The scope of work carried out by primary care providers is far-reaching, including initial steps of diagnosis, subsequent treatment planning, and follow-up of active disease. Preventative medicine is also an important part of the job and it encompasses screening modalities and patient education, a large part of which involves counselling on lifestyle modifications such as weight loss, optimized nutrition, improved physical activity, smoking cessation, etc. Offering comprehensive patient education is more involved than a simple written prescription of topical steroids for an eczematous rash. Ultimately, our patients are no different than we are when it comes to establishing more optimal lifestyle habits, and as individuals we all have varying degrees of what’s called a “locus of control”, which describes how much control we feel that we have over our own lives and the experiences that arise within them. Some people might be externalizers; they will feel as though the events of life are happening to them. Internalizers on the other side of the spectrum believe that the events of life are happening because of the actions they have taken. This mental setpoint of control guides a person’s inner drive and motivation which is important to be familiar with when counseling patients about lifestyle medicine; for some people increasing weekly exercise may be a goal that’s perceived as highly attainable and therefore perhaps less time can be spent in the clinic discussing personal and/or financial barriers to reaching that goal. But this might not be the case for other patients who, for various reasons, may need more time dedicated to counselling and education. Additionally, patients who are more likely to externalize may require a closer look at personal and material resources they have available to “spend” on a lifestyle goal (time, money, considerations for family care and travel, etc.). Primary prevention and lifestyle counseling is hard work and in many ways, the topics of discussion around these goals can be stigmatizing for some people.
Lifestyle counselling aligns well with a participatory model for medicine, one which puts patients in the driver’s seat with regards to their health choices and outcomes. In many ways this is the path that healthcare providers continue to take with regards to patient care when compared to previous generations of paternalism where clinical decision-making was very much an isolated process rather than a shared one. Conversations about lowering sodium intake in cardiac patients or weight loss targets in a diabetic are important and they are always relevant to improving clinical care; after all, we are taught and trained to address these factors with our patients. But an important question arises about the extent to which a care provider should dedicate clinical time to discussions around mindfulness-based approaches to disease and disease prevention. Mindfulness-based programs have been studied as effective modalities for treatment of various conditions; mindfulness-based (MB) stress reduction, an 8-week program is one of the better-known courses however other targeted programs have been developed such as MB cancer recovery, MB chronic pain management, and MB relapse prevention to name a few.
When these programs are carried out in a controlled setting such as a research study, participants are engaging voluntarily with the service. In the clinic however, many patients may not have heard of such interventions, may not be aware of the appropriateness or benefits of mindfulness meditation, or may be reluctant to engage with something which requires a significant investment of time and energy. After reading stories and perspectives from care providers who have initiated these programs with their patients, it seems as though the approach often starts with learning to develop a practice for yourself. By engaging with meditation personally, not only will you benefit from stress reduction, decreased emotional reactivity, and increased empathy for example, but you’ll gain experience and the sense of “competence” making these discussions with patients more comfortable. That being said, a clinician need not be a certified MBSR instructor to offer guidance in the clinic, since referrals can be made to specialized centers to that end. I have yet to learn of a health institution that includes mindfulness teachers within the treating multidisciplinary team, but I wonder whether this might be a tangible possibility in the future of participatory medicine.
One of the major challenges that comes to mind when I think about introducing mindfulness approaches in a mainstream way into hospitals, is just that, “medicalizing” mindfulness and meditation. How can we offer mindfulness which is all about non-striving and which is non-goal oriented without selling it as a “pre-packaged” treatment protocol that respects certain guidelines for patients to follow. Doing so would assume that there are expected health outcomes that can be derived from participation and this seems to go against the ultimate heart and soul of the practise itself, a very individually defined experience. I think it’s important to always keep this is mind and to offer patients the basic evidence regarding meditation and to remind them that it is not a quick-fix solution to their health problem but rather a potential symptom-reliever and opportunity for leading a full life despite illness. A balance can be found with regards to how mindfulness is presented to patients, including both the latest evidence-based research findings and the less scientific but equally important “troubleshooting” tips for someone new to the practise (mindful exercise techniques, guided meditation series, articles, etc.). And again, different people will have different capacities to engage with mindfulness as it is a self-driven process for the most part, and some patients may need more guidance than others. The patient experience with health and disease is so private and subjective and I think mindfulness may have a valuable place in the repertoire of clinical tools we have to offer those under our care.
This article was written by Madison Le Gallee, a medical student at McGill University and member of the McGill Med Mindfulness Team.
The Mindful Medical Learner 