5.2 - Presence
What does it mean to truly be there for our patients? Why is presence so vital to patient care? How can we grow in attention to our patients and those we love? Join us as we discuss the mindful approach to treating patients and how our practice of presence can help us in and out of the hospital.
Recommended readings
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"What is clinician presence? A qualitative interview study comparing physician and non-physician insights about practices of human connection," Brown-Johnson et al. (2019) - British Medical Journal
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"Brief, daily meditation enhances attention, memory, mood, and emotional regulation in non-experienced meditators," Basso et al. (2019)
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"Patient as Gift: Understanding the Clinical Relationship," Dugdale (2020)
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"Counting blessings versus burdens: An experimental investigation of gratitude and subjective well-being," Emmons & McCullough (2003)
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"Mindfulness, APA Dictionary of Psychology," VandenBos (Ed.) (2007)
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"Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter," Zulman et al. (2020)
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"Mindfulness meditation improves cognition: evidence of brief mental training," Zeidan et al. (2010)
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"The Neuroscience of Gratitude and Effects on the Brain," Chowdhury (2019)
Transcript
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[Intro music]
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Hi and welcome to the Hippocratic Society Podcast. This podcast is a project of the Hippocratic Society.
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In the podcast, we aim to reflect on deeper questions in medicine, all with the aim of rediscovering the ideals that brought us to medicine in the first place in order to better serve our patients and colleagues.
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Thank you for joining us and we look forward to engaging with you through this podcast.
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Foreign.
Michael Egan
Welcome to the Hippocratic Society Podcast.
Michael Egan
My name is Michael and I'm joined again by Dr. John Rhee.
Michael Egan
Today's episode follows our interview with Dr. Wes Ely where we talked about suffering,
Michael Egan
both personal and how we respond to the suffering of others.
Michael Egan
As we look at this topic through the lens of our daily work, we want to explore an aspect that touches the very heart of patient care presence.
Michael Egan
This concept is more than just a buzzword. It's essential to the practice of both physicians and patients.
Michael Egan
Why don't we start with a story to put the topic in context?
Michael Egan
So this story comes from the article suffering absence by Dr. Ben Frush, who is trained in internal medicine, pediatrics and palliative care.
Michael Egan
Smith and 13 just passed. Can you go declare her weary? I glance up at the intensive care unit nurse caring for this patient,
Michael Egan
offer a slow nod and follow her to the room.
Michael Egan
As the intern on the team given the task of Goals of Care discussions, I knew both Ms. Smith and her two sisters well.
Michael Egan
As we enter the room, Ms. Smith's two sisters greet me with warm hugs and tears.
Michael Egan
I share their grief, but I'm also strangely grateful to be here during my time in the mcu. These settings, void of medical decision making, are often the places where I feel most useful.
Michael Egan
I am frequently flummoxed by discussions of vasopressors, chest tubes and organ failure on rounds as I fumble through my presentations.
Michael Egan
It is in these moments I'm grateful to be present because it doesn't take much training to know that sad and lonely people need company.
Michael Egan
It's 3:30am and both the family and I are exhausted.
Michael Egan
Nevertheless, I experience an overwhelming sense of peace as the family shares a prayer.
Michael Egan
It is towards the end of this prayer that the senior resident rushes in and whispers in my ear, we just got two more. I need you to document this death and start working on those notes.
Michael Egan
I apologize to the family and slink back to my computer.
Michael Egan
So, given this example of clearly a beautiful moment of presence but also difficult in the sense that he had to be taken away from other four other patients that needed his attention,
Michael Egan
why don't we just dive right in from the beginning.
Michael Egan
What is presence?
John Rhee
Yeah, thanks, Michael.
John Rhee
I think I want to talk about presence, both as the word presence, but also a key aspect of presence, which is the aspect of attention.
John Rhee
And in a 2019 article from the British Medical Journal,
John Rhee
they describe presence in clinical practice as a purposeful practice of awareness, focus, and attention with the intent to understand and connect with individuals, patients.
