It will take exactly the length of time that's right for YOU. Over time, by reading his enormous record and by slipping in a new question here or there and giving him a long time to think it over, I was able to learn a lot about Paul. Possibly the most important information was that he so easily felt embarrassed. He knew that he wasn't right in the brain, and he tried hard to cover over his impairment, because, as he told me at least once each week, he didn't want people to laugh. Paul pretended that his was a normal life and that he was independent and on my own. He wanted desperately to pass as normal, like any of the other people who ate in the cafeteria, or visited the hospital, or bought a paper from Louie. But his incapacity was so visible that even he had to admit that he wasn't normal. But not that different, either, he would add. I felt a great sadness each time I saw Paul: a sense of a life so utterly alone, so devoid of human contacts. But I don't think Paul saw it that way. For him it was a struggle to do all the things he had to. There is a pertinent literature on taking life histories, in which students will find various strategies to elicit patients' life narratives and to write up brief biographies. But, most important, students must be given frequent chances to interpret the chief meanings of these life accounts. Students' experiences can be enriched by reading biographical and fictional stories from the worlds of patients. In addition, medical school faculty must explicitly support the importance of these learning experiences. For students to believe that understanding illness is a crucial part of their education, they must know that they will be tested on the acquisition of relevant skills. Failure to perform adequately or to show the appropriate attitudes or knowledge should be treated in the same way as failure to understand and examine disease processes in cardiology, surgery, or obstetrics. Students should be required to undergo remedial study and reexamination. Persistent inability to demonstrate the requisite attitudes, knowledge, and skills should lead to dismissal. Nothing would so concentrate the minds of medical students and residents as the recognition that if they perform poorly in learning how to provide psychosocial care for the chronically ill, they will not graduate as doctors.

The medical school faculty must show through their actions that they share the vision that illness is as important as disease in the training of the general doctor. Start Small Earlier in this article, I suggested meditating for 10 minutes. If you're super stressed-out, this may be too long to expect yourself to stay focused. If this sounds like you, then first let me say, I am SO glad you're here! If five minutes is more do-able, or even if you can do only one minute or so, then that's where you start. You can stay in a deep meditative state for as long as you like, but to begin with, a few minutes feels like plenty. You can extend your meditation time up to an hour or longer if you have that kind of time. Nobody has ever discovered any negative side effects of meditation. Remember to stay relaxed in your body, because this will help you keep a relaxed mind. Never force the issue. His feeling was not one of sadness but shame, because he knew that he was different and that everyone saw him this way, and he wanted to pass as competent in spite of knowing that he was inadequate. His day was a good one if he could get through it believing that no one had stared or laughed at him or treated him like a child. I came to realize just how often he was shamed: by children in the hospital who gawked at him and mimicked his behavior; I found myself contributing to this pattern, inadvertently. I had so many patients to see; I would cut the interview off halfway through. Then I would see such a look of humiliation on Paul's face, as if to say: I did badly, didn't I, doc? I don't even know how to be competent at being a brain-injured patient, do I? Paul Sensabaugh's personality had become immature and his cognitions seriously limited, but his sensitivity to others' reactions was intact.

