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ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
ABSTRACT
INTRODUCTION
Explicit
and Tacit Knowledge
Professional
Knowledge and Self-awareness
Mindful
Practice
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Levels
of Mindful Practice
Becoming
Mindful
Conclusions
AUTHOR/ARTICLE
INFORMATION
REFERENCES
INDEX
OF FIGURES AND TABLES
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Mindful
Practice
Ronald M. Epstein, MD
Mindful
practitioners attend in a nonjudgmental way to their own physical and mental
processes during ordinary, everyday tasks. This critical self-reflection
enables physicians to listen attentively to patients' distress, recognize
their own errors, refine their technical skills, make evidence-based decisions,
and clarify their values so that they can act with compassion, technical
competence, presence, and insight. Mindfulness informs all types of professionally
relevant knowledge, including propositional facts, personal experiences,
processes, and know-how, each of which may be tacit or explicit. Explicit
knowledge is readily taught, accessible to awareness, quantifiable and
easily translated into evidence-based guidelines. Tacit knowledge is usually
learned during observation and practice, includes prior experiences, theories-in-action,
and deeply held values, and is usually applied more inductively. Mindful
practitioners use a variety of means to enhance their ability to engage
in moment-to-moment self-monitoring, bring to consciousness their tacit
personal knowledge and deeply held values, use peripheral vision and subsidiary
awareness to become aware of new information and perspectives, and adopt
curiosity in both ordinary and novel situations. In contrast, mindlessness
may account for some deviations from professionalism and errors in judgment
and technique. Although mindfulness cannot be taught explicitly, it can
be modeled by mentors and cultivated in learners. As a link between relationship-centered
care and evidence-based medicine, mindfulness should be considered a characteristic
of good clinical practice.
JAMA.
1999;282:833-839
Reflection
and self-awareness help physicians to examine belief systems and values,
deal with strong feelings, make difficult decisions, and resolve interpersonal
conflict.1,
2 Organized activities to foster self-awareness
are part of many family medicine residency programs3
and some other residency4,
5 and medical school curricula.5-8
Exemplary physicians seem to have a capacity for critical self-reflection
that pervades all aspects of practice, including being present with the
patient,9 solving problems,
eliciting and transmitting information, making evidence-based decisions,
performing technical skills, and defining their own values.10
This
process of critical self-reflection depends on the presence of mindfulness.
A mindful practitioner attends, in a nonjudgmental way, to his or her own
physical and mental processes during ordinary everyday tasks to act with
clarity and insight.11-15
This article first describes the nature of professional knowledge, competence,
and values and then presents current thinking about the philosophical,
psychological, and practical aspects of mindfulness. It also explores how
mindfulness is integral to the professional competence of physicians and
suggests ways to cultivate mindfulness in medical training. In doing so,
however, I recognize that mindful practice, although supported by
empiric observation of clinical practice,16-21
educational research,22-26
philosophy,11, 27
and cognitive science,11,
28-30 is fundamentally personal and subjective.
Consider
a situation that I recently faced with a patient who required an expanded
view of professional knowledge and mindful reflection to achieve a satisfactory
resolution. A 42-year-old mother of 2 small girls, despondent over job
difficulties, was contemplating genetic screening for breast cancer as
she approached the age at which her mother was diagnosed as having the
same disease. Aside from the difficulties in taking an evidence-based approach
to assigning quantitative risks and benefits to the genetic screening procedure
(How much should I trust the available information?) and uncertainty about
the effectiveness of medical or surgical interventions (Would knowing the
results make a difference, and, if so, to whom?), the case raised important
relationship-centered questions about values (What risks are worth taking?),
the patient-physician relationship (What approach would be most helpful
to the patient?), pragmatics (Is the geneticist competent and respectful?),
and capacity (To what extent is the patient's desire for testing biased
by her fears, depression, or incomplete understanding of the illness and
tests?).
For
me, book knowledge and clinical experience were insufficient. I had to
rely on my personal knowledge of the patient (Is she responding to this
situation in a way concordant with her previous actions and values?) and
myself (What values and biases affect the way I frame this situation for
myself and for the patient?) to help us arrive at a mutual decision. These
reflective activities applied equally to the technical aspects of medicine
(How do I know I can trust the interpretations of medical tests?) and the
affective domain (How well can I tolerate uncertainty and risk?). An attitude
of critical curiosity,31
openness, and connection17,
32, 33 allowed us to defer
the decision and reconsider testing once the immediate crises had passed.
Explicit
and Tacit Knowledge
Clinical
judgment is based on both explicit and tacit knowledge.34-36
Medical decision making, however, is often presented only as the conscious
application to the patient's problem of explicitly defined rules and objectively
verifiable data.34,
37, 38 This form of explicit
knowledge can be quantified, modeled, readily communicated, and easily
translated into evidence-based clinical practice guidelines.
Seasoned
practitioners also apply to their practice a large body of knowledge, skills,
values, and experiences that are not explicitly stated by or known to them.34
This knowledge may constitute a different kind of evidence, which also
has a strong influence on medical decisions. In everyday life, examples
of tacit knowledge abound. Riding a bicycle involves judgments about speed,
orientation, and position that are rarely made conscious except when something
goes amiss. Similarly, an experienced neurologist can recognize Parkinson
disease within moments of meeting a patient, before processing the objective
and subjective data to support it. During this preattentive processing,39
the brain rapidly scans a wide array of perceptions, detects conspicuous
features, and relegates some information to the background, all before
the content of the perception is analyzed. Clinical skills, such as the
depth of insertion of an otoscope, the manipulation of the fetal head during
a delivery, and the realization that the patient has given sufficient information
to diagnose major depression involve tacit knowledge and preattentive processing.
