Heroes Not Zombies

Mindfulness has become very popular, especially in America, where it has been pioneered by Jon Kabat-Zinn and others, but also in Europe. The French term for mindfulness is “en pleine conscience” – which more literally translates as “in full consciousness”.
I think it’s become so popular because it’s so helpful, particularly in the field of mental health where it has been developed through “Mindfulness Based Cognitive Therapy” (MBCT) to treat depression, and through “Mindfulness Based Stress Reduction” (MBSR), which does what it says on the tin.
But it’s more than a psychological tool for easing mental disturbances. It’s been found to influence the patterns of neurones and their connections (synapses) in the brain. Yes, it seems to actually have an influence on not just the function, but the shape, of the brain. This takes it into a realm beyond that of a therapy for diseases. As it develops the brain, so it can expand the mind. In other words it seems to have the potential to aid creativity, the growth of emotional intelligence and to increase resilience.

Freedom vs control
All through my working life as a doctor I was keen on therapies which did more than merely reduce suffering. A treatment which simply suppressed symptoms or kept a disease process under control, while potentially valuable (because who wants more symptoms and more disease?) was never that satisfying to me. I was always way more impressed with a therapy which enabled people to deepen their understanding of themselves and their lives, and free them up to grow and develop, to make life changing decisions, and, in so doing, to transform at least some of the underlying factors which caused their illnesses.
Mindfulness meditation is one such therapy. But then so are the exercises which enhance cardiac coherence, like “Heartmath”. And so are other meditation practices, whether they be “Vipassana meditation”, “transcendental meditation”, guided visualisation or “compassion meditation”.

Paying attention and non-judgement
As best I understand it, there are two fundamental tenets of mindfulness –

• Paying attention
• Non-judging

I would claim that these were the key tools of successful medical practice long before “mindfulness” became so popular in the West.
The absolute best I could ever do for any patient required that I paid attention to them, giving them my full focus, living together in the present time and place of the consultation. And that I listened with a determination to do two things – to understand them (through empathy), and to help them. I often thought that these were exactly the reasons why people came to consult me – to be understood, so that they could understand what was happening in their lives, and their bodies; and, to be helped, because they’d reached a place where they couldn’t solve their difficulties alone.
The non-judging part was equally crucial, because it’s one thing to pay attention, but if you judge what you hear it’s very hard to hear clearly. Judgement stops thought, as Hayakawa, the “general semanticist”, wrote in “Language in Thought and Action”

“A judgement is a conclusion……The premature judgement…often prevents us from seeing what is directly in front of us”

Diagnosis
Of course a diagnosis is a kind of judgement. It’s a summing up of the patient’s story, their symptoms and their signs. Diagnosis surely is the key to successful treatment. If you don’t know what you are treating, how can you offer the best treatment? So, I wasn’t against judgement as such, just “premature judgement”. In other words, trying to avoid reaching a diagnosis before I’ve paid sufficient attention.

Always more to discover
Ah, yes, I’m sure you’re thinking….so what is “premature” and what is “sufficient”?
And those are great questions. The answers to which are always “time will tell”. You can never be 100% in any particular moment that you’ve grasped the full story, that you’ve completely understood. In fact, it was quite common that patients would tell me towards the end of the consultation that they’d never told anyone the things they had just told me. But I’d respond to that by saying I don’t think anyone can be fully understood. In fact I think we each spend a lifetime trying to better understand ourselves and I’m not sure any of us reach a final, full point of understanding. There will always be more to discover.

“There will always be more to discover”

would be one of my mottos.

The ongoing relationship
Even when I’d made a diagnosis and initiated a treatment, it was important to follow through and follow up. To meet the patient again after an interval and to begin the loop of the spiral – to pay attention and to listen without judging. Failure to do that meant I’d potentially mis-judge how helpful the treatment was for this individual, and would deny me the opportunities to understand them even better.
It wasn’t unusual to hear a story from a patient which transformed my understanding of them, a story told by them several years into our therapeutic relationship. People who had told me several times things they said they’d never revealed to anyone else, could, after many, many consultations, tell me something of fundamental significance which they’d never even hinted at before. That kept me humble and reminded me of my motto “There’s always more to discover”.
I should just add here that my experience of sharing work with colleagues showed me time and time again that I could never say I was always the best person for the patient to work with. Other colleagues would discover things I’d never discovered, just as I’d discover things they’d never discovered. “There will always be more to discover” reminded me to be humble. I should never claim that I was “The One” who “knew best”.

Personalised Medicine
I think it’s those last two points which are forgotten about by some of the adherents of “Evidence Based Medicine”. The only way to know if a treatment is effective for this individual is to continue to pay attention, non-judgementally, to them. The Randomised Controlled Trials, and met-analyses, might help you to select a treatment but the proof is always in the experiencing, the personal experiencing. Only this patient can tell you whether or not their pain is improved, they are sleeping better, they feel less depressed, they can move more easily, or whatever. Only the changes in your measurements of this individual’s body can reveal the success or otherwise of this treatment. The truth is revealed in the follow up.

Personal benefits of medical practice
Finally, I think the work of a GP is a kind of mindfulness training in itself. When consulting at a rate of about ten or fifteen minute intervals you encounter a lot of different people in one day. For each and every one of them you have to be fully present and give them your complete attention. The moment they walk out of the door, and the next patient walks in, you have to stop thinking about them and switch your attention to the person right here, right now. It’s a continuous practice of attending, letting go, and attending again. It’s also a great non-judgement training. Again and again you seek to avoid rushing to conclusions, and again and again, you have to be prepared to drop your diagnosis because now you see there is a better one.
I felt blessed in many ways working as a doctor. Paying attention and listening without judging allowed me to reach levels of understanding with others which felt like a privilege. And, maybe it helped my brain while I was at it! I’d like to think so.