Building resilience in times of uncertainty

Grounding his work in academic theory, mindfulness expert Dr. Ron Epstein will explore how mindfulness practice can be used by physicians to manage stress and build resilience in times of uncertainty.

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About Dr. Ronald Epstein

Dr. Ronald Epstein is a leading authority on communication and mindful practice in medicine and on patient/family-centered care. He's the author of Attending: Medicine, Mindfulness, and Humanity, the first book for the general public about mindfulness in medical practice. Dr. Epstein is a professor at the University of Rochester School of Medicine and Dentistry, co-director of its Mindful Practice Programs, and director of its Center for Communication and Disparities Research.

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Building resilience in times of uncertainty

Dr. Jillian Horton:

Welcome to the COVID-19 physician learning series brought to you by Joule and the Canadian Medical Association. I'm Dr. Jillian Horton. I'm a general internist, medical educator, writer, and podcaster, and I'm your host for this series. The clinical applications of mindfulness and patient care are well described, but there's also a significant body of work showing that health care providers can enhance both their quality of care and their quality of life by learning how to apply mindfulness for their own practice.

Dr. Ron Epstein has been at the forefront of this topic for more than 20 years. With this session, it's our intention to provide you with a deeper understanding of how you may be able to employ mindfulness, to mitigate some of the stress and distress that you are undoubtedly experiencing in response to current events. Dr. Epstein is joining me today from the University of Rochester. Ron, thanks for taking the time to be with us today.

Dr. Ron Epstein:

It's really a pleasure. Good to see you, Jillian.

Dr. Jillian Horton:

You, too. Ron, just to begin, can you remind everyone of what we're talking about when we talk about mindfulness?

Dr. Ron Epstein:

We're talking about an attitude of mind, a purposeful attentiveness to things that are the most important, and all with the idea that you can actually regulate your own attention. You can regulate your reactivity to situations, pleasant ones and unpleasant ones. And it's a quality that we all have. But we can often cultivate a bit more of it.

Dr. Jillian Horton:

Some people will say that mindfulness right now is irrelevant. And I can just imagine, and I know you can too, colleagues saying these people are out to lunch, I don't need mindfulness, I need ventilators. I need PPE. So can you talk for a bit about why that kind of reaction misses the point of mindfulness and our need for other techniques for self-regulation, especially during times of crisis?

Dr. Ron Epstein:

I'm not going to debate the importance of having ventilators and supplies that keep us safe, but there are other ways of keeping ourselves safe and healthy and connected that are equally important. One is understanding what your own reactions are to a situation. You'd think that in a situation that's difficult, aversive, gut-wrenching, nauseating that you'd want to turn away from your feelings.

But we all know that eventually our feelings catch up with us, and they direct our behavior in ways that may or may not be the kinds of reactions that we want to have to those circumstances. So mindfulness is a conscious and purposeful turning towards and examining being curious about and being present with those experiences of distress to the point that they can actually direct us to do the things that are in the best interests of our patients and best interests of ourselves.

So why now? I think that we're all facing a tremendous amount of uncertainty. And in fact, we're even uncertain about how uncertain we should be. It's what's called epistemic uncertainty. A sarcastic uncertainty is the kind of uncertainty that you would have, for example, if you know that in a certain situation, 70% of people will benefit from a treatment and 30% don't. And you just wonder whether you're in the 70% or 30%.

But with the current situation, we're in a situation of epistemic uncertainty. We just don't even know what the rules are, what the bounds are. And so trying to figure those things out through problem solving work only up to a certain point. And at a certain point, we have to recognize that there is going to be parts of this uncertainty that we just can't-- we can't get rid of, we can't put away.

So in my view, a healthy reaction to that epistemic uncertainty is curiosity. It's an opening up. It's trying to understand, trying to see this exceptional patient that does well why is that happening. And it's only with a certain kind of openness that you can actually begin to see and appreciate and act on those observations. So we're not talking about the kind of mindfulness that we all think about sitting by a still pond, Lotus flowers, beautiful scenery, warm day. We're talking about the kind of mindfulness that during a cope or during an incubation or during assessing a patient who you know is not going to do well, and anticipating talking with that patient and their family. And so what is the attitude of mind that will be your best guide during those kinds of circumstances? That's what we're talking about.

Dr. Jillian Horton:

I wonder if we could talk about mindfulness and some of the literature around it. Can you talk about the evidence for its application in high stress medical environments?

Dr. Ron Epstein:

There is a little bit of evidence on mindfulness training, for example, of CPR teams, and showing that when you train teams to be more mindful, the outcomes are better, and also the communication among the teams seems to be improved. And we know that that resuscitation can often be quite chaotic. People don't always listen to each other. It's hard to know who's in charge. Information transfer often gets lost. So people are able to stop and pause before reacting and focusing collectively on that, which is most important. Then the outcomes, it would seem would be better.

