A Multicenter Study of Physician Mindfulness and Health Care Quality

Abstract

Purpose:
Mindfulness (ie, purposeful and nonjudgmental attentiveness to one's own experience, thoughts, and feelings) is associated with physician well-being. We sought to assess whether clinician self-rated mindfulness is associated with the quality of patient care.

Methods:
We conducted an observational study of 45 clinicians (34 physicians, 8 nurse practitioners, and 3 physician assistants) caring for patients infected with the human immunodeficiency virus (HIV) who completed the Mindful Attention Awareness Scale and 437 HIV-infected patients at 4 HIV specialty clinic sites across the United States. We measured patient-clinician communication quality with audio-recorded encounters coded using the Roter Interaction Analysis System (RIAS) and patient ratings of care.

Results:
In adjusted analyses comparing clinicians with highest and lowest tertile mindfulness scores, patient visits with high-mindfulness clinicians were more likely to be characterized by a patient-centered pattern of communication (adjusted odds ratio of a patient-centered visit was 4.14; 95% CI, 1.58-10.86), in which both patients and clinicians engaged in more rapport building and discussion of psychosocial issues. Clinicians with high-mindfulness scores also displayed more positive emotional tone with patients (adjusted β = 1.17; 95% CI, 0.46-1.9). Patients were more likely to give high ratings on clinician communication (adjusted prevalence ratio [APR] = 1.48; 95% CI, 1.17-1.86) and to report high overall satisfaction (APR = 1.45; 95 CI, 1.15-1.84) with high-mindfulness clinicians. There was no association between clinician mindfulness and the amount of conversation about biomedical issues.

Conclusions:
Clinicians rating themselves as more mindful engage in more patient-centered communication and have more satisfied patients. Interventions should determine whether improving clinician mindfulness can also improve patient health outcomes.

Full text

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A Multicenter Study of Physician Mindfulness
and Health Care Quality
ABSTRACT
PURPOSE Mindfulness (ie, purposeful and nonjudgmental attentiveness to one’s
own experience, thoughts, and feelings) is associated with physician well-being.
We sought to assess whether clinician self-rated mindfulness is associated with
the quality of patient care.
METHODS We conducted an observational study of 45 clinicians (34 physicians,
8 nurse practitioners, and 3 physician assistants) caring for patients infected with
the human immunodeciency virus (HIV) who completed the Mindful Atten-
tion Awareness Scale and 437 HIV-infected patients at 4 HIV specialty clinic sites
across the United States. We measured patient-clinician communication quality
with audio-recorded encounters coded using the Roter Interaction Analysis Sys-
tem (RIAS) and patient ratings of care.
RESULTS In adjusted analyses comparing clinicians with highest and lowest
tertile mindfulness scores, patient visits with high-mindfulness clinicians were
more likely to be characterized by a patient-centered pattern of communication
(adjusted odds ratio of a patient-centered visit was 4.14; 95% CI, 1.58-10.86), in
which both patients and clinicians engaged in more rapport building and discus-
sion of psychosocial issues. Clinicians with high-mindfulness scores also displayed
more positive emotional tone with patients (adjusted β = 1.17; 95% CI, 0.46-
1.9). Patients were more likely to give high ratings on clinician communication
(adjusted prevalence ratio [APR] = 1.48; 95% CI, 1.17-1.86) and to report high
overall satisfaction (APR = 1.45; 95 CI, 1.15-1.84) with high-mindfulness clini-
cians. There was no association between clinician mindfulness and the amount of
conversation about biomedical issues.
CONCLUSIONS Clinicians rating themselves as more mindful engage in more
patient-centered communication and have more satised patients. Interventions
should determine whether improving clinician mindfulness can also improve
patient health outcomes.
Ann Fam Med 2013;421-428. doi:10.1370/afm.1507.
INTRODUCTION
M
indfulness refers to a person’s tendency to remain “purpose-
fully and nonjudgmentally attentive to their own experience,
thoughts and feelings.”
1
Mindfulness has gained popularity as
a medical treatment for patients, primarily through mindfulness-based
stress reduction (MBSR), with beneficial effects shown for pain, psoriasis,
and depression, and with biochemical evidence of changes in immune
function.
2,3
Less attention has focused on the potential benefits of mind-
fulness among physicians and other health professionals. During the past
decade, it has been recommended that physicians enhance their own
capacities for mindfulness when practicing medicine and interacting with
patients.
1,4-7
Mindfulness is likely to have numerous personal benefits to
practicing clinicians. Several studies have shown that MBSR reduces psy-
chological distress or improves the well-being of nurses and physicians
in training,
8-12
and a recent study found that a program teaching mindful
communication reduces burnout, as well as improves self-reported well-
Mary Catherine Beach, MD, MPH
1
Debra Roter, DrPH
1
P. Todd Korthuis, MD, MPH
2
Ronald M. Epstein, MD
3
Victoria Sharp, MD
4
Neda Ratanawongsa, MD, MPH
5
Jonathon Cohn, MD
6
Susan Eggly, PhD
6
Andrea Sankar, PhD
6
Richard D. Moore, MD, MHS
1
Somnath Saha, MD, MPH
2,7
1
Johns Hopkins University, Baltimore,
Maryland
2
Oregon Health Science University, Port-
land, Oregon
3
University of Rochester, Rochester, New
York
4
St Luke’s-Roosevelt Medical Center, New
York, New York
5
University of California, San Francisco,
California
6
Wayne State University, Detroit, Michigan
7
Portland VA Medical Center, Portland,
Oregon
Conflicts of interest: The authors report none.
CORRESPONDING AUTHOR
Mary Catherine Beach, MD, MPH
Room 2-511
Division of General Internal Medicine
Johns Hopkins University
2024 East Monument St
Baltimore, MD 21287
mcbeach@jhmi.edu

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being, psychosocial orientation, and empathy among
practicing physicians.
13
In addition to improving the personal well-being of
health professionals, a theoretical potential of mind-
fulness to improve the quality of care delivered to
patients has been described. Epstein writes of mindful
practice: “This critical self-reflection enables physicians
to listen attentively to patients’ distress, recognize their
own errors, refine their technical skills, make evidence-
based decisions, and clarify their values so they can
act with compassion, technical competence, presence,
and insight.”
1
In particular, by enabling physicians to be
more attentive to patients and their needs, a mindful
orientation holds promise for making clinical encoun-
ters more patient centered and for enhancing patient-
clinician communication.
Despite the theoretical benefits of mindfulness
to the patient-clinician relationship and to patients’
experiences and outcomes, these associations have not
been empirically studied. The purpose of this study
was to assess the associations of clinicians’ self-reported
mindfulness with the patient-centeredness of clini-
cal encounters, patient and clinician communication
behaviors, and patients’ evaluations of their care. We
hypothesized that clinician mindfulness would be asso-
ciated with higher quality interpersonal care.
METHODS
We conducted a cross-sectional analysis of data from
the Enhancing Communication and HIV Outcomes
(ECHO) Study.
14,15
Study participants were patients
infected with the human immunodeficiency virus
(HIV) and their clinicians at 4 HIV care sites in the
United States (Baltimore, Detroit, New York, and
Portland). The study received institutional review
board approval from each of the 4 sites; both patients
and clinicians gave written informed consent. Clini-
cians who agreed to participate completed a baseline
questionnaire. Research assistants then enrolled a
convenience sample of 10 patients per clinician, plac-
ing a digital audio-recording device in the examination
room to record the patient-clinician encounter. After
the encounter, patients completed an interview with
trained research assistants that assessed demographic,
social, and behavioral characteristics, as well as patient
evaluations of care.
Main Measures
Clinician Mindfulness
Our independent variable was clinician self-rated mind-
fulness, as measured on the baseline questionnaire by
the previously validated Mindful Attention Awareness
Scale (MAAS).
16-19
The MAAS contains 14 items, such
as, “I tend to walk quickly to where I am going without
paying attention to what I experience along the way,”
“I find myself listening to someone with one ear, doing
something else at the same time, “ and “I forget a per-
son’s name almost as soon as I’ve been told it for the
first time.”
