Being Present: Medicine, Mindfulness, and Humanity

I delivered babies for many years as part of my family practice. At first, I found it difficult to look directly at the faces of women experiencing the intensity of labor. Reflexively, I’d avert my gaze. Witnessing raw and unfiltered expressions of pain made me feel uncomfortable and inadequate. I’d busy myself with a task—check the electronic fetal monitor, talk to the patient’s partner, talk to the nurse. When I was doing something—prescribing a medication, actually helping a newborn glide into the world—I felt calm and confident. But I foundered when the situation didn’t demand action—or demanded inaction. Perhaps patients noticed, or perhaps they didn’t.

I undertook a practice of presence. I began, consciously, taking in each patient’s face, recognizing yet resisting the urge to look away. I became aware of my own gaze and my facial expressions, noting when I drew back. I discovered that observing is not necessarily seeing. I could observe a woman’s labor without seeing the person. Observing is much like what the philosopher Michel Foucault called the “clinical gaze”—a way of viewing a patient as a disease, a diagnosis, a clinical problem, somewhat less than a person.1 In contrast, by not merely observing, and instead seeing, I could explore what it was like for me to be present.

Gradually I grew more comfortable. Distance—physical distance and emotional distance—seemed to dissolve. I no longer felt that I was going to drown. I could be more helpful, seeing ways in which I could relieve patients’ discomfort. It felt genuine, intimate.

At first, presence was an interior experience for me; only later did I realize that it was shared. Patients responded differently when I was present. They looked back, they took my hand. The presence I could bring to a woman in labor seemed like the presence I felt as a performing musician. Being present had an impact on the care I delivered. I discovered what good midwives always knew—that you can “tell” when a woman is progressing in labor; this “telling” depends on presence. I was better able to wait before acting.

The Ineffable

At its most basic, presence is made visible when the clinician makes good eye contact, responds to patients’ concerns, and doesn’t stand up and leave before the conversation is finished. However, when patients say their doctor is “really there,” most patients are referring to a quality of being. Presence is a sense of coherence and imperturbability. Internist Tony Suchman calls it the “connexional” dimension of care, often unspoken. Presence is a quality of listening—without interrupting, interpreting, judging, or minimizing. In case you hadn’t noticed, doctors don’t do this well. When psychologist Kim Marvel and I analyzed audio-recorded primary care office visits, we saw how doctors would get restless and take control after patients had spoken for an average of only 23 seconds.

The philosopher Ralph Harper, in his book On Presence, considers presence to be a “bonded resonance” in which two people are in touch and in tune with each other. Presence, according to Harper, is especially important in “boundary situations,” times when people feel vulnerable, when life is particularly uncertain and when it’s hard to find meaning. In medicine, these are times when patients face serious illness and loss of function, when patients and their loved ones are frightened, when there are unexpected mishaps. Presence is a gift of dignity and respect when patients need it most. Harper also points out that presence is always shared with a real or imagined other; presence requires a witness, even if that witness is another part of oneself—an observing self. In that way, I can be present with a patient even when a patient is unable to speak for herself.

I feel a bit daunted in trying to characterize presence, to render the ineffable visible and leave it no less wondrous. Presence has historically been the domain of poets, philosophers, and mystics; however, it is at the core of healthcare. When clinicians write about presence, they rarely do so using clinical language. They write stories. Surgeons, internists, family physicians, and psychiatrists have described how you cannot force presence into existence, nor does presence reliably happen on its own; you have to make space within which presence can emerge. In that sense, presence depends on emptiness, getting yourself out of the way, setting aside inner chatter—what the Buddha called “monkey mind”—to connect more directly with a person, a task, or a part of yourself. Societally, more than ever we crave presence with ourselves and shared presence with others, patients and clinicians included. With our attention increasingly parsed among tasks that compete for the same set of neural pathways, we are divided into too many fragments—too many to maintain a sense of being whole. Every day our sense of presence is constantly being fractured and repaired—an exhausting prospect. Try having a conversation—a meaningful conversation— while entering data on a computer. At the least, your sentence structure becomes disjointed and you lose your train of thought.