There's better evidence from other places outside of medicine. For example, among first responders and also in the military. And the military has really jumped on using mindfulness as a way of preventing irrational behavior in the face of extreme stress. So to not have repeat performances of some of the horrors of war and rather have teams or units or individuals be able to stop, take a breath, assess the situation, achieve a certain degree of focus, attentiveness, and calm, and presence before proceeding.

It's not that this all takes a long time. When you practice mindfulness techniques, you can bring them to bear on situations that require very quick decisions. Surgeons know this. I mean, you have to cultivate a certain degree of mindfulness in order to deal with the unexpected in the operating room. And that's really the test of a good surgeon. I'm not a surgeon myself, but I do know that learning the technical skills, learning how to operate instruments and suture and those cuts are really only part of the picture. It's that moment to moment decision making that distinguishes a good surgeon from a great surgeon. I think it's the same thing that's true of us confronting the uncertainties during this current time that if we're able to step back understand our own thoughts and feelings a little bit more in touch with those, it allows us to listen to others better and act better in patient-- on patients' behalf.

Dr. Jillian Horton:

I want to talk for a few minutes about resilience. And we both know that resilience is sometimes a word that makes physicians and learners bristle because it's perceived as an accusation or problem with us that we're not strong enough to withstand a very challenging or stressful work environment. But there are other ways to look at resilience, and I wonder if you could talk about your definition of the word and why people shouldn't resist the concept of working even now to increase their own resilience.

Dr. Ron Epstein:

I'll start off by saying that by virtue of surviving organic chemistry, medical school residency, and whatever came after that, we all as physicians are intrinsically very resilient. And I would say that that's also true of nurses and other people who are on the front line of health care, social workers that resilience is just-- and we have that propensity. What I notice, though, is that there is kind of resilience in the short term getting through an acute crisis. And there's also this more long-term resilience of not letting the stresses of clinical care wear you down over time.

So the short term resilience, I think, we generally do pretty well versus long-term resilience that concerns me more. Long-term meaning more than an hour or a day when things start going on for days or weeks. So resilience was an idea that was first developed by engineers. And you think about it the-- you're building a building and there's a strong wind, the building will actually bend a little bit, but what you want is for the building to actually restore itself to the shape that it was in previously. So it's a restoration to a previous stage of stability. But living organisms don't work that way. Living organisms are growing. They're always regenerating in a way.

And so embedded in resilience is the necessity for growth. So if you were under a stress and just simply return to your previous resting state but didn't regenerate the cells in your body that were somehow damaged in the process, you wouldn't really be a resilient individual even though superficially things seem-- would seem to have gone back in balance. So although it may seem pollyannaish to say that in the midst of a crisis like what we're experiencing now, we all should experience some form of growth. In fact, if we didn't, we would start to crumble. So embedded in this idea of resilience is that it is to find those things that help us grow, and not just grow physically, but also emotionally and spiritually that the things that sustain us that help us increase our potential as humans.

And I think in terms of mindfulness, that falls into four categories. One is attention. We want to grow our capacity to pay attention to the right things. Growing the ability to be curious, especially when situations are stressful, and we feel like shutting down. That capacity of opening up. So I'm a palliative care doctor and frequently deal with situations in which there's tremendous conflict within families or between families and clinicians. And it's so tempting to want to kind of shut that conflict down, and just speed up and to try to resolve things quickly. But in fact, if you slow down and listen, and don't act quite as quickly, often things actually resolve themselves more quickly. So that really has to do with opening up and being more curious.

The third has to do with a beginner's mind, and especially important in situations that are unanticipated and novel so that if we're trying to apply situations from the 1918 flu pandemic to the 2020 of COVID pandemic, we're going to be right some of the time, but a lot of the time we won't be. Obviously technology has changed, but if we go back a decade and look at SARS and try to apply those sorts. So we need to actually have that ability to see the situation for what it is, which is something that's unique. And in fact, to see each human being is unique. So that's attentiveness, curiosity, beginner's mind.

And the fourth thing is presence. And that's perhaps a bit harder to define, but we all know what it feels like when we are present with someone else. And we know what it's like when someone else is present with us. And in health care, that's always important, but especially important when things are so overwhelming that we just want to withdraw into ourselves. And there are lots of ways of being present, and some of them are pretty simple.

So one thing that I've been doing since this all started is just making a point to call or email or text or send a brief message to a friend or colleague that I otherwise might not have. So it's creating a sense of virtual presence. It doesn't have to be an hour long Zoom session, it can be a two line text. And just that sense of connectedness with colleagues creates a sense of collective presence.