While
explicit elements of practice are taught formally, tacit elements are usually
learned during observation and practice.40
Often, excellent clinicians are less able to articulate what they do than
others who observe them. Nor do they appreciate all of the biases in their
own reasoning processes.41
Subsidiary awareness35 is a term that
describes how the practitioner makes accessible the flow of unprocessed
experience and tacit knowledge.
In
the words of Anaïs Nin, "We don't see things as they are, we see things
as we are."42 Evidence-based
medicine offers a structure for analyzing medical decision making, but
it is not sufficient to describe the more tacit process of expert clinical
judgment.43 All data,
regardless of their completeness or accuracy, are interpreted by the clinician
to make sense of them and apply them to clinical practice.44
Experts take into account messy details, such as context, cost, convenience,
and the values of the patient.36,
43, 45, 46
Physician factors such as emotions,47
bias,48 prejudice,49
risk-aversion,50-53
tolerance for uncertainty,54,
55 and personal knowledge of the patient also
influence clinical judgment.50-55 Most of
the processes described above remain relatively unconscious to the practitioner.
Clinical
judgment is a science and an art.36 Even
those who are uncomfortable with the notion of tacit knowledge recognize
that it is impossible to make explicit all aspects of professional competence.43
Evidence-based decision models are very powerful tools, but clinicians
do not always use them, especially in complex situations.30,
56 Information necessary to construct explicit
models is frequently incomplete or conflicting. Some important tacit knowledge
about the patient, such as personality, simply does not fit into predefined
categories. To clinicians, these models may resemble computer-generated
symphonies in the style of Mozart—correct but lifeless.
Professional
Knowledge and Self-awareness
Eraut57,
58 defines 4 types of professionally relevant
knowledge, each of which can be tacit or explicit (Table
1). The most familiar is propositional knowledge, or what most people
call fact: theories, concepts, and principles, usually acquired from books,
electronic media, or instructors. Self-awareness of what one does not know
and the appreciation for the transient nature of facts can direct ongoing
learning.
Knowledge
acquired through experience, or personal knowledge, is a collection of
information, intuitions, and interpretations that guides professional practice.35
Consider the following example. Returning from vacation, I saw one of my
patients who was infected with human immunodeficiency virus and said to
the resident caring for him, "Mr Charles looks worse. Looks like he might
have adrenal insufficiency." The personal knowledge exemplified in this
scenario differs from an anecdote because it is contextualized. I can say
that Mr Charles looks worse because I know him as a person, not just because
I know about him, and because I recognize a pattern of disease (weakness
and skin color change). This knowledge enters into my mind in an inductive,
impressionistic way, providing the gestalt or feel of a clinical situation
in addition to the propositional facts.29
However, confusion between personal knowledge and anecdotal information
results in both being neglected and discounted during medical training.
An example of the uncritical application of a decontextualized anecdote
is when a physician who after missing a diagnosis of colon cancer, subsequently
overtests all of his patients. In contrast, if he had raised tacit personal
knowledge to awareness, it could have been subjected to critical reflection.
Process
knowledge is knowing how to accomplish a task,59
such as gathering information, performing procedures, making decisions,
and planning for the future.58 Process knowledge
also includes metaprocessing, or the process of reflection on one's own
mental processes. This is particularly important in practice, because "we
do not observe nature as much as we observe nature exposed to our method
of questioning."60 Metaprocessing
might be called thinking about thinking or feeling about feelings. It is
both a concrete action (such as the modification in a trajectory of light
in a mirror) and an act of self-observation in which the mind attends to
its own actions (including the subject who is performing those actions).
Metaprocessing allows the physician to uncover areas of unconscious incompetence,61
the blind spots wherein a physician might not know his or her deficiencies.
Fortunately, clinicians can often readily identify these blind spots and
gain insight into the influence of the observer, for example, when they
review their own videotaped patient visits.62,
63
Eraut's
fourth type of professionally relevant knowledge, know-how, is knowing
how to get things done. A resident working in a new setting may know that
a diagnostic test is important, but may not know that the test will happen
sooner with a friendly call to the radiologist. Learning the steps necessary
for getting something done is important in professional development of
physicians, but it is often relegated to the informal64
or hidden24, 26 curriculum.
Mindful
Practice
Mindfulness
is a logical extension of the concept of reflective practice.4,
12, 14 The mindful practitioner
is present in everyday experience, in all of its manifestations, including
actions, thoughts, sensations, images, interpretations, and emotions.12,
13, 65 Mindfulness "leads the
mind back from theories, attitudes and abstractions . . . to the situation
of experience itself,"11 which prevents us
from "falling prey to our own prejudices, opinions, projections, expectations"
and enables us to free ourselves from the "straightjacket of unconsciousness."66
Mindfulness is attending to the ordinary, the obvious, and the present.
Johann Sebastian Bach is reported to have said, when asked how he found
melodies: "The problem is not finding them, it's—when getting up in the
morning and out of bed—not stepping on them."67
Although
mindfulness is a practice that derives from a philosophical-religious tradition,12,
14, 15 the underlying philosophy
is fundamentally pragmatic13 and is based
on the interdependence of action, cognition, memory, and emotion. These
connections represent a relatively new idea in neuroscience research.28,
68 Western approaches to the understanding of
mental processes have historically separated mental activity from action
in the world, and the schism between behavioral and psychodynamic psychology
has reinforced some of this separation. However, in the East.11,
14 and in phenomenological traditions in the West,27
philosophy has linked cognition to emotion, memory, and action in the world.
