusses this with his medical students and residents. In addition to his hospitalist practice and teaching, Dr. Ali does patient-related quality work, which refreshes his energy.
Dr. Ferguson also thinks mindful practice can be cultivated. “I took cues from the nursing profession in realizing that you do have to care for all aspects of the patient,” she says. “But you can learn this from mentors and people who are successful: people you can emulate, shadow, and follow.”
For her, such a person is Lisa Cooper, MD, MPH, an associate professor in the department of medicine at Johns Hopkins University School of Medicine. Dr. Cooper, both a practicing internist and a researcher, studies and teaches about communication between physicians and minorities—that is, how physicians interact with people of the same or different races and ethnicities. Dr. Ferguson says she feels fortunate to have adopted a mindful awareness in that regard.
As director of the medicine clerkship, Dr. Lang came into contact with Dr. Epstein’s project through her Dean’s Teaching Fellowship, a competitive program at the URSM for faculty members who have a special interest in education.
“The discussions with other educators and clinicians really got me thinking about how my own feelings, whether they had to do with a patient or anything else in life, affect my decision-making,” says Dr. Lang. “You see the phenomenon in residency where you’re in morning report when the residents present a patient and everyone is sitting around a table—not involved with the patient—making judgments about what they should have done. It’s so much easier when you’re not involved [in the situation].”
Though Dr. Lang thinks there are a lot of reasons for that, “part of it is that you are not in the excitement of the moment. And the other factor is that when you’re presenting a patient to a group, you wouldn’t convey your own emotions, what else was going on, what were the competing pressures. Even if you have a wonderful intellect and clinical reasoning skills, you might make the wrong decision when you’re in the thick of the situation.”