His constant effort was to show others and himself that he was no less human than they. This redirection will require the re-education of faculty, along with a system of academic rewards that makes clear through promotion and respect that the psychosocial domain of medicine is central to the mission of the teaching faculty. The presence of practitioners who are models of the psychosocially oriented practitioner is crucial. The challenge for the postgraduate training of residents is even greater. Perhaps it should begin with the honest, if deeply upsetting, recognition that at present many training programs tacitly inculcate values and behaviors that are antithetical to the humane care of patients. Building psychosocially sophisticated components into existing training programs is probably going to be insufficient, because the entire structure of training militates against their effective assimilation. For example, care of the chronically ill is very largely an outpatient phenomenon in which the clinician must work together with the community's network of social service agencies. Many training programs, however, emphasize the inpatient care of acutely ill patients and deemphasize the outpatient care of the chronically ill. Programs isolate trainees from the community, and they often create the impression that the chronically ill are problem patients for their failure to improve and for their frequent need of physicians' services. Moreover, by creating a menacing ethos that exhausts interns and turns them into survivors, training programs perpetuate the very conditions that work against learning humane care (Groopman 1987). To change these conditions would require fundamental change in hospital training programs, which often are driven more by demand for cheap medical labor than by concern for the care of patients. You may be tempted to get impatient with yourself when an unwanted thought enters your consciousness. Just smile inwardly and return your focus to your breathing. Thoughts will happen - you are human, after all! Part of learning to meditate is accepting your stream of consciousness without judging it. If you return to the present moment each time, your ability to meditate for longer periods will develop naturally. Slowly bring yourself back to a fully alert and conscious state by becoming aware of whatever is supporting your body. The chair, the ground, whatever it is. Notice how it feels. Then open your eyes slowly, and have a good stretch.

Don't rush this step. I often wondered: a hospital is organized to protect physically those patients who are in wheelchairs, or who are blind, or who need oxygen or special diets or assistance in caring for themselves; Disability, as Zola (1982) among others has shown, places the disabled person in a difficult situation. His world is no longer the same. Others react to him with great ambivalence, ranging from gross inattention to embarrassing overconcern. Few lay persons, family members, or health professionals are able to accept the disabled person on his own grounds. They expect him to try to cover, pass, or normalize his status. Paul Sensabaugh's brain injury left him incompetent in a number of the routine skills of life. But he had fashioned a world for himself. As he used to tell me: I'm an adult. I'm the same as the others. We must stop dehumanizing young physicians if we are to stop their usually inadvertent dehumanization of patients. Programs that teach residents to spend five to ten minutes treating each chronic patient who comes for a follow-up visit or that emphasize the use of expensive techniques over labor-intensive interview and talk therapy skills are on the wrong track. Turning them around would require both a new priority system and different guidelines for delivering care. The evaluation of patient care cannot be limited to an overly narrow quantification of cost effectiveness; Ultimately, the financing of care comes to the forefront. If by passing an endoscope a clinician can earn ten times in fifteen minutes what he can make in half an hour of sensitive interviewing, there is little chance that psychosocial training will have any significant effect on health care behavior. Thus, the financing of care must include appropriate levels of funding for helping patients cope with the illness experience. Inasmuch as there is evidence that psychosocial intervention can reduce the costs of health care as well as of long-term disability, it is not impertinent to demand reform of the system of reimbursement for physicians (Mumford et al. Osterweis et al.

Without the appropriate institutional support, it is very unlikely that what would be learned in medical school and residency programs would be applied in actual practice. Savoring it makes it more likely that you'll be able to maintain this luscious calm state as you go about your day. Tweak as needed When you're learning how to meditate, you may come across something challenging. If so, don't quit. Just make adjustments. If you're sitting somewhere that has too many distractions for you to relax fully, then find another spot. Eventually you'll get to the point where you can meditate in the middle of just about anything. I'd draw the line at an earthquake or terrorist attack. Get to safety, THEN meditate. If you try one style of meditation and find you're not comfortable with it, try another form instead. I can look after myself. Most central to his view of that world was his need to be like the others, not to be seen as different, not to be ridiculed, rejected, or made to feel inhuman. The work of the doctor in this situation should be to try to understand the boundaries as well as the possibilities of that world, to respond to the disabled person's needs and potential on his own terms, and to do what he can to avoid making the person feel like a freak or not fully human. I saw Paul Sensabaugh weekly for forty-five minutes for over a year. I can remember only one conversation that went much beyond the regular round of questions, the answers to which he had long before committed to what memory remained and which he would savor as he repeated them, as if they were his gift to me. One cold January day, there was a heavy snow and my train was delayed. Paul waited for several hours, until finally I arrived to find a waiting room full of patients. I excused myself as best I could, then took Paul into my office. I apologized to him and explained that because so little time was available and so many patients were waiting, I could only speak to him for a few minutes.