The
goals of mindful practice are to become more aware of one's own mental
processes, listen more attentively, become flexible, and recognize bias
and judgments, and thereby act with principles and compassion (Table
2). Mindful practice involves a sense of "unfinishedness,"31
curiosity about the unknown and humility in having an imperfect understanding
of another's suffering. Mindfulness is the opposite of multitasking. Mindfulness
is a quality of the physician as person, without boundaries between technical,
cognitive, emotional, and spiritual aspects of practice.
Mindful
practitioners have an ability to observe the observed while observing the
observer in the consulting room. This process, not often discussed in medical
practice, is considered essential to musicians, whose task is to perform
and listen at the same time, attending simultaneously to the technical
challenges, emotional expression, and overall theoretical structure of
the music.69 The accomplished
musician performs midcourse corrections of finger movements, compares the
sound produced with the imagined sound, and, at the same time, brings expressive
spontaneity to the performance. However, if the musician were to attempt
to control each finger movement while simultaneously analyzing the harmonic
structures, rhythms, and silences that constitute expressive playing, playing
would become impossible. Thus, focal awareness on the music is accompanied
by subsidiary awareness35 of technique and
analysis—a mix of peripheral vision and semiautomatic action that is highlighted
only when the unexpected or difficult occurs.
In
medicine, consider what a resident in a busy pediatric emergency department
might do when he is unable to determine whether an ear examination is normal
or abnormal and the attending physician is not immediately available. The
resident has several options, consideration of which could be conscious
or unconscious. The resident weighs the consequences of misdiagnosis for
the patient, the humiliation of having to call an otolaryngology resident
out of the clinic, the loss of self-esteem by having to admit incompetence,
and the pride in being strong enough to admit his need to learn. An unmindful
practitioner who is conscious of the dilemma might judge or blame himself
or others. He might base his course of action on an external standard of
correctness or on expedience. However, little would be learned, and he
would be no better prepared for the next situation. A mindful conscious
approach would be to cultivate awareness not only of the correct course
of action but also of the factors that cloud the decision-making process.
The mindful practitioner is mentally and technically better prepared for
the next situation.
The
object of mindfulness can apply to any aspect of medical practice and within
any domain of tacit or explicit knowledge. Intrapersonal self-awareness
helps the physician be conscious of his or her strengths, limitations,
and sources of professional satisfaction. It helps the individual avoid
blind spots, such as a physician who, because his or her parent was an
alcoholic, avoids discussions of alcohol with patients. It may clarify
deeply held values and motivations for becoming a physician. Interpersonal
self-awareness, or social intelligence,70,
71 allows physicians to see themselves as they
are seen by others and helps to establish satisfactory interpersonal relationships
with colleagues, patients, and students. Awareness of metaprocessing allows
physicians to be aware of their own clinical reasoning, including the necessary
connections between cognition, memory, and emotional processing.28
Self-awareness of learning needs allows physicians to recognize areas of
unconscious incompetence and to develop a means to achieving their learning
goals.61 Ethical self-awareness is the moment-to-moment
cognizance of values that are shaping medical encounters. Technical self-awareness
is necessary for self-correction during procedures such as the physical
examination, surgery, computer operations, and communication.
Often
reflection is prompted by a critical incident involving an error, a difficult
situation, or an unexpected result of one's actions.25,
72, 73 At other times, reflection
is prompted by the maturing of an idea rather than by a discrete external
event. However, many of these events go unnoticed by all but the most creative
thinkers. The discoveries of penicillin, radiation, and the benzene ring
were not accidents, but rather the result of someone making what had been
considered an outlier (a tainted Petri dish) into data (a useful medication).
Mindfulness
enables the practitioner to use a wider set of perceptual resources. The
fluidity of mind that can maintain some constant subthreshold awareness
of preattentive and subsidiary processes has been described as a "beginner's
mind."12 A beginner's mind is open and allows
for new diagnostic and therapeutic possibilities, as may happen when a
patient meets a new physician. By contrast, the expert's mind narrows possibilities,
using prior experience to delimit and confine observations. Langer13
describes mindfulness as a state of "could be," welcoming uncertainty rather
than trying to avoid it. Difficult patients might then become interesting
patients; unsolvable problems might become avenues for research. Critical
curiosity shows the limits of categories and helps create more meaningful
ones. For example, the recognition of panic disorder as a common cause
of chest pain might help physicians recategorize these patients from symptom
amplifiers74 to patients
with a serious and treatable illness. Expertise is often well served by
beginner's mind, especially in new, unfamiliar, or stressful situations.
Mindfulness
implies examining the relationship between the knower and the known as
suggested in the "I-Thou" relationship of Martin Buber75
or the "connected knowing" of ideas, people or things, suggested by Belenky
and colleagues.33 Knowledge, then, does not
exist independently but rather in relationship to the one observing and
using it. Theories are seen as fragile approximations rather than reality
itself.76 Suchman and
Matthews17 have described this as the connexional
dimension of medical practice, in which there is a tacit bond between patient
and physician that transcends professional roles.
Mindlessness:
Gaps Between Knowledge, Values, and Actions
Physicians
make moment-to-moment value-laden decisions that entail cognitive and emotional
factors. They decide how much effort to expend in pursuit of knowledge,
how much pain medication to prescribe, how much time to spend with each
patient, and when to return patients' telephone calls. These rapid decisions,
usually based on personal knowledge, level of skill, efficiency, and values,
ultimately result in actions. Thus, objectives for the practice of medicine
calling on physicians should include the ability to perform or knowledge
about important aspects of medical care77
as well as the requirement to actually use those practices in daily work.
