Omotenashi (おもてなし): An Art of Mindful Medicine

During the opening ceremony of the Tokyo 2020 Summer Olympics, as Japanese tennis player Naomi Osaka lit the Olympic flame, volunteers, staff, and support personnel observed the moment with respectful bows while ensuring that the event proceeded smoothly amid the ongoing COVID-19 pandemic. Despite the absence of spectators, the ceremony reflected Japan’s cultural emphasis on humility and hospitality. This principle is often described as omotenashi (おもてなし), a concept highlighted by television announcer Christel Takigawa during Japan’s bid to host the Olympics as emblematic of Japan’s unique spirit of hospitality. Omotenashi is a concept encompassing mindfulness and selfless service that originated in Japan. Omote (おもて) means “the public face”—an image meant to be shown to others—and nashi (なし) literally translates to “nothing.”1 Together, this means that a person serves with candidness and honesty. The practice of omotenashi began with the tea ceremony tradition, in which the host remains actively aware of minute details contributing to the guest experience, including careful preparation of tea and the choice of utensils, cups, and ambience of the room to create a welcoming environment.2,3 In an increasingly fast-paced and disconnected world, the omotenashi philosophy would be valuable across all elements of society.4 However, its application in a world in which interactions are increasingly digitized and efficiency prioritized is challenging. As people live faster lives, traditional appreciation of meaningful human interactions diminishes. Despite being more interconnected through a digital world, our interactions with others are often diluted, promoting a sense of incivility.5,6 A greater emphasis on individualism leading to a decrease in adherence to social norms has resulted in a loss of politeness and respect for others. This can be attributed to a variety of reasons, such as fewer face-to-face interactions, busier lives, and the polarization of belief systems. As a result, the lack of genuineness leads to a decrease in the art of thoughtfulness. This editorial details the importance of omotenashi in the field of medicine and how these principles can be implemented thoughtfully. THE ROOTS OF OMOTENASHI Although omotenashi originated as a form of hospitality in the tea ceremony, its ideology has roots across diverse cultures. Islamic teachings and the Prophet Muhammad’s hadiths describe guests as gifts sent by God. Therefore, people should treat guests with the utmost respect, as doing so is a religious practice. These actions include providing shelter, food, and water to demonstrate hospitality. Many believe that these actions should be upheld because treatment of others reflects personal virtue. As a result, this display of altruism is an integral part of omotenashi. The ideas of omotenashi also reverberate throughout Eastern philosophy, including thinkers such as Confucius, Laozi, and Mencius. Confucius believed in virtues such as benevolence and righteousness to achieve harmony among people. His ideals of genuine respect toward others reflect the underpinnings of omotenashi. Acts of kindness should not be a script, but rather a way to connect with others. Laozi emphasized humility; to show proper respect to guests, one must adopt a mindset of humbleness that supersedes the interests of the host. Mencius maintained the idea of inherent goodness, a quality that allows one to become both a respectful host and an appreciative guest. With the right conditions, our compassionate self can be revealed. The fundamental principles of omotenashi within Eastern philosophy are also mirrored in the West. Socrates taught the importance of observation and thinking. It is the duty of the host to carefully discern the needs of the guest to properly serve them. Plato reinforced the idea of “The Good,” a principle that led to the general well-being of citizens. This is a goal that hosts work toward to provide generous and warm-hearted care. Aristotle emphasized the ideal of excellence: providing omotenashi should not be treated as an item on a checklist, but rather a way of living. Through embracing omotenashi as a habit, one can maintain excellence within their sphere. The fundamental ideologies supported by each philosopher relate to the underlying idea of omotenashi. THE IMPORTANCE OF OMOTENASHI A good deed has beneficial effects for both the recipient and the donor.7 People who perform acts of kindness can strengthen their empathy, integrity, and personal values, further positively shaping their character. This is known as “helper’s high”: a release of dopamine and endorphins attributable to the feeling of pride from making another person’s day better.8,9 In the domain of the social world, this helps boost one’s sense of self-esteem, purpose, and identity. As a result, the benefits of displaying a kind gesture lead to a net benefit in society. In addition, the initial kind gesture may be reciprocated.10,11 For example, most people are willing