Transcription of Dr. George (Joe) Dreher for the show Mindfulness, #120
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Dr. Dreher: It’s important to understand that mindfulness is as much as any an experience. It’s I think, the present moment that has the greatest potential to give us a sense of belonging and value within ourselves and in whatever work we’re doing around in our life. Be aware of what you’re doing right now.
Maureen: I think a lot of people can benefit from just learning the skills about how to sustain their attention in a different way and how to be gentle with themselves when they’ve lost their focus, and how to bring their focus back to whatever it is that they had been intending on resting their attention on.
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Dr. Lisa: This is Dr. Lisa Belisle and you are listening to the Dr. Lisa Radio Hour & Podcast show number 120, Mindfulness, airing for the first time on Sunday, December 29th, 2013. Our guests today include Dr. Joe Dreher, clinical associate professor at Tufts School of Medicine, affiliated with the Maine Medical Center and Maine Health, and Maureen Callnan, mental health clinical nurse with a specialty in mindfulness and memory issues.
As we move into a new year, many of us are taking time to count our blessings and look forward to blessings ahead. We are best able to know the bounty of our lives when we are fully present enjoying the moments as they come to us. Today we speak with experts in the field of mindfulness who are helping educate healthcare providers and patients about being more fully present. We hope that our conversations may give you an opportunity to count your blessings from 2013 and consider the importance of mindfulness in the year ahead. Thank you for joining us.
A known doctor, Joe Dreher, George Dreher who is a clinical associate professor with Tufts School of Medicine located here at Maine Medical Center for many years. In fact, Dr. Dreher was one of my teachers and my advisor when I was a family medicine resident at the Maine Medical Center. I felt like I got to know him a little bit more when I spent time up at Mayo Hospital in Dover-Foxcroft even though he had already gone by that time when I was spending time as a resident. I understood where he had been as he had processed through being a family doctor then and then deciding to go back into medical education training and become a psychiatrist.
It’s great fun for me to have Dr. Dreher across the microphone from me today to talk about a subject that I believe is pretty dear to his heart and that is mindfulness. Thanks for coming in.
Dr. Dreher: My pleasure.
Dr. Lisa: Dr. Dreher you started your whole, I guess, adult career in the Navy as part of the Submarine Corps. I’m fascinated by this because I don’t think I knew this about you. You’ve come a long way from submarine and this is part of medical school to now working with Tufts School of Medicine. Why did you become a submariner?
Dr. Dreher: I was greatly motivated by the draft. It was during Vietnam and I actually got into the Navy one week before I was to be reporting for act of duty in the army. My family had a background in the Navy and I’ve always been fascinated by submarines so it was a natural choice.
Dr. Lisa: From being in the Navy and spending time in … Were you in Vietnam proper or were you just training and working State side?
Dr. Dreher: I was in the submarine in the North Atlantic playing tag with the Russians. Did that for 3-1/2 years and actually while I was in the Navy had the opportunity to spend time with some physicians and decided to change my career path from doing oceanography research at Scripps in La Jolla, California to going to medical school.
Dr. Lisa: That was going to be my question, which is how did being in the Navy and this interesting turn of, twist of faith called the draft. How did that propel you into this career as a doctor?
Dr. Dreher: I enjoy working with people and I enjoyed science a lot. As I spent some time reflecting on all this in the Navy and visiting some of my previous college professors, I became aware that life of working with people as a physician was probably going to be more satisfying to me than a life involving teaching in science, but a little more abstract in some ways. I made the choice and headed for medical school.
Dr. Lisa: You took a dramatic turn. You went first into family medicine and then you decided that you wanted to go into psychiatry. That required going back to … Essentially went back to school getting more training. Where did that come from?
Dr. Dreher: In the middle of all that I was also doing a lot of work in Addictions. I was aware in family practice and even more so in Addictions how much psychiatry played a role in the wellbeing of people. It also gave me more of an opportunity to spend time with people and patients. I decided that would be the best way, the next logical step. It was a very difficult decision because I really enjoyed family practice and the work I was doing there. I had also enjoyed Addictions but I could just feel that there was something more I wanted to learn so I went back.
Dr. Lisa: You’ve also done work with palliative care and end of life issues. You’re not really choosing the easy things.
Dr. Dreher: I think I’m probably a fringe physician. I always get involved with things that are not quite mainstream. Family practice wasn’t really mainstream, Addictions wasn’t mainstream, palliative care, ethics. They’re all things that I feel are very important parts of medicine and need to be paid more attention to, and it just drew me in. I find them very interesting areas. They all seem to have a lot to do with the suffering of people and trying to find ways to alleviate that, particularly the emotional suffering.
Dr. Lisa: What you’re describing is I guess fringe medicine. It is really actually core to people and our humanity and yet it does get shunted off to the fringes because it’s easier for us just to say, “Okay. Well, here’s an ear infection. Here’s an amoxicillin.” Rather than, “Here’s an ear infection, here’s a parent who smokes, here’s a parent who’s unemployed, here’s a grandmother who’s depressed.” It’s easier to deal with that one thing rather than the whole. Was that one of the reasons why you decided to spend more time on the fringe because you wanted to look at this bigger picture?
Dr. Dreher: The term fringe for me implies not anything good or bad but rather that American medicine is understandably very good at technology and very good at finding treatment and cures for a various sort of diseases which is an important thing to do. I’m concerned, in the process, the doctor-patient relationship has become lessened and that folks who are in primary care, family medicine, internal medicine, pediatrics have not been well taken care of, compensated, listened to in the process of making decisions about what we need in healthcare in America.
The medical systems around the world that are doing more for their patient’s overall health and spending a lot less money have a better primary care system. Where a primary care doctor really has time with patients and can really provide not only the, if you will, technological medical care they need but also the personal care. Certainly it’s very great to have all the technology available we have here for the more complex illnesses, but without the foundation of primary care, it’s somewhat a tail wagging the dog in my opinion about how healthcare probably would be best delivered.
We’re in a frantic race now to try and catch up and build enough primary care practices to allow the planned healthcare systems in this country to function in a more, not only economical, but I think actually productive way particularly in preventing disease which is one thing the family medicine I know does a really good job with. I say fringe just because it’s fallen out that way due to all the kinds of forces that I’m sure I don’t understand. There’s not all bad things by any means about the way it’s fallen out but a balance would be good.
Dr. Lisa: You’ve seen a lot of changes between the time that you went in to medicine and the time that … I guess in theory you’ve quote “retired” unquote, which I think is not entirely true. You’re no longer practicing clinical medicine as of this past summer but you’re still actively involved in the teaching program. What have you seen as far as physician attitudes, behaviors, wellbeing? Because I know that a very important piece of this for you is physician and provider wellbeing.
Dr. Dreher: You are correct that I’ve stopped doing official clinical medicine and my focus now is trying to help the providers themselves. Physicians, nurses, physician assistants, nurse practitioners. All of whom are under tremendous pressures and losing a lot of what gives them meaning in their work. The more this occurs and the more burned out those folks are becoming, the more they’re going to be leaving medicine sooner or the more prone they are to make mistakes or other things that we don’t want to have happen.
The shift has just been for me from, if you will official patients to another whole group of people who are suffering just as patients do and trying to help them. The change has been for I’m sure many reasons that we can’t get into here. Part of it is because medicine has become a business model. That’s partly because of the expense of it and trying to provide care and not spend as much money without doing so by putting providers in a row where they don’t have enough time to spend with each patient, or really to attend to the details of the patient’s needs. It’s something that we’re struggling with right now.
I think we’re going from a fee-for-service model where we get paid for everything we do to hopefully something that’s more holistic and is really looking at the whole patient’s needs and the populations of patient’s needs, and preventing illness as much as we’re treating it. I think when we get there things will be much better but this transition time is very tough on providers and the administrators who are trying to run the system as well. I’m trying to do what I can to help modulate that a little bit.
Dr. Lisa: I assume that that’s part of the reason why mindfulness appeals to you?
Dr. Dreher: It’s always appealed to me to try to help myself be more centered and clear when I’m working with patients. I find it’s one of the useful tools to help the providers I’m working with and there are many others as well. Mindfulness is a powerful tool but it also takes some time and effort to learn it and make it part of your life to a point where it becomes a constant background part of one’s self. It can make a big difference. There are things one can do in little ways to be mindful to help you re-center during the day and reground yourself, and that’s what I’m trying to work with folks on. Again, this is only one of the many tools we’re trying to find to use to help providers be healthier.
Dr. Lisa: Here on the Dr. Lisa Radio Hour & Podcast we’ve long recognized the link between health and wealth. Here to speak more on the topic is Tom Shepard of Shepard Financial.
Tom: I’d like to take this opportunity to wish you and yours a holiday season filled with an abundance of love and gratitude. Be thankful for the things in your life that matter most and enjoy your time with family and friends. From all of us here at Shepard Financial, happy holidays.
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Dr. Lisa: Let’s take a step back and define what mindfulness is specifically or as specific as you would like to be. Because I think a lot of people believe that being mindful is just being sort of paying attention, which it does in a more simple way but it means something more than that.
Dr. Dreher: It does. There’s a lot of discussion about what this means. There’s actually books written on just that, what’s mindfulness about. To me it’s trying to be present in each moment as it occurs without judgment and with as much awareness as you can bring to that moment. It’s very natural and our society reinforces our focused on worrying about the past or worrying about the future and ending up losing the moment we have right now. We are trying to accomplish something in this moment such as working with a patient. It’s good to be able to as much as you can put aside the past and future focus and bring more of yourself to what you’re doing at the moment.
Awareness or noticing is another way to consider the basics of it and you take that awareness and noticing and then do some work and training yourself in it. One form of such training would be meditation, there are others. Then you become aware of what your mind is doing as you go through your day and how much you may be adding unnecessary [plurifiration 00:15:31] to what’s being thought about and worried about and what’s really true and what’s really present before you, and using that presence then be more effective whenever you’re trying to do and being less fanatic yourself.
There’s a win-win for both the person who is doing it and for whatever person or product they’re working on. That’s a short outline to it. There’s a lot more to it obviously.
Dr. Lisa: One of the reasons that I know or became aware that you are working on mindfulness was that you and I had a conversation several years ago about how I had been incorporating mindfulness in my practice. As you know, I did Mindfulness-Based Stress Reduction fellowship with Jon Kabat-Zinn’s program at the University of Massachusetts when I was a preventive medicine resident. When I came back into medical practice, I spent a lot of time working with patients on their breathing. That was the basis of my attempt to help them self-heal.
You’ve done a lot of work with medical students, residents and physicians on mindfulness and it’s looked slightly different because it’s a different population. Tell me how you’re incorporating mindfulness in the work that you’re doing.
Dr. Dreher: Reflecting on a comment you just made about the breath. That’s frequently used as part of a mindfulness training because you always have it with you and it reconnects you with your body. One thing that I believe we all can do and particularly people in an intellectual professional do is become lost in our minds and lose track of the many other facets of who we are as a person. Of which being aware of one’s body is a good anchor if you will to come back to, to pull you away from all the ups and downs and in and outs of the mind which is always going.
The anchor can be used, the breathing anchor can be used for meditation practice but it can also be used in very brief ways. If you’re going from one task to another just stopping for a moment, physically stopping and let yourself catch up to where you are, taking a breath or two and using the out breath as a relaxation process to bring you to this moment. Just be there for it, just a second or two, and collect yourself to then be ready to bring all of yourself into the next project.
There’s one example of ways to be mindful. The important thing about this is that it works much better if you do some training if you will to become present. Just telling somebody well stop, breathe, be and you’ll be in better shape doesn’t work. It’s like giving somebody a pair of tennis shoes and say, “Okay, run a marathon.” You got the shoes but you need to practice and learn how to run in them and be with them. When you do that and also get a more in tune with your body and all the other aspects of yourself. Then when you do the stop, breathe, be, they all sort of ruse for a second and really slow down the monkey mind that’s always going and bringing you to the present moment.
With providers there’s a number of things we’re underway with. We’ve been doing a course in mindful practice in Maine Medical Center for providers, nurses, physicians, respiratory technologists, physical therapist for about 3 years now. We have one going on right now. It’s a 12-week course where people learn some mindfulness tools, but then also look at how they have been dealing with the stressors in practice such as how they deal with professionalism or the lack of it in other people. How they deal with suffering or death and dying and bringing all those things into a quieter place or class to look at them in how they cope with them and reminding them about how they cope with the well many times. Particularly if they’ll let themselves just sit down and remember when they did these things well.
Cultivating that memory of skill renews many aspects of themselves besides just technology and just knowledge base. It really renews the parts that allows them to be a healer and that’s what’s really, I think, key for us not to lose as medicine forges its new role in our society and around the world. It’s to remain healers and not just good technologist.
Our work focus on that, our work in physician health and resilience is taking a bit of a different track. Still hoping to use mindfulness some but really looking at what it is that gives professionals, in this case providers in medicine, a sense of autonomy, a sense of mastery and a sense of meaning or purpose in their work. Then how to promote those three things so that their work doesn’t become empty and they don’t become as burned out.
There’s been some very interesting research in how rather minimal time spent with physicians particularly in attending to the meaning in what we do really renews them in a deep way and allows them to be much more satisfied in their daily work even though the stressors may be the same. It’s how they bring themselves there and how they live within that stress that makes all the difference. There’s a lot of research going on around the country trying to find ways to do this that aren’t too time consuming or too expensive. It’s interesting how some various minor things such as more opportunities for peer to peer connection can really make a big difference in folk’s daily work.
It’s those kinds of things that we’re trying to begin to find and find ways to incorporate in what we’re doing, in our practices and in the practices themselves looking yet inward to see what they can do. We’re having a conference on October 17th inviting several people from major practices around the Portland region to come together and start thinking about what is it that we might be able to do within our own practices, but also work with each other collaboratively to build up these resources that will save the people we’re trying to have be well enough to save others and heal them.
Dr. Lisa: How are the providers responding to this idea of mindfulness? It’s been I know having worked in this field for many years it can a challenge to do all the things that we’re supposed to do and then also simultaneously take a moment to sit down and breathe. Because there’s always this feeling of being rushed, there’s always this feeling of having to multitask to almost an extreme degree. What do people say when you say, “Okay, now we’re going to learn about mindfulness and this is important. And we’re going to fit this into your curriculum somehow.”
Dr. Dreher: It’s interesting that when I have conversations with physicians and talk about what’s causing their burn out and their dissatisfaction, they all are enthusiastically agreeing with it. They would all like to find some ways to change that. Many of them are open to ideas to try out of which mindfulness is one. Many just can’t click with that idea and want to try other things and that’s fine too.
What I’ve learned is that just working with the physicians alone is not likely to make an adequate change so that they can back away from the edge of burn out. That’s why I’m trying to work with physicians and the administrative systems to find ways they can work together on this program. Because the administrative systems are also aware that when physicians are burned out and tired they make more mistakes. Patient satisfaction drops, prescription practices are not as good. There’s all kinds of clinical things that have been shown to be less well done by a burned out provider even if the patient doesn’t know they’re burned out. The systems also want to correct this, not to mention it is just the right thing to do to try and help their employees if you will be in better health.
The difficulty with suggesting mindfulness as a treatment for this is first of all, is not everybody is in to mindfulness. It won’t click for them and that’s fine. Second of all, when I say mindfulness everybody thinks they go off somewhere and meditate for 6 weeks on the top of an isolated mountain in a cave which is not what I’m thinking at all. It’s learning how to do it a little bit everyday in your life.
