Cultivating presence in chaotic clinical environments
Ron Epstein, MD, FAAHP, FACH
As a palliative care physician and a primary care physician, I am always aware of the centrality of presence. Patients value a sense of shared presence with their physician and with their care team. In a beautiful and insightful 2016 Lancet article, psychiatrist/anthropologist Arthur Kleinman describes presence as “the intensity of interacting with another human being that animates being there for, and with, that person;” shared presence is “an interpersonal process that mobilizes vitality from both clinician and patient, and from family caregiver and recipient of care.” In addition, the practice of presence “deepens ties of intimacy,” inspires patients, sustains clinicians and family caretakers during the dark and difficult moments, protects us from burnout, and leads us to a sense of purpose and meaning.
Presence provides for me the vitality and energy to take on the complex demands of patient care. Edwin Krogh describes how presence involves deep listening to patients, colleagues and oneself. Presence is redirecting attention to what matters most, and an attitude of curiosity and beginner’s mind during disturbing and difficult moments. Yet, clinical environments are filled with opportunities for ”distracted doctoring”: responding to administrative exigencies and tasks of secondary importance, leading to mechanical and routinized care. While some people might naturally have a greater capacity for presence, presence is a quality of mind that all of us can cultivate and bring to our clinical, teaching and administrative work.
Cultivating presence is one of the underlying themes of Mindful Practice workshops. We develop skills of presence through contemplative practices that can be brought into work settings and through narrative and deep listening exercises to promote non-judgmental shared presence. Presence involves creating time, enhancing “perceived time” so that our patients feel that we’ve spent more time with them despite the limitations of “clock time.” It involves the use of compassionate and eloquent silence.
For those of us who care for the seriously ill, presence means meeting patients in their raw fear and terror. The other day, my colleague Fred Marshall reminded me that for patients, serious illness is often a unique experience yet clinicians may have had innumerable encounters with patients facing illness and death. It can be so easy to slip into mechanical care during which we’re just going through the motions but not really engaged.
Yet, there is a certain ordinariness to presence. Often we only notice its importance when it is not there, when we don’t feel seen or heard. Sometimes we need to remind ourselves that it is possible to cultivate habits of beginner’s mind during everyday practice – seeing novelty in the familiar, being curious about our habits and routines, taking more than one perspective on a situation. In recent writings, Betsy Toll reminds us that the 21st century poses the extraordinary challenge of incorporating electronic media – normally seen as annoyances and interruptions – into clinical work in ways that might enhance presence.
If you’re interested in learning more about how you can be more attentive and present in clinical practice and teaching, click here for more information.
For further reading and references:
Epstein RM. Being Present. In Attending: Medicine, Mindfulness, and Humanity. New York: Scribner, 2017.
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