Disclosures: Ramondetta and Sanft report no relevant financial disclosures.
September 23, 2021
8 min read
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Mindfulness in oncology requires continual practice of being present in the moment

Disclosures: Ramondetta and Sanft report no relevant financial disclosures.
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Data suggest that practicing mindfulness — the quality or state of being conscious or aware — may decrease levels of burnout, enhance satisfaction with life and lead to better patient care among oncologists.

Mindfulness-based interventions have also gained traction across the world in light of the uncertainties and anxieties caused by the COVID-19 pandemic.

Quote from Tara Sanft, MD - “The act of self-compassion through mindfulness and recognizing that we are doing our best to help our patients today allows me to keep treating patients with serious illnesses.”

“There is the idea of a ‘pause’ and extending that pause and recognizing the potential influences that are changing your thoughts or behaviors and maybe ‘reeling them back in’ to make sure that you are being guided by your true intentions,” Lois M. Ramondetta, MD, gynecologic oncologist and professor in the department of gynecologic oncology and reproductive medicine at The University of Texas MD Anderson Cancer Center, said during an interview with Healio. “For me, mindfulness is the act of pausing between typing an email and pressing send or taking a moment to pause between a thought or action before it becomes audible or tangible.”

Mindfulness is integral to finding happiness or contentment and can be especially helpful for oncologists, Ramondetta added, particularly during the pandemic.

“Mindfulness can allow us to let go of clinging to the notion of who we are or what we do or don’t want in order to be right here, right now, in this moment, where everything is okay,” she said. “For example, in a patient’s room, you may not recognize that you are projecting or absorbing some of the patient’s situation and that could potentially take you out of the present moment, which is theirs, and not allow you to be of assistance to them.

“Mindfulness is recognizing that much of our unhappiness comes from clinging to this notion of the way we want things to be and then fighting with ourselves because it is not that way, whether that is the pandemic, how a patient is doing or the way we performed,” Ramondetta added. “It is okay to have some reflection on those things, but we must pull ourselves back to the present moment through the best tool that we have — our breath — because that is what is happening in the present moment.”

‘A second wind’

Ramondetta, who is also a certified yoga instructor and teaches yoga and mindfulness at MD Anderson, became involved in the practice of mindfulness after realizing midcareer that she needed an outlet to help her get through the difficult parts of being an oncologist.

“I have known that physical activity is important for mental health, and I found a way for me to get a ‘second wind’ through yoga practice but then realized that I wanted to go further in learning about the philosophy of yoga,” Ramondetta said, adding that after completing both 200-hour and 300-hour trainings, she earned her American College of Lifestyle Medicine certification last year.

What Ramondetta enjoys most is guiding others through yoga and the practice of mindfulness — helping others to recognize that a simple movement of the hand can change the way one feels in the moment and bring awareness to their thoughts.

“One of my most favorite things pre-COVID-19 was teaching yoga at MD Anderson and knowing that I can help my colleagues feel centered and refill their own fountain of compassion for themselves and for others. This year, I had the opportunity to teach the practice to patients and I am loving it,” Ramondetta said. “I truly love my job, and this has made me a better teacher in the operating room, it has helped me be much more patient with trainees, and it has helped me to recognize in a conversation with a patient that it is not about me when emotions get high. Mindfulness is absolutely important in oncology.”

Tara Sanft, MD, oncologist and director of the Survivorship Program at Yale Cancer Center and Smilow Cancer Hospital, said although she is a novice in mindfulness practice, becoming involved in the practice during the COVID-19 pandemic, she finds its ability to prevent burnout life changing.

“Dealing with life-threatening illness in other human beings, oncologists often feel responsible for the outcomes of their patients,” she told Healio. “Whether or not we intellectually know that we cannot control it all, our feelings, thoughts and emotions are often tangled up in that sense of responsibility. The act of self-compassion through mindfulness and recognizing that we are doing our best to help our patients today allows me to keep treating patients with serious illnesses. I wish that we talked about this more in our field because we suffer when we hold those thoughts and feelings inside.”

Sanft added that she was not necessarily open to the idea of mindfulness a year ago and wouldn’t be surprised if others are resistant at first, too.

“Mindfulness has had a bad reputation of being this ‘super Zen’ and blissed-out practice and many of us think there is no way we can practice it,” Sanft said. “But I practice mindfulness every day without sitting on a cushion. I do it on my drive to work or just before bed. Even taking one conscious deep breath and being aware of that one breath, just once per day, for 1 minute, can matter.”

Different techniques

There are various techniques that can be used to practice mindfulness.

For Ramondetta, the practice of yoga has helped her to be more mindful because it calls on those who practice it to recognize what is pulling you out of the present moment.

“The practice of breath work and movement and withdrawing from your senses — all of that requires practice and the knowledge that the human mind is not going to be very good at any of this,” she said. “There is a need for a bit of detachment from outcome, which requires the recognition that it is normal to not always be mindful and that we should all have a sense of forgiveness toward ourselves, a sense of nonjudgment toward ourselves and others.”

Ramondetta also said that mindfulness requires continual practice to make it a habit.

“It requires practice, practice, practice and more practice,” she said. “Practice and detachment.”

Sanft agreed and said one must be constantly reminded to be present in the moment.

