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Behavioral Medicine: A Guide for Clinical Practice, 4e >

7: Mindful Practice
Ronald Epstein

INTRODUCTION
CASE ILLUSTRATION 1
Jeffrey Borzak, a patient I knew well, seemed to be recovering from coronary artery bypass surgery. On
rounds, I sensed that there was something that was wrong, but I could not put my finger on it. In retrospect, his
color was not quite righthe was grayish-pale, his blood pressure was too easily controlled, he was even
hypotensive on one occasion, and he seemed more depressed than usual. He reported no chest pain or
shortness of breath, and had no pedal edema, elevated jugular venous pressure, or other abnormalities on his
physical examination. But still I did not feel comfortable, and although there were no red flags, I ordered an
echocardiogram which showed a new area of ischemia. An angiogram showed that one of the grafts had
occluded. After angioplasty, Mr. Borzak looked and felt better, and he again required his usual
antihypertensive medications.

CASE ILLUSTRATION 2
Elizabeth Grady recently came to be a patient in our practice. The practice, despite having long waits for
appointments, was recently reopened to new patients to boost productivity. Mrs. Grady left her previous
physicians practice because of a disagreement over seeking care in the emergency room rather than in the
office for her out-of-control diabetes. Her blood sugar has never been below 400, and often was in excess of
600 mg/dL. Despite claiming to be on a diet, her weight kept increasing, and now she weighed nearly 500 lb.
At the first visit, an irate sister accompanied her demanding that the patient be hospitalized immediately. On
the second visit, Mrs. Grady was so anxious that she could not sit in the examination room; she was pacing in
the waiting room until her appointment, and then indicated that she was in a rush to leave even though the
appointment was on time. She no-showed for the subsequent appointment, and is now returning for her third
appointment.
Excellent patient care requires not only the knowledge and skills to diagnose and treat disease but also the
ability to form therapeutic relationships with patients and their families, recognize and respond to emotionally
demanding situations, make decisions under uncertainty, and deal with technical failures and errors. These
capabilities require that clinicians have self-awareness to distinguish their values and feelings from those of
their patients, recognize faulty reasoning early in the diagnostic thinking process, be attentive to when a
technical procedure is not going as it should, recognize the need to gather more data, and be able to
incorporate disconfirming data into an evolving assessment of the patient. Often, there is no tool or instrument
that can help physicians with these situations on a moment-to-moment basis other than their own cognitive and
emotional resources.
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Mindful practice refers to a clinicians capacity for reflection, self-monitoring and self-awareness during an
actual clinical practice in order to practice with clarity, insight, expertise, and compassion. Clinicians generally
value the principles of mindful practiceattentive observation, critical curiosity, presence, and capacity to see
a familiar situation with new eyes (beginners mind). Yet, during training and practice, clinicians spend little
time sharpening the sawdeveloping, refining, and calibrating their own capacity for self-understanding as
they think and feel their way through the complex demands of clinical practice. For psychotherapists, athletes,
and musicians, self-calibration and self-awareness are considered fundamental to excellence and are often
explicit aspects of training. Yet, for clinicians, there is often the assumption that knowledge and technical
expertise are sufficient, when on reflection most clinicians value adaptive expertise and cultivating habits of
mind that allow them to self-calibrate and reflect continuously during everyday work. This chapter will suggest
why mindful practice is important and indicate ways in which it can be cultivated.
Mindful practice is fundamental to excellent patient care. It means being attentive, on purpose, to ones own
thoughts and feelings during everyday clinical practice and educational activities. Mindfulness implies a
nonjudgmental stance in which the practitioner can observe not only the patients situation but also his or her
own reactions to it. A mindful practitioner can see a situation from several angles at the same time. Mindful
practice implies curiosity rather than premature closure and presence rather than detachment. Mindfulness is
especially helpful when dealing with difficult relationships with patients and families, challenging clinical
situations, and in recognizing the need for self-care. Furthermore, recent research among students, residents,
and practicing clinicians suggests that mindfulness is associated with better communication, better quality of
technical (e.g., fewer errors) and interpersonal (e.g., empathy) care, and greater clinician well-being (e.g.,
lower burnout).
Fushimi Inari Shrine, Kyoto, Japan. Photograph by Mitchell D. Feldman, MD, MPhil

