By Adam Perlman, MD, MPH, FACP
In order to transform our healthcare system through the adoption of an integrative approach to care, it has become clear that to make such a shift, leaders are needed who are not only dedicated to the values inherent in integrative medicine but who can also think critically, create collaborative environments, develop strategic approaches to change and inspire excellence throughout an organization. A grant from The Bravewell Collaborative in 2013 to develop a program that might train such leaders — The Leadership Program in Integrative Healthcare at Duke — afforded me the opportunity to contemplate exactly what core attributes were needed to effectively lead.
As I thought about the question and talked with other leaders within integrative medicine, the idea of “Informed Mindfulness” began to emerge.
Mindfulness, a concept that is more than 2500 years old, originally comes to us from Buddhism. In its simplest essence, it means paying attention, in a nonjudgmental way, to what is occurring in the present moment. Practicing mindfulness deepens self-awareness and fosters self-regulation such that our actions rise from a clear well rather than the muddy waters of emotional and mental turmoil.
Jon Kabat-Zinn, PhD, Founder of the Center for Mindfulness in Medicine, Health Care and Society at the University of Massachusetts Medical School, mainstreamed mindfulness into the healthcare system through his Mindfulness-Based Stress Reduction Program. It proved so beneficial that it is now taught widely to both patients and providers.
But true mindfulness is much more complex than simple self-awareness. Scholar R.M.L. Gethin, who analyzed all the ways that mindfulness has been used throughout Buddhist history, summed up the elements of mindfulness practice as:
- Not forgetting, which means not losing what is before the mind in the present moment.
- Presence of Mind, which means directly facing what is arising.
- Remembering, which refers to calling to mind what is skillful and what is not, what is beneficial and what is harmful.
- Close association with wisdom, which means innate wakefulness coupled with clear comprehension or seeing something precisely and thoroughly from all sides.
It was the last two bullets on this list that intrigued me — remembering and close association with wisdom — and I wanted to find a way to make those concepts less esoteric and more accessible. I am not a regular meditator and not Buddhist, so I wanted to find a way to talk about it that did not require someone to be a 20-year meditator or even a meditator at all. I also began to recognize that often, although being more mindful, more aware was an important first step, to see change that led to new and extraordinary results, one needed to couple mindfulness with know how.
Hence, the concept of “Informed Mindfulness” came into being. It connects mindful self-awareness and self-regulation with educated decision-making. The mindful person is aware, non-judgmentally, of what is occurring in the present moment, and understands that his or her response is a choice. With informed mindfulness, as situations arise and decision points are faced, that same person is able to place what is happening in its larger context and, having clear values and being sufficiently educated, he or she is able to make an informed choice within that moment. In other words, we need our self-awareness to be coupled with knowledge, skills, values, and wisdom. We need to know what to do with our awareness once it is developed.
Let’s say in practicing mindfulness you come to realize that you, as a leader, are conflict adverse. Being aware of your aversion can help you self-regulate. Recognizing your own behavior patterns, you can take a step back from it and stop yourself from running away from the situation. But in order to build a new behavior that will yield more positive results, you need conflict resolution or mediation skills. You need to be educated about your options so you can develop an appropriate new way of being.
Here at Duke Integrative Medicine we are trying to work on our Press Ganey patient satisfaction scores. To help us be mindful, we have buttons that say “Strive for 5.” When everyone wears that button, patients ask us about it and we see it on others and it reminds us and keeps us present to the fact that we are trying to improve our patient experience and get all “5’s” on the survey, the top score. So that’s a technique to strengthen our awareness. But if all we are doing is walking around with buttons and we don’t understand what it is going to take to actually improve the patient experience, then it’s unlikely we’ll accomplish our goal in a sustained and meaningful way..
When I became associate vice president for Duke Health and Wellness, I inherited many teams in diverse settings, each operating as small satellites. My job, as a leader, was to bring cohesion, to get everyone rowing in the same direction, as it were. But if I had not understood how I could help my organization develop a shared sense of commitment to our values and goals then I would never have been able to achieve that goal. It would just have been a game of chance as to whether I succeeded or not. I needed to be fully aware of self and others, build trust and rapport, but I also needed to know what to do with that trust and rapport.
 Robert Mark Lovell Gethin, The Buddhist Path to Awakening. One World, Oxford, England. 2001.