Self-knowledge
is essential to the expression of core values in medicine, such as empathy,
compassion, and altruism. To be empathic, I must witness and understand
the patient's suffering and my reactions to the patient's suffering to
distinguish the patient's experience from my own. Then I can communicate
my understanding and be compassionate, to use my presence to relieve suffering
and to put the patient's interests first. Perhaps lack of self-awareness
is why physicians more often espouse these values than demonstrate them78-81
and why they tend to be less patient-centered82
and confuse their own perspectives with those of the patient1,
80 in situations that involve conflict and strong
emotions.
Curiosity
is central both to caring about the patient and to solving problems.83
Fitzgerald16 describes a trainee who reported
a patient as having had a history of "BKA" (below-the-knee amputation)
without noting that the patient, in fact, had both feet. A transcriptionist
had mistranscribed DKA (diabetic ketoacidosis) and the assertion went unchallenged.
The student's lack of curiosity, or overconcreteness, led to mistaking
the chart for the patient. Similarly, caring requires an interest in the
patient as a person rather than as an abstraction of disease.84,
85 For example, Stetten18
described how his physicians were uninterested in his adaptation to blindness
while they attempted to treat his macular degeneration; they saw the disease
but not the person.
Mindlessness
accounts for many deviations from professionalism, which seem to occur
more often in emotionally charged situations, during situations of uncertainty,
and under pressure to resolve problems. For example, many medical students
and residents, and presumably practitioners as well, report findings that
were not observed and do not seek correction for errors.20
Actions diverge from professional knowledge and values because of attempts
to be efficient, a desire to please supervisors, feelings of embarrassment,
and a sense of being overwhelmed.2,
19, 21, 82, 86,
87 Practitioners may not think to apply knowledge
gained in a classroom context (such as an ethics course) in a stressful
clinical environment. Deviations often involve avoidance of difficult issues,
rationalization, externalization, or frank denial rather than the healthy
processing of emotional feelings toward patients.88,
89
Levels
of Mindful Practice
To
guide physicians' professional development, I would like to propose 5 levels
of mindfulness, each of which subsumes the previous level and is subject
to verification in future observational studies (Table
3). At the extreme of mindless practice, the practitioner's response
is denial (level 0). By making the problem "out there," the practitioner
may avoid responsibility and reflection or describe the situation (or the
patient) in ways that are contrary to the evidence.
Level
1 describes practitioners who do not necessarily use reflection but take
some responsibility for the situation and solve it by conforming to an
external standard of behavior. For example, a practitioner might deal with
his attraction to a patient by reciting a rule, such as "sexual intimacy
with patients is wrong," but may not seek understanding of the factors
that put physicians at risk for misconduct.86
Level
2 describes medical decision analysis based on the assumption that explicit
cognitive models guide physician behavior and the key to change is the
transfer of information. While curiosity and reflection are required to
generate hypotheses and important questions, physicians at this level ignore
personal knowledge, tacit knowledge, and emotions. Level 3 includes curiosity
about feelings, thoughts, and behaviors without attempting to suppress
or label them as good or bad. By including emotions and personal knowledge,
the clinician has more tools available to promote patient care. Level 4,
insight, has 3 facets: understanding the nature of the problem, understanding
how one attempts to solve it, and understanding the interconnectedness
between the practitioner and the knowledge that he or she possesses.15
Insight facilitates the calibration of mental processes, in addition to
correction of the external problem. Finally, practitioners at level 5 can
use their insight to generalize, overcome similar challenges in the future,
incorporate new behaviors and attitudes, express compassion, and be present.
Becoming
Mindful
Recent
articles1, 5,
90 have described a variety of ways for becoming
more self-aware. Individually, practitioners might keep a journal, practice
meditation, review videotapes of sessions with their patients, and use
learning contracts. In medical education, self-evaluation forms for students
and residents have been important adjuncts to the evaluation process. Learners
can compare their perceptions with those of a teacher or mentor. Peer evaluations
have been useful in bringing awareness to aspects of professionalism and
social skills for students, residents, and practicing physicians.91,
92 Critical incident reports written by practitioners
about mistakes,20, 93
impairment,94 ethical
dilemmas,95 and difficult
situations can be discussed in small group settings and raise awareness
about common situations and one's reactions to them. Sharing of family
information and cultural background, using genograms or illness narratives,
can help practitioners learn about the expectations, biases, strengths,
and tendencies that influence clinical care.96-99
These approaches, historically focused on the emotional aspects of medical
practice and the patient-physician relationship, usually consist of exercises
separated in space and time from actual clinical practice. Mindfulness
training goes one step further. It applies to all aspects of practice,
from looking up references to performing physical examinations, from tying
sutures to giving bad news.
Mindfulness
can link evidence-based and relationship-centered care and help to overcome
the limitations of both approaches.37,
43, 100 The success of evidence-based
approaches depends on the ability of the practitioner to decide which issues
require further investigation and how to frame a question. These, in turn,
require that the practitioner identify his or her own biases and the influences
of the patient-physician relationship on framing of the question to investigate.
This personal knowledge should also be considered a form of evidence and
could be integrateded into decision making to incorporate patients' preferences.
Evidence-based data that are not specific to one patient-physician relationship
would then be applied in a more mindful way.
Seminars
about difficult topics such as HIV management, delivery of bad news, medical
mistakes, professionalism, and adherence to treatment can foster reflection
and raise practitioners' awareness of their own emotions and biases, while,
at the same time, attending to the practicalities of the patient's problem.101,
102 However, the ability to reflect in a classroom
environment is not equivalent to reflection in a stressful clinical environment.
For example, ethics courses might increase students' knowledge base and
improve their ability to solve difficult problems, but ethics courses do
not necessarily produce physicians whose behavior is more ethical than
it would be otherwise. Clinician-mentors can help students put ideas into
action by modeling a moment-to-moment awareness of their own knowledge
and emotions that inform their decisions when values are on the line. Professionals
can learn to articulate their personal knowledge by observing their own
actions (How do I respond to uncertainty? How do I present risks? How do
I self-correct when doing a difficult technical procedure?) Professional
knowledge is defined, then, not by its validity, but by how it is used.23
There
is an inherent paradox in teaching or writing about mindfulness. The teacher's
task is to invoke a state of mindfulness in the learner, and, thus, the
teacher can only act as a guide, not a transmitter of knowledge. In a recent
example of a resident about to face a dreaded follow-up visit with an angry
patient who thought that earlier treatment of his hepatitis C might have
prevented his end-stage cirrhosis, the mentor's role was complex. He had
to help the resident identify his feelings of guilt and defensiveness that
might interfere with communicating effectively with the patient, determine
the risks and benefits of liver transplantation, and explore the patient's
wishes regarding end-of-life care. The mentor's approach was to help the
resident identify how he psychologically prepares for each visit with a
patient, a "centering" process that had been previously tacit, which usually
is not explicit for most practitioners, and to use it more effectively.
The mentor helped the resident observe himself, effecting a transition
from unconscious incompetence to critical reflection and allowing him to
come to a satisfactory decision with the patient based on both objective
evidence and personal knowledge.
Barriers
to mindfulness are numerous in medical training, even in reformed curricula.
Fatigue, dogmatism, and an emphasis on behavior (rather than on consciousness)103
close the mind to ideas and feelings. Unexamined negative emotions lead
to emotional distance and arrogance. McWhinney identified 3 additional
barriers: unexamined negative emotions, failure of imagination, and literal-mindedness
(I. R. McWhinney, MD, oral presentation, London, Ontario, October 6, 1995).
Failure of imagination limits the curiosity that is the first step in any
process of inquiry. Concrete literal mindedness may serve simple diagnostic
processes well, but impedes creative problem solving and limits the physician's
view of the patient. Lack of opportunities to learn how to become mindful
in practice and the lack of forums to deal with fears and anxieties create
further barriers. Finally, some clinicians may fear that mindfulness is
the same as excessive self-absorption that would delay necessary clinical
actions. They would need to be educated that navel-gazing is antithetical
to mindful practice, which has as its goal clarity and attention to the
tasks at hand.
Conclusions
Mindfulness,
critical reflection, learning, and patient care all "begin with the self
as the first, but not the only, object of knowledge."104
Mindful practice extends beyond examining the affective domains and involves
critical reflection on action, tacit personal knowledge, and values in
all realms of clinical practice, teaching, and research. Mindfulness is
a discipline and an attitude of mind. It requires critical informed curiosity
and courage to see the world as it is rather than how one would have it
be. Mindful practitioners tolerate making conscious their previously unconscious
actions and errors. The goal of mindfulness is compassionate informed action
in the world, to use a wide array of data, make correct decisions, understand
the patient, and relieve suffering.
Mindful
practice requires mentoring and guidance. Recognition of one's limitations
and areas of incompetence can be emotionally difficult and can invite avoidance
in even highly motivated practitioners. Although mindfulness is an individual
and subjective process, each of us can identify practitioners who embody
these attributes, learn from them, and identify unique ways of being self-aware.
Educators can take on the task of helping trainees become more mindful
by explicitly modeling their means for cultivating awareness.
Author/Article
Information
Author
Affiliations: Departments of Family Medicine and Psychiatry, University
of Rochester School of Medicine and Dentistry, Rochester, New York.
Corresponding
Author and Reprints: Ronald M. Epstein, MD, Department of Family Medicine,
University of Rochester School of Medicine and Dentistry, 885 S Ave, Rochester,
NY 14620 (e-mail: ronald_epstein@urmc.rochester.edu).
Funding/Support:
Dr Epstein received support from the Robert Wood Johnson Foundation Generalist
Physician Faculty Scholars Program and the Fulbright Foundation.
Acknowledgment:
The ideas in this article were generated during a seminar at the Institute
for Health Studies, Barcelona, Spain, and also borrows generously from
conversations with Jeffrey Draisin, MD, Pieter LeRoux, PhD, Larry Mauksch,
CSW, Maria Nolla, MD, Dennis Novack, MD. I would like to thank Arthur Frank,
PhD, Cindy Haq, MD, and Ian McWhinney, MD, for their comments on early
drafts of this article, and to the JAMA reviewers whose suggestions
were extraordinarily thoughtful and helpful.
REFERENCES
1.
Novack
DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C.
Calibrating
the physician.
JAMA.
1997;278:502-509.
MEDLINE
2.
Balint
M.
The
Doctor, His Patient and the Illness.
London,
England: Pitman; 1964.
3.
Brock
CD, Stock RD.
A
survey of Balint group activities in US family practice residency programs.
Fam
Med.
1990;22:33-37.
MEDLINE
4.
Hewson
MGA.
Reflection
in clinical teaching: an analysis of reflection-on-action and its implications
for staffing residents.
Med
Teach.
1991;13:227.
MEDLINE
5.
Novack
DH, Kaplan C, Epstein RM, et al.
Personal
awareness and professional growth: a proposed curriculum.
Med
Encounter.
1997;13:2-7.
6.
Novack
DH, Volk G, Drossman DA, Lipkin Jr M.
Medical
interviewing and interpersonal skills teaching in US medical schools: progress,
problems, and promise.
JAMA.
1993;269:2101-2105.
MEDLINE
7.
Novack
DH, Dube C, Goldstein MG.
Teaching
medical interviewing.
Arch
Intern Med.
1992;152:1814-1820.
MEDLINE
8.
Makoul
G, Curry RH, Novack DH.
The
future of medical school courses in professional skills and perspectives.
Acad
Med.
1998;73:48-51.
MEDLINE
9.
McPhee
SJ.
The
practice of presence.
Presented
at: Alpha Omega Alpha Honor Society Spring Lecture; April 17, 1981; Piscataway,
NJ.
10.
Westberg
J, Jason H.
Fostering
reflection and self-assessment.
Fam
Med.
1994:26;278-282.
11.
Varela
FJ, Thompson E, Rosch E.
The
Embodied Mind: Cognitive Science and Human Experience.
Cambridge,
Mass: Massachusetts Institute of Technology Press; 1991.
12.
Suzuki
S.
Zen
Mind, Beginner's Mind.
New
York, NY: Weatherhill; 1980.
13.
Langer
EJ.
Mindfulness.
Reading,
Mass: Addison-Wesley Publishing Co Inc; 1989.
14.
Streng
FJ.
Emptiness:
A Study in Religious Meaning.
Nashville,
Tenn: Abingdon Press; 1967.
15.
Nhat
Hahn T.
Peace
Is Every Step: The Path of Mindfulness in Everyday Life.
New
York, NY: Bantam Books; 1992.
16.
Fitzgerald
FT.
Curiosity.
Ann
Intern Med.
1999;130:70-72.
MEDLINE
17.
Suchman
AL, Matthews DA.
What
makes the patient-doctor relationship therapeutic?
Ann
Intern Med.
1988;108:125-130.
[published correction appears in Ann Intern Med. 1988;109:173].
MEDLINE
18.
Stetten
Jr D.
Coping
with blindness.
N
Engl J Med.
1981;305:458-460.
MEDLINE
19.
Christakis
DA, Feudtner C.
Ethics
in a short white coat.
Acad
Med.
1993;68:249-254.
MEDLINE
20.
Christensen
JF, Levinson W, Dunn PM.
The
heart of darkness.
J
Gen Intern Med.
1992;7:424-431.
MEDLINE
21.
Dimsdale
JE.
Delays
and slips in medical diagnosis.
Perspect
Biol Med.
1984;27:213-220.
MEDLINE
22.
Coles
C.
Approaching
professional development.
J
Contin Educ Health Prof.
1996;16:152-158.
23.
Eraut
M.
Developing
Professional Knowledge and Competence.
London,
England: Falmer Press; 1994.
24.
Hafferty
FW, Franks R.
The
hidden curriculum, ethics teaching, and the structure of medical education.
Acad
Med.
1994;69:861-871.
MEDLINE
25.
Schon
DA.
The
Reflective Practitioner.
New
York, NY: Basic Books; 1983.
26.
Wear
D.
Professional
development of medical students: problems and promises.
Acad
Med.
1997;72:1056-1062.
MEDLINE
27.
Baron
RJ.
An
introduction to medical phenomenology.
Ann
Intern Med.
1985;103:606-611.
MEDLINE
28.
Damasio
AR.
Descartes'
Error: Emotion, Reason, and the Human Brain.
New
York, NY: GP Putnam's Sons; 1994.
29.
Peters
RM.
The
role of intuitive thinking in the diagnostic process.
Arch
Fam Med.
1995;4:939-941.
MEDLINE
30.
Wartofsky
M.
Clinical
judgment, expert programs, and cognitive style: a counter-essay in the
logic of diagnoses.
J
Med Philosophy.
1986;11:81-82.
31.
Friere
P.
Pedagogy
of Freedom.
New
York, NY: Rowman & Littlefield; 1998.
32.
Matthews
DA, Suchman AL, Branch Jr WT.
Making
"connexions."
Ann
Intern Med.
1993;118:973-977.
MEDLINE
33.
Belenky
MF, Clinchy McVicker B, Goldberger NR, Tarule JM.
Women's
Ways of Knowing: The Development of Self, Voice, and Mind.
New
York, NY: Basic Books; 1997.
34.
Goldman
GM.
The
tacit dimension of clinical judgment.
Yale
J Biol Med.
1990;63:47-61.
MEDLINE
35.
Polanyi
M.
Personal
Knowledge: Towards a Post-Critical Philosophy.
Chicago,
Ill: University of Chicago Press; 1974.
36.
Feinstein
AR.
"Clinical
Judgment" revisited: the distraction of quantitative models.
Ann
Intern Med.
1994;120:799-805.
MEDLINE
37.
Sackett
DL.
Evidence-Based
Medicine: How to Practice and Teach EBM.
New
York, NY: Churchill Livingstone; 1997.
38.
Pauker
SG, Kassirer JP.
Decision
analysis.
N
Engl J Med.
1987;316:250-258.
MEDLINE
39.
Austin
JH.
Zen
and the Brain: Toward an Understanding of Meditation and Consciousness.
Cambridge,
Mass: Massachusetts Institute of Technology Press; 1998.
40.
Epstein
RM, Cole DR, Gawinski BA, Piotrowski-Lee S, Ruddy NB.
How
students learn from community-based preceptors.
Arch
Fam Med.
1998;7:149-154.
MEDLINE
41.
Nisbett
RE, Wilson TD.
Telling
more than we can know: verbal reports on mental processes.
Psychol
Rev.
1977;84:231-259.
42.
Nin
A.
The
Diary of Anais Nin, 1939-1944.
New
York, NY: Harcourt Brace & World; 1969.
43.
Tonelli
MR.
The
philosophical limits of evidence-based medicine.
Acad
Med.
1998;73:1234-1240.
MEDLINE
44.
Tanenbaum
SJ.
What
physicians know.
N
Engl J Med.
1993;329:1268-1271.
MEDLINE
45.
Benner
P.
From
Novice to Expert.
Menlo
Park, Calif: Addison-Wesley; 1984.
46.
Malterud
K.
The
legitimacy of clinical knowledge: towards a medical epistemology embracing
the art of medicine.
Theor
Med.
1995;16:183-198.
MEDLINE
47.
Greenberg
DB, Eisenthal S, Stoeckle JD.
Affective
aspects of clinical reasoning.
Psychol
Rep.
1984;55.
48.
Franks
P, Culpepper L, Dickinson J.
Psychosocial
bias in the diagnosis of obesity.
J
Fam Pract.
1982;14:745-750.
MEDLINE
49.
Todd
KH, Samaroo N, Hoffman JR.
Ethnicity
as a risk factor for inadequate emergency department analgesia.
JAMA.
1993;269:1537-1539.
MEDLINE
50.
Holtgrave
DR, Lawler F, Spann SJ.
Physicians'
risk attitudes, laboratory usage, and referral decisions: the case of an
academic family practice center.
Med
Decis Making.
1991;11:125-30.
MEDLINE
51.
Bertakis
KD, Callahan EJ.
A
comparison of initial and established patient encounters using the Davis
Observation Code.
Fam
Med.
1992;24:307-311.
MEDLINE
52.
Nightingale
SD.
Risk
preference and laboratory test selection.
J
Gen Intern Med.
1987;2:25-28.
MEDLINE
53.
Pearson
SD, Goldman L, Orav EJ, Guadagnoli E, Garcia TB, Johnson PA.
Triage
decisions for emergency department patients with chest pain.
J
Gen Intern Med.
1995;10:557-564.
MEDLINE
54.
Kassirer
JP.
Our
stubborn quest for diagnostic certainty: a cause of excessive testing.
N
Engl J Med.
1989;320:1489-1491.
MEDLINE
55.
Quill
TE, Suchman AL.
Uncertainty
and control: learning to live with medicine's limitations.
Humane
Med.
1993;9:109-120.
56.
Detsky
AS, Redelmeier D, Abrams HB.
What's
wrong with decision analysis? can the left brain influence the right?
J
Chronic Dis.
1987;40:831-838.
MEDLINE
57.
Eraut
M.
The
context for professional education and development.
In:
Eraut M, ed. Developing Professional Knowledge and Competence. London,
England: Falmer Press; 1994:1-18.
58.
Eraut
M.
Learning
professional processes: public knowledge and personal experience.
In:
Eraut M, ed. Developing Professional Knowledge and Competence. London,
England: Falmer Press; 1994:100-122.
59.
Ryle
G.
The
Concept of Mind.
New
York, NY: Barnes & Noble; 1949.
60.
Heisenberg
W.
Physics
and Philosophy.
New
York, NY: Harper & Brothers; 1958:58.
61.
Westberg
J, Jason H.
Collaborative
Clinical Education: The Foundation of Effective Patient Care.
New
York, NY: Springer Publishing Co; 1993.
62.
Epstein
RM, Morse DS, Frankel RM, Frarey L, Anderson K, Beckman HB.
Awkward
moments in patient-physician communication about HIV risk.
Ann
Intern Med.
1998;128:435-442.
MEDLINE
63.
Westberg
J.
Teaching
Creatively With Video: Fostering Reflection, Communication, and Other Clinical
Skills.
New
York, NY: Springer Publishing Co; 1994.
64.
Hundert
EM, Hafferty F, Christakis D.
Characteristics
of the informal curriculum and trainees' ethical choices.
Acad
Med.
1996;71:624-642.
MEDLINE
65.
McWhinney,
IR.
Fifty
years on: the legacy of Michael Balint.
Br
J Gen Pract.
1999;49:418-419.
66.
Kabat-Zinn
J.
Wherever
You Go, There You Are: Mindfulness Meditation in Everyday Life.
New
York, NY: Hyperion; 1994.
67.
Goldberg
P.
The
Intuitive Edge: Understanding and Developing Intuition.
Los
Angeles, Calif: JP Tarcher; 1983.
68.
LeDoux
JE.
Emotion,
memory and the brain.
Sci
Am.
1994;270:50-57.
MEDLINE
69.
Bernstein
S.
With
Your Own Two Hands.
New
York, NY: Schirmer Books; 1981:215-217.
70.
Goleman
D.
Emotional
Intelligence.
New
York, NY: Bantam Books; 1995.
71.
Gardner
H.
Multiple
Intelligences: The Theory in Practice.
New
York, NY: Basic Books; 1993.
72.
Schon
DA.
Educating
the reflective practitioner.
San
Francisco, Calif: Jossey-Bass Publishers; 1987.
73.
Argyris
C, Schon DA.
Theory
in Practice: Increasing Professional Effectiveness.
San
Francisco, Calif: Jossey-Bass Publishers; 1974.
74.