In contrast, mindless practice involves self-deception, often with the illusion of competence. Blind certainty,
ignoring of disconfirming data, and arrogance without self-examination or reflection dooms us to seeing
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things not as they are, but as we are. An example of mindlessness is the common practice of reporting
findings that were not actually observed, because they must be true.
Mindfulness is especially important in the diagnosis and treatment of mental disorders because there are few
anchors other than the clinicians own judgment to assess the severity or pervasiveness of anxiety, depression,
or psychosis in a particular patient. However, mindfulness also applies to other cognitive and technical aspects
of health care. Self-monitoring and mindfulness are equally essential to expertise in other domains of medicine
as they are to primary care or behavioral medicine. For example, hepatobiliary surgeon Carol-Anne Moulton
eloquently describes ways in which expert surgeons remain attentive in automaticity. They work quickly, yet
recognize aberrant and problematic situations, and slow down accordingly, thus switching from automatic to
deliberative thinking. In this chapter, I will explore several aspects of mindful practice and some ways of
recognizing and practicing mindfulness in clinical settings.

MINDFULNESS & CLINICAL CARE


Mindful practice depends on the ability to be aware in the moment. The champion tennis player is being
mindful when he or she is not only attentive to the ball but also to his or her state of balance, expectations for
what will happen next, physical sensations such as pain or discomfort, and level of anxiety. All of these factors
can affect performance and can be modified by specific attention to them. Like tennis players, physicians
lapses in awareness and concentration can have dire consequences. For physicians, these lapses directly affect
the patients welfare. The result of lapses may include avoidance, overreactions, poor decisions, misjudgments,
and miscommunications that affect survival and quality of life for the patient. Thus, physicians have a moral
obligation to their patients and themselves to be as aware, present, and observant as possible.
By cultivating the ability to be attentive to the unexpected, mindful practice can improve the quality of care
and help prevent errors. Case Illustration 1 presents some observations that led to a change in care resulting in
an improved outcome. Being aware in the moment and receptive to new informationespecially information
that is unexpected, unwanted, or upsettingcan help the clinician be more attentive to patients needs and,
thus, be more likely to meet them. The clinicians job in Case 1 would have seemed easier, at least in the short
run, if he had ignored his intuitions.
Mindful practice involves allowing awareness of our own areas of ignorance, as well as our areas of expertise.
Yet many clinicians are not as aware as they should be of the accuracy of their first impressions and tacit
judgments. Clinicians, whether beginners or experts, often are aware of things before they are named,
categorized, or organized into a coherent diagnosis. For example, the unusual gait of a patient walking toward
the chair in the examining room may be the first clue to a neurodegenerative disorder, and such first
impressions can often be quite accurate. Educators, psychologists, and cognitive scientists have called these
automatic nonconscious mental processes unconscious competence, the unthought known, or preattentive
processing.
Conversely, the capacity for inattentiveness and self-deception can be impressive. The same capacity for
automatic nonconscious processing can backfire if unexamined biases and preconceived ideas dominate
clinical reasoning without some capacity for deliberation. Thus, the goal might be to be attentive in
automaticity. A patient of mine, hospitalized with urinary infection, was suspected of having adrenal
insufficiency because of hyperpigmented skin. He was later noted to only have hyperpigmented forearms and
face, whereas the rest of the body was pale. Yet, the residents and attending physicians continued to evaluate
the possibility of adrenal insufficiency in spite of being made aware of the faulty observation. A classic article
on curiosity in clinical education reported a story about a patient who was presented on rounds as below knee
amputation (BKA) times 2; clearly no one had noticed that he actually had two legs, and, through several
hospital admissions, did not correct the mistranscribed diabetic keto-acidosis (DKA). Although these
examples are dramatic, similar misperceptions are perpetuated with regard to patient personality or
psychological states. For example, one study showed that patients asking for antidepressant medications tend
