Attending
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For twenty-five years I’ve studied communication in health care settings. As a communications researcher, I notice how physicians systematically pay attention to some kinds of information more than others. It is particularly alarming how often physicians are oblivious to patients’ emotional distress, despite their providing clues that they are afraid, distrustful, confused, or depressed. Patients will say, “I’m tired,” “Just shoot me,” “My sister’s cancer is progressing,” and get little acknowledgment.9 In one study of thoracic surgeons seeing patients with lung cancer, over 90 percent of the emotional content of conversations went unacknowledged.10 Admittedly, some physicians intentionally ignore emotional content, feeling that is not their job (I disagree).11 Yet, when reviewing audio-recordings of their consultations, physicians are often surprised at how many of those concerns went unheard.
A few years ago, I set out to understand how this kind of inattention happens in primary care. I trained actors to pose as patients with chest pain who made appointments to see primary care physicians in the Rochester area. The doctors had previously consented to participate in the research, but had no idea when the actors would come and what symptoms they might present. The roles were constructed so that the actors were likely to escape detection. Generally it worked. The vast majority of the time physicians thought that they were real patients. In an intentional effort to simulate the ambiguities of primary care practice, the actors portrayed chest pain that was not typical of heart disease, heartburn (gastroesophageal reflux, or GERD), or musculoskeletal pain; sometimes it would be worse with movement or after eating or at night, with no pattern to the symptoms. We also trained the actors to ask the doctors a key question: “Could this be something serious?”
We were intentionally trying to increase physicians’ cognitive load, to force them to choose among competing explanations for the patient’s symptoms. One doctor said to the patient, “Maybe this is heartburn, let’s get an EKG.” While an EKG might provide useful information about the heart, it would certainly not help diagnose heartburn. The physicians were befuddled.
Furthermore, when patients asked the “something serious” question, few received any empathy or even acknowledgment of their worry.12 Rather, physicians tended to ask further questions about physical symptoms, provide bland reassurance or more medical information, or change the topic. If these had been real patients, their fears might have been compounded, or they might have felt sheepish that they had brought up a trivial concern. This might affect their future decisions about when to seek health care and from whom.
I met with a focus group of physicians after the study. None said that they thought their patient’s emotional distress was trivial. Rather, they said that they just didn’t register the emotional content, that diagnosis and medications were more on their radar. Cognitive load drove them to distraction. Clearly, talking about serious illness is difficult for both clinicians and patients, and some physicians consciously avoid such discussions. But if these physicians had a moment-to-moment awareness of their own attentional choices, most would have prefaced their response with “I can see how concerned you are about this.”
There is some good news, though. Given the opportunity, physicians can be keen detectors of their own blind spots—they can raise that which is just below the level of awareness into consciousness. In a study from the 1990s, I asked physicians to watch video-recordings of their consultations with their patients who were at high risk for AIDS.13 These patients were often terrified; at that time the treatments for AIDS were not effective. Patients not only feared the disease; they also feared stigmatization. When patients expressed distress, physicians often missed it.
When the doctors reviewed their video-recordings, they were shocked—just as people watching the basketball video a second time couldn’t believe that they missed the gorilla. One doctor was mortified when he viewed himself asking questions about intimate sexual behavior (a good thing) as he was performing a testicular exam (not exactly the way to make a young male patient feel less vulnerable). While missing the gorilla in an online video generates amusement and wonder, missing emotions or causing humiliation in the examining room has real and important consequences—the physician may have missed an opportunity to detect and treat the HIV infection before it progressed to AIDS. Patients who feel unheard are less likely to disclose important information and less likely to follow their doctors’ recommendations.14
I CAN’T HEAR YOU WHILE I’M LISTENING
You might think that if you were in a quiet, controlled setting, such as an exam room, it would be relatively effortless to pay attention. While lack of distraction helps, it’s not enough. In a brilliant article from the 1980s, primary care internist Richard Baron wrote about a time when he was listening to a patient’s heart with a stethoscope. The patient started talking (uncanny how often they do), and Baron said, “Quiet . . . I can’t hear you while I’m listening.”15 While technically true that it is hard to hear speech through a stethoscope and virtually impossible to hear subtle breath sounds and heart murmurs when a patient is talking, it points to the realities of medical practice: that our moment-to-moment choices reside just below our level of conscious awareness, somewhat like our awareness of what’s in our peripheral vision.16 Stimuli compete for clinicians’ attention in a time-pressured, psychologically demanding, and unforgiving environment. Clinicians need the ability to focus their attention on the task at hand, while also having access to their subsidiary awareness—perceptions that are just below the surface of awareness.
Learning how attention works is important to both doctors and patients. I know, for example, that long-winded rambles and repetitive descriptions of symptoms by patients tire me, yet buried in their ramblings might be clues to something serious. With practice, I might be able to avert missing something important by increasing my awareness of my attentional habits and blind spots and switch more adeptly between autopilot and focused attention; like a “mental muscle,” the capacity for attention can be grown and developed.
