Deviant Skill: Mindful Practice Part 2

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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!

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

Deviant Skills: Mindful Practice

Want to take your expertise to the next level?  Do you really want to become a deviant?  To do so, then you must become a student of "Mindful Practice."  In this post, the first of two parts, I hope to explain about types of knowledge present in medical practice.  In part 2, I will explain the nature of mindful practice and mindless practice.  

Mindful practice is a term that is applied to a practice used by elite clinicians.  At it's most basic, it is critical self reflection.  Unlike normal reflection, used at the end of a process, mindful practice is experienced in real time.

It is the ability of a physician to listen attentively to a patient while recognizing personal biases in play; it is the ability to recognize and correct for mistake, refine technical skills, make evidence based decisions, and act within a personal value system.  It allows the practitioner to act with the highly desired skills of compassion, competence, and insight.

In practice, there are 2 types of knowledge that we use: explicit and tacit.  Explicit knowledge we all know and love.  It is the conscious application of rules or objective data to a patients condition.  It also tends to be easily quantified and studied.  Tacit knowledge, on the other hand, tends to be unconscious and not easily studied.  It is gestalt at its finest.  Think about riding a bike.  As you ride, you make adjustments for speed, position, and direction almost without thinking.  In a similar fashion in emergency medicine, a expert can walk in the room and determine that a patient is septic before having objective data before them to confirm their suspicions.  

This ability is the result of preattentive processing by the brain.  Essentially, the unconscious mind of the expert is evaluating perceptions and features and relegating some information to the background, all before these thoughts are made conscious.  There are many tasks in medicine that fall within this behavior: realizing that a patient has provided enough history to make a diagnosis, proper depth of insertion of a laryngoscope, or manipulating a hip to reduce a dislocation.

Unfortunately, this tacit information is very difficult to teach and is learned instead through practice and observation.  While many of us practice some form of evidence based medicine, the tacit knowledge of an expert takes the evidence and adds to it the messy details:

-Cost

-Context

-Convenience

-Patient Values

-Personal emotion

-Bias

-Prejudice

-Risk aversion

-Tolerance for uncertainty

-Personal knowledge of the patient

The awareness of this process remains relative unconscious to the expert and continues to demonstrate how judgement is both a science and an art.

In addition to tacit and explicit knowledge, there are also some domains of knowledge that we all have:

Propositional: fact, theories, concepts, and principles

Since this knowledge often comes from books and instructors, we need to be self aware of what we know and do not know.  We also need to appreciate the transient nature of this knowledge as it is constantly changing

Personal: knowledge gained through experience; intuition, personal interpretation

This knowledge is often neglected during training due to confusion between personal knowledge and anecdote.  Consider uncritical application: What if you missed a pulmonary embolism and subsequently ordered a d-dimer on every patient with pain or shortness of breath?  This is application of an decontextualized anecdote.  We see this all the time in medicine.  How many of you have been taught: "Any patient with an elevated WBC count and belly pain gets imaging."  Compare instead the physician who increased their tacit knowledge by self reflection that made them aware of the processes and thought that led to the misdiagnosis and allowed them to recognize the error in the future.

Process Knowledge: knowing how to accomplish a task, gathering information, procedures, etc

This includes the knowledge of metacognition, or thinking about thinking.  Process knowledge allows us to modify actions, whether diagnostic or procedural.  Reflection on processes also all us to gain insight into our blind spots.  It uncovers "unconscious incompetence."

Know How: knowing how to get things done

Remember your first month on the real job?  You probably we a fairly inefficient physician.  Know how is knowing not only what test to order, but that communication with all involved parties, i.e. nursing or radiology may get the test completed sooner.

So now that we know what knowledge is, how do we become mindful to using it to become a positive deviant?  In the next post, I will cover the characteristics of a mindful practitioner and cover the dreaded opponent: mindless practice.  Stay tuned!

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