Proactive Mindfulness for Health Care Professionals

Dr. James Fish is a general practitioner in the UK’s National Health Service. Having firsthand experience with overwork and burnout, Fish realizes how important it is for doctors like him to have solid coping strategies for getting through the stressors and mental health triggers that could impair their work. In 2016, Fish cofounded Still Practising, a meditation group explicitly aimed at UK clinicians. In a recent interview, Tricycle contributor Ellie Broughton talked with Fish about his life story, his early Buddhist influences, and why it is imperative to have proactive mental health care in medical settings.    

This interview has been edited for length and clarity.

What has surprised you about studying the role of mindfulness and meditation in medicine? The first surprise that really hit me was how much research there has been: There’s over sixty years of research around mindfulness in particular. There are now more than 17,000 research articles on mindfulness. If you type “mindfulness” into Google Scholar, you get nearly 1.3 million results.

The other surprise that I’ve really noticed in the last five years is a real shift from skepticism to recommendation by national and international medical bodies. Mindfulness interventions now have support for a number of conditions, particularly depression and anxiety, but there’s also support for their use in treating physical health conditions such as hypertension. And in the UK, in 2022, our national occupational health guidance called for every employer to facilitate either mindfulness meditation or yoga for their employees for their well-being.

It sounds like Buddhist practice has played an important role for you as a doctor. Can you tell me about that? I learned to meditate in my early 20s, about fifteen years ago, when I was a psychology student at Leeds University. I learned with the Friends of the Western Buddhist Order, now called Triratna. I came into meditation as a response to the stress of being a student.

After that, my interest in Buddhism became quite a solitary activity. Authors, particularly Stephen Batchelor and Thich Nhat Hanh, helped me develop some understanding of Buddhist ideas and, actually, apps—Buddhify, Ten Percent Happier, and the Waking Up app—have supported my practice.

About three or four years ago, I started an online group for any clinician within the NHS to come and meditate. We ran it for a while, but then I got a bit inundated with work, and I hadn’t been  trained to teach at that point, so I was relying on the goodwill of other teachers. Over the last six months, a trainee psychiatrist friend, whom I met on retreat, and I both agreed to basically run it for an hour and a half every other week. Our aim is to bring clinicians to sit together and try to explore some of the benefits of meditation for our personal and professional lives.

In my experience, most parts of the NHS consider themselves to be constantly on the defensive, putting out fires, so proactive mental health support for staff and prevention of deterioration hasn’t really been a priority. It’s very much been about having organizations intervene once individuals are sick or once they’re in really quite a distressing place.

I try to meditate every day, even if that’s only for five minutes in the car before I go into work—mindfulness practices, metta practices, and emptiness practices. On a good day, I can experience the whole day practicing medicine with mindfulness, but at other times, it’s more like a coping strategy. I try not to be too directional, or have a clear plan as much as I used to, because often the effort is the thing that I need to loosen.

What kind of reactions do patients and doctors have to mindfulness interventions? A couple of weeks ago, I had two reactions on the same day that represent the different extremes people feel when confronted with mindfulness interventions. 

During a clinic in the morning, a patient who had some complex mental health problems and chronic pain was telling me, completely unprompted, that mindfulness had changed her life, and that she would meditate for thirty minutes during her lunch break, and this had allowed her to cope with her pain and some of her mental health problems so well that she could stay in work. 

But, by contrast, I was promoting an online mindfulness group that I’m running for clinicians, and I had to put all these slightly annoying marketing messages up on Facebook, and one family doctor responded that they’d rather eviscerate themselves with a spoon. I don’t completely understand the doctor’s reaction, but I guess some people might see meditation as culturally incongruent. Or maybe sitting “doing nothing” would irritate them.

How does mindfulness support your work as a doctor? There’s something so positive and enriching about the work that we do. So despite the stresses, caring for other people can be really fertile ground for cultivating qualities of mind that are helpful for ourselves and others. Obviously, though, when you’re right in the thick of it, it doesn’t always feel that way.

Yes, I get the tick-box benefits of mindfulness: Mindfulness improves my mood and helps me cope with stress. But the real thing that’s changed for me is that it’s helping me understand my own psychological suffering better, and respond better to it. I’m now more able to sit with whatever’s going on in my own experience, and also with patients, and be able to be comfortable—not having to constantly grasp to explain or solve things. 

What is your advice to practitioners who work in the helping professions, and feel burned out? I qualified as a GP when I was 32. I entered a job in a practice where I was seeing up to about thirty-three patients a day, including home visits, and I was really struggling. [The British Medical Association, the main union for doctors, recommends a cap of twenty-five a day.] I also suffer from insomnia, so when I get really stressed, I start losing sleep. I felt alienated from colleagues, and to some extent even patients, and when you feel disconnected in those ways, it’s time to stop and reassess what’s going on. There was even a point for me when I no longer felt safe practicing medicine. In a way, I actually see my insomnia as a bit of a positive, because it forced me to adjust my behavior.

Self-care is essential, even if your ultimate aim isn’t to look after yourself but is to help others.

It’s really important to recognize that exhaustion, cynicism, and guilt are quite understandable reactions to the stresses of helping others within dysfunctional, increasingly stressed systems. Self-blaming is so unhelpful, but I can completely understand why it happens. When you’re working in these environments, it’s very hard to switch from firefighting and helping others to responding to your own needs. It can feel wrong and selfish. 

But self-care is essential, even if your ultimate aim isn’t to look after yourself but is to help others. I often see a pattern where self-care just gradually erodes until a practitioner can’t cope anymore. Sometimes, the only way you can assess what’s going on is by leaving a system for a while. Often it’s only at this crisis point that things really can change. Of course, if you reach the point where you’re so low you’re having to leave work, especially if you are having thoughts of suicide, it is really important to see a health care professional. Practitioners are not immune from poor mental health.  

When I burned out, I still had an established mindfulness practice. While it didn’t necessarily stop me from burning out, I recovered within a couple of weeks, and it involved far less blaming of myself than it had in the past. I grew from it, in some ways, and I believe I’m a better doctor for understanding my limits and how I can practice medicine safely.