John Rhee
I think that's a good definition, but I think that that still is a little bit.
John Rhee
It doesn't fully explain what presence is in the sense that if we think a little bit about how the word attention is used in our culture, we often say, pay attention, right?
John Rhee
So there's a sense in which attention is kind of lended there.
John Rhee
You know, I lived a year in Spain, and even the word prestar attention,
John Rhee
there's a sense in which you're lending attention there as well. And so we see this idea of attention and presence as something that we're kind of giving for a period of time, but then that is really ours.
John Rhee
If we think about it in terms of patient care, I think that perhaps we could think about it in a different way.
John Rhee
And recently I started as an attending,
John Rhee
and just the word attending within it has the word attend.
John Rhee
And so it's core to what an attending does, which is to attend attentively to the patient in front of us.
John Rhee
When we think about attention, I think that all of us have had the experience.
John Rhee
And I could think of one particular friend, as I think about this,
John Rhee
where we're sitting down for coffee and when we have a conversation, he is just so good with attention in the sense that I could sense that his whole being is paying attention to me.
John Rhee
Like, there is a sense in which nothing can distract him from listening to me talking about how my day's been or how my months have been since I've seen him.
John Rhee
And I think we have this experience where in friendships, there is that particular friend who could just.
John Rhee
Who's just really good at being attentive, Right.
John Rhee
And what is special about that is the fact that that person puts their whole being into attention.
John Rhee
So it's not just an individual aspect of eye contact or body motion,
John Rhee
but it's that one's whole mind and heart are on that person.
John Rhee
And so I think that that. That is perhaps an aspect of how we could understand presence or attention.
John Rhee
This idea where one is putting together one's whole being and giving that attention to the patient in front of us.
John Rhee
And as we all become attending, physicians can conceptualize what it truly means to be an attending through the main role in which we're playing, which is putting our whole being into attending to that patient in front of us.
Michael Egan
Yeah, I love that answer. And I love especially your point about paying attention and how it is almost an aspect of how we're giving something,
Michael Egan
but it also has this sense of being a finite resource.
Michael Egan
And I think one thing that is really essential to attention is staying in the present moment, as you were saying.
Michael Egan
And something that you mentioned frequently is looking at time as almost a vertical plane rather than a horizontal plane.
Michael Egan
And so instead of thinking about the past, the present and the future,
Michael Egan
being entirely aware of the present moment, not worrying about the future or the past.
Michael Egan
And so in terms of attention, it's almost like when we're worrying about the present or worrying about the future, or thinking about things that have just happened in the past,
Michael Egan
we are giving our attention.
Michael Egan
We are paying attention to those other things and not paying fully to the present moment.
Michael Egan
And so I think that idea of attention as almost a finite resource, although it's not the exact way to think about it, but I think that does beautifully add to this idea of saying 100% in the present moment.
John Rhee
Yeah, there is an infiniteness to the present,
John Rhee
that each present moment is a here and now.
John Rhee
And that in the present moment, we can go so deep within ourselves as we also kind of contemplate that which I am in my innermost being.
John Rhee
Because being itself is the act of just being now, right. A present person now.
John Rhee
And so there is this.
John Rhee
This infiniteness of the present moment that we often, I think, in our culture lose, like you said, Michael,
John Rhee
by living completely, either in the past or the future.
John Rhee
In fact, I think it's a very spiritual idea.
John Rhee
There's this German philosopher, Simone Weil, that I really like.
John Rhee
And she talks about attention as the rarest and purest form of generosity.
John Rhee
And part of that is because of this full giving of self and attention.
John Rhee
And it results in this spiritual transformation where she talks about attention,
John Rhee
or this transformation within us is not done just by our will alone,
John Rhee
but rather through attention.
John Rhee
So we do not change or transform only through willing it.
John Rhee
But actually the process that's important of transformation is attention.
John Rhee
Because of this extraordinary generosity and because of this awareness of our current state of being as being really important.