With patients, the more complex and difficult the situation we find ourselves in, the more important it is to take 30 seconds or a minute or a minute and a half at the beginning of every encounter just to listen. Even though you might have an agenda, even though there might be some urgency, say, OK, what's going on with you? And just stop and listen. That has a few effects. One is it helps you be more attentive and curious and open to what's really novel about this situation.

And the second thing is that the person you're with is actually feeling hurt, and we know that that will reduce their sympathetic activation. They will think it'll help them to listen to what you have to say. So just investing 30 seconds or a minute in the beginning.

Another way to be present is to find ways of taking brief pauses during your day. By brief, I mean, two seconds or three seconds. So you've just finished up with one patient and you're going into the next cubicle to see the next patient, what do you do? Ron, we wash our hands. You draw your answer. But what do you do mentally during that time?

So we know about cleansing your hands during that situation, but what do you do to be able to set aside what's just happened in the previous encounter so that you can actually listen and be present and best serve the needs of the next person? So something that I do habitually is just when I touch the doorknob, the door handle, I take a breath. I mentally set aside what's just happens. I don't suppress it. I know it's there. And then with that breath feel a sense of openness when I'm about to see the next patient.

There's always a tendency to deny and minimize. And I guess the extreme of that would be to sugarcoat the situation. And especially now people see through that pretty easily. And I would ask-- and we all have that tendency. I kind of want to make things better, right? It's a human tendency. We don't want to see people suffer or want to anticipate seeing them suffer. But by sugar coating, it creates a sense of distrust and falseness because we all know that this is serious.

Now you don't have to hang crepe and talk about doom and gloom. That's where the idea of beginner's mind comes in because when things are uncertain, especially in that situation of epistemic uncertainty, we don't know what's going to happen next. And whether that not knowing there's always hope. There's always room for optimism. And so it's just by confronting that catastrophe of the situation that we're in, it actually opens the space for real hope as opposed to pretend the situation is somewhat different.

And the final thing that I'll say is that one of-- some of the best advice I've ever been given is never to worry alone. So don't worry alone. So when you're feeling afraid, and all of us are going to be feeling afraid. Afraid for ourselves, afraid for our families, afraid for our jobs, afraid of something. Two things, seek out connection with yourself. We are all resilient. We are all robust. We're all strong. And so seek out knowledge of that part of yourself. We've all dealt with adversity before.

And then aside from seeking out connection with yourself, seek out connection with others. And think of those who nourish you. There are people who need you, and it's important to reach out to them. But at these moments when you're feeling very afraid, think about the people who nourish you the most. Again, it could be a two line text, it can be a brief phone call. It can be an email. It could be whatever. But just even establishing that bridge, that connection is important.

Dr. Jillian Horton:

Ron, you and your colleague, Mick Krasner, have been running mindfulness retreats for many years. And I've participated in them, and my experience was so transformative that I went on to train to teach with you. But it strikes me that in addition to mindfulness, one of the core restorative aspects of that experience was peer support. And can you talk about why peers and community have proven to be such an integral aspect of doctors learning mindfulness?

Dr. Ron Epstein:

As important as it is to be mindful, it's also difficult. Looking at the dark side of things, looking at your own difficulties being unflinching in your willingness to see situations as they are as opposed to how you like them to be is hard work. And part of the reason that people do this in communities and classes and in collectors as opposed to alone is because even if you're not necessarily talking about the struggles that you're having yourself, you know that other people are approaching the struggles they have with that same intention, that same sense of purpose, that same commitment to doing the right thing, to being compassionate, to being clear, but to being effective.

And that's incredibly powerful. You can kind of feel it when you go into a room of people who share a common purpose. And when you leave that room, that sense of common purpose doesn't disappear. And now you need ways of maintaining connection around that. And now that we have so many ways of doing that, even though we have to be two meters away from one another, and sometimes have meetings at long distance, it's still possible to maintain that sense of connection.

Dr. Jillian Horton:

It's our goal in this series to leave listeners with things that they can deploy right now to improve their locus of control in this situation and their sense of well-being. So could we spend our last few minutes talking about active listening and how we can employ it in an online format?

Dr. Ron Epstein:

Well, I think the virtual presence that we created online is generally more powerful with those that we've actually had some kind of physical presence with. So I would say that there are really two categories of maintaining that sense of online connection. When it's with people that you-- Like example, I have a young grandchild, now three months old in Los Angeles. I have been there twice before the whole COVID thing happened. And doing Zoom or various other online platforms, the translation between the physical presence and emotional presence is much more possible.