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to receive them regardless of whether they fulfill diagnostic criteria for depression. Patients who are labeled
difficult, uncooperative, or demanding (such as Mrs. Grady, Case Illustration 2) seem to be stuck with
such labels for life, and disconfirming data tend to be ignored. Furthermore, the difficult patient is
approached as if the difficulty is only the patients, rather than considering that the physicians expectations
and attitudes may also contribute to the difficulties.
Mindfulness means being simultaneously attentive to external data as well as to internal datathe clinicians
own thoughts, feelings, and inner states. Negative thoughts about a patient might promote a pejorative label
(somatizer); negative feelings might provoke anger or disgust; and negative inner states might induce
boredom or hostility. Positive feelings also present difficulties. Sexual attraction toward a patient obviously
can be problematic, but so can an unusually keen interest in a patients illness. As a medical student, I was
assigned a patient with hairy-cell leukemia, a disease whose genetic basis was just being uncovered. Although
she was considered an exciting and fascinating case, I was disappointed, when meeting her, that she was a
sad, weak, pale woman dying of cancer, hardly matching my excitement and that of my colleagues.
Mindfulness of thoughts allows clinicians to follow intuitions while also accommodating for biases and
cognitive traps in the process of making clinical decisions. Awareness of feelings is particularly useful in
diagnosing mental disorders; clinicians tend to feel down when in the presence of a depressed patient, or
confused in the presence of patients with subtle delusions and mild dementia. Awareness of their own fatigue
can help clinicians recognize when their cognitive, attentional, or technical capacities are not at their best; the
fatigued resident in the emergency room late at night might then get corroboration for an important finding on
physical examination (such as the degree of nuchal rigidity in a febrile child) from a trusted colleague.
Mindfulness improves learning. Trainees who are more aware of the difference between what they believe and
their actual performance can make adjustments and improvements. Key features of mindful learning are the
ability to see novelty in familiar situations and the ability to consider facts provisional and contextual. Studies
show that mindfulness and self-awareness training can improve reasoning and communication skills.
Mindfulness can be a corrective for those who otherwise might believe that they are expert and are surprised
when that notion is challenged by an outside observer or objective test. Other types of professionalsnot only
medical personnelalso can suffer from the illusion of competence. Musicians know the delusion of the
practice-room virtuosoan illusion which is often shattered when the performer is put in front of a
discerning audience. Clinicians, however, usually practice unobserved, so the opportunities for external
validation and learning are much scarcer than for the musicianand the stakes are much higher than a wrong
note.
Mindful practice involves cultivating the ability to monitor and modulate ones own emotional reactivity.
Faced with emotionally challenging situations, humans often overreact by blaming (oneself, another clinician,
or patient) or becoming overinvolved. Others may underreact by avoiding, minimizing, or distancing. In
contrast, mindful practitioners can observe their own reactions, and thus have choices about the way they
might respond that enhances quality of care and quality of healing relationships. Clinicians thus respond with
empathy based on an understanding of the patients experience rather than making assumptions about the
patient leading to further alienation (see Chapter 2). This same awareness can inform the small ethical
decisions that clinicians make during everyday practicesuch as which patients phone call to return first, or
whether to acquiesce to a patients slightly unreasonable demand.
Finally, mindfulness involves monitoring the clinicians own needs. Self-awareness can directly enhance
clinicians own well-being by helping them feel more in touch and in tune with themselves. Self-awareness can
also motivate the clinician to seek needed help and support. Mindful self-care can lead to greater well-being
and job satisfaction; clinicians who report greater job satisfaction and well-being tend to express empathy
more readily, report making fewer errors, and have patients who report greater satisfaction. The selfreinforcing process of self-care and well-being can contribute to productivity and reduce burnout and attrition
(see Chapter 6).