“The way that we do that is through deep breathing or simply paying attention to the breath or other parts of the body. For example, scrunching your toes and being aware of that sensation. A simple act can be enough to bring you ‘out of the clouds’ of thought and emotion and bring you back into the present moment,” Sanft said. “Mindfulness requires being a bit detached from your own thoughts and emotions and recognizing them as just that — thoughts and feelings that can change and that they can come and go.”

Ramondetta offered practical tips to practice mindfulness.

“The simplest thing is to recognize that what often pulls us out of the present moment is being too much in the future or too much in the past, which is often associated with a sympathetic flight-or-fight response,” Ramondetta said.

She also offered steps for how to engage the parasympathetic system, a technique that can be done sitting, lying down or standing:

  • Extend your exhales longer than your inhales.
  • Bring your breath into your lower abdomen and out of your chest.
  • Try to double your exhalation from your inhalation very slowly through your nose and breathe in, trying to extend to a count of three or four breaths and then exhaling the same amount of air for six to eight counts.
  • Follow the flow of air pulling into your nostrils and into the back of your throat, into your upper chest, your middle chest and all the way down into your belly.
  • Lower your diaphragm and get that parasympathetic stimulation, which can slow you down and pull you right into this moment.

“A great place for a surgeon to practice mindfulness is outside of the scrub area, where they can set their gaze on one area, observe and set the focus and then begin the breath work,” Ramondetta said.

Another option for mindfulness is to set an intention, whether for the day, a surgery or an interaction with patients or your family member after getting home from a hard day at work.

When setting an intention, follow these steps:

  • Stand still and straight with your feet about shoulder-width apart.
  • Move up, thinking about all of your toes pressing into the ground, press your heels into the ground, lift your kneecaps and your hip points and send your tailbone down, engaging your core and your pelvic floor.
  • Bring that energy up into your chest to lift your sternum, pulling your shoulder blades together on your back.
  • Put energy into your hands and then lift your head a little bit taller toward the sky and maybe bring a smile to your face.

“Follow this with some good deep breaths,” Ramondetta said. “This is one of the best ways to slow yourself down and know that you are right here in this moment.”

Sanft said there are many ways to practice mindfulness, such as while walking.

“As you are walking, notice your five senses: What do you see? What do you hear? What do you feel? What do you taste? What do you smell? Or some variation of that,” she said.

“There are also a lot of resources to help people like me, who are new to the practice, get started and find something that is right for you,” Sanft added. “It is a practice that can be individualized, and there are great data to support the ability of stepping out of the swirl of our thoughts and emotions and recognize them for what they are — just fleeting thoughts and emotions. This allows for a sense of control so that we recognize what is going on, acknowledge that it is normal to feel these things or think these thoughts, and then give yourself some kindness about it, which can allow you to move on from it.”

Maintaining mindfulness

Life circumstances can be overwhelming and “turning it all off” is sometimes needed, Ramondetta said.

“This does not mean that we do not continue to do the things that are important or that we pull ourselves out of the things that need to get done,” Ramondetta said. “For example, I try to convince every patient to get vaccinated if they are not vaccinated. The practice is to recognize that I am not always going to succeed. Yet, we have to keep working and staying in the present moment without some level of attachment to the outcome. It is such a hard concept because it does not mean that we do not care, it means that we can only do what we can do.”

Ramondetta referenced the book The Four Agreements: A Practical Guide to Personal Freedom by Don Miguel Ruiz, which is about finding happiness throughout life.

“The first agreement, make your words impeccable, requires mindfulness. For example, not pressing send when you are writing an email or taking a pause before something leaves your mouth,” Ramondetta said. “The second agreement is do not make any assumptions, the third is do not take anything personally and the fourth agreement is always do your best. If you use these four agreements, you can find yourself in a sense of serenity.”

Ramondetta added that there is also something about being around other people who are also “doing the work” that helps with the practice of mindfulness.

“This does not necessarily mean abandoning people who need help and need you,” she said. “The fountain can be filled from within, and you are the one who is responsible for the energy you bring into the room, but you can also be affected by someone else’s energy and you may need to have enough people around you who are also doing their best to do the work of being mindful so that you can stay the course and be present in the moment.”

Every individual will discover mindfulness when they are ready, Sanft said.

“When ready, if one can embrace some of the techniques previously mentioned, it can be truly revolutionary in how you feel about yourself and how you understand the world,” Sanft added. “There are so many wonderful resources for anyone who struggles with anxiety or imposter syndrome or feelings of great responsibility and loss of control, either in cancer care or in a pandemic or both. Having an open mind and the curiosity about these techniques can be beneficial.”

Sanft recommended the book Unwinding Anxiety by Judson Brewer and downloading the 10% Happier app by Dan Harris and its companion podcast.

Kristin Neff, PhD, who talks about self-compassion, did an interview with Harris on mindfulness and self-compassion that was actually the first time that I realized that the science behind this supports the practice of it,” Sanft said. “Oncologists in particular like to feel grounded in data, and Harris truly speaks to me because he is all about the science and the data behind mindfulness. Remember that mindfulness does not have to be a marathon. It can be practiced in baby steps.”

For more information:

Lois M. Ramondetta, MD, can be reached at lramonde@mdanderson.org.

Tara Sanft, MD, can be reached at tara.sanft@yale.edu.