By Adam Perlman, MD, MPH, FACP
As we attempt to transform our healthcare system through the adoption of an integrative approach to care, it has become clear that to make such a shift, we need leaders 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:
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 Jewish 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.
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. 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 we haven’t accomplished much.
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 so there was trust and rapport, but I also needed to know what to do with that trust and rapport.
DEVELOPING SELF AWARENESS
Even though I named it “informed mindfulness,” there are many ways to develop self-awareness and gain a deeper understanding of your own self. A structured practice like mindfulness or meditation might be the most direct, but it’s not for everyone. You can build that awareness in other ways. For instance, it can come through self-exploration and reflection, through reading and studying, through Jungian analysis or depth psychology sessions, through contemplative practices, and even through discussions with mentors and advisors.
Personally, I don’t have a formal mindfulness practice but I spend a lot of time thinking about who I am and who I want to be and how I show up in this world. I would describe my practice as both reflective and contemplative. Along the way I have looked for tools and resources to help me in my journey. For instance, a while back I bought The Power of Now by Eckhart Tolle. I only read about 100 pages but his concept of not listening to this voice in your head that’s talking about the past or babbling about the future but instead being present in the moment, really struck me.
Tolle said: Identification with thoughts and the emotions that go with those thoughts creates a false mind-made sense of self, conditioned by the past: the “little me” and its story. This false self lives mainly through memory and anticipation. Past and future are its main preoccupation. The present moment, at best, is a means to an end, a stepping stone to the future, because the future promises fulfillment, the future promises salvation in one form or another. The only problem is the future never comes. Life is always now. Whatever happens, whatever you experience, feel, think, do — it’s always now. It’s all there is. And if you continuously miss the now – resist it, dislike it, try to get away from it, reduce it to a means to an end, then you miss the essence of your life, and you are stuck in a dream world of images, concepts, labels, interpretations, judgments — the conditioned content of your mind that you take to be “yourself.” And so you are disconnected from the fullness of life that is the “suchness” of this moment.”
I could see that it was something that I was doing. I spent a lot of time either thinking about the past or dreaming about the future. And that one idea was enough to propel me on a better course and I began to practice “not listening” to the voice inside my mind.
Another book that helped me was The Four Agreements by Don Miguel Ruiz. The second agreement is “don’t take it personally.” Ruiz said: “Whatever happens around you, don’t take it personally… Nothing other people do is because of you. It is because of themselves.”
When I read it, I thought, wait a minute, I can see how I have been making things personal and reacting to other people’s judgments and negative emotions. It resonated with me so I began working with it and as I did, I rescued myself from a lot of turmoil.
Here’s the concept — these nuggets of wisdom are like food. You need to take that food in and digest it. You need to assimilate it into your body and mind until it becomes your own.
WHY IT MATTERS
You can see from the above examples, how self awareness and reflection often lead naturally into a more informed state — an idea triggers reflection and that reflection leads to a new way of being. I think you can also see how developing informed mindfulness makes a big difference in one’s ability to lead.
Who would be the better leader — the person who is always worrying about the mistakes of the past and fantasizing about the future, or the person who is deeply rooted in the now, seeing and responding to things as they truly are?
Who would be the better leader — the person who constantly worries what other people think and is always trying to change him or herself in response, or the person who knows who he or she is and always acts in accordance with his or her values?
Who would be the better leader — the person who is aware of what was happening but doesn’t know how to resolve the situation or the person who is aware of what was happening and understands which path leads them out of the forest?
Let’s all become better leaders by becoming mindful and informed.
Adam Perlman, MD, MPH, is an Associate Professor of Medicine and works within the Duke University Health System as Executive Director of Duke Integrative Medicine and Associate Vice President for Health and Wellness. In addition, he is the Director of The Leadership Program in Integrative Healthcare at Duke. integrativehealthleaders.org.
 Robert Mark Lovell Gethin, The Buddhist Path to Awakening. One World, Oxford, England. 2001.
 http://www.eckharttolle.com/article/The-Power-Of-Now-Spirituality-And-The-End-Of-Suffering. Accessed 12 March 2015.
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