to buy lunch for someone who previously covered the bill. Reciprocating generosity leads to a more thoughtful and genuine relationship between individuals, contributing to a more cohesive social unit with deeper trust. The concept of omotenashi is important because it helps create an environment in which people can trust and depend on each other. People aim to feel a sense of belonging and mutualism. Omotenashi is a concept that cuts across cultures and bridges diverse backgrounds. Omotenashi helps promote a social support system, improve mental health, and foster group identity. Through principles of generosity and care, greater feelings of satisfaction and intimacy result.12 In health care, integrating principles of omotenashi can promote a sense of trust between patients and providers, fostering a synergistic dynamic in which they work together against a disease. Patients are more likely to follow a treatment plan when there is an established sense of trust with the physician. In accordance with omotenashi, giving patients the opportunity to understand the reasoning behind treatments can help increase patient compliance. This elevates the patient experience and leads to patients feeling heard and cared for. HOW IS OMOTENASHI INTEGRATED IN HEALTH CARE? Health care is a field that benefits from compassionate care for patients. Hospitals and health care staff support patients through a patient-centered care model that maintains a sense of mindfulness.13 The goal of patient-centered care focuses on how medical workers can support patients and their needs. This promotes a selfless attitude toward patient care that helps health care workers achieve omotenashi, leading to patients feeling respected and engaged in conversation with physicians about their health.14 This quality of being heard is essential in health care because patients need to feel valued. When thoughtful health care is provided, patients are more likely to feel involved and motivated to overcome their health problems as a team with their physician (Fig. 1).Fig. 1.: Current practices of omotenashi in health care.Hospitals also contribute to aspects of omotenashi by paying attention to minute details such as color schemes and interior design to create a more relaxing environment. Studies have shown that exposure to natural light has a beneficial effect on mood,15 and assorted colors can have beneficial effects on well-being. For example, blue has been shown to lower blood pressure and green has the ability to reduce anxiety.16 Another interesting display of omotenashi is the installation of artwork or screens on the ceiling in rooms where patients receive radiation treatments.17 These diversions can provide a source of relaxation to reduce some of the stress inherent in undergoing radiation treatments. In addition, hospitals have been investing in single-patient rooms with their own windows.18 The benefits of privacy and natural sunlight are both components of providing a hospitable environment for patients, aligning with the principles of omotenashi. Omotenashi is also introduced in health care during the early education of medical students, including providing warm blankets and helping patients with personal hygiene and grooming. Aspects of omotenashi are also included in objective structured clinical examinations in medical schools, with a goal to understand how students can provide tailored care for patients.19,20 This is accomplished through addressing social determinants of health and promoting interdisciplinary health care. As a result, physicians can offer care that goes beyond the traditional care pathway. In surgery, omotenashi helps create trust between surgeons and patients. Before surgical intervention, omotenashi is essential to initiate transparent conversations to aid in decision-making with patients. Patients frequently have expectations regarding appearance outcomes. As surgeons, we can uphold the patient’s interests by providing thoughtful care. During the procedure, a surgeon should reflect on the individual and emotional consequences of the patient’s situation. To many, such procedures have profound influence over self-esteem, confidence, and overall quality of life. Omotenashi is also evident in the proper implementation of follow-up care, such as understanding the patient’s needs outside the medical environment. Surgeons must spend effort and time educating patients on self-care so that the desired result can be attained. HOW TO PRACTICE OMOTENASHI IN HEALTH CARE Understanding the differences between practicing and embracing omotenashi helps show how deeply it shapes our interactions. In many areas of society, elements of omotenashi are reduced to checklist items, distinct from genuine interactions. Treating omotenashi as a mindset rather than a directive can prevent health care workers from exhaustion associated with “performing compassion.” Omotenashi starts with a change in mindset rooted in mindfulness, which is less about grand gestures and more about daily and conscientious awareness. Omotenashi