When they're with people you don't know, when it's a work meeting or with people you don't see very often, there are some few tricks, one, is don't talk for too long. Talk for 30 seconds or a minute, leave a space so that other people can talk because it's so much easier to tune out in an online format. It's so much easier to flip your screen so you're checking your email. And so making a conscious effort to be more interactive.

It is possible to make eye contact. It's tricky because you have to look at the camera and not necessarily the face of the person that you're talking to, but periodically, glancing at the camera as if that were the face is another way of maintaining a sense of virtual connection. Trying to understand what the other person's intention is. So we get a lot from gesturing and posture, and we can see a little bit of that on screen, but it's not quite the same as if it's three dimensional. So trying to visually imagine. And I guess frequency and familiarity with the medium. So it feels kind of odd at first, and then after a while, it feels familiar.

And then finally, know your saturation point. It's interesting because-- for me because the physical distance has actually made my connections with family and colleagues stronger. I'm actually communicating with colleagues more in depth than I would do in my everyday life when I'm rushing around doing other things. But I think there was one day when I had six straight hours of Zoom meetings, and I just couldn't-- I mean, six straight hours of in-person meetings is difficult enough, but I think that our tolerance for online formats is much just recognize. So now I schedule my meetings for 50 minutes rather than an hour so I actually have some breathing time in between. I think we'll all figure out our way through this. It's not the way we all wanted to have had to learn. But I do think it's a way of increasing social connectedness while physical distance is mandatory.

Dr. Jillian Horton:

And Ron, before we close today, could you talk about vagal activation and breathing and leave our listeners with something simple that they can do going forward starting today?

Dr. Ron Epstein:

Yeah, so I've mentioned two other simple things previously, one is what you do when you go from one room to the next, and what you do when you touch the door handle [INAUDIBLE] taking your breath. And then spending the first few minutes of any encounter listening. But the third thing I'd like to leave you with is just a brief breathing exercise. And we can actually control vagal tone. So this exercise has been one of many things of ways of actually helping you lower your own heart rate, lowering your oxygen to the end, lowering the speed of your thoughts so that you can actually not feeling quite so overwhelmed. And it's really simple. It just involves taking an in breath for a count of four, holding your breath for a count of four, and breathing out for a count of four. And then take a few normal breaths, and then do that again.

And this is something that you can do while you're on rounds, while you're going about everything-- your everyday work. Doesn't have to be a particularly deep breath, but just consciously regulating a few breaths will actually lower your vagal tone. So you could do and try that now. So I can guide you through it. And then, again-- and just to see what it's like for you.

So when you're ready to take an in breath. Do so counting to four, one two, three, four. Holding for four, one, two, three, four, and then exhale for four, one, two, three, four. And then taking a couple of normal breaths, and then at your own pace, doing it again. OK, and then maybe take a couple of other normal breaths, and a third time, one, two, three, four. Hold, one, two, three, four. Exhale, one, two, three, four.

It sounds ridiculously so simple, but as with many, I see mindfulness as a practice. It's not just a thing. And so finding one thing that you can practice every day, and do it over and over again. It's like learning a piece of music. It's like learning to play tennis. It's like learning to be a good surgeon. It's the acquisition of habit. And if you practice a simple breathing exercise like this, you'll find that it comes back to you at the times when you're afraid of stress, the times when you are in a cold situation or some other acute situation.

And you-- there are so much that you can't control in those situations. But you can control your response and your reaction to that situation. And if that response is to be more present, to be calmer, to be more available, to begin to see the novelty of that situation and that particular unique solutions of that situation requires, then your day will have been better than it would have otherwise been.

Dr. Jillian Horton:

Ron, I want to thank you so much for setting aside the time to spend with us today sharing your knowledge and experience.

Dr. Ron Epstein:

It's been a pleasure. Thank you.

Dr. Jillian Horton:

I'm Dr. Jillian Horton. And thank you for joining us for this COVID-19 webinar series powered by Joule. Take care of yourselves. Thank you for all that you do. And I'll see you again soon.

Building resilience in times of uncertainty

About Dr. Ronald Epstein

Topics

Know what to do when a peer is experiencing significant stress

Maintaining wellness during a pandemic

COVID-19 learning series

How to care for health professionals during crisis and beyond

Trauma-informed Medical Education

COVID-19 and Moral Distress

Are you in distress? Get help now.

Building resilience in times of uncertainty

About Dr. Ronald Epstein

Topics

Related resources

Know what to do when a peer is experiencing significant stress

Maintaining wellness during a pandemic

COVID-19 learning series

How to care for health professionals during crisis and beyond

Trauma-informed Medical Education

COVID-19 and Moral Distress

Are you in distress? Get help now.

Building resilience in times of uncertainty