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CULTIVATING MINDFULNESS IN ONESELF & TRAINEES


Although it is self-evident that self-awareness is a necessary ingredient in developing and maintaining clinical
expertise, achieving a state of moment-to-moment self-awareness in a chaotic and busy health care
environment is not straightforward. For several years, a variety of training venues in medicine, psychology,
and other disciplines have offered small group settings for trainees and practitioners to present difficult
situations for group discussion, with the intent that the resulting insights then might inform future clinical
practice. These sessions have been associated with improvement in communication skills and satisfaction with
clinical practice. One program (Krasner et al., 2009) reported the results of an intensive course in mindful
communication, which included a variety of self-awareness and body-awareness exercises, narratives about
meaningful clinical experiences, appreciative interviews, didactic material, and discussion. Participating
physicians not only reported lower burnout and lower psychological distress but also greater empathy and
psychosocial orientation in care. Some small group formats are listed in Table 7-1, each with a particular focus
but with the common thread of providing both support and insight.
Domains that are amenable to training include:
Clinicians habits (meditation, body awareness, exercise, interactions with others, and so on).
Clinicians beliefs and attitudes (health beliefs, beliefs about human behavior and relationships, attitudes
toward patient autonomy or psychosocial aspects of care, family, cultural influences, and so on).
Clinicians feelings and emotions (joy, fulfillment, vigor, attraction, anger, frustration, conflict, setting
boundaries, and so on).
Challenging clinical situations (difficult decisions, sharing bad news, facing mistakes, apologizing to
patients, dying patients, demanding or difficult patients, conflict within the health care team, and so
on).
Clinician self-care (impairment, balance between home and work, burnout, healthy approaches to stress,
finding meaning in work, and so on).
Other educational strategies can enhance the capacity for reflection and mindfulness. Reviewing videorecordings of patient sessions are surprising and instructive, whether reviewed individually or with a tutor.
Learning contracts or agreements can focus learning on areas of deficiency, including becoming more selfaware. Peer evaluations of work habits and interpersonal attributes with medical students can foster greater
awareness of how students function on the clinical team and interact with their colleagues and patients.
Keeping a journal not only promotes reflection on ones actions but also appears to be therapeutic in itself,
offering a venue for self-expression so needed by busy and overwhelmed clinicians.
Table 7-1. Group learning experiences that promote mindful practice.
Type of Group
Mindfulnessbased stress
reduction
courses
Support groups
Balint groups

Description
Promote attentive awareness through meditation, yoga and
discussion
Promote balance between the human and technical aspects of
health care by sharing difficult and challenging situations
Recognizing that the clinician is a drug (a therapeutic agent),
groups aim to improve clinician effectiveness by examining
thoughts and feelings that may interfere with care

Qualifications of
Facilitator
Mindfulness training
Training in psychotherapy
or group facilitation
Training through the
International Balint Society
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Family of
origin groups

By drawing genograms (family trees), participants learn about Family therapy training
influences family and culture have on their values and attitudes

Personal
awareness
groups

Unstructured experience focused on individual needs of


participants, these groups examine personal issues that affect a
broad array of aspects of being a clinician