Presentness of Time

Sometimes a simple gesture and a few well-placed words can signal presence. One day on rounds in the hospital, as we walked into the room, Laura Hogan, a nurse-practitioner on our palliative care team, said three words to the patient: “What beautiful flowers.” The patient looked at the flowers and smiled. The previous day the patient had had a biopsy that would let her know whether her cancer had progressed; she was still awaiting the results. We all feared that the news would not be good. Laura’s comment communicated that even in dire circumstances it is possible to see beauty and to honor those who loved and cared for the patient, that she was not alone. More often, though, presence is communicated nonverbally—a softness of gaze, a quality of touch, a handshake that is felt genuine rather than perfunctory, a gentle examination of a patient’s tender abdomen.

Presence is also “presentness” of time. When I feel that I’m being present while caring for patients, time seems to expand or stand still. Several years ago, I went to a jazz concert by Chick Corea’s group. During the opening piece, after each of the musicians had had a chance to improvise, the music reached a resting point, a silence that probably only lasted two seconds. Even though the concert was in a three-thousand-seat auditorium, everyone seemed to feel the same sense of intimacy and connection in that silence. That moment had an exquisite spaciousness, as if the outside world had ceased to exist, a spaciousness that resolved only when the musicians simultaneously struck a chord marking a new section of the music. Think of speeches by Martin Luther King Jr. or Mahatma Gandhi. You are captivated, entranced, transported, and time seems to stop or ceases altogether.

When physicians are being present, patients feel that spaciousness. I remember the first time I felt it as a patient. I was in my late teens and had not been feeling well for over a month; I was weak, tired, and feverish, with a sore throat, headaches, and no energy. I would get better for a while, then it would come back. I had recently graduated from my pediatrician to a new “adult” doctor, whom I did not know well. He was thorough and gentle as he examined my ears, throat, neck, chest, and abdomen. I presume that the physical examination was normal and uninformative; it confirmed a diagnosis that he had already made. Time seemed to stand still. I was worried; he was imperturbably calm. He was much older than I, but that didn’t seem to matter; he was warm and his eyes had a softness. I felt that he understood me and my situation, and the distance between us seemed to dissolve. He said that he’d seen this cluster of symptoms, which was probably a lingering virus, and that time would heal. He ordered a blood test just to make sure. That’s all I needed.

This was the first time I felt understood and cared for—honored and respected—by a physician. I carried his presence with me after I went home and found his virtual presence quietly reassuring; I was not worrying alone. A couple of weeks later, I began to feel more myself. His image came to me years later as I was contemplating going to medical school and later during the dark moments when I wondered whether memorizing names of bacteria and reciting differential diagnoses was all that it could be about.

Later still, I discovered that I could be present in that way—and share my presence with patients. I had a new patient in my practice—Haqim, 16 years old, muscular, confident, and robust. He had acne on his back and shoulders. He asked question after question—about hormones and how they affect the skin (and why they make people unattractive), how each medication worked, whether he could try two of them at the same time, and how long it would take for the bumps and cysts to go away. He was worried—very worried. I listened, without interpreting or reflecting—I just listened. I explained that time would heal, with the help of a few creams and pills. After a few more questions about how the pills actually worked, he relaxed and even smiled. We spent the remaining five minutes of the 15-minute visit talking about his family. Since then Haqim has mentioned to me on more than one occasion that he wants to become a doctor.

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Excerpted with permission from Attending: Medicine, Mindfulness, and Humanity, © 2017, by Ronald Epstein, MD.

Ronald Epstein, MD, family and palliative care physician, teacher, researcher, and writer, has devoted his career to understanding and improving communication, quality, and clinician mindfulness in healthcare through groundbreaking research and educational programs.

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