Reflective practice and mindfulness
Reflective practice is the ability to reflect on one’s actions so as to engage in a process of continuous learning.
Studies have shown that self-reflection and mindfulness practices can decrease burnout, improve clinician satisfaction and maintain compassion. Mindfulness, empathic communication and listening skills leads to better mood perception, lower stress perception, and an ability to respond to stimuli more effectively. These impacts are not only important for physician well-being and excellent patient care but also to assist in changing the culture of medicine.
As medical students and future physicians, many stressors impact your life. Whether these stressors are personal, professional or academic, there’s a risk that they will lead to fatigue, depression or burnout. Burnout matters – it is associated with negative consequences for patient care, the physician workforce, and physicians’ own care and safety.
Your faculty are committed to your wellness. One of our aims as College faculty is to create a space for community where students and faculty can develop relationships of support and opportunities for reflection. As future physicians these tools can help to maintain your health as you prepare for a lifetime of caring for others.
Reflecting on Practice
Over the course of FCM there will be many opportunities to reflect on practice individually and in small groups.
Dr. Tony Back who is a medical oncologist and palliative care physician at Harborview Medical Center shares some brief thoughts about mindfulness and reflection.
Some of these reflections will involve more formal discussion or written reflections related to a specific prompt or question. It is also possible to use the skill of reflection more informally and briefly during clinical, professional or other interpersonal encounters. So how do we do it?
Dr. Back shares how a brief reflection practice impacted the care of his patient.
We look forward to practicing these skills with you.
Practicing reflection in our professional spaces helps us to have an open mind and allows us to acknowledge and connect with our emotions and the emotions of our patients. Reflection helps us to consider others’ perspectives. It also helps us deepen our learning through identifying learning gaps, errors or problems. It creates space to foster a growth mindset and develop plans to tackle our learning goals.
Mindful and reflective practice has been shown to encourage patient-centered and empathic care, improve quality of care for patients, and improve clinician well-being. Reflection requires observation, introspection, and articulation. Having an intentional approach to reflection can help to deepen the impact of the learning. Over the course of the Foundations of Clinical medicine course we will have many opportunities for reflection. When these opportunities arise we would like you to start practicing brief reflections before, during and/or after academic and clinical encounters. Utilizing the mnemonic SPARK can give you a systematic approach.
Mindfulness Skills
Mindfulness, as described by Dr. Jon Kabat-Zinn, the creator of mindfulness-based stress reduction (MBSR), is the practice of moment-to-moment, open-hearted awareness, focused in the present. It is a process of intentionally paying attention to experiencing the present moment with curiosity, openness and acceptance of each experience without judgment.
In FCM sessions, you will learn and practice a variety of mindfulness skills. The ones you choose to use may change depending on your preference, the situation or the emotions you are feeling – the important thing is to keep practicing so that you have tools to call on when you need them
Stretching
Stretching is a practice that can be done quickly and is important for body awareness.
“In the moment” office stretches:
- In a chair sitting twist your body, holding it for 5 seconds.
- At a desk do a modified downward dog, stretching your shoulders, arms and back.
- At a desk do a modified side plank, stretching your chest and arms.
- Standing do a sun salute, stretching your back and neck.
- Stretch fingers, and wrists.
Grounding
Grounding brings our body’s attention to the present moment and helps us to presence (listen mindfully and deeply).
This is a way we can ground:
- Sit up straight, feet on the floor, ground yourself, feel the support of the floor or the chair, be aware of our bodies, areas of tension, and relax our centered body.
S.T.O.P.
S.T.O.P is a brief, resiliency practice that can help decrease stress and improve focus.
Presencing/mindful listening
Presencing is mindful, deep listening where we listen without judgment and focus on just being present and aware.
H.A.L.T.
Consider HALTing when you notice yourselfing getting frustrated or overwhelmed or you are losing compassion or empathy. Stop and reflect on the immediate moment and how you are feeling. Is there something that could be contributing to you not being your “best self” right now or not being able to maintain compassion? Is there a way to address this in the moment or soon thereafter? This reflection can provide some concrete ways to reflect on your current emotions and needs.
Quiet mindful breathing
Quiet mindful breathing techniques are another way to ground. There are two main breathing exercises to explore: basic breathing, and Tonglen.
Basic breathing
There are many different basic breathing techniques to help one become present in the moment. Here are just a few
Diaphragmatic breathing
- Lie down on a flat surface with a pillow under the head and pillows beneath the knees. Pillows will help keep the body in a comfortable position OR sit comfortably, with your knees bent and your shoulders, head and neck relaxed.
- Place one hand on the middle of the upper chest.
- Place the other hand on the stomach, just beneath the rib cage but above the diaphragm.
- To inhale, slowly breathe in through the nose, drawing the breath down toward the stomach. The stomach should push upward against the hand, while the chest remains still.
- To exhale, tighten the abdominal muscles and let the stomach fall downward while exhaling through pursed lips. Again, the chest should remain still.
4 box breathing
- Breathe in counting to four slowly. Feel the air enter your lungs.
- Hold your breath for 4 seconds. Try to avoid inhaling or exhaling for 4 seconds.
- Slowly exhale through your mouth for 4 seconds.
- Repeat steps 1 to 3 until you feel re-centered.
Tonglen breathing
This is an ancient Buddhist healer’s breath (meditation) that increases empathy, and our ability to be present to ourselves and others.
In our culture we are taught to breathe in all our positive energy and get rid of our negative energy. This ultimately is a selfish breath. The Tonglen teaches us to breathe in negativity and transform it. Our heart and bodies have the capacity to heal. We breathe in the negative, transform it in our hearts, and breathe it out as positive clean air, as light, healing and love. That air bathes us and others in healing.
References
West CP, et. al. Physician burnout: contributors, consequences and solutions. J Intern Med. 2018 Jun;283(6):516-529. PMID 29505159
Compassiononics: The Revolutionary Scientific Evidence that Caring Makes a difference (authors: Trzeciak & Mazzarelli)
Edgoose JY, et. al. BREATHE OUT: a randomized controlled trial of a structured intervention to improve clinician satisfaction with “difficult” visits. J Am Board Fam Med. 2015 Jan-Feb;28(1):13-20. PMID: 25567818
University of Washington, a guidebook for Well-Being for Life & Learning with the aim of integrating more practices to support student well-being .