Patients can help too. As a patient, when you don’t get the information or understanding that you need, you can say, “I just want to make sure I’ve been clear about _____.” Or “I’m particularly worried about _____.” Or “I’m not sure I understand what that means.” This can help you and your doctor focus on what’s most important. Just as doctors need practice to communicate effectively, patients also need practice in assertive communication. It pays off in two ways: you’re more likely to reorient your physician’s attention toward your needs and you are more likely to get an answer that makes sense. Knowing about inattentional deafness means that you can appreciate that a lack of response from a physician may mean that you’ve simply not been heard, and not that your concern is unimportant (especially when your doctor has the stethoscope in her ears or is typing on a computer). Fortunately, in conversation, with more flexible parsing of our attention, we can recalibrate and go back to clarify something that has been missed or misunderstood.
The fast pace of clinical practice—accelerated by electronic records—requires juggling multiple tasks seemingly simultaneously. Although commonly thought of as multitasking, multitasking is a misnomer—we actually alternate among tasks. Each time we switch tasks we need time to recover and, during the recovery period, we are less effective. Psychologists call this interruption recovery failure, which sounds a bit like those computer error messages we all dread. We increasingly feel as if we are victims of distractions rather than in control of them.17
In addition to information that comes from the outside world, we are constantly processing information that comes from the “sixth sense”—the mind itself. While focusing on a task (for a physician it might be examining a patient’s abdomen or suturing a wound), we all have spontaneously arising thoughts, emotions, and visceral sensations that may or may not relate directly to the situation at hand. If you have any doubt about the constant flow of these mental events, take a couple of minutes, close you
r eyes, and simply watch the flow of sensations, feelings, thoughts, and emotions, without trying to alter them in any way. We doubt ourselves, remind ourselves about other tasks, feel anxious or sad, and notice grumblings in our stomach or tension in our shoulders.
The brain strives for efficiency. Under high cognitive load—when assaulted with difficult problems, too much information, and emotional stress—the brain tends to simplify. It privileges familiar and expected information and relatively ignores that which is novel, unpleasant, or unexpected.18 In clinical practice, I find that I tend to pay closer attention to the first thing—or the last thing—that the patient says. When Emil Laszlo mentioned his vitamin D level and prostate symptoms in addition to his shoulder pain, he was unknowingly adding to his physician’s cognitive load just by virtue of presenting more concerns. In medicine, the imperative to simplify often leads to premature closure—after reaching a certain information threshold, the brain admits no more information, comes to a conclusion, and treats that conclusion as fact. At that point, we tend to consider only that which confirms our initial impression (shoulder pain and a history of tendinitis), and to ignore the rest (fever, sweats, and a lump). Overconfidence and hurry make matters worse. While inattention is the starting point for many failures of clinical reasoning and empathy, the lack of awareness can undermine effective and humanistic care in many other ways.
TOP-DOWN
During the surgery described at the beginning of this book, Dr. Gunderson, the resident, and the nurse were all focused on the right kidney, and with good reason. They wanted to bring their visual awareness, motor skills, and judgment to a delicate task. They knew that with one false move, things could go sour. Their minds were processing vast quantities and varieties of complex sensory information. They needed to anticipate the likely challenges and come up with a game plan. The surgeon might have had an inner dialogue: “Need to be careful not to injure the ureter, so I’ll focus exclusively on that part of the anatomy for now.”
Goal-directed attention is also known as top-down attention, or orienting attention. It is about anticipating something that is known and expected with heightened vigilance. Although we like to think that we’re in control of our minds, most of our thought process occurs outside our everyday awareness.19 While top-down attention can go awry, as we’ve seen, it usually serves us well. To take an everyday example, on my short commute to work there is a stop sign at the corner of Hemingway Drive and Elmwood Avenue. As I approach Elmwood, my mind is primed to see that stop sign and to respond accordingly—even though I’m not aware of thinking about it. In clinical practice, when I see a child with a fever, my eyes automatically and effortlessly direct themselves toward her skin (are there spots?), her neck (is she moving it?), and her breathing (fast? slow? shallow?) even before her mother finishes describing the child’s symptoms. When in top-down mode, I decide what’s important (making sure she doesn’t have measles or meningitis or pneumonia), and I look and listen for it.20 Neuroscientists have identified what seems to be the major top-down attention pathway in the brain, known as the dorsal frontoparietal network, which interprets information and guides decision making.
CIRCUIT BREAKERS
While top-down attention is initiated by our expectations and goals, “bottom-up” attention is stimulus driven. It is otherwise known as alerting attention because it maintains vigilance for the unexpected. You are driving to work along your usual route, and before you get to that familiar stop sign, a deer suddenly leaps into the road. Your foot reaches the brake before you even realize you’re seeing a deer, and not a gorilla or a pedestrian. A surgeon notices red blood in the surgical field and slows down so that her attention can be directed to the bleeder; then she cauterizes it before proceeding.
Some bottom-up stimuli are universal and innate—they capture one’s attention whether one grew up in Boston, Barcelona, or Borneo. Moving objects, bright objects, blood, bared teeth, and loