Rachel Levin, M.D., M.P.H. presents at the Johns Hopkins Department of PM&R’s Grand Rounds on October 16, 2018.
So, thanks so much for the to come in and talk with you today. I was asked to talk about something related to teaching or education. And I picked this topic actually, because it's of particular interest to me. And really, I think it's just something interesting to think about. So, what I hope to do in the session today is talk a little bit about mindfulness, what it is and also talk about some strategies related to mindfulness that you might use in your teaching. Um So yes, we're gonna talk about what mindfulness is and what it's not the potential benefits of mindfulness uh for teaching. And I'm gonna draw from the literature from other settings because we really don't have specific literature in medical education. And I'm gonna talk about some specific strategies that you might use to incorporate mindfulness into your teaching. So I don't have any disclosures. I will say that while I think about this a lot, I'm not as mindful as I'd like to be and I'm going to keep practicing. Um Actually, before we go there. So just so I have a sense of who's in the room. So, uh who teaches learners, everybody. Ok. Wonderful. So, in general, let's say who spends more days than less than a week with a learner who's teaching in clinical settings? Ok. Who's teaching in settings that aren't clinical? Can you give me an example of what those settings are? Just? Lab? Ok. Wonderful. Yeah. Lab. Wonderful. Same classroom. Ok. Ok. So lots of diversity in the group, but lots of teaching in the group. Ok. Wonderful. Before we get into the meat of this, um I'm gonna speak to you from my role in the um dean's office and also my role um on the Institute for Excellence and Education um managing board and tell you about some opportunities to build teaching skills. So some of you may know about our teaching camp. It's a two day course in this summer, we have dates for next summer. Those two full days are devoted to developing teaching skills. You can sign up for one day or both days. Um We have on the, your top left, the foundations of teaching and learning. We have two dates coming up for this course. This is a half day that really focuses on foundational skills in teaching. We focus on the learning environment, feedback and coaching, questioning as a teaching tool. Um We talk about some other clinical teaching. We talk about small group teaching and we have a session on active um making your lectures more interactive. Um We have a new course for folks who see themselves along uh program along the educator pathway. This is modeled after our teaching skills workshop. This is going to be a foundations of educational scholarship and it's designed to introduce participants to the basics of educational scholarship, how and why it might be a little different from other research and also what are local resources available to support you in that type of work? And then the on the IEE website, we have a, a website that's called Improve your Teaching that has different modules on different teaching subjects. You can go to that website and go through the modules at your time or as needed based on content. So if you a lecture coming up and you want to review the lecture module or if you have challenging feedback scenario coming up and you want to review some of those skills, you can go to the website and do it at your own time. So I just wanted to put that up there so that you guys are all aware of the resources available in the School of Medicine for you. So I wanna start here. Um And so this really is um meant to be an opportunity. We'll spend about an hour, I'll share information with you. But I really want you to think about this proposition and that is that paying attention and being aware will help us to be more effective and engage teachers by ensuring that teaching is a thoughtful response and not a reaction. Um I wanna be really clear that this talk is not about teaching learners mindfulness practice. Although there is a um increasingly robust literature on that. Um But rather this talk is more about us being more mindful teachers and incorporating mindfulness into our teaching. OK. OK. So again, as I said, we're going to just as a reminder, we're going to define mindfulness. I'm gonna describe the benefits of mindfulness more broadly in medicine. And I'm gonna share some teaching tips or strategies that incorporate mindfulness. So I'm gonna show you two definitions of mindfulness. The first is from John Cazin, who is probably single handedly responsible for bringing Zen Buddhism um to North America and introduced it on such a large scale. So um John Cazin defines mindfulness as the awareness that emerges through paying attention on purpose in the present moment and non judgmentally to the unfolding experience moment by moment. OK. And then I'm going to share a second definition that has been used in some of the research around mindfulness and specifically in a really interesting study that looked at mindfulness as a strategy for reducing implicit bias among physicians in caring for their patients. And in this study, they define mindfulness as a meta cognitive skill involving attentional control, including pay, paying attention to one's experience in the present moment, emotional regulation, self awareness and a non judgmental and curious orientation towards one's experiences. OK. What I want to emphasize from these definitions is that mindfulness is really a set of skills and habits of mind that can be developed through practice. Um I wanna just um show you a little bit of my own journey around um through mindfulness, which initially began for me in reading some of Ron Epstein's work. Does anyone know Ron Epstein? Yes. So he's at Rochester. He is a family medicine doc and palliative care specialist who's been writing about this and thinking about this for a really long time, he recently published this book called Attending. It's really excellent and I really recommend it for anyone who has any interest in this. It's a very um accessible read and really engaging and really resonates. So this is sort of where this began for me and thinking about it. And this is really about one of the only papers I have been able to find over time that really talks about how mindfulness can be important for medical educators. And again, it's mindfulness no different from any of the way of thinking about it in the work that we might do with patients or just in our lives more broadly, but rather describing it in the context of being an educator. So um I'm just gonna put this up there and I'm gonna ask you to um just bear with me for a moment. Mindfulness is about creating space. There are generally seven principles that many practitioners or teachers of mindfulness use to talk about or think about um how we might um think about mindfulness and I want you to sort of look at this list. I want you to actually notice what reactions you're having to this list as you see it or what questions are popping up for you. Um And we're gonna come back to it in a little bit and talk about it in a little bit more detail. OK? OK. So