American Academy of
Communication in
Healthcare offers training
courses

Using published written works or writings of group members,


participants explore the human dimensions of health care

Narrative medicine training

Using videotapes or critical incident reports, participants


explore the moment-to-moment actions they took during a
clinical encounter

Facilitation training

Literature in
medicine
groups
Challenging
case
conferences

However, these individual and small group activities may not necessarily translate the insights gained into the
moment-to-moment drama of clinical practice. Mindful practice refers not only to reflection on ones actions
but goes one step further by emphasizing habits of mind during actual practice. Mindful practice refers not
only to the social and emotional domains of practice but also to the cognitive processes of data gathering and
making decisions as well as the technical skills employed during physical examinations, surgery, and
procedures. Following are some general suggestions on how to enhance mindfulness in practice, for oneself
and for trainees:
Priming. This involves creating the expectation for mindfulness. By observing what they do during
clinical practice, clinicians can be more present, curious, and attentive. Sometimes, it is as simple as
pausing and taking a breath before entering the patients room or taking time to look at the patient rather
than at the chart or screen. Clinicians use these techniques to bring themselves into the present, and then
can be invited to pay attention to how those techniques enhance their capabilities as clinicians and to
expand their ways of applying those or similar techniques to other aspects of their practice. Trainees can
be expected to pay attention not only to the patient but also to their own thoughts and emotions during
the clinical encounter. These thoughts and emotions are fodder for discussion following an encounter,
whether it occurs in hospital or in outpatient settings. Writing narratives about these experiences can
help practitioners recognize their own mental states and learn to be aware of how they contribute to
creating a coherent patient story while eliciting what often seems like fragmented information from the
patient.
Availability. Just as clinicians can make themselves psychologically and physically available to their
patients, teachers should carve out time and space in which they are available to observe and discuss
students progress toward greater self-awareness, whether in a small group setting or individually.
Asking reflective questions. Reflective questions explore the inner landscape; only clinicians themselves
can answer them. They are designed not to elicit facts or answers but rather to foster reflection in the
moment. Teachers can ask reflective questions, but more importantly, clinicians themselves can adopt a
habit of self-questioning. Examples of reflective questions are shown in Table 7-2. The internal dialogue
that they foster can contribute to mindful practice.
Active engagement. When in learning situations, mindful practice can and should be observed directly.
Students reports of what they said and did during a clinical encounter are biased by their own values,
expectations, and anxiety; thus the presence of a tutor or observer has no substitute. Imagine if in music
instruction or tennis lessons, the student simply reported on his or her progress and difficulties, giving a
narrative account of how the piece of music or tennis match went. Ludicrous as it sounds, we often do
exactly that in medical education.
Thinking out loud. When facing a challenging clinical situation it can be useful to describe ones
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observations, impressions, or clinical reasoning to a colleague or tutor, or to put them down on paper in
the form of a written narrative. Similarly, experienced clinicians can think out loud in the presence of
learners to demonstrate how recognizing ones own ignorance, biases, and predispositions can lead to
more deliberative responses rather than mindless reactions. These methods help clinicians hear the story
or rationale as if it were told by a third person, allowing them to examine their own thinking processes
and emotional reactions, identify what might be missing in their perception of the situation, and correct
faulty logic. These methods can allow for reflection that cannot be accomplished simply by moving
forward with problem solving.
Practice. Medicine, like music and tennis, must be practiced; the same is true of mindfulness. There is
both formal and informal practice. Formal practice includes mindfulness exercises, such as meditation,
yoga, movement exercises, and body awareness exercises. Equally important are informal practices that
can be incorporated into daily work, and may be unobserved by others.
Most important is the practice of stillness. Even momentary stillness during a busy day can open the
mind, allow for new possibilities, and allow greater self-awareness. The stillness may be short informal
practicesa momentary pause before seeing the next patient, or a huddle before commencing a
surgical operation. Touching the doorknob before going into an examination room, a clinician might
develop a habit of stopping momentarily, taking a breath, being aware of potentially distracting
thoughts, feelings and preconceptions, allowing him or her to set aside what has just occurred and be
more attentive to the next patient. Longer episodes of stillness might include formal meditation exercises
or other contemplative activities. A daily meditation practice can provide a powerful means for learning
how to be centered, observant, and attentive. Meditation involves watching ones thoughts, feelings, and
bodily sensations (such as breathing) without necessarily trying to change them. By learning to evoke
similar states of attentiveness, even briefly, during clinical practice, the clinician can learn to approach
new situations with a lowered reactivity and to tolerate ambiguity. Meditation can be an entirely secular
activity and need not have religious or spiritual overtones.
For clinicians and educators, mantras for daily practice can be cultivated. Clinicians might use the it
might not be so mantra when facing a new patient or new diagnosis; the clinician develops a habit of
trying to see the situation from another angle that might question an emerging hypothesis.
Unexpecting is a practice of becoming aware of ones own expectations or eliciting those of a learner,
and then actively imagining another outcome (the it might not happen that way mantra). The goal of
using these techniques is not to adopt a different, contrasting perspective; rather their purpose is to
debias ones thinking, recalibrate feelings, and train the mind to consider two or more perspectives at the
same time.
Praxis. Clinical skill is not truly learned and known until it is used. Increasing expertise is associated
with the development of habits that become second nature. At that point, an expert clinician may not be
able to describe easily exactly why he or she is making each decision, because many of the early steps in
the decision process may have become automatic or tacit. Just as a habitual approach to history taking or
physical examination becomes second nature, mindfulness training should have as its goal developing
habits of reflection, self-questioning, and awareness in the moment during clinical practice.
Assessment and confirmation. As is true for any newly acquired skill, some kind of assessment and
confirmation of achievement are important for learning and reinforcement. Facilitated self-assessment,
assessment by peers, and feedback from supervising clinicians are important to identify markers of and
barriers to practicing mindfully. A supervisor might evaluate, for example, the degree to which the
learner was able to articulate his or her reactions to a particular patient. Patients and peers can assess
presence and attentiveness.
Table 7-2. Reflective questions.
What am I assuming about this patient that might not be true?
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If there were data that I neglected or ignored, what might it be?


What about my prior experience with this patient (or with other patients) is influencing my thinking and
reasoning process?
What surprised me about this patient? How did that surprise affect my clinical actions?
What would a trusted colleague say about the way I am managing this patient?
What outcomes am I expecting from this clinical situation? Are those expectations reasonable?
How do I know when I have gathered enough data?
Gardens at Tofukuji Temple, Kyoto, Japan. Photograph by Mitchell D. Feldman, MD, MPhil

CONCLUSIONS
Mindful practice is a process and a goal, not a static state of mind. Even the most accomplished practitioners
cannot claim to be mindful all the time. Efforts toward becoming more attentive, curious, and present, and
approaching familiar situations with a beginners mind, can lead clinicians to be better listeners and
diagnosticians, and to critique their own technical skills more objectively. Many medical schools and some
residency programs offer training in mindfulness and self-awareness, in recognition that these approaches help
in the process of professional development, reduce burnout, and improve communication. Resources for
mindfulness and self-awareness training are also available through organizations such as the Center for
Mindfulness at the University of Massachusetts (www.umassmed.edu/cfm/index.aspx) and the American
Academy on Communication in Healthcare (www.aachonline.org), the Northwest Center for Physician Well
Being (www.tfme.org), and the Mindful Practice Programs at the University of Rochester
(www.mindfulpractice.urmc.edu). Research using functional magnetic resonance imaging (MRI) scanning,
cognitive testing, and other techniques is only beginning to uncover reasons why mindful practice improves
performance, compassion, and well-being in a variety of professional activities.

SUGGESTED READINGS
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Balint E, Norell JS. Six Minutes for the Patient: Interaction in General Practice Consultation. London:
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Beach MC, Roter D, Korthuis PT et al. A multicenter study of physician mindfulness and health care
quality. Annals of Family Medicine 2013;11(5):421428.
Beckman HB, Wendland M, Mooney C et al. The impact of a program in mindful communication on
primary care physicians. Academic Medicine 2012;87(6):15.
Epstein RM. Mindful practice. JAMA 1999;282:833839.
[JAMA and JAMA Network Journals Full Text]
Epstein RM. Just being. West J Med 2001;174:6365.
Epstein RM, Krasner MS Physician resilience: what it means, why it matters, and how to promote it.
Academic Medicine 2013;88(3):301303.
Grepmair L, Mitterlehner F, Loew T et al. Promoting mindfulness in psychotherapists in training influences
the treatment results of their patients: a randomized, double-blind, controlled study. Psychother Psychosom
2007;76:332338.
Krasner MS, Epstein RM, Beckman H et al. Association of an educational program in mindful
communication with burnout, empathy, and attitudes among primary care physicians. JAMA
2009;302(12):12841293.
[JAMA and JAMA Network Journals Full Text]
Novack DH, Suchman AL, Clark W et al. Calibrating the physician. Personal awareness and effective
patient care. JAMA 1997;278:502509.
[JAMA and JAMA Network Journals Full Text]
Sibinga EMS, Wu AW. Clinician mindfulness and patient safety. JAMA 2010;304:25322533.
[JAMA and JAMA Network Journals Full Text]
Smith RC, Dorsey AM, Lyles JS et al. Teaching self-awareness enhances learning about patient-centered
interviewing. Acad Med 1999;74:12421248.

WEB SITES
Center for Mindfulness at the University of Massachusetts. www.umassmed.edu/cfm/index.aspx. Accessed
July 2013.
Mindful Practice Programs, University of Rochester School of Medicine and Dentistry.
www.mindfulpractice.urmc.edu Accessed January, 2014.
Northwest Center for Physician Well Being www.tfme.org. Accessed July 2013.
McGraw Hill
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