Being with suffering

Ronald Epstein, MDTimothy Quill, MDMichael Krasner, MDScott McDonald, MD

Mindful Practice Module 2

Departments: Family Medicine, Internal Medicine, Psychiatry Divisions: Oncology, Medical Humanities, Palliative Care

What we hope you will learn

Describe physicians’ common reactions to suffering

Describe helpful and unhelpful responses to suffering

To be mindful of your own reactions when encountering suffering in clinical settings

To use these insights to be more mindful and compassionate in patient care settings

Domains of suffering

Physical Emotional Social Economic Existential Spiritual

In what ways do physicians commonly respond to suffering? Unhelpful ways

In Between

Helpful ways

Mindful practice

Moment-to-moment purposeful attentiveness to one’s own mental processes during every day work with the goal of practicing with clarity and compassion

A mindful response to suffering Being attentive both to the patient’s experience and

to your own reactions

Maintaining curiosity and interest

Seeing the situation from more than 1 perspective

Being present, without being overwhelmed, and without disengaging

Witnessing suffering mindfully: a walk on the wild side…

Paired interview: suffering Find a partner Focus on a time when you were present for a

patient and/or family in a moment of deep sadness and suffering; perhaps a time… When you dealt with a patient/family whose suffering

moved you or affected you in some way When you had to cause pain such as giving bad news or

doing a painful procedure When you yourself experienced suffering in having to deal

with a very unpleasant task or situation Perhaps jot down a few key elements of the story

before telling it to your partner

Take 10 minutes For the storyteller,

address:

What happened?

What helpful qualities did you bring to that moment?

Who else was involved, and how did they contribute?

What aspects of the context made a difference?

What lessons from this story are useful to you?

For the listener:

Be attentive, don’t interrupt

Ask questions to help your partner clarify and provide details

Don’t talk about your own ideas or experiences

Use reflective questions and empathy when appropriate

If you get done sooner, just be silent. We’ll let you know when it is time to switch.

Debriefing:Discuss your reactions to the exchange Now discuss your personal reactions to

telling and hearing the story Thoughts Feelings Bodily sensations

What did your partner say or do that was helpful?

What The Doctor Said

by Raymond Carver

He said it doesn't look good

he said it looks bad in fact real bad

he said I counted thirty-two of them on one lung before

I quit counting them

I said I'm glad I wouldn't want to know

about any more being there than that

he said are you a religious man do you kneel down

in forest groves and let yourself ask for help

when you come to a waterfall

mist blowing against your face and arms

do you stop and ask for understanding at those moments

I said not yet but I intend to start today

he said I'm real sorry he said

I wish I had some other kind of news to give you

I said Amen and he said something else

I didn't catch and not knowing what else to do

and not wanting him to have to repeat it

and me to have to fully digest it

I just looked at him

for a minute and he looked back it was then

I jumped up and shook hands with this man who'd just given me

something no one else on earth had ever given me

I may have even thanked him habit being so strong.

Formal practice

This being human is a guest house.Every morning a new arrival.

A joy, a depression, a meanness,some momentary awareness comesas an unexpected visitor

Welcome and entertain them all!Even if they are a crowd of sorrows, who violently sweep your houseempty of its furniture,still, treat each guest honorably.He may be clearing you out for some new delight.

The dark thought, the shame, the malice,meet them at the door laughing,and invite them in.

Be grateful for whoever comes,because each has been sentas a guide from beyond.

The Guest House

Rumi, 13c

Home practice

Stop, breathe, be. For the next week, each time you begin a new

activity, or see a patient, stop momentarily before beginning, take a breath, and then begin.

Formal practice Two minutes each morning Two minutes each evening Increase as tolerated

Questions…

Readings

Emanuel, L. The privilege and the pain. Ann Intern Med. 1995 May 15;122(10):797-8.

Cassell, EJ. The nature of suffering and the goals of medicine. N Engl J Med.1982 Mar 18;306(11):639-45.

Kannai, R. The genogram. Ann Intern Med. 2006 Nov 21;145(10):786-7.

Rumi, J. The guest house. In: Essential Rumi by Barks, C. 1997. Harper press. San Francisco.

Carver R. What the doctor said. In: A new path to the waterfall. New York:The Atlantic Monthly Press, 1989:113.

Connelly J. Commentary. Acad Med. 2008 June;83(6):588-89.