now I just want to talk a little bit about some of the benefits of mindfulness that have been demonstrated in the, in three settings. And these are some um articles that these are drawn from, but there really is a very large literature on this. So I'm I'm gonna share with you um outcomes in patients, physicians and trainees and I'm gonna emphasize a couple of them. So some of the um outcomes that have been noted um as a benefit of mindfulness training are reduced stress and burnout. And this has been demonstrated in physicians and trainees increased positive emotion and energy sometimes described as resilience among patients physicians and trainees, cognitive de biasing and flexibility among physicians, greater attentiveness and conscientiousness among physicians, greater comfort with uncertainty among physicians improved safety. There are some fascinating studies that look at things like preventing patient falls, needle sticks, hand washing and this has been demonstrated among health care providers and trainees improved empathy and person centered orientation to clinical care among physicians and trainees, better ratings of communications and relationships with patients among physicians and trainees and greater sense of community among some of these groups. And this is a um an article that came out in Jama about in 2009. And um Ron Epstein is one of the authors on this article. And this essentially um was an intervention that they conducted with physicians that self selected to be part of this intervention. And it was basically a seven week program that focused on mindfulness. They also so mindfulness in terms of different types of meditation and mindfulness practice, they also used um narrative medicine. So a lot of storytelling in this program and also an appreciative inquiry approach, which is essentially a model for organizational or individual change that focuses on what you're doing well and doing more of that. Um And they demonstrated improvements in many of the outcomes that I showed you up to 15 months out. And I'm showing you this um paper for a particular reason in that there's an increasing interest in mindfulness in our world, right? Because we are faced with so many challenges in particular among the physician work force in terms of things like um physician burnout, et cetera, right? And so in a moment, I'll tell you about a course that's offered here at Hopkins, but you will see mindfulness put out there as a way to address some of the challenges that we, this is one piece of the problem, but it's evidence based and has demonstrated some effectiveness. And so you will see that there's a lot of interest in this. Um I will tell you that when I was coming here today, I walked down a set of steps just out here that I hadn't walked down recently or, and I don't often walk down and I came upon, has anyone seen this between the stairs out there on the other side of the, the um the waterfall there? The Clarity Capsule. Has anyone seen that? No. Yes. Ok. So I stopped, I noticed um it is this little cube cubby, it looks like an egg. It has these beautiful velvet curtains and I stopped in red. There's a sign that says why it's there. It's a place to sit and contemplate, meditate whatever you want to do they talk about why it's there just creating a place for anyone to go and sit and you know, relax meditate whatever it might be. So I went in and I spent a few minutes in there, listen to my app that I like to use. But again, it shows you the increasing awareness of some of these benefits from mindfulness and then responses from institutions to that. So I actually recommend you, check out the clarity capsule. You'll have to take turns because you won't all fit in, but it's very comfortable, it has a nice comfortable couch, it's very nice. OK. Um OK, so I've told you what some of the outcomes are I'm gonna show you some. Um this slide comes from Netta Gould who runs the mindfulness based stress reduction course at Hopkins. And I'll tell you a little bit more about that in a moment. Um We don't necessarily know exactly what is going on done with mindfulness or meditation and those outcomes, we do have some um we can show you changes that occur in the brain that are assumed to be associated with those outcomes yet, the sort of final common pathway is not yet known. And so what this slide shows you is that there are different parts of the brain, it shows you what their functions are and it shows you what changes have been noted when functional MRI s are done. Um And in these persons who take a 77 to 8 week mindfulness based rest um reduction course. And I think what's important about this is these changes are seen in persons who have been meditators for a very long time. And they've been shown in people who have been meditators for eight weeks, right? Not necessarily the exact same changes but similar changes, right? So of the um the assumption is that just a small amount of meditation or mindfulness practice can actually create these changes. OK. So how can we become more mindful? Well, there are lots of ways to do that. So there's some structured ways to do that. So now it happens, there's a mindfulness based stress reduction force um there are popping up and oops, sorry, there are popping up in lots of different places, modified um courses. So shorter versions of that, the traditional mindfulness based stress reduction course that was developed by John Cazin, which was actually developed for patients is an eight week course, right? It's about 2.5, 3 hours a week for eight weeks, which isn't necessarily something that everyone can do. There are on online modules, there are mobile apps and there are different kinds of um practices such as compassion, meditation or mindful communication. I wanted to show you this too. Another example of something the institution is doing. So I don't know if anyone noticed this email the other day or knew that this was available. But the university covers the cost of calm, which is probably one of the most used um mindfulness apps that you can um you can purchase. And so now Hopkins is paying for the premium access, which is a pretty good deal. So just so, you know, you can do that. OK. So how can we become more mindful? So I want to just tell you a little bit about what meditation can look like. Um And this book actually is a lovely way of reading about mindfulness in a way that connects it or resonates with the the type of work that you do on a regular basis with examples that um generally um resonate. So I think of meditation as attention or awareness training um where I might fo um practice a focused attention. So I might focus on my breath or focus on some other um sound or um image. Um or I might practice an open awareness um meditation where I might just notice what's happening. What does it feel like for my feet to be standing on the ground right now? What sounds am I hearing? What does it feel like to notice my clothes on my body? Those kinds of things. Um The other thing that you could think about are their informal practices, something that you just pay attention to on a regular basis. So for example, in the mindfulness based stress reduction, course, one of our activities was an informal practice and we could choose what it is that we wanted to do to pay attention to on a regular basis. So some people chose something like washing their hands. And so each time they wash their hands, they made an effort to notice. What did it feel like to get their hands wet to move the soap over their hands, to rinse their hands. What did the air feel like against their wet hands before they dried it on the towel, et cetera? You might think about when you're walking from one place to another instead of feeling rushed and hurried or looking at your phone, you might think about just noticing 1 ft touching the ground after the other, right? Um What I chose for my practice in that course, was mindfully greeting others. So sometimes we greet others and the immediate response is how are you? I'm so busy. Right. So I made an effort to specifically not respond in that way to find a more positive affirmation. It was hard and it also made me notice how often other people greet us in that way. Right. I'm so busy, right? Think about it. OK. Um So this is just a description of the mindfulness based stress reduction. Um The typical course and I wanted to just make you guys aware that Dr Netta Gould here um in the Department of Psychiatry offers this program a couple of times a year. I know that some in the room have taken the course. Um If you are interested, you can reach out to Gould. It's a really wonderful course. Thank you. OK. And so Netta um loaned me this um copy of some pilot data from about 80 persons who have already participated in this program. And I'm showing you this because they're very similar to the study that Ron Epstein and his colleagues at Rochester did. And also these are your peers, right? These are your peers who participated in this course and noted improvements in the burnout measures of burnout, um their perceptions of stress, a mind using a mindfulness attention scale reported feeling more attentive and feeling more engaged in their work. So these are all really um I think compelling measures and, and pretty positive in terms of the benefit that something like mindfulness can have on you. And again, as I said, you needn't be meditating, you know, excessive hours in the day. Really, these this data and from other studies show that it really just takes a little bit of mindfulness practice. OK. So you're saying, yeah, maybe this sounds OK, I'm not sure. Um but I just wanted to, is anyone thinking any of these things you don't have to raise your hand? No, not so much. OK. Does anybody want me to talk about any of these? Do you have any questions about any of these? Say it again? Yes. Yeah. So, um if I were a Buddhist monk, what I might respond to you and um I think that so I might say to you. So on um days, I feel busy. I might meditate for 10 minutes on days. I feel really busy. I'm gonna meditate for 30 minutes, right? Yeah. And you can think about it, you know, um sometimes when you're well, in a moment, we'll talk about what happens when we are so busy, right? So what are some of the outcomes related to that? I think the first one is one that sometimes people really struggle with. And I think this is just a misunderstanding of what meditation is. It's not about clearing your mind, it's about paying attention and practicing and noticing when your mind starts to wander which it will because that's how our brains work. Right? But noticing that and bringing it back to the focus, whatever it might be, your breath a sound, a count, whatever it might be. Right. So it's not. Yes. Um my colleague out right in front of me for this busyness, one just sent me a structure for, to so fitting in mindfulness. And it, it's a, it's a program, mindfulness carve out 15 minutes. Which, yeah, all of us are too busy, maybe for 15 minutes. But once it's on your calendar is structured, we seem to do better at a hearing the structure. I think that, you know, that's an excellent point. And the other thing that I would add is even if you feel like you can't find out, uh you can't carve out, you know, 5, 10, 15 minutes to actually sit still and practice sort of meditation. You can practice paying attention, right. Everyone is gonna walk out of this room and go somewhere where you could practice paying attention in that moment. OK. And we'll give you some more examples there. But yeah. So I think you're absolutely right. If you just Google, sort of tips for mindfulness, it's sort of all over the place. Oh, so there's a little bit of accountability there too. OK. Yeah, that's helpful for a lot of people too. Yeah. OK. So, yes. Do you want me to go back to that slide? Sorry. I, there, we go and someone who has practiced it for a couple of decades, I can tell you I am more. Yeah. And I know. Right. And there is, there are, are good studies to show us that we aren't good at multitasking. Can you say how, you know, you're more productive or what's your sense of how that works for you? Um OK. It's uh part of it is I get the same amount done without feeling physical, so more productive in the sense of uh less effort, less stress. Yes. Yes. So overwhelmed. Yes. Less of that feeling, overwhelmed, stressed, um anxious about getting it done. OK. And, and also a couple of ways of looking at things uh even with a very difficult, um there's something good about what you learned or you did or help them to do something and you think we can really only think so if you're thinking of that positive thing, you're not saying. Yeah. Yeah. Or what's happening when you leave the room or all the other patients, you have to see if you can focus in that moment on the patient, you can accomplish more. Yes. 11 thing that I heard from a, a teacher uh was sort of thinking about being free versus being sort of two different things in the sense that um when we feel busy, a lot of times we sort of sort of feel hurry, but a lot of this sort of self, I there's this kind of our, our brain that sort of impose things on it. But the reality is that we need to be quick in this, you know, we have to make a lot of decisions and things like that. And so that for me was really helpful to kind of think about those things differently in terms of our, yeah, I think that's a wonderful observation. And I've noticed as I practice mindfulness more that there are times when I feel very busy or overwhelmed. And I think, oh, I'm never going to get this done. I have all this to do and then a little bit later when I've accomplished some of it, all of that goes away. And I try to sort of remember in the moment there's not that much difference between here and there and, you know, sort of how can I change my thinking a little bit around that? So reframing it. So that's a wonderful point. So I want to pause here and I want to ask you guys what keeps you from being mindful? What keeps you from paying attention? What keeps you from awareness in the present moment? Really? About things that, yeah. So you're thinking about yesterday or tomorrow or whenever? OK. Yeah. What else? It's very hard to be present in the moment. Yeah. Contextualizing what you're doing context often, see. Yeah. Mhm. I think about it as being in my head, not being in my body. Oh, say more about that help me understand that um it's kind of like this paying attention to the thoughts that are in my mind about the things that they have mentioned, like what I need to be doing or how much I need to accomplish. And then when I am not in my head, when I'm in my body, it allows me to and, and kind of connect with the sensations in my body and it just helps me kind of ground. Then the thoughts in my brain kind of slow down some more able to. So he brought up, he's myself and yeah, that's a wonderful description. I'm I'm glad that you were able to share that because I think that's exactly right. You're got all these things going on in your head and if you can't just notice them and just put them here and not, and then be in your body in the present moment doing what you're doing. Right. That's a great description. Yeah. How about here? And then in the back, I think we all have a tendency to be able to be mindful towards things that we are passionate about or that we care about or enjoy. And when we don't necessarily have that same passion or enjoyment for that thing, then we are less able to and thinking about just having a, a daughter or a baby. And that seems to be one of the things that I can always be mindful to and why is that versus the task at work that feels stressful or, you know, XY or Z. So I think when we can find our passion or love or joy to something, it's much easier to be mindful to that thing. Good. I think his health care providers are too big across the board. Um We're having crucial conversations, the time of the very stressful times, hostile, upset, depressed and a lot of that goes off on us. So when I think about what keeps me from being mindful, it's like planning for those conversations debriefing myself from those conversations after I've had them and all that takes away from that mindfulness that maybe would make me more effective in those conversations. Turn that up a little bit kind of feedback on that I, I have found in my practice that using my body to meditate to actually practice like a movement meditation, uh practice has really helped me have all that energy from the conversations that we're talking about kind of charge throughout the day to kind of use my body to metabolize that, that energy. And it sounds really hippy, but it really works for me and I kind of diffuse that and that's how I, that's what's helped for me. That's a great point because if you didn't diffuse it, what would happen and we'll get to that in a moment. Yeah, let's take one more. What keeps you from being mindful? I was just gonna, so I, I sort of think of a lot of the stuff that we have to do in, like, uh, let's say if we're reading a paper, you know, you're doing a research project, like, in some ways you have to start engaging in your mind. I think the nature of what we do requires us to start thinking and, and part is, um, you sort of just you get caught up in that and it's, and it's sort of hard to what's the key to kind of get you out of that state. Um So uh I think just kind of the nature of Yeah. Yeah, you have a lot to think about, right? OK. So many of the things that you all just talked about are things that keep us from being mindful. We just have a lot to do. We have a lot of information coming at us whenever I look at this slide, I just think Epic. Yeah. And I, I feel like it is the poster child for this, right? I have a terrible headache every time I'm done spending hours on Epic, right? But that to me is what it's about. Too many tasks, too much information coming in, all kinds of choices. Somebody said we have to make decisions, choices, decisions, we get interrupted all the time in our work, right? Oftentimes we don't feel like we have a lot of control over our work environment, right? So I'm talking about the work environment often here but this could resonate in other settings as well. Right. So it's hard to be mindful when you have all of this going on. And so what happens when you're not paying attention when you're not being mindful? You miss things? Ok. Do you miss things? What else? Like a waste of time? It feels like time is wasted like. Yeah. Ok. What else? Yes, you get hurt. You could or you might hurt others. You might, you might unintentionally maybe, you know, react, right? You might bite. Yeah. Yeah. You might fail to appreciate that, that positive thing about that patient in the moment, right? Which really is contributing to that relationship with that patient and maybe their um you know, sort of road to wellness or health. Yeah. Yeah. That's really good. Yeah, you will. Yeah, you won't. Yeah. So give me an example of that. Um Well, I just think that, you know, we're engaging in conversation with a student or a patient or whomever it would be and later on you want to go back and maybe give feedback or document and you have zero recollection of perfect. Beautiful. Right on for the teaching part. Yes. Um The other big exam people example that I hear a lot is um driving. I get to work and I'm like, wow, I did not pay attention to any of that, which is really scary. Yeah. Uh Thinking back on stats and that's really appreciating to work other than them. But appreciating yourself trying to get lost. That is like, what you could possibly learn that day and, um, like just the knowledge or the experiences react to that. Yeah. I think when we're not paying attention, we're not, um, aware, we are often framing things in a negative way and again, that can trickle down it can, you know, make it difficult for us to see what's really happening or a more positive approach. Yeah. Any other? Yes, forget to take. And I think that's one of the reasons why a lot of us. Yeah, we have. Mhm Yeah, to appreciate what being done. Yeah, absolutely. I think that's a really important point. OK. So some of the things that you guys talked about were on autopilot, um we tend to rely on our fast thinking, right? We just sort of respond without slowing it down and we'll talk about that again in a moment, we might actually be unaware of biases um and act on those, right? And there um the study that I mentioned earlier was really fascinating about using mindfulness to become aware of implicit biases that may impact patient care, right? As a strategy for changing that we might, I ignore important data. When we're taking care of patients, we might sort of engage in premature closure, deciding, you know, we have all the information we need errors came up, poor communication and, you know, ultimately we're reacting instead of responding. OK? So I wanna just go back to this list of seven, sort of principles around mindfulness. Um Are there any, so I'm gonna talk about beginner's mind a little bit in the context of teaching. But is there any of these that you have questions about or wonder about? Um, sometimes people think letting go means giving up, but it's really about letting go of yesterday and tomorrow in this moment knowing that you can't, you can't act on that yesterday and tomorrow in the moment, but you can act on what's right in front of you, right? Any other of these lists that you have questions about or wonder about? Yeah. Um I get all of them except no, we're talking about a teaching. Yes, I have a goal. Yes. Yes. What I would say in that way is that we talked about how um mindfulness is also about a curious orientation, right? So you can have a goal. You can be curious about how you get to that goal. You can be flexible, how you get to that goal. You can be open to learning from your learners about how you get to that goal. So I think this is the piece, this is a little bit about being curious, right? And not being focused that there's only one way to get to that goal. Does that make sense? And there are situations where one way to get to the goal is kind of important like when someone's coding Right. But, but there are lots of opportunities for us to be a little bit more um focused on the process and curious about the process. Yeah. Does that make sense? Ok. Good. Wonderful. OK. So now we're gonna um transition and talk a little bit about mindful teaching and I'm gonna break this down into three sections. I'm gonna talk about attention and noticing and give you some ideas and tips, strategies around teaching. I'm gonna talk a little bit more about the beginner's mind and mindful of communication. So in a moment, I'm gonna ask you to do an exercise. Ok. And actually, um, we might, well, I think we could stay in this room. Ok. So what I would like you to do is we're gonna take about five minutes, probably a little bit less. And I want you to write down the name of everything red that you see in this room, you can get up and walk around. Ok? But don't talk to others. Ok. And, um, just write it down. Ok. And we'll reconvene, let's do three minutes. I think that will be sufficient. All right. So what did you notice about how you were paying attention? What were you thinking or feeling more awake? Ok. Yeah. OK. I was like being my mind was doing something. Yeah. OK. Good, good. Yes. Since I know what red looks like, I was just kind of like scanning and then when the red chopped up that's why I noticed. Ok. So you were sort of passively waiting for the red to find you? Ok. Good. How about others not valuing anything that wasn't, I don't care about that. It's not red. Ok. Yeah. Good. How about, I think there was someone in the back. Yeah. Yes. Yes. And did you notice that? And when you noticed that, what did you think or do or say, or to yourself? Perfect. Great. Wonderful. Yeah. So he, what he said was he noticed that he started to become competitive with himself. Right. Right. I've got to find all the red um, things, right? And then I said, you know what, what was that like to notice that? He said it was ok. Yeah. And sometimes when we notice things like that we might attach a judgment to it. Right. Yeah, I noticed how many things I hadn't noticed in the room prior to being in here, like things that are kind of important, like a fire alarm at the exit sign that I completely put out of my mind but are really valuable things and all I have to do is take a few minutes. Yeah, excellent. So, so you notice things that you hadn't noticed before because you were paying attention? Yeah. Any anyone else wanna share what that was like for them? Yeah. So you saw red but not anything else. You didn't see that it was the exit sign, right? But, but it didn't, it didn't register? Oh, that's the exit sign. That's important. Yeah. Good. Great. Yes. So you felt comforted knowing that, you know what you're supposed to be looking for? Is that what you're saying? Ok. Ok. You thought it was gonna be a big tricky test, but it was ok. It's good. Ok. Wonderful. So you, you felt comfortable having a task and knowing what the expectations were? Ok. Wonderful. Great. So there's no right or wrong to this exercise. It really is just an exercise in noticing, right? Paying attention. And also though noticing what does it feel like when you start paying attention? Right? And how easily your brain can go to? I got to find all the things or hey, that's really important or what am I not noticing or getting laser focused? Right? But just noticing all of those, right? So just before this slide, I showed you guys an image, I'm going to show you the image again and I just wanted curious if anyone notices anything different about this image or maybe something they didn't notice before. So what do you notice you see more red? That is true. Yeah. What else? There's a giant letter. Did everyone see the letter from the first time? Yeah, not everybody does. And you could see how if you weren't paying attention or if you were focusing on something else, you wouldn't necessarily see that letter. So that that image with the letter um comes from this book Visual intelligence. This is a, this is a really interesting book. This is written by the woman who has created all these programs that take medical students, physicians, detectives, scientists to um uh art museums, to study art, to really develop observation skills. And one of the things that she talks about is intentional blindness, right? And um you know, of course, there's an quote that fits perfectly this, right? But we miss more by not seeing than not knowing, right? But this is a really wonderful book, if you, if you are looking for something to read, um to really kind of develop skills around this and, and um well, her focus is on visual attentiveness, right? There's a lot of sort of mindfulness incorporated in this. OK. So how can we take those experiences that exercise that I hope um helped you to get a sense of why paying attention is really important? How can we take this um to our teaching? Right. So all I would ask you to do is pay attention, right? But pay attention to a couple of things, right? So in particular, pay attention to the learning environment, the learning environment is really really important, right? Notice what's going on with your learners, what's promoting learning, what's inhibiting learning is anyone struggling in this learning environment? Right. Right. So pay attention. Notice those things. Think about when you're observing learners, right? Paying attention, right? So think about being very, very intentional about observing for teaching and learning, right? So you might think about asking learners what they're working on to improve and what they would like you to observe and give them feedback on. Right? And then being really focused, trying to balance the clinical and teaching hats. Sometimes that's really hard when we're in a in the clinical supervisory role to sort of balance those two, but sort of being aware of that, right? And then observing really with intention. So writing down just as you had mentioned, I forget what I want to give feedback on to my learner, right? Write it down, be specific, prime yourself ahead of time. What do they want feedback on? Right. OK. So the takeaways here are think about being more attentive to the learning environment. What can you do to enhance the learning environment and then thinking about being more attentive when you are observing a learner by asking the learner to help you figure out what they're working on and what feedback on and then paying attention and and um providing specific details so that they can improve, right? Um Some other things that I like to do with learners and while this is not necessarily teaching them mindfulness, it's using principles of mindfulness in my clinical teaching with them. So I might ask learners, especially early learners who feel like they don't have much else to contribute to the team. For example, I might ask the medical student. So I'm a general internist and I take care of patients. Um sometimes in the inpatient setting with learners and I might say to the medical student, you know, we've done a lot of talking about what's the best way to care for patients in a patient centered way when we go into this patient's room, I want you to look for anything, notice things that could help us care for this patient in a more patient centered way. Right? So what do you see? What do you notice and what do you not see this was brought up before? Right? What do we not see? So we might go into a room, the students love this. They get really into it and you could change the content area, right? But we might go into the room and they say, you know, I noticed that they had lots of cards from their family on the wall or they had a stuffed animal or they had an adult coloring book. So I think that's something they like to do, right? We could ask that patient about that whatever it might be or they might say there was nothing in the room, right? Doesn't look like anybody's come to see this patient, right? They don't have any of their own personal belongings in the room, right? So using this attention or observation as something to teach and then we can talk about patient centered care. How can we better serve the needs of this patient? Right? I might use this in the setting of physical exam. I might specifically, you know, ask the um the team to just describe what the patient looks like. We've sort of lost the art of this, right? Really describing in detail how um a per how a patient looks to them, right? Um You can use um attention and observation to debrief powerful experiences, right? So you might take the learners back to that situation when that patient got really angry with us. How are you feeling in that moment? Right. What, what were your thoughts? What did you want to do? What would you want to do differently? Right. Asking the learner to notice in that moment what was happening for them to create a teaching moment, right? And then really role modeling in an intentional way. So I might invite learners to watch me and I might be very explicit about what I'm intending to do with the patient, right? OK. I, I'm gonna have a conversation about Xy or Z, right? I'm gonna really practice, you know, using language that this patient can really understand. And I'm going to really try to get a sense of what this patient's um goals are, for example, tell me how I do on that. What do you notice that I do to accomplish that? How could I have done that better? Right. OK. So this is about using attention and noticing to really be deliberate and having learners observe and using that to create a teaching moment. So these are sort of four areas that you could do it in, right? So observing the patient physical exam, using it to debrief something that happens that was difficult or challenging or powerful experience and using it very explicitly to role model things that you want to teach learners. OK. So now I'm gonna shift to the beginner's mind. Um I think this is a really um lovely concept for thinking about the work that we do with patients and with learners. Um So the um monk says in the beginner's mind, there are many possibilities, right? They're wide open, but in the experts, there are few, right? So this is about um you know, holding our expertise lightly, right? So that we can be curious or open to other ways of seeing, right? And I think that this is a really helpful thing to think about both in um all of our work, but particularly in teaching. And there's a couple um places where I really think this is helpful for teaching. So when I'm teaching learners about communication skills and relationship building skills, really teaching them to be curious with patients, right? Um using what I would call respectful curiosity, to understand differences or to understand the patient's perspective, right? Asking those questions being not making assumptions, being open to whatever the conversation might take them or lead them to, right? Um Becoming aware of biases in the moment, right? When they're taking care of patients um using non questioning, um framing conversations through empathy. Sometimes if I feel like in the moment I'm having a really challenging conversation with a patient or I'm having trouble connecting them, I might pause and think to myself, you know, you know, first of all, I might say, well, why am I, why am I feeling like this isn't going well? And I might say, am I assuming something that might not be true? Maybe I need to step back and recheck this or I might say to myself, you know, is there another way that I could understand this story? Right? I need to find a new perspective around this. I love working with medical students because they are wide open, right? They are beginner's mind. So another way to think about using beginner's mind is when you're thinking about teaching clinical reasoning with learners, this is just a um a very basic uh schema about how clinical reasoning happens and it really gets at the non analytic and the and the analytic. So this is sort of Daniel Kahneman classic fast and slow thinking, right? So the non analytic is really fast. This is our pattern recognition. This is what experts who walk into a patient's room, sort of magically know the diagnosis and everyone, you know, all the junior learners on the group are sort of like, how did you know that? Right? It's about pattern recognition, all of these things right. The analytic component of clinical reasoning is when we slow down, it's more deliberate, it's deductive, we're building on information to help us collect more information, et cetera. We're testing hypotheses. And I think understanding this dual process theory and clinical reasoning, really, I think promotes us teaching this by thinking about this from the perspective of the beginner's mind. So slowing it down and teaching learners to be really thoughtful about their analytic process and also being super transparent when we're being non analytic and helping them understand how that develops. Um So with this, I sort of just think about like creating space, slowing thinking down, encouraging meta cognition. So sometimes when I have learners who get a transfer or a patient from the emergency room, I might say, especially with the medical students, don't look at any of the notes that have been written, don't look at the diagnosis, go see the patient on your own, right? Start from the beginning, right? This is a great way for learners um to really understand how um diagnostic reasoning works. When I'm working with learners, I will pause often for early hypo hypothesis generation and then testing back and forth, inviting them to think out loud. Tell me about your thinking. Why did you ask that question? Um I might um try as much as possible to coach them or role model. Um How I'm balancing again, this pattern recognition in the back and forth, like speaking out loud about why one thing makes me think this way or another makes me think that way, right? And helping um learn to create a mental awareness around this by using language like, well, here's my approach to weakness, right? Or here's my approach to dizziness as an example or when I'm working with a learner, what's your approach to anemia? How do you think about this? Right. Slow it down. Um You know, this idea of role modeling, uncertainty. So much of what we do as physician is, is uncertain and that's something that learners need to begin to understand. And so again, you know, how do we demonstrate to them holding our expertise lightly? Right. And then the last one is just a pneumonic that I think is a way of thinking about how you can slow down thinking for clinical reasoning, it's called and it just so it just reminds you of these components that can result in errors in clinical reasoning, right? But they're really about slowing it down. It's about meta cognition, thinking about thinking. So second opinion, this is really a recognition of, you know, my limits of knowledge or memory, right? So do I need to ask myself, you know, do I need help in this situation? Right. Is there something that I need an expert to help me? Someone who sees this diagnosis all the time? Who could say yes, no, here's what you need to do next. I might want to slow down if I'm, if I'm, you know, really relying on my non analytic, right? My fast thinking. So that eureka moment, right? Is this pattern recognition? But I really have to ask myself, well, you know, what data doesn't support this? What else could this be? Which leads to anti evidence, you know, what other data am I ignoring? Again? Thinking, thinking about the process of clinical reasoning. Um sometimes it might just be, you know, am I over confident here? Should I slow it down? And then what else could I be missing? So there's a lot of overlap here. But again, um ways to slow down the thinking. And again, I think we can train our learners to similarly slow down their thinking. Ok. So we, the last piece that I wanna talk about is mindful communication as a teaching strategy. Um I really like this quote and you can, um so most people do not listen with the intent to understand, they listen with the intent to reply. So you might imagine how many times you're having a conversation with someone and you just can't not talk, you have to say something or fix it or give advice or whatever. We are often, you know, that's our job. That's what we're supposed to do. I just want us to think about that because there are times when this can get in the way, right? So what we're gonna do right now is we're just going to do a quick exercise around mindful communication. So I want you to think about a time when you are not as mindful as you might like to be. What are some of the factors that made it difficult to be mindful? It could be any situation. What were some of the consequences if you want to write something down? You can. And then I'm gonna ask you in pairs to share your stories, but there are very um specific instructions, expectations about how you're gonna share your stories. So one person is the storyteller and the other person, the listener should spend most of the time listening. You may ask questions to deepen understanding and I would encourage you to think about using curious questions. So these are questions that only your partner could know the answer to, right? And as much as possible, try not to interrupt or interject your own story or interpretation advice or fixes, right? And because again, we, we, when we talk to people, we listen for something that resonates with us, something that we can share related to that. OK. So what I would invite you to do is you're listening to a story each time you feel like you would love to interject something, I just want you to sort of take that feeling and that thought and maybe that idea and just like set it down gently next to you on the table, it will still be there. You can come back to it if you want, but just consciously be aware of that urge and just set it aside without judgment. Right? Because it will happen. That's how we function. OK. Um, all right. So I'd like you to go ahead and get started. Um, take, we're gonna take maybe two minutes to think of a story, maybe jot some notes down and then I'll invite you to talk in, in pairs. Ok? If we don't have time for both, that's really ok because there's benefits to both parts of the exercise your partner loves you. Evidently. Exactly. Ok. If you're ready to tell your story, feel free to get started, but please try to follow the instructions. Wait. So I just, yeah, you, so I if you want to switch partners and take on the role of listener, if you were the talker or talker, if you were the listener, go ahead and do that. Sorry, I, ok, I'm going to ask if we can all come, bring our attention back to the front of the room. I'm going to interrupt your stories. So I want to ask, I hope, I hope that you were able to follow the instructions. And I'm curious to know for those of you who was predominantly a listener. Great. Ok. So what was it like to listen? Mindfully comfortable? It felt comfortable? Ok. Good party. So it was hard, why was it hard to engage in a conversation like that? So, in, in this exercise? Were you able to be, um, a little bit more aware of that? And, ok. And typically are you aware of that? Yeah. And do you attach judgment to that usually? No. Ok. I'm just asking. Um, ok, wonderful. So, you, you were really kind of mindful of that in the moment? Was it hard not to interrupt? Ok. Could you, um, could you be, um, could you actually think in the moment of? OK, I have this thing, I want to interrupt and I'm just going to set it over here for the moment and really focus my attention on my, my partner. You feel like you have something really important to say in that moment and you don't want to forget it and go back to it later and then frequently you'll just say like, oh, I'm gonna note this down and tell the person later and then by the time I go home, I realize that I didn't tell a person what I wanted to tell them. OK. Um But, and what did you notice about your, your listening? What did you hear? Or I was more able to feel the person in the OK. So definitely some more connection are being a little bit more in tune with the speaker. OK. Great. Other listeners. Well, your story was so interesting that uh I was fascinated. I didn't have, I didn't have anything to add other than what you do. Great. Perfect. That's a curious question. You couldn't know the answer to that. Wonderful. And that keeps the story going terrific. Ok, great. Others listening in this context, I found it. Ok. Um Maybe I, I'm an interrupter too, but I'm also planning how I'm gonna respond knowing that wasn't something that I was expected to do. It was nice to just be able to sit there and not have to give any sort of feedback, that particular scenario. And um I definitely feel like I heard more of the details and I think I uh sympathize more. Um And um and I was also able to think a little bit about my own experience and how I would do things differently if I were in. Great. That's great. OK, let's take one more um listener and then we'll hear from a speaker. I think clinicians are often so focused on treating and getting to the next step of that treatment. So as soon as someone gives us some little bit of information in our practice, we're automatically going to how we can best serve them work as well. But when we just focus on solutions to really understand the problem, a lot more in detail, what maybe to the difficulties the person is experiencing, how they're currently processing that. And then that would then lead to a more effective solution later when that's appropriate. Yeah, that's great. Thank you. All right. So who was a speaker and would like to share something about what it was like to speak in this exercise. Anyone? Yeah. I guess I found myself hoping that I would actually, at some point be interrupted. Like I was rambling and at some point I was thinking, ok, I need to stop so that they can say something. So it is a Monica move. Yeah. And you notice that discomfort? Yeah. That's interesting. That's not the first time that I've heard that. Right. Yeah. So we're not used to being alone with our thoughts and words. Yeah. Wonderful. So a little bit of uncomfortable. Did anyone feel comfortable, like, appreciated being able to share their full story? Yeah. Yeah. Yeah. It was, it was nice to talk. I was talking about something that happened to me at work and because I was talking to somebody who works in the same profession because I didn't have to put context because I realize now that when I talk to people, I always try to put context into it instead of just getting, getting to the heart of the matter because I think people aren't gonna understand me if I don't put it in context. Ok. Great. That's good. All right. One more. Yeah. In the back. Um I definitely felt the pressure of, oh, I need to make this story interesting. Not because my listener was, my listener was an excellent listener and I was like, oh my gosh, my story is actually kind of stupid. And, um, you know, like, I, I was kinda forced to hear myself and listen to myself more because someone else. Yeah. So one thing I would say is when we pay attention, sometimes we begin to attach judgments to what we notice, right? And so one of the pieces of mindfulness, right? One of the practices is really trying to um approach that with non judgment just noticing it. Isn't that interesting that I should feel pressure to keep talking or to make an interesting story, right? That that's hard work that takes a lot of practice, right? Yeah. OK. Super. All right. So how could we think about this kind of communication in a teaching setting with learners? Well, what if we use this in feedback? Right? What if we invited a learner to share their perspective? Right? And we approached it with curiosity, right? They might do a lot of the talking and actually come up with the issues and the solutions on their own, right? When we trust our learners because in many situations they can do that, right? We can use this type of language when we're coaching learners about getting better at something. Right. Right. Figuring out what their perspective is. What's their frame? How are they understanding what's going on to help them, maybe see it a little bit differently to improve, right? It might be helpful when we're working with a learner who's really struggling through remote mediation, right? Or around more challenging issues like professionalism, right? Um Or you know when debriefing mistakes, errors, critical events, right? This kind of language, really listening to others. Um the other way that we can um use mindful co communication is when we're really thoughtful about how we use questions, right? We use questioning a lot in medicine, right? But we can use them, I think a little bit more mindfully, right? So we can use questions to assess a learner's goal in learning, right? So what are you working on? What would you like to be back on? What are some learning points for you today? What is still unclear, right? Maybe assessing where a learner's learning stance is, right? Is there anything going on for you that's making it hard for you to focus on your learning, right? Um Maybe using questions in a way to probe deeper learning as opposed to just have them feed you back information or a list of causes of an illness or whatever it might be, but to really have them think through um processes, right? Explain your thinking to me. How is this situation with this patient different from that other patient? Right? What will you think will happen? What do you think will happen if we treat with this or if we stop that medication? Right? Or if we make this recommendation? Right? I think mindfulness is a great sort of metaphor for making space for learners to respond, right? And valuing their responses, right? And really avoiding this sort of what am I thinking question? Right? Where there's only one right response, right. This is, I think the non striving piece, right? OK. So that sums it up. Um So I'd love you for you to think about mindfulness, incorporating more mindfulness into your teaching. Right? And I would love to hear if you would like to share something that you learned today or something that you think you'd like to do differently in your teaching or just in general based on the discussion that we've had together and we have one minute to do that. I try to stay mindful of the time. Yes, I would be intense. Understand that. Yeah. Wonderful. Keep practicing. I'm practicing all the time. Yeah. Is there? Yeah. Um, just being less focused on the clock and in a moment it's ok that two or three extra minutes that you spend doing something is not going to totally throw your whole day off, but may actually make it more productive. And that so being attentive and not worrying about. Yeah. Ok. I like the idea of asking when you're working with students asking questions that only they know the answer to. I think oftentimes we get stuck or I get stuck in this pattern of asking questions that I also know the answer to. And so I want to see if they have the quote un quote, right answers which focus differently on questions that they only know the answer to and that we can just have a, would have been learn that the less time that you think you have to be my time you should probably spend. Yeah. Yeah. I'd like to share one thing that I already do be much maligned, you know, before we click print after visit summary we're supposed to answer. Is there anything else I can do for you or anything else? Him and sometimes they've been working on something, the whole prison. I, I call it a doorknob that, that you almost tear your hand on the doorknob and they say, 01 more thing and it might be the most important thing in the prison. Yeah. So making space for that. Ok. Yeah. All right. Well, thank you all very much. I enjoyed being with you. Bye.
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