Excellent patient care requires not only the knowledge and skills to diagnose and treat disease but also the ability to form therapeutic relationships with patients and their families, recognize and respond to emotionally demanding situations, make decisions under uncertainty, and deal with technical failures and errors. These capabilities require that clinicians have self-awareness to distinguish their values and feelings from those of their patients, recognize faulty reasoning early in the diagnostic thinking process, be attentive to when a technical procedure is not going as it should, recognize the need to gather more data, and be able to incorporate disconfirming data into an evolving assessment of the patient. Often, there is no tool or instrument that can help physicians with these situations on a moment-to-moment basis other than their own cognitive and emotional resources.

Mindful practice refers to a clinician’s capacity for reflection, self-monitoring and self-awareness during an actual clinical practice in order to practice with clarity, insight, expertise, and compassion. Clinicians generally value the principles of mindful practice—attentive observation, critical curiosity, presence, and capacity to see a familiar situation with new eyes (“beginner’s mind”). Yet, during training and practice, clinicians spend little time “sharpening the saw”—developing, refining, and calibrating their own capacity for self-understanding as they think and feel their way through the complex demands of clinical practice. For psychotherapists, athletes, and musicians, self-calibration and self-awareness are considered fundamental to excellence and are often explicit aspects of training. Yet, for clinicians, there is often the assumption that knowledge and technical expertise are sufficient, when on reflection most clinicians value “adaptive expertise” and cultivating habits of mind that allow them to self-calibrate and reflect continuously during everyday work. This chapter will suggest why mindful practice is important and indicate ways in which it can be cultivated.

Mindful practice is fundamental to excellent patient care. It means being attentive, on purpose, to one’s own thoughts and feelings during everyday clinical practice and educational activities. Mindfulness implies a nonjudgmental stance in which the practitioner can observe not only the patient’s situation but also his or her own reactions to it. A mindful practitioner can see a situation from several angles at the same time. Mindful practice implies curiosity rather than premature closure and presence rather than detachment. Mindfulness is especially helpful when dealing with difficult relationships with patients and families, challenging clinical situations, and in recognizing the need for self-care. Furthermore, recent research among students, residents, and practicing clinicians suggests that mindfulness is associated with better communication, better quality of technical (e.g., fewer errors) and interpersonal (e.g., empathy) care, and greater clinician well-being (e.g., lower burnout).

In contrast, mindless practice involves self-deception, often with the illusion of competence. Blind certainty, ignoring of disconfirming data, and arrogance without self-examination or reflection dooms us to “seeing things not as they are, but as we are.” An example of mindlessness is the common practice of reporting findings that were not actually observed, because “they must be true.”

Mindfulness is especially important in the diagnosis and treatment of mental disorders because there are few anchors other than the clinician’s own judgment to assess the severity or pervasiveness of anxiety, depression, or psychosis in a particular patient. However, mindfulness also applies to other cognitive and technical aspects of health care. Self-monitoring and mindfulness are equally essential to expertise in other domains of medicine as they are to primary care or behavioral medicine. For example, hepatobiliary surgeon Carol-Anne Moulton eloquently describes ways in which expert surgeons remain “attentive in automaticity.” They work quickly, yet recognize aberrant and problematic situations, and slow down accordingly, thus switching from automatic to deliberative thinking. In this chapter, I will explore several aspects of mindful practice and some ways of recognizing and practicing mindfulness in clinical settings.

Mindful practice depends on the ability to be aware in the moment. The champion tennis player is being mindful when he or she is not only attentive to the ball but also to his or her state of balance, expectations for what will happen next, physical sensations such as pain or discomfort, and level of anxiety. All of these factors can affect performance and can be modified by specific attention to them. Like tennis players, physicians’ lapses in awareness and concentration can have dire consequences. For physicians, these lapses directly affect the patient’s welfare. The result of lapses may include avoidance, overreactions, poor decisions, misjudgments, and miscommunications that affect survival and quality of life for the patient. Thus, physicians have a moral obligation to their patients and themselves to be as aware, present, and observant as possible.

By cultivating the ability to be attentive to the unexpected, mindful practice can improve the quality of care and help prevent errors. Case Illustration 1 presents some observations that led to a change in care resulting in an improved outcome. Being aware in the moment and receptive to new information—especially information that is unexpected, unwanted, or upsetting—can help the clinician be more attentive to patients’ needs and, thus, be more likely to meet them. The clinician’s job in Case 1 would have seemed easier, at least in the short run, if he had ignored his intuitions.

Mindful practice involves allowing awareness of our own areas of ignorance, as well as our areas of expertise. Yet many clinicians are not as aware as they should be of the accuracy of their first impressions and tacit judgments. Clinicians, whether beginners or experts, often are aware of things before they are named, categorized, or organized into a coherent diagnosis. For example, the unusual gait of a patient walking toward the chair in the examining room may be the first clue to a neurodegenerative disorder, and such first impressions can often be quite accurate. Educators, psychologists, and cognitive scientists have called these automatic nonconscious mental processes “unconscious competence,” the “unthought known,” or “preattentive processing.”

Conversely, the capacity for inattentiveness and self-deception can be impressive. The same capacity for automatic nonconscious processing can backfire if unexamined biases and preconceived ideas dominate clinical reasoning without some capacity for deliberation. Thus, the goal might be to be attentive in automaticity. A patient of mine, hospitalized with urinary infection, was suspected of having adrenal insufficiency because of hyperpigmented skin. He was later noted to only have hyperpigmented forearms and face, whereas the rest of the body was pale. Yet, the residents and attending physicians continued to evaluate the possibility of adrenal insufficiency in spite of being made aware of the faulty observation. A classic article on curiosity in clinical education reported a story about a patient who was presented on rounds as “below knee amputation (BKA) times 2”; clearly no one had noticed that he actually had two legs, and, through several hospital admissions, did not correct the mistranscribed “diabetic keto-acidosis (DKA).” Although these examples are dramatic, similar misperceptions are perpetuated with regard to patient personality or psychological states. For example, one study showed that patients asking for antidepressant medications tend to receive them regardless of whether they fulfill diagnostic criteria for depression. Patients who are labeled “difficult,” “uncooperative,” or “demanding” (such as Mrs. Grady, Case Illustration 2) seem to be stuck with such labels for life, and disconfirming data tend to be ignored. Furthermore, the “difficult patient” is approached as if the difficulty is only the patient’s, rather than considering that the physician’s expectations and attitudes may also contribute to the difficulties.