begins by looking at a situation from another person’s perspective to predict what they would need. Small acts of thoughtfulness, such as making breakfast for a partner, sending an “I appreciate you” note to parents, or slipping a warm note into the lunchbox of a child, are not monumental, but can change a person’s day (Fig. 2).Fig. 2.: How omotenashi could be practiced further.As we continue to perform omotenashi and promote it to become second nature, our attention would naturally shift toward our colleagues, such as asking members of the team about their day or asking questions about their lives. Support can sometimes also mean quietly asking “How can I help you succeed?” Leadership shows in quiet spaces by offering encouragement or creating an environment for others to contribute with their strengths. Demonstrating care for a nurse, medical student, or technician leads to positive reception, resulting in feelings of reciprocity. As kindness becomes integrated into our daily lives, it can reflect outward—particularly in our care for patients. Practicing omotenashi helps physicians see past their own perspectives, allows them to consider how their actions can affect others, and illustrates how individuals in society can fundamentally change to become more thoughtful to others. At its heart, omotenashi is about how we change not only our actions, but also our views. When physicians understand how patients feel, the opportunity is created for thoughtful and personal care. Therefore, beyond medical care, physicians must change to better identify and consider cultural, emotional, or systemic barriers. Current medical literature details several strategies for promoting mindfulness and empathy in the clinical setting. A systematic review conducted by Gong et al.21 found that Balint groups—meetings held between physicians to talk about challenging interactions with other individuals, including patients or colleagues—are effective for empathy training among medical professionals. These conversations can help physicians learn how to better navigate serving patients. The Schwartz Center Rounds, a program implemented in MyMichigan Medical Center Midland, is another method for health care professionals to discuss the emotional and social aspects of care. By providing a space to reveal the emotional burden of being a caregiver, these groups can explore ways to overcome these barriers and prevent feelings of distress. When physicians are supported, they may start to ask questions, such as what it means to offer sincere care.22,23 Recognizing the root causes of negative factors, such as physician burnout, can play a major role in inspiring mindfulness. Whereas individual acts of omotenashi are impactful, lasting effects result when the culture of health care sustains these ideals. Omotenashi is a 3-way process: the act of hospitality, the recipient of care, and the environment of the act. Therefore, the responsibility of implementing omotenashi must not rely solely on physicians. Although omotenashi can be implemented from a selfless perspective, it is necessary to promote the conditions that cultivate such culture. From the perspective of the recipient, it is important to recognize the effort behind each act of care and transform a routine exchange into a meaningful interaction. Omotenashi requires time and effort from the giver. Thus, small gestures of appreciation will profoundly reinforce this cycle of care. When patients see this demonstrated sense of hospitality, an expression of gratitude can help physicians affirm their positive practices. Therefore, this leads to a continuous loop that rewards physicians through emotional satisfaction. This sense of reciprocity will also promote an unequivocal sense of omotenashi from physicians. This feedback loop creates a more pleasant environment. Cultivating the right environment will allow omotenashi to flourish. When practiced in isolation, omotenashi is impractical. Changes in systems can make compassionate care possible. This includes a shift in the health care model with a greater emphasis on value-based care over pay-for-performance. As a result, the patient’s interests and feelings become central to the model of care. This also means giving physicians the time and space to care—not rushing from room to room, but being present. Allowing physicians to slow down and pay more attention to patients enables higher-quality care. Supportive environments not only reduce burnout, but restore a sense of purpose. Studies show that structural factors such as a reduction in administrative burdens, improved workplace flexibility, and promotion of team-based care environments to share responsibilities help physicians deliver compassionate care.24 If omotenashi is to succeed, the right infrastructure must support the people practicing it. DISCLOSURE Dr. Chung receives funding from the National Institutes of Health and book royalties from Wolters Kluwer and Elsevier. Dr. Zhu has no financial disclosures to report. No funding was received for this work.