Practice of the Month: Four Questions a Day

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By Carly Smith, BS, MPH(c) 

This blog is part of our Gratitude & Reflection newsletter. If you like this content, sign up to receive our monthly newsletter!

Spiritual practices do not have to take place in a church; therefore, every person lives with spirituality in some way. Individuals connect to their spirits and create meaning through various activities, including religious rituals, but also through music, art, or exercise. 

“Spirituality, broadly, is the way that we find purpose, connection, belonging, and dignity as human beings,” says Bruce Feldstein, MD, BCC, Stanford Lifestyle Medicine Head of Gratitude and Reflection. “People find it in various ways–it’s not important where you find it; what’s important is just to get started looking for it.” 

Dr. Feldstein is a board-certified chaplain at Stanford, where he directs Jewish Chaplaincy Services serving Stanford Medicine and an Adjunct Clinical Professor in the School of Medicine. He sees spirituality as the critical element missing from most lessons on healthy aging from elementary to medical school. His experiences as an Emergency Medicine Physician turned Clinical Chaplain inspired him to create the Spiritual Fitness ToolKit, which helps individuals cultivate well-being by exploring rituals for meaning, purpose, and connection.

 “A spiritual practice is as essential to cultivating well-being as physical fitness or nutrition. However, our ‘spiritual fitness’ is typically not discussed as concretely as these other aspects of health,” says Dr. Feldstein. 

Four Questions a Day Exercise

The Spiritual Fitness ToolKit opens with a reflection exercise titled “Four Questions a Day.” To develop habits of gratitude and reflection, Dr. Feldstein recommends spending ten minutes of quiet time at the end of the day to contemplate these four questions, one at a time. 

     The Four Questions:

1. What surprised me today?

2. What touched me today?

3. What inspired me today?

4. For what am I grateful?

Start by asking yourself the first question, What surprised me today? Reflect backward on your day until you come to the first thing that surprised you. Make a note of it in a little journal or on a file on your smartphone. It’s important to write it down. Then do the same with the other questions, one at a time. (This exercise is drawn from research on gratitude and from the teachings of Rachel Naomi Remen MD, originator of the Healer’s Art course.)

After a few weeks of practice, you may begin thinking about these questions throughout your day. Eventually, you may find yourself noticing moments of surprise, being touched, inspiration, and gratitude as they occur. This heightened awareness can allow you to see and respond to  situations in your life with “new eyes,” and bring elements of emotional well-being into your everyday experience.

“The Four Questions exercise could be essential in two ways for people getting started,” says Dr. Feldstein. “It can help develop a capacity for increased emotional awareness and encourage people to become reflective practitioners in action.”

Dr. Feldstein suggests committing to this practice for at least three weeks to develop a new habit, and for 90 days to create a new lifestyle. He also suggests engaging in the daily writing activity with a friend to promote connection and enjoyment.

Sharing Moments of Gratitude

An extension of the Four Questions practice is Sharing Moments of Gratitude, another valuable practice  in the Spiritual Fitness Toolkit .

Feeling gratitude within oneself is one part of the experience. When we feel grateful for something wonderful in our lives, we can share our appreciation of others by saying or doing something for someone else. Doing so expands the experience of gratitude to those around us.

Sharing gratitude can be done in many ways. Most simply, we can say, “I really appreciate what you just did. Thank you so much.” This is most powerful and the positive experience is mutual and immediate. We may also send a thank you note, or offer a small gift. 

One of Dr. Feldstein’s favorite practices is to produce small moments for gratitude at the end of each conversation, discussion, or meeting.

“I often ask my patients or people I am with ‘What can I wish for you today?’ I listen with openness, take in what they say, then respond genuinely with an open heart. This is a practice for offering a blessing. It is one that produces mutual gratitude,” says Dr. Feldstein. “It is a simple practice you can incorporate into any conversation or interaction and greatly encourages connection, healing, and finding peace.”

So, dear reader, what can the Stanford Lifestyle Medicine team wish for you today?

 

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Gratitude is Good Medicine

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By Sharon Brock, MEd, MS

This blog is part of the Gratitude & Reflection newsletter. If you like this content, sign up here to receive our monthly newsletter!

