Eyeworld

March 2017 • Ophthalmology Business 13 that beset contemporary medicine, perhaps mindfulness techniques can be especially helpful in delivering quality ophthalmologic care and maintaining excellent relationships with patients as well as among office personnel. OB ing trajectory in knowing where opportunities for disaster lurk. This oftentimes only comes with consid- erable experience wherein the MP is exposed to numerous preventable adverse events and learns what can be done to avoid them. Commits to life-long learning. The MP realizes that he or she is on a life-long learning curve and that one of the reasons for disaster is the unceasing innovation occurring in health care through new technology, drugs, devices, regulations, policies, and standards of care. The MP there- fore understands life-long learning as inevitable and resigns him or herself to the relentless cognitive demands that innovation requires. Reviews, studies, and teaches botched cases. This is painful, but reminding oneself of how things went wrong and what could have been done to avert crises is part of most training curricula in high risk occupations like airline safety or police work. It is well recognized that the best people commit error. Also, disaster occurrences usually require multiple people making multiple errors. Consequently, a good strategy for reviewing botched cases is with a group. And teaching such material, especially by seasoned veterans, sug- gests to learners that no one performs flawlessly. Humility It is remarkable how an attitude of humility underlies mindful- ness. Without it, our psychological defenses, which are typically un- leashed when one perceives his or her self-esteem under threat (such as from error commission), tend to get in the way. Paradoxically, while mindfulness seems a solitary and socially detached undertaking, much of it works best with others, who can help analyze the forces at play, maintain a just culture, and develop strategies for balancing the always present safety-productivity tradeoff. Again, the above recommendations apply to all clinicians. However, as ophthalmology practice is hardly immune to the production pressures assuming, and are my assumptions reasonable or defensible? What are reasonable diagnostic or treatment alternatives? Do I have enough infor- mation to go forward?" Seeks feedback. The MP knows that performance is in the eyes of beholders, who are colleagues, supervisors, and consumers of care. So, the MP is eager for feedback since he or she knows that without it, it is very difficult for performance to improve. The MP takes a page out of the professional athlete's handbook: always seeking instruction and some- times even coaching, no matter how experienced he or she is. Again, left to our own devices, our performance will eventually hit a ceiling beyond which we won't improve. The only way to get better is with indepen- dent, objective, and expert instruc- tion and advice. Resists being overly optimis- tic. Excessive optimism is one of the most pernicious causes of disaster. Because it is difficult to approach and correct a colleague whose perfor- mance is poor, clinicians often ratio- nalize their reluctance to speak up or take remedial measures by becoming excessively and unreasonably opti- mistic. The frequently heard excuses are, "Nothing bad has happened so far;" "It isn't my job to fix poor work habits;" "I don't have time;" "He usu- ally gets through, and he's been here a long time;" and so on. The fact that everything is fine so far, however, doesn't mean it will stay that way. Expects things to go wrong. The mindfulness counterweight to excessive optimism is what James Reason described as a "feral" or "twitchy" vigilance. Given the MP's embrace of Herbert Simon's bounded rationality, he or she expects that things will often go wrong; indeed, as Richard Cook opined, systems always run in a degraded mode. The MP is always exercising "foreseeability" by imagining how factors affecting work operations might invite disaster and then goes the extra yard to fix them. Knows where the landmines are. The MP develops important knowledge through his or her learn- Dr. Banja is a medical ethicist and a profes- sor of rehabilitation medicine at Emory University in Atlanta. He is a past mem- ber of the ASCRS Governing Board and can be contacted at jbanja@emory.edu. Suggested readings Cook R. How complex systems fail. Cognitive Technologies Laboratory, University of Chicago. 2000. Croskerry P. From mindfulness to mindful practice—cognitive bias and clinical decision making. N Engl J Med. 2013;368:2445–2448. Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med. 2003;41:110–120. Institute of Medicine Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. 2000. National Academies Press. Reason J. The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. 2008. Burlington, VT: Ashgate. Simon HA, et al. Economics, Bounded Rationality and the Cognitive Revolution. 1992. Brookfield, VT: Edward Elgar Publishing. Teper R, et al. Inside the mindful mind: How mindfulness enhances emotion regulation through improvements in executive control. Current Directions in Psychological Science. 2013; 22:449–454.

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