16
Possible responses are on a 6-point Likert
scale anchored between almost always and almost
never. The total score is an average of the 14 items;
higher scores indicate more mindfulness.
Audio-Recorded Measures of Patient and Clinician
Communication
Audiotapes were analyzed using the Roter Interaction
Analysis System (RIAS), a widely used coding sys-
tem with well-documented reliability and predictive
validity in assessing patient and clinician communica-
tion behaviors during medical encounters.
20-24
RIAS
analysts assign 1 of 37 categories to each complete
thought expressed by the patient or clinician. These
categories can be combined to reflect broad types
of exchange, such as rapport building (talk oriented
toward enhancing the patient-clinician relationship),
biomedical talk (oriented toward the patients’ illness
and therapy), and psychosocial/lifestyle talk (oriented
toward the patients’ experience and life situation).
RIAS codes are used to construct a summary
measure of patient-centeredness as a ratio of patient-
centered categories of talk (all talk about psychosocial
or lifestyle-related issues, physicians’ information giv-
ing about biomedical topics, all patients’ questions, all
physicians’ emotionally focused talk, and partnership
talk) divided by physician-centered categories of talk
(physicians’ biomedical question asking, physicians’
directive statements, and patients’ biomedical informa-
tion giving).
14,15,25-28
A value greater than 1 denotes a
more patient-centered and a value less than 1 a more
doctor-centered encounter.
In addition to providing information on what was
said in an encounter, the RIAS also provides global
ratings of how the words were said. Emotional tone
scores are calculated by summing coders’ subjective
ratings for patients and physicians (separately). RIAS
analysts additionally recorded for each encounter the
total duration of the recorded visit (visit length) and
the ratio of clinician-to-patient talk during the visit
(verbal dominance). All RIAS coding for this study was
done by 2 women.
Patient Evaluations of Care
Patient-reported dependent variables in our analysis
included (1) patients’ perceptions of clinician commu-
nication, and (2) patients’ overall satisfaction, derived
from postencounter patient interviews. Patients rated
clinician communication behaviors using the Interper-

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sonal Processes of Care Instrument’s general commu-
nication subscale, which consists of 21 items.
26
Possible
responses were on a 5-point scale between never and
always. We measured overall satisfaction with the
question, “Overall, how would you rate the quality of
medical care you have received in the past 6 months?”
Possible responses were on a 5-point scale ranging
between poor and excellent.
Covariates
Patient interviews also elicited the patients’ sociodemo-
graphic information (age, sex, employment, education,
drug use, and the single racial/ethnic group with which
patients identified themselves). Medical records pro-
vided data on patients’ most recent CD 4 lymphocyte
counts. Clinician baseline questionnaires provided self-
reported basic demographic information including age,
sex, and primary racial/ethnic group.
Analysis
We used descriptive statistics to explore and describe
the characteristics of our study sample. We examined
the distribution, means, and internal consistencies of
the mindfulness scale. Based on the nonnormal distri-
bution of scores, we divided our mindfulness variable
into low, medium, and high tertiles to account for the
skewed distribution while still allowing the examina-
tion of graded associations. We then performed t tests
for continuous variables and χ
2
tests for categorical
variables to test for differences in patient and clinician
characteristics (covariates) by clinician mindfulness.
Audiotapes from 1 of our 4 study sites included
the patients’ interactions with more than 1 clinician (a
nurse or nurse practitioner in addition to the primary
HIV clinician). For that site, it was impossible to distin-
guish which RIAS communication behaviors emanated
from interaction with the primary HIV clinician whose
mindfulness we had assessed. We therefore restricted
analyses of audio-recorded communication behaviors
to data obtained from the other 3 sites.
We categorized patient-centered visits vs physician-
centered visits based on whether the RIAS patient-
centeredness ratio for the visit was greater than or
equal to 1 or less than 1, respectively. We used logistic
regression to examine the association of clinician mind-
fulness with patient-centered visits. We used linear
regression to compare patient and clinician communi-
cation behaviors by tertiles of clinician mindfulness.