John Rhee
And so that touches also a little bit on, like, the why of attention being so important.
John Rhee
And I think it also highlights why perhaps there may be a lot of.
John Rhee
Or in our current culture today, that where there is a lot of a dispersion of attention, especially with the use of our phone,
John Rhee
with the use of social media,
John Rhee
the use of many sound bites.
John Rhee
It seems as though attention is constantly scattered in our here and now.
John Rhee
And I often reflect on how and what consequence that has for the ability of a person to be able to then reflect on the meaning of one's life and the ability to just be.
Michael Egan
Yeah, I love that reflection. And bringing it back again to the analogy of patient care or the practical situation of patient care,
Michael Egan
when you were talking about attention causing change, rather than just the will,
Michael Egan
it relates directly to patient care in that you can't just will the complete healing of a patient. Although there are certain aspects of physical care that you can prescribe medicine and it will most likely get better.
Michael Egan
If we're looking at medicine as truly aiming for the flourishing of the patient with regards to their health, it is more than just the physical.
Michael Egan
And in a sense, it requires the attention of the physician to heal more than just the body and look deeper into the suffering of the other,
Michael Egan
which is the whole concept of presence.
John Rhee
Yeah, I think that's right. And it's something that we'll talk about in a future podcast as well. But just this idea that patients want to be seen as persons, right?
John Rhee
They don't want to be seen as just a part of them, whether that just be their disease or the illness,
John Rhee
which I think as physicians we have a tendency to do.
John Rhee
I mean, in some ways it's good because that's what we're trying to do, right? We're trying to really think deeply about what the patient needs in terms of healing or cure to the particular disease.
John Rhee
But if we over focus on the disease itself, then we actually lose the sense of attention to the whole person that is in front of us,
John Rhee
and also how hard attention is,
John Rhee
especially again in a culture where attention is constantly scattered.
John Rhee
As a physician who is trying to pay attention to the patient in front of us,
John Rhee
there are a million things going through our minds. What medication is needed, what procedure is needed, what's the differential diagnosis,
John Rhee
what's the treatment paradigm.
John Rhee
So many things going through our mind, but not just that. We're also thinking about,
John Rhee
you know, there's this other patient that's been pretty sick this morning.
John Rhee
And then also personal things, right? Like I just had a fight with my wife this morning and now it's like lingering in my mind.
John Rhee
The act of giving our whole being to the person in front of us is really hard.
John Rhee
Yet that is what the patient really not only desires, but I think needs.
John Rhee
Because in the moment of suffering,
John Rhee
what another human being needs is an act of total presence, a Total relationship, a total. A deep bond with the other in which they also receive healing and are seen as who they are truly, deeply, by the physician who they have entrusted.
John Rhee
Entrusted themselves to their care.
Michael Egan
Yeah. That makes me think of the article we referenced from the beginning with the story by Ben Frush. He references Warren Kinghorn as saying that the entire. The main role of the physician is this exact presence is to give their whole being to the person who is suffering.
Michael Egan
Because suffering in itself isolates them from their community, from other people trying to help them and being frustrated from others who want to understand them but can't.
Michael Egan
And so it is really core to the practice of medicine. And so I think we've seen both why it's very important and what exactly is presence?
Michael Egan
But how can we develop this? And how do we grow in presence both in the clinic and in our daily life?
Michael Egan
Yeah.
John Rhee
I hope the themes that we're talking about convince the listeners of how important presence and attention are.
John Rhee
And it's a theme that we talk about in the Hippocratic Society, this idea that virtue cultivation is not an isolated thing that just happens in the hospital,
John Rhee
but that rather it's a continuum. Right. So how we live our lives outside the hospital.
John Rhee
Also affect how we're living it in the hospital.
John Rhee
And so I think it's good to reflect on how we live. A constant sense of perhaps scattered attention.
John Rhee
And where we can be more attentive and live and be in the present moment.
John Rhee
And so I often think about this in the setting of medicine, where a lot of physicians feel the need to be. And I am guilty of this as myself as well,
John Rhee
the need to be constantly connected to one's email, constantly connected to one's phone,
John Rhee
checking one's phone, like on the walk between patient rooms or perhaps on an elevator.
John Rhee
That there is never really a moment of silence or silence or just a sense of being in the present moment and being attentive to what is going on just right now in front of us.
John Rhee
And so if we cultivate that sense of practice, of attention,
John Rhee
which actually is a muscle that we have to practice. Right, right.
John Rhee
This is true from a neurologic standpoint. Right. That we have to use our frontal cortex and really practice paying attention.
John Rhee
And the more that we practice it, the better we become at it.
John Rhee
That we want to therefore be aware where there are many things that scatter our attention.
John Rhee
There's this interesting experiment that Cal Newport talks about.
John Rhee
He's written various books on different aspects of, like, deep work or attention.
John Rhee
Where they had different people experiment on checking like something distracting, maybe their email and then going back to their work. And the fact that, like, just shifting attention itself is not just something that's distracting that happens for 10 seconds, but actually there's a really long lag effect that lasts for tens of minutes.
John Rhee
And a person is not as kind of efficient in what they were doing as they were before.
John Rhee
Now, of course, this is not about only efficiency, but it does show how, when we live in a sense of constant scattered attention,
John Rhee
how much that's actually affecting our attentiveness to things around us, including our patients. And how really we can be giving our whole being to the patient in front of us.
John Rhee
And so,
John Rhee
you know, not just in the in between moments can we be attentive,
John Rhee
but the other place that I think we could practice attention is in our work. Because we're spending most of the day in work, right? Most of the hours of our day are doing some type of work.
John Rhee
And if we're doing our work with an approach in which we are scattering our attention, a lot of shifting between reading news or music and the thing that we're doing.
John Rhee
And then I think that what we're doing is actually atrophying the muscle of attention.
John Rhee
But if we approach our work with a sense in which we are really trying to put our whole attention into it,
John Rhee
as Simone Weil would say. She would say that even if one is not a mathematician,
John Rhee
just the practice of attention in doing a geometry problem,
John Rhee
that is actually what's most important,
John Rhee
because one is cultivating attention through that practice.
John Rhee
And so here, too, in our work or in our study,
John Rhee
we could always be cultivating deeper attention not just for ourselves in terms of being able to be more present in the now. And therefore,
John Rhee
that results in a sense of that reaching for the infinite,
John Rhee
but also the practice there directly translates to how attentive we can be and put our whole being into the patients that we take care of and that particular unique individual in front of us.
Michael Egan
Yeah, I think those were very helpful tips. And the only thing that I wanted to add was the practice of setting aside time at the beginning or maybe the end of the day to practice longer periods of intentional presence.
Michael Egan
You could say,
Michael Egan
whether that's meditation or contemplation,
Michael Egan
prayer for some people,
Michael Egan
I think that both feeds and benefits from the presence throughout the day. So as you grow in the ability to be present for extended periods of time,
Michael Egan
once or twice a day, then throughout the day, you find it easier to be present on those small periods of time.
Michael Egan
And again, it feeds your work, it feeds those in between times and just a nice virtuous cycle, if you will.
Michael Egan
Well, great. I think this was a very beneficial discussion both for myself and hopefully our listeners.
Michael Egan
I've learned a lot. Thank you so much. John.
Michael Egan
Great.
John Rhee
Thanks.
John Rhee
Michael.
John Rhee
Thank you very much for joining and reflecting with us today.
John Rhee
Keep up with new episodes by subscribing to the Hippocratic Society Podcast.
John Rhee
For more information on the Hippocratic Society,
John Rhee
visit us at hipsoc.org. The Hippocratic Society is a 501(c)(3) and depends on the generous support of its listeners.
John Rhee
And as always, we'll see you next time on the Hippocratic Society Podcast.