Another example, I teach a course to medical students called the Healer’s Art and particularly by Rachel Naomi Remen. One of the really neat exercises there is the Three Question Journal where at the end of the day you literally think about your day going backwards from where you are now, backwards into the day and think about what inspired you in that day and just write it down. Then start again from where you are going backwards in the day and find what intrigued you and write that down. Then again, starting from where you are in the evening usually going backwards in the day and find what surprised you.
Just doing that and writing those three things down will help people be aware of the many fascinating things of how many in the day inspiring things that are lost in the rush. If you do that on a routine basis in the evening, after a while you’ll start to notice it as it occurs in the day. You’ll have these little pockets of the feelings of renewal and a sense of meaning in what you’re doing. It will help you through the day.
I’m not pretending that all these things are going to make everybody’s life happy and wonderful. There’s going to be a lot of stress still but I think of it as a tachometer where there’s on a car, there’s a red line. You get above a certain RPM and that’s where the engine starts to fall apart. I’m just trying to help people move back from the red line a little ways and keep them practicing in a way that they’re happy, their patients are happy and they’ll stay in practice longer. We need as many docs as we can get right now and anything to help the doctors do better, feel better in a small way I think will help all of the system be better as well.
Mindfulness is a nice tool but it comes in many different forms. You can be mindful of what you’re reading. Instead of talking during a meal or reading a newspaper or reading the back of a cereal box, sit there and really just taste the food. Chew it a few times and look at the food before you eat it and just appreciate it. I think appreciating the moments you have during the day. If you’re caught in a traffic jam, okay, appreciate the taillights flashing on or off in front of you. Finding something to just settle you down and not get all rived up when you can’t do anything about it or enjoying the things you do have. Time with the people you care about. Some time outdoors.
There’s these little pockets we can all find in our day to be a little more aware of the day and of our lives and slow down for a few minutes. That can be helpful. Mindfulness comes in many different shapes and forms and there isn’t any activity that I can think that you couldn’t use a little mindfulness for and just be aware what you’re doing right now.
Dr. Lisa: Dr. Dreher, how can we find out more about the work that’s being done in mindfulness in medicine through Tufts School of Medicine and the Maine Medical Center here in Portland?
Dr. Dreher: We’re just beginning locally and there’s many things we’d like to do and are trying to mindfully choose amongst them with our limited resources. I would suggest if people want to learn more about this that when you discuss the Mindfulness-Based Stress Reduction would be a great place to start.
The Maine Medical Center Learning Resource Center provides what they call MBSR course a couple of times a year. There are great practitioners in the community who do this. A number of them Nancy Hathaway is one I know who does this kind of work.
You can probably go to the website for the Mindfulness-Based Stress Reduction program on the University of Massachusetts and they’ll have a list of people who’ve been certified by them to teach. That would be a convenient way I think to start. That is filled with the most fuel because it’s really based on the physiology and science of awareness and not requiring one to take a transcend or a spiritual approach to it, although that may arise from it. That’s where I would start, MBSR.
Dr. Lisa: Dr. Dreher, thank you for coming in today and speaking with me. Thank you for also being my teacher, my mentor and my advisor when I was a family medicine resident back in the day. We’ve been speaking with Dr. Joe Dreher, clinical associate professor with the Tufts School of Medicine and affiliated with the Maine Medical Center right here in Portland.
Dr. Dreher: Thank you.
Dr. Lisa: As a physician and a small business owner, I rely on Marci Booth from Booth Maine to help me with my own business and to help me live my own life fully. Here are a few thoughts from Marci.
Marci: On this the last episode of 2013, I wish you all a happy, healthy and above all prosperous new year. As you enter into 2014, take a moment each day to give thanks and appreciate the joy that is all around you. Happy New Year. I’m Marci Booth. Let’s talk about the changes you need, boothmaine.com.
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