We examined several communication behaviors: rap-
port building, psychosocial talk, biomedical talk, and
emotional tone.
Based on the positive skew in the distribution of the
2 patient evaluation variables, we dichotomized patient
evaluations of communication quality (at the median
score) and overall satisfaction (excellent vs all other
responses). We used logistic regression to compare
patient evaluations of clinician communication and
patient satisfaction by clinician mindfulness tertiles.
Data for these analyses came from all 4 sites.
In both bivariate and multivariate analyses, we
adjusted for site and accounted for nesting of patients
within clinicians using generalized estimating equa-
tions. We conducted multivariate analyses in 2 steps.
In the first, we adjusted for patient and clinician age,
sex, and race/ethnicity, as well as any other character-
istics found to be associated with clinician mindfulness
in bivariate analyses at P <.20. In the second step, we
added visit length to each model. Adding visit length
was particularly important for analyses in which our
dependent variable represented counts of specific com-
munication behaviors, because longer visits afford the
opportunity for more talk by both patients and clini-
cians. All analyses were conducted using Stata/SE 9.0
(StataCorp LP).
RESULTS
Study Sample
There were 55 clinicians eligible for the study, and 45
(82%) agreed to participate. We identified 617 eligible
patients. Clinicians refused to allow 18 patients to be
approached for the study (12 because the clinician
felt too rushed, 5 because the patient was too sick,
and 1 because the patient was coming for laboratory
results only and not a complete visit). Of the remain-
ing 599 patients, 437 (73%) agreed to participate and
completed all study procedures. Of the 162 patients
who declined to enroll in the study, the most common
reasons were that they did not have time to complete
the interview (n = 106), were not feeling well (n = 22),
or were no interested in studies (n = 13).
Mindfulness scores among clinicians ranged from
2.57 to 5.93 (possible range = 1-6) with a mean of
4.33. The scale had good internal consistency (Cron-
bach’s α = .90). The mean score in the low tertile
was 3.53, in the middle tertile 4.31, and in the high
tertile 5.17. Patient and clinician characteristics are
displayed in Table 1. Clinician mindfulness was asso-
ciated with such characteristics of his or her patient
panel as patient race/ethnicity, but not with patient
age, sex, education, active drug use, or CD4 lympho-
cyte count. Clinician mindfulness was not associated
with clinician age or training background, but was
associated with clinician sex and race, in that female
clinicians were more likely to be in the highest mind-
fulness tertile and nonwhite, non-Asian clinicians
were also more likely to rate themselves as high on
the mindfulness scale.

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Association of Clinician Mindfulness With
Observed Communication Behaviors
The overall intercoder reliability, calculated on a
random sample of 41 audiotapes, across categories
for patient and clinician behaviors was 0.71-0.95. In
both unadjusted and adjusted analyses, higher clini-
cian mindfulness was associated with higher odds of
having a patient-centered visit (Table 2). There was
some evidence of a graded association, with the odds
of a patient-centered visit increasing as mindfulness
increased, but only clinicians in the high tertile com-
pared with the low tertile of mindfulness were signifi-
cantly more likely to engage in patient-centered visits.
Associations of clinician mindfulness with specific
clinician and patient communication behaviors are
shown in Table 3. In encounters with clinicians in the
high compared with the low tertile of mindfulness, both
patients and clinicians engaged in substantially more
rapport building and psychosocial
talk. On average, clinicians with
high compared with low self-rated
mindfulness made 30 more state-
ments per visit categorized as rap-
port building (95% CI, 5-55), and
16 more statements related to psy-
chosocial issues (95% CI, 3-29).
In visits with high-mindfulness
compared with low-mindfulness
clinicians, patients made 40 more
rapport-building statements (95%
CI, 18-63) and 46 more state-
ments about psychosocial issues
(95% CI, 20-73) per visit. Clini-
cians’ affect, or emotional tone,
during the encounter was more
positive as mindfulness increased.
Patients’ emotional tone was not
significantly associated with clini-
cian mindfulness, and we found
no association between clinician
mindfulness and the amount of
biomedical talk during the visit.
When comparing communica-
tion in the high-mindfulness with
communication in the medium-
mindfulness categories, we also
found differences only in patient
rapport-building and psycho-
social talk, with no statistically
significant differences comparing
high- with medium-mindfulness
categories in the overall commu-
nication measures or in any of the
clinician behaviors.
Effect of Visit Length
The average visit among HIV-
infected patients and their
clinicians lasted about 22 min-
utes (Table 3). After adjusting
for study site and patient and
clinician characteristics, high-
mindfulness clinicians spent on
Table 1. Characteristics of Study Sample
Characteristics All
Clinician Mindfulness Tertile
a
P
ValueLow Middle High
Patient, No. 437 150 146 141
Age, mean (SD), y 45.4
(9.4)
44.8
(9.6)
43.9
(9.1)
47.6
(9.2)
0.41
Female, No. (%) 147 (34) 48 (32) 46 (31) 53 (36) 0.45
High school degree, No. (%) 317 (73) 44 (37) 37 (31) 39 (33) 0.74
Race/ethnicity, No. (%)     <0.01
Black 254 (58) 97 (65) 61 (42) 96 (68) 
Hispanic 62 (14) 13 (9) 33 (23) 16 (11) 
White 106 (24) 37 (25) 44 (30) 25 (18) 
Other 15 (3) 3 (2) 8 (5) 4 (3) 
Active drug use, No. (%) 128 (29) 50 (33) 47 (32) 41 (22) 0.07
Depression score, mean (SD) 2.11
(0.64)
2.13
(0.69)
2.08
(0.67)
2.11
(0.56)
0.81
CD4 cell count, mean (SD) 470 (329) 458 (318) 440 (278) 513 (383) 0.37
Length of patient-physician
relationship >5 year, No. (%)
144 (33) 51 (34) 53 (37) 40 (29) 0.39
Clinician, No. 45 15 15 15
Age, mean (SD), y 44.5
(8.6)
43.7
(9.7)
47.5
(6.8)
42.3
(8.6)
0.23
Female, No. (%) 25 (56) 4 (27) 8 (53) 13 (87) <0.01
Physicians, No. (%) 34 (76) 13 (38) 10 (29) 11 (32) 0.43
Race/ethnicity, No. (%)     0.05
White 30 (67) 11 ( 73) 12 (80) 7 (47) 
Asian 11 (24) 4 (27) 3 (20) 4 (27) 
Other 4 (9) 0 (0) 0 (0) 4 (27) 
a
Mean mindfulness scores: low tertile = 3.53, middle tertile = 4.31, high tertile = 5.17.
Table 2. Patient-Centeredness of Clinical Encounter, by Clinicians’
Self-Rated Mindfulness
Clinician Evaluation
Clinician Mindfulness Tertile
Low
(n = 116)
Middle
(n = 127)
High
(n = 119)
Patient-centered visit, No. (%) 23 (19.8) 38 (29.9) 51 (42.9)
Unadjusted, OR (95% CI) – 1.64 (0.79-3.38) 3.76 (1.69-8.37)
Adjusted for covariates, OR (95% CI) – 1.64 (0.73-3.67) 4.14 (1.58 -10.86)
Adjusted for covariates + visit
length, OR (95% CI)
– 1.30 (0.54-3.11) 3.36 (1.17-9.60)
OR = odds ratio.
Note: Data from 3 sites. Unadjusted and adjusted logistic regression models account for clustering of patients
within clinicians using generalized estimating equations and adjust for study site; adjusted model also includes
patient age, sex, race/ethnicity, and current drug use, and clinician age, sex, and race/ethnicity. Referent group
for odds ratios is the low clinician mindfulness tertile.

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average 5.8 (95% CI, 0.9-10.8) minutes longer with
their patients than did those in the lowest tier. After
adjusting for visit length, the association between mind-
fulness and the odds of a patient-centered visit (Table
2) remained significant, as did differences in patient
expression of rapport-building and psychosocial state-
ments (Table 3). Adjusting for visit length, however, did
substantially reduce differences in the amount of physi-
cian rapport-building and psychosocial talk (Table 3).
Patient Evaluations of Care
The Cronbach’s α for the interpersonal processes of
care measure of communication quality in our sample
was .88. In unadjusted and adjusted analyses, patients
of clinicians in the high tertile compared with the low
tertile of mindfulness had greater odds of reporting
high-quality communication and high overall satisfac-
tion with care (Table 4). Neither of these associations
changed after accounting for visit length.
DISCUSSION
Mindfulness among health care clinicians was associ-
ated with more patient-centered communication, pro-
viding the first evidence of which we are aware that
clinician mindfulness is associated with the quality
of care patients receive as measured by patient-cen-
teredness and patient satisfaction. Mindfulness among
clinicians was associated with more rapport building
and communication about psychosocial issues between
patient and clinician, and a more positive emotional
atmosphere within the clinical encounter. These find-
ings give empirical weight to Epstein’s speculation that
the benefits of mindful practice extend beyond the
practitioner to his or her patients; it is not only that
mindful practitioners can listen attentively, but that
their patients are empowered to make their voice heard
in areas that matter to them. It is perhaps this recipro-
cal communication dynamic that drives the differences
observed across levels of mindfulness and the patient-
centeredness score and related categories.
How might clinicians’ mindfulness affect their
communication with patients? Although our study did
not address this question directly, we can speculate
on possible explanations. Mindfulness is defined as
attentiveness, curiosity, presence, and the ability to
adopt multiple perspectives simultaneously—all quali-
ties that promote greater awareness of self and oth-
Table 3. Observed Patient-Clinician Communication, by Clinicians’ Self-Rated Mindfulness
Measure
Clinician Mindfulness Tertile
a
Mean No. (SD)
β Coefcient (95% CI)
Adjusted for Covariates
b
Adjusted for Covariates
b
+ Visit Length
Low
(n = 116)
Middle
(n = 127)
High
(n = 119)
Middle
vs Low
High vs Low
Middle
vs Low
High vs Low
Overall measures       
Visit length,
minutes
22.7 (9.0) 22.2 (8.9) 22.5 (10.5) 2.2
(–1.9 to 6.3)
5.8
(0.9 to 10.8)
– –
Verbal dominance 1.36 (0.6) 1.49 (0.5) 1.24 (0.4) 0.12
(–0.10 to 0.34)
–0.09
(–0.34 to 0.15)
0.12
(–0.12 to 0.37)
– 0.15
(–0.45 to 0.15)
Clinician behaviors     
Rapport-building
talk
80 (37) 87 (38) 89 (44)
c
17 (–3 to 38) 30 (5 to 55) 12 (–5 to 29) 15 (–5 to 36)
Psychosocial talk 18 (18) 23 (27) 27 (29)
c
5 (–6 to 16) 16 (3 to 29) 3 (–8 to 12) 9 (–3 to 21)
Biomedical talk 120 (63) 135 (71) 111 (66) 27 (–1 to 56) 17 (–17 to 51) 16 (–8 to 40) –12 (–42 to 17)
Emotional tone 11.6 (1.7) 11.8 (1.7) 11.8 (1.8) 0.69
(0.11 to 1.3)
1.17
(0.46 to 1.9)
0.60
(0.04 to 1.6)
0.92
(0.22 to 1.6)
Patient behaviors     
Rapport-building
talk
95 (48) 97 (47) 107 (59)
d
14 (–4 to 33) 40 (18 to 63) 6 (–7 to 19) 19 (3 to 35)
Psychosocial talk 52 (47) 62 (63) 78 (55)
d
13 (–9 to 34) 46 (20 to 73) 6 (–14 to 25) 28 (4 to 52)
Biomedical talk 94 (56) 91 (52) 96 (65) 8 (–14 to 29) 23 (–4 to 50) 0 (–16 to 16) 2 (–18 to 22)
Emotional tone 21.1 (1.8) 21.0 (2.0) 21.3 (1.6) 0.07
(–0.53 to 0.66)
0.62
(–0.12 to 1.36)
0.04
(–0.56 to 0.64)
0.53
(–0.22 to 1.29)
Note: Data are from 3 sites.