A few months ago, Stanford Chaplain Bruce Feldstein, MD, BCC, received a call to offer compassion and spiritual care for a woman in her 90s at Stanford Hospital. When Dr. Feldstein entered the hospital room, he saw her husband sitting at her bedside, holding her hand, and looking at his wife of 62 years with eyes of devotion and appreciation. Taking a seat, Dr. Feldstein was deeply touched and inspired by the love they shared between them and the immense gratitude the husband had for his wife. With reverence for the sacred moment, Dr. Feldstein whispered to the man, “Your gratitude and love is a kind of medicine that doesn’t come in an IV.”

Intuitively, we know gratitude is good for our health, and in recent years, researchers have proven this scientifically. Several studies have shown that gratitude practices are associated with a reduction in depression, anxiety, and an improvement in overall mental health. Studies also show that gratitude practices improve physical health, such as lowering blood pressure, improving sleep quality, and creating positive changes in brain activity.

This evidence that gratitude promotes mental and physical health begs the question, “How do we experience more gratitude in our lives?” Perhaps the first step is to have a deeper understanding of what gratitude is.

Gratitude is a Mood

So, what is gratitude, exactly? Although everyone has experienced gratitude to some degree, it isn’t easy to define. Some people have an overall attitude of gratitude, while others only feel thankful when they receive a gift or something good happens in their lives. Many people, however, are somewhere in the middle. They experience gratitude as a mood that comes and goes throughout the day.

It’s useful to be aware of our moods because they serve as metaphorical lenses that determine how we assess situations. For example, if a friend cancels dinner plans, a grateful person might appreciate the extra time in their evening to relax, whereas a person who chronically complains might think they don’t have any true friends. Even though the situation is the same, the responses are different due to the variance of their moods.

Dr. Feldstein notes how we can shift our mood toward gratitude by pausing and reflecting on what we are grateful for. Even with a busy schedule, we can weave in moments of reflection to experience more gratitude and enhance our mood.

“Reflection is an antidote to busyness. When we are busy, we typically don’t notice the wonderful things in our lives. We don’t stop to appreciate what is already there,” says Dr. Feldstein. “Some people say they don’t have time to stop and reflect, but it’s not about time. It’s about having a readiness to notice with appreciation and gratitude what is going on in the midst of our activity. It only takes a brief moment to stop and notice,  reflect, and appreciate the things we care about. Doing so contributes to a meaningful life and this can be cultivated.”

Gratitude is a Choice

Due to our biological need to survive, our default thoughts and emotions are often riddled with fear, defensiveness, and complaints. Without consciousness, our instincts prompt us to be on guard and defend ourselves from potential predators, which can be both physical and emotional. When we begin to spiral in these negative emotions, Dr. Feldstein recommends that we make a conscious choice to shift our focus from stressful circumstances to something good.

“Gratitude is a choice,” says Dr. Feldstein. “We don’t have control over what happens, but we do have choices related to how we see things, what we focus on, and ultimately how we respond.”

At any given moment, we can break the spiral of negative thinking by pausing and asking ourselves, “What am I grateful for right now?” By including moments for reflection multiple times a day, we can gradually shift our default thinking from negativity to gratefulness and other elements of well-being due to the neuroplasticity of the brain.

As a chaplain, Dr. Feldstein offers this understanding while accompanying patients in the hospital. “When a patient is going through a difficult time, I compassionately acknowledge their situation and then gently ask, ‘What sustains you?’ and ‘What is something you’re grateful for?'” he says. “This shifts their focus in the direction of well-being, and they begin to feel more at ease, which is a healing experience for both the patient and caregiver.”

Gratitude is Good Medicine

With enough practice in cultivating gratitude, we can start to embody the essence of gratitude while interacting with others. When we start saying “thank you” and “you’re welcome” more often, we feel more connected, and our relationships become stronger, sweeter, and more meaningful.

“Gratitude is not just something we have, it can also be something we are,” says Dr. Feldstein. “Rather than simply knowing the feeling of gratitude, I can be the expression of gratitude that I am inside and share it with others as a way of being. In doing so, we can be a healing force for ourselves, those around us, and the world.”

Dr. Feldstein shares that when healthcare workers pause during the day to prepare their attention and intention to allow for the emergence of presence, appreciation, and gratitude, they have more meaningful and healing connections with their patients.

