Mindful Moments in Medical School

Mindfulness is all the rage these days. In fact, I wish it had been as “in-my-face” when I started college as it is now, in my first year of medical school, where, increasingly, we are being taught about the value of mindfulness — both for patient care and our own health and well-being. It surely would have spared me many moments of overwhelm as a pre-medical student, had I known about the practice and experienced its benefits sooner. Fortunately, since adopting the practice of mindfulness meditation five years ago and cultivating my skills in a local mindfulness-based stress reduction course, I have found it much more natural to transform moments of overwhelm into mindful ones.

Dr. Jon Kabat-Zinn, who is largely responsible for bringing mindfulness meditation into mainstream Western medicine, defines mindfulness as “awareness that arises through paying attention, on purpose, in the present moment, nonjudgmentally.”

Here is an example of what this has looked like for me during moments of stress or emotional difficulty in medical school.

Sometimes, I become fearful of how much material I need to know for an upcoming exam. My thoughts turn foreboding (“I’m going to fail”), and my body may respond instantaneously — in the form of a sinking feeling in my stomach.

Recognize.

First, I simply recognize what is happening. As Jon Kabat-Zinn says, “When you are in the shower, be in the shower.” This sounds funny at first, because if I am taking a shower, of course I am in the shower! The point Kabat-Zinn is making, though, is that while my body may be there, my mind is not. Instead, I’m thinking about a thousand other things outside of what is presently occurring: my showering.

Similarly, with the emergence of fear, I can be tempted to let my mind wander. Since the present reality is distasteful (showering is boring; fear is unpleasant), I want to distract myself so that I do not have to acknowledge it. But when I try to ignore or push through the fear, it is almost always futile. So instead, I pause. I notice that I am afraid, and I gently greet the fear in my mind by naming it for what it is.

Allow.

Second, I allow the fear to be there without resisting it or adding to it. This is probably the most unnatural step and the one that has required the most practice. When I am afraid, my instinct is to try to make the fear go away. Fighting with or running from the fear, though, almost always aggravates it. Another temptation is to pile on more fearful thoughts. The thought “I am going to fail this exam” somehow insidiously and irrationally evolves into “I am not going to match into a good residency” and “I am going to have a bad life.” Spiraling thoughts are then accompanied by worsening sensations in my stomach and perhaps new physical manifestations, like a racing heart. Allowing the fear to be there means simply sitting with it rather than trying to change it. An analogy called the Lazy River has helped: if my fearful thoughts and feelings are like boats and rafts floating down a river, I imagine myself observing them as they float downstream without jumping into any of them. That way, I can calmly watch what is happening without getting carried away by the river.

Investigate.

Next, I investigate the fear. I curiously “peruse” the thoughts and feelings, trying to fascinate myself with them, as if I were watching an interesting movie for the first time. I try to take on a posture of mindfulness called “beginner’s mind,” which involves examining the experience of the present moment (in this case, fear), as if it were my first time ever experiencing something like it. This way of looking at my fear not only disempowers it, but allows me to get to know its features as I ask myself honest questions, like: Why I am afraid? Is the fear warranted? What can I do about it? Most often, this helps me recognize that the catastrophic thoughts I have about the importance of a single exam are irrational and that there are clear practical steps I can take to mitigate any lingering worries.

Nonidentify.

Finally, I practice nonidentifying with the fear, which means not allowing the fear to define me. Prior to learning how to do this well, it was easy for me during stressful times to believe that the stress was a part of me. Likewise, when fear arose, I felt like in that moment I was the fear. Nonidentification allows me to make the switch from “I am afraid” to “I am experiencing a fearful sensation.” This subtle change in wording makes a profound impact on my relationship to the thoughts and feelings associated with fear. It allows me to view the fear as if I were a detached observer, which significantly lessens its intensity because I no longer take the fear personally. In one part of a guided meditation I have enjoyed, Michael Sealey guides me to “watch my own state of watching.” To nonidentify with the fear when I am feeling afraid, I picture in my mind that I — the “first person” me — am watching myself — the “third person” me — experience fear. This is what I mean by being a detached observer: the essence of nonidentification.

This four-step process to dealing with difficult emotions is a popular mindfulness practice, called R.A.I.N. (Recognize, Allow, Investigate, Nonidentify). What began as a strained effort to systematically go through each step anytime a moment of overwhelm arose is now a natural response to stress that provides mindful moments for me as I journey through the ups and downs of medical school.

For anyone who is interested in and new to R.A.I.N., I would recommend beginning with a guided meditation.

For more information on mindfulness resources at Johns Hopkins, contact the Mindfulness Program at Johns Hopkins.