a
Visit-level data for each variable. Verbal dominance is the ratio of clinician to patient talk. Talk variables are numbers of statements. Emotional tone is sum of scaled
ratings by coders listening to audiotaped dialogue.
b
Results from linear regression models using generalized estimating equations to account for clustering of patients within clinicians and adjusting for study site; patient
age, sex, race/ethnicity, and current drug use; and clinician age, sex, and race/ethnicity. Referent group for β coefcients is the low clinician mindfulness tertile.
c
P <.05.
d
P <.01, for comparisons of middle or high- vs low-mindfulness tertile, accounting for clustering of patients within clinicians and adjusting for study site.

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ers. Mindfulness training also includes skills to lower
reactivity and to enhance responsiveness to stressful
situations. Mindfulness may free clinicians’ attention
so that they are better able to attend to others’ experi-
ence, less likely to distance themselves from distress-
ing situations, and more likely to consider a variety of
explanations in complex situations. As mindful clini-
cians maintain greater attention to their own, as well
as their patients’, experiences, they may be more able
to appreciate the impact of an illness on the patient’s
life or the nuances of the patient’s emotions. This
deeper appreciation of the patient’s experience per-
haps enables the clinician to respond to such opportu-
nities with understanding, empathy, and compassion,
attending to the “lifeworld” in which in which the
patients reside,
29
and these exchanges are conveyed
through emotional tones of warmth, acceptance, and
positive regard. Although patient-centered commu-
nication skills must still be learned, the practice of
mindfulness may make it more likely that the clinician
is able to employ this technique.
Notably, the association between clinician mind-
fulness and both clinician and patient communication
behaviors was partly attributable to the increased aver-
age time spent with patients by clinicians with high
self-rated mindfulness. In addition, many associations,
particularly those with patient evaluations of their care,
were not solely attributable to longer visits; therefore,
mindfulness may enhance patient-centeredness in clini-
cal encounters by improving both the quantity and
quality of attention clinicians give to their patients.
Greater patient-centeredness
and improved patient experiences
with mindful clinicians as found
in this study could ultimately also
enhance retention in care and
clinical outcomes, especially in
the setting of HIV care, where
positive patient-clinician relation-
ships have been linked to higher
quality, greater medication adher-
ence, and better outcomes.
30,31
It may furthermore be true
that these benefits extend to all
patients, especially to those from
underserved or marginalized pop-
ulations who may be particularly
attentive to a clinician’s affective
demeanor and for whom issues of
trust and respect are central.
32
Our study had several limi-
tations. One limitation relates
to the difficulty in measuring
both mindfulness and patient-
centeredness. Mindfulness is a highly complex practice
and may be imperfectly measured by the MAAS. The
MAAS measures only 1 of several constructs inherent
in mindfulness, and more recently developed opera-
tional definitions and instruments
33-35
may allow a more
nuanced understanding of which aspects of mindfulness
are important. A somewhat similar methodological issue
may be raised in regard to patient-centeredness—a
concept with many dimensions.
36
Nevertheless, the
RIAS measure used is well validated and has been found
to be predictive of patient outcomes in other stud-
ies.
24,27
Also, patients and clinicians in our study knew
that they were being recorded and may have attempted
to communicate differently, which could bias our study
toward more favorable communication behaviors. Prior
studies, however, have directly addressed this issue and
have not found that recorded visits were substantively
different from nonrecorded ones
37,3 8
; moreover, any
Hawthorne effect would have to have differentially
influenced clinicians with varying levels of mindfulness
to have affected our findings. The clinical context of
these study visits was HIV care. HIV-infected patients
have a serious, chronic illness. Perhaps as a result, they
may have particularly close relationships with their cli-
nicians within which the effect of a clinician’s mindful-
ness may be more (or less) pronounced than in routine
ambulatory care. Although we found an association
between mindfulness and physician race/ethnicity, we
had a limited number of nonwhite, non-Asian clinicians.