Barsky
III AJ.
Patients
who amplify bodily sensations.
Ann
Intern Med.
1979;91:63-70.
MEDLINE
75.
Buber
M.
I
and Thou.
New
York, NY: Scribner; 1970.
76.
James
W.
Pragmatism.
Cambridge,
Mass: Harvard University Press; 1975.
77.
Association
of American Medical Colleges.
Report
I: Learning Objectives for Medical Student Education: Guidelines for Medical
Schools.
Chicago,
Ill: Association of American Medical Colleges; 1998.
78.
Stern
DT.
Practicing
what we preach? an analysis of the curriculum of values in medical education.
Am
J Med.
1998;104:569-575.
MEDLINE
79.
Suchman
AL, Markakis K, Beckman HB, Frankel R.
A
model of empathic communication in the medical interview.
JAMA.
1997;277:678-682.
MEDLINE
80.
Crawshaw
R.
Greed.
BMJ.
1996;313:1596-1597.
MEDLINE
81.
Epstein
RM, Belle Brown J, Anderson K, Frarey L, Meredith L, Stewart M.
Physician
ineffectiveness in discussions of emotionally charged topics.
In:
Programs and Abstracts of the 3rd International Conference on Communication
in Medicine; July 22, 1999; Chicago, Ill.
82.
Mengel
M.
Physician
ineffectiveness due to family of origin issues.
Fam
Syst Med.
1987;5:176-190.
83.
Peabody
F.
The
care of the patient.
JAMA.
1927;88:877-882.
84.
McWhinney
IR.
Illness,
suffering, and healing.
In:
McWhinney IR, ed. A Textbook of Family Medicine. 2nd ed. New York,
NY: Oxford University Press; 1997:83-103.
85.
McWhinney
IR.
William
Pickles Lecture 1996: the importance of being different.
Br
J Gen Pract.
1996;46:433-436.
MEDLINE
86.
Frankel
RM, Williams S.
Sexuality
and professionalism.
In:
Feldman M, Christensen T, eds. Behavioral Medicine: A Primary Care Handbook.
Stamford, Conn: Appleton & Lange; 1997:30-39.
87.
Feudtner
C, Christakis DA, Christakis NA.
Do
clinical clerks suffer ethical erosion: students' perceptions of their
ethical environment and personal development.
Acad
Med.
1994;69:670-679.
MEDLINE
88.
Hahn
SR, Thompson KS, Wills TA, Stern V, Budner NS.
The
difficult doctor-patient relationship: somatization, personality and psychopathology.
J
Clin Epidemiol.
1994;47:647-657.
MEDLINE
89.
Groves
JE.
Taking
care of the hateful patient.
N
Engl J Med.
1978;298:883-887.
MEDLINE
90.
Novack
DH, Esptein RM, Paulsen RH.
Toward
creating physician healers: personal awareness, growth and well-being in
medical training.
Acad
Med.
1999;74:516-520.
MEDLINE
91.
Asch
E, Saltzberg D, Kaiser S.
Reinforcement
of self-directed learning and the development of professional attitudes
through peer- and self-assessment.
Acad
Med.
1998;73:575.
MEDLINE
92.
Ramsey
PG, Wenrich MD, Carline JD, Inui TS, Larson EB, LoGerfo JP.
Use
of peer ratings to evaluate physician performance.
JAMA.
1993;269:1655-1660.
MEDLINE
93.
Wu
AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP.
To
tell the truth: ethical and practical issues in disclosing medical mistakes
to patients.
J
Gen Intern Med.
1997;12:770-775.
MEDLINE
94.
LaCombe
MA.
Problems
of professionalism: physician impairment.
Am
J Med.
1996;5:654-656.
95.
Fleetwood
J, Novack DH, Feldman D, Farber N.
MedEthEx:
Standardized Patient Exercises in Medical Ethics and Communication Skills.
Philadelphia,
Pa: Allegheny University of the Health Sciences; 1997.
96.
McDaniel
SH, Landau-Stanton J.
Family-of-origin
work and family therapy skills training: both-and.
Fam
Process.
1991;30:459-471.
MEDLINE
97.
Crouch
M.
Working
with one's own family: another path for professional development.
Fam
Med.
1986;18:93-98.
MEDLINE
98.
Epstein
R.
Is
there a doctor in the family?
Internal
Medicine News.
April
1997:13.
99.
Epstein
R.
Physician
know thy family: looking at one's family-of-origin as a method of physician
self-awareness.
Med
Encounter.
1991;8:9-9.
100.
Tresolini
C, and the Pew-Fetzer Task Force.
Health
Professions Education and Relationship-Centered Care: Report of the Pew-Fetzer
Task Force on Advancing Psychosocial Health Education.
San
Francisco, Calif: Pew Health Communications; 1994.
101.
Hensel
WA, Dickey NW.
Teaching
professionalism: passing the torch.
Acad
Med.
1998;73:865-870.
MEDLINE
102.
Epstein
RM, Christie ML.
HIV
as a chronic disease: teaching using simulated clinical encounters.
In:
Programs and abstracts of the 29th annual meeting of the Society of Teachers
of Family Medicine Annual Meeting Workshop; April 30 1996; San Francisco,
Calif.
103.
Searle
JR.
The
Rediscovery of the Mind.
Cambridge,
Mass: Massachusetts Institute of Technology Press; 1992.
104.
Aronowitz
S.
Introduction.
In:
Friere P, ed. Pedagogy of Freedom: Ethics, Democracy, and Civic Courage.
New York, NY: Rowman & Littlefield; 1998:1-27.
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