1. Being with suffering Ronald Epstein, MD Timothy Quill, MD Michael Krasner, MD Scott McDonald, MD Mindful Practice Module 2 Departments: Family Medicine, Internal Medicine, Psychiatry Divisions: Oncology, Medical Humanities, Palliative Care

2. 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

3. Domains of suffering Physical Emotional Social Economic Existential Spiritual

4. In what ways do physicians commonly respond to suffering? Unhelpful ways In Between Helpful ways

5. 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

6. 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

7. Witnessing suffering mindfully: a walk on the wild side…

8. 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

9. 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.

10. 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?

11. 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

12. 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.

13. Formal practice

14. This being human is a guest house. Every morning a new arrival. A joy, a depression, a meanness, some momentary awareness comes as an unexpected visitor Welcome and entertain them all! Even if they are a crowd of sorrows, who violently sweep your house empty 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 sent as a guide from beyond. The Guest House Rumi, 13c

15. 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

16. Questions…

17. 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.