“When we give and receive gratitude, we all feel better, we see more connection with other people, we see more possibilities in life. Whatever is happening with our physical bodies, gratitude allows us to be in a state of well-being,” says Dr. Feldstein. “So, when we [healthcare workers] are being grateful, it’s an expression of caring, which is enlivening for both the patient and ourselves, and that’s the promise of what medicine is all about.”

 

For more thoughts on gratitude, read What We Get Wrong About Gratitude written by Stanford Lifestyle Medicine team member, Barbara Waxman.

 

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Dr. Bruce Feldstein: Bridging Medicine and Spirituality

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By Maya Shetty, BS

Bruce Feldstein, MD, BCC, is a distinguished chaplain, physician, and educator at Stanford, renowned for his unique influence in healthcare that bridges the realms of spirituality and medicine. His work is motivated by a desire to inspire a more holistic and compassionate approach to healing. Presently, he serves as a guiding light for the Stanford Lifestyle Medicine Gratitude and Reflection pillar, seamlessly integrating the essence of human existence into the broader field of lifestyle medicine.

“Within healthcare, I see lifestyle medicine as a pathway to recognize the human dimension of living that reflects the essential nature of being human itself,” says Dr. Feldstein. “Through this perspective, we appreciate the human experience with a more comprehensive embrace.”

One of the remarkable aspects of Dr. Feldstein’s work is the emphasis on an individual’s humanity. As an Adjunct Clinical Professor of Medicine at Stanford, he surpasses the boundaries of traditional medical education by bringing forward  an understanding of human beings as biological, linguistic, and historical beings who are fragile, interdependent, and mortal. His educational focus includes caring for structural human concerns such as meaning, purpose, connectedness, belonging, and dignity.

At Stanford, he has taught courses that encompass these principles, such as “Spirituality and Meaning in Medicine” and “Physician Self Care and Well-being.” He also teaches “The Healer’s Art,” created by Rachel Naomi Remen, MD, and “Reflection Rounds,” in which medical students, physicians, and chaplains gather to reflect on their inner life experiences. “Reflection Rounds” is now a subject of doctoral dissertations supervised by Dr. Feldstein. He also mentors students, residents, physicians, and chaplains across the country, as well as teaches and gives talks on spirituality and medicine globally.

Humble Beginnings

Born in Detroit, Michigan, Dr. Feldstein’s journey has taken him through diverse experiences in music, medicine, and spirituality. He reminisces, “I’ve been in medicine since I was 2 years old, when my father’s drug store burned down and he went to medical school. As a child, I would join him on countless house calls and hospital rounds.”

Dr. Feldstein attended the University of Michigan, taking advanced pre-medical courses while earning a Bachelor of Science in music focused on theory, analysis, and history.

“Experiencing music can bypass our intellect and touch the core of our meaning and being. There is a healing power in music,” he says. This deep connection to music resonates in his life today as a chaplain, incorporating singing into his spiritual care for its healing energy, meaning, and ritual.

He completed his undergraduate education in just two years, earning membership in Phi Beta Kappa and receiving numerous awards. Remarkably, he was accepted into medical school at the University of Michigan at the age of 20.

His childhood experience of religion, like many assimilating immigrant Jewish families, was oriented around private family gatherings rather than lived publicly or professionally. Yet, Dr. Feldstein was drawn to spiritual and religious experiences throughout his medical education and clinical practice. As a medical student, he witnessed a Christian physician in a small Michigan town emergency room who offered a prayer from his pocket-sized Bible while caring for his long-time patient. Initially, Dr. Feldstein was taken aback, but soon understood the immense comfort this act provided to the patient. Through many moments such as this, he began to recognize the spiritual dimensions of medicine.

Emergency and Disaster Medicine Physician

After graduation from medical school, Dr. Feldstein volunteered as a physician in the pediatric ward of a Cambodian refugee camp on the Thai border. It was the winter of 1979 – 1980, in the aftermath of the genocide and famine that killed one-quarter of the Cambodian population by the country’s Prime Minister, Pol Pot. There, he saw indescribable suffering and horror, as well as the unforgettable human will to live. He also witnessed equanimity and power among the people due to their Buddhist practices. Unavoidably, he began to recognize the crucial importance of the spiritual-humanistic dimensions of human life and how they were missing in Western medicine.

Upon returning to the US, Dr. Feldstein practiced emergency and disaster medicine for 19 years. During this time, he spent a two-year sabbatical with Fernando Flores, PhD, who introduced him to the essential nature of language in medicine, helped him appreciate what it is to be human (ontology), and the power of incorporating these understandings into healthcare, clinical medicine, and everyday life. Flores remains one of Dr. Feldstein’s lifelong teachers.

Shifting from Physician to Chaplain

In 1998, he faced a life-altering injury that rendered it impossible to carry on as an emergency physician. Exploring different career avenues, he became a visiting scholar at the Stanford Center for Biomedical Ethics, mentored by Ernlé Young, PhD. He also ventured to Jerusalem to study Jewish religion and ethics, then returned to Stanford where he discovered a deeper sense of his life’s work as a chaplain.

He completed the residency program in Clinical Pastoral Education to become a spiritual care professional in 2000. He was still serving those in pain and suffering, but now offering comfort and healing from an emotional and spiritual perspective. As a chaplain who was previously an emergency physician, “I had the distinct impression I was bridging two worlds.”

In 2000, he also established the Jewish Chaplaincy Services (JCS), a program dedicated to providing spiritual care and guidance to hospital patients, their families, and caregivers at Stanford Medicine. This involved training spiritual-care volunteers and, as a physician who is a chaplain, contributing to the integration of spirituality into the practice and profession of medicine through education.

Since 2001, as an Adjunct Clinical Professor at the School of Medicine, Dr. Feldstein has developed and taught an award-winning curriculum on spirituality and well-being for medical students and faculty. He received the John Templeton Spirituality and Medicine Curricular Award and was the first recipient of the Isaac Stein Award for Compassionate Care presented by the Stanford Health Care Board of Directors. He is recognized as a Board Certified Chaplain by Neshama: Association of Jewish Chaplains, the professional association for Jewish chaplains worldwide, where he was a past president.

In his multifaceted roles as a leader in lifestyle medicine, chaplain, professor, and director of JCS, Dr. Feldstein remains dedicated to nourishing the souls and minds of the Stanford community.

“Stanford’s commitment to including the spiritual dimension of medicine resonates with my core belief that understanding the essence of being human enhances the ability to address pain and suffering and promote healing in a more profound way,” he says.

 

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Welcoming Our New Program Manager, Sharon Brock

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By Carly Smith, BS, MPH

Stanford Lifestyle Medicine (SLM) is pleased to welcome Sharon Brock, MEd, MS, as the new program manager and lead writer/editor. With a master’s degree from Columbia University journalism school and 17 years of experience as a science journalist, Brock brings a wealth of editorial knowledge to the position and is committed to the overall goal of growing the program with enhanced content across all platforms. 

“I am excited to be at Stanford Lifestyle Medicine,” says Brock. “I’m incredibly inspired by the researchers of SLM. I believe their work is essential for the future of medicine and I’m honored to be part of this movement.”

In addition to improving content quality, Brock works closely with the team’s research fellows. As a team under Brock’s leadership, they produce social media posts, blogs, and newsletters that translate complex scientific research into language that is understandable and practical for the general public.

“Lifestyle medicine has traditionally been neglected in modern medicine, but with the help of Stanford researchers and this great team of writers, we can make it more mainstream and accessible for everyone,” says Brock.

Brock grew up in Los Angeles and graduated from University of California, Santa Barbara in 1999 with a bachelor’s degree in the biological sciences and a master’s degree in education. After teaching high school biology in the Bay Area for five years, she moved to New York to earn a second master’s degree in journalism from Columbia University.  

For the past 17 years, Brock has been working as a health and medical editorial professional, including a writing position at UCSF and as the editor-in-chief of the USC Keck Medicine magazine KeckMD, which highlights the work of USC physicians and researchers. She hopes to similarly collaborate with Stanford’s team to share their research findings and innovations in the field of Lifestyle Medicine. 

In addition to being an editorial professional, Brock is also a UCLA-certified mindfulness teacher and bestselling author of the book The LOVEE Method: Mindfulness Meditation for Breast Cancer. Following a breast cancer diagnosis in 2018, her training in mindfulness helped her navigate the year-long journey of chemotherapy treatments and surgeries with greater strength. 

When the mindfulness practices not only served her emotionally, but also physically–she had minimal side-effects from chemotherapy–she saw it as her duty to publish a book providing mindfulness tools for other women facing this diagnosis. In 2021, her book became a bestseller and was featured on Good Morning America, and it continues to serve as a mental health resource for women going through breast cancer treatment across the country.

“It was a very challenging time, but I asked myself, ‘How can I turn this pain into purpose? How can I use this experience to serve others?’” says Brock. “Although writing this book was a lot of work, when I receive emails from women I’ve never met saying this book was their greatest source of support while going through cancer, it makes it all worth it.” 

Brock was thrilled to find this position at Stanford Lifestyle Medicine, which is a great fit with her education and editorial experience. Also, as evidenced by her book, Brock is aligned with the mission of the program to educate and empower the general public with actionable lifestyle choices to enhance health and wellbeing. 

“The other day, a researcher on the team spoke about a study where meditation and gratitude practices supported women going through cancer treatment, as shown by blood test results,” says Brock. “As the researcher spoke, I smiled and thought to myself, ‘I’m in the right place.’”

 

 

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Laughter Your New Prescription

Laughter: Your New Prescription

When was the last time you laughed? Do you remember the way it made you feel? Many people note that laughter can heal the soul, but what about other aspects of our health? From boosting your mood to enhancing social connectedness, laughter is one of nature’s feel-good remedies, and it has a positive clinical relevance in the treatment of mental, physical, and physiological conditions.

Recent reviews of randomized-controlled trials report reduced levels of stress, anxiety, depression, and fatigue when patients underwent laughter and humor-based interventions. Certain studies have even found humor to be beneficial in improving people’s ability to focus and remember different aspects of lectures, conversations, etc. Furthermore, the opportunity to share a laugh with other people helps to build stronger bonds and deeper connections, fostering a greater sense of belonging and helping crush feelings of social isolation and loneliness.

When our team reflected on how laughter could be used as a tool for a healthy lifestyle, it was agreed that laughter is much more than just a sound. Sometimes even just thinking of a time that you let out a big belly laugh is enough to brighten your mood and ease some of the stress from your body. Seeking opportunities to laugh and engage with others in such a lighthearted fashion may just be the tool many of us should embrace to lead happier and healthier lives. So, we encourage you to take a moment to relive the last moment you left out a laugh and reflect on the different ways it helped you at the time.

“Let laughter be our song. Listen for laughter. Enjoy. Chuckle. Smile. Laugh. Try it sometime, and see for yourself. “

– Dr. Bruce Feldstein, MD, BCC, Head of Gratitude & Reflection Pillar

 

By: Carly Smith, BS, MPH(c)

Sources:

  1. Stiwi K, Rosendahl J. Efficacy of laughter-inducing interventions in patients with somatic or mental health problems: A systematic review and meta-analysis of randomized-controlled trials. Complement Ther Clin Pract. 2022 May
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A Strong Sense of Life Purpose is Associated With Better Quality of Life

A Strong Sense of Life Purpose is Associated With Better Quality of Life

A Strong Sense of Life Purpose is Associated With Better Quality of Life

Purposeful living is a self-organizing life aim to stimulate goals, promote healthy behaviors and give meaning to life. Many of us are most likely agree that having a sense of purpose in life is associated with overall both physical and mental health quality of life. Needs a scientific proof to this? This article showed a very interesting association of life purpose with all-cause mortality in older adults. The study analyzed a total of 6,985 individuals between 50-60 year. Hazard ratio, 2.43; 95% CI, 1.57-3.75, comparing those in the lowest life purpose category with those in the highest life purpose category. There were also significant association between life purpose and specific cause mortality attributed to heart, circulatory and blood conditions. There are several possible mechanisms through which life purpose might potentially be associated with mortality such decreased expression of proinflammatory genes in purposeful living (studied by Fredrickson et al), lower cortisol and proinflammatory cytokines in purposeful living (studied by Ryff et all), elevated inflammatory markers such as CRP and inflammatory cytokines such as IL-6 in those without low to no purposeful living (studied by Harris et, Reuben et al and De Martinis et al).

By: Rusly Harsono, MD, & Maya Shetty, BS

 

Journal Reference:

  1. Alimujiang A, Wiensch A, Boss J, Fleischer NL, Mondul AM, McLean K, Mukherjee B, Pearce CL. Association Between Life Purpose and Mortality Among US Adults Older Than 50 Years. JAMA Netw Open. 2019 May 3;2(5):e194270. doi: 10.1001/jamanetworkopen.2019.4270. PMID: 31125099; PMCID: PMC6632139.
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