One clinician had been trained in mindfulness, and we
do not know how amenable to training clinicians would
Table 4. Patient Evaluations of Care, by Clinicians’ Self-Rated
Mindfulness
Patient Evaluation
Clinician Mindfulness Tertile
Low
(n = 150)
Middle
(n = 146)
High
(n = 141)
High clinician communication score,
No. (%)
a
62 (41.3) 67 (46.5) 79 (56.8)
Prevalence ratio (95% CI)
Unadjusted – 1.23 (0.92-1.64) 1.47 (1.15-1.87)
Adjusted for covariates – 1.27 (0.98-1.65) 1.51 (1.21-1.87)
Adjusted for covariates + visit length – 1.26 (0.96-1.66) 1.48 (1.17-1.86)
Highest patient satisfaction,
No. (%)
b
82 (54.7) 91 (63.2) 95 (68.4)
Prevalence ratio (95% CI)
Unadjusted – 1.23 (0.97-1.55) 1.36 (1.05-1.76)
Adjusted for covariates – 1.25 (1.00-1.55) 1.46 (1.16-1.83)
Adjusted for covariates + visit length – 1.26 (1.01-1.58) 1.45 (1.15-1.84)
Note: Unadjusted and adjusted regression models account for clustering of patients within clinicians using
generalized estimating equations and adjust for study site; adjusted models also include patient age, sex, race/
ethnicity, and current drug use, and clinician age, sex, and race/ethnicity. Referent group is the low clinician
mindfulness tertile.
a
High clinician communication score dened as higher than median patient ratings of clinician communication.
b
High patient satisfaction dened as overall quality of care rated as excellent vs all other responses.

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be. Finally, we cannot determine from this cross-sec-
tional analysis whether mindfulness training for health
care clinicians will result in better clinical interactions,
or whether some other characteristics of mindful physi-
cians were responsible for the positive patient outcomes
we observed.
Future research should attempt to replicate these
findings by measuring mindfulness among clinicians
and exploring its effects on the quality of patient care
in terms of patient-centeredness, as well as consider-
ing other aspects of quality, such as safety, effective-
ness, efficiency, and equity. Such research might also
consider exploring potential explanatory mechanisms
for such findings in terms of the quality of information
gathered by the clinician, clinical decision making,
patient engagement, and trust. Further, studies should
test whether interventions to improve the mindfulness
of practicing clinicians affect patient satisfaction and
other aspects of quality.
Mindfulness may be an important pathway to a
more humanistic, effective, and satisfying practice of
medicine. The highly reciprocal influence of patients
and clinicians on one another is in itself a powerful
and positive medical tool—perhaps in some situations
more powerful than other interventions that can be
offered to patients. In an era in which many physicians
suffer professional burnout, mindful practice may be
the way in which physicians not only heal themselves,
but heal their patients as well.
To read or post commentaries in response to this article, see it
online at http://www.annfammed.org/content/11/5/421.
Key words: patient-physician relations; patient-physician communica-
tion; mindfulness; HIV; acquired immunodeciency syndrome
Submitted September 9, 2011; submitted, revised, November 29, 2012;
accepted December 27, 2012.
Funding support: This research was supported by a contract from the
Health Resources Service Administration and the Agency for Healthcare
Research and Quality (AHRQ 290-01-0012). In addition, Dr Korthuis was
supported by the National Institute of Drug Abuse (K23 DA019809), Dr
Saha was supported by the Department of Veterans Affairs, Dr Beach
was supported by the Agency for Healthcare Research and Quality (K08
HS013903-05), and both Drs Beach and Saha were supported by Robert
Wood Johnson Generalist Physician Faculty Scholars Awards.
Disclaimer: None of the funders had a role in the design and conduct
of this analysis, nor was it subject to their nal approval.
Previous presentations: The results relating to mindfulness were pre-
sented in part at the International Conference on Communication in
Healthcare (Oslo, Norway, September 2008) and the Society of General
Internal Medicine’s Annual National Meeting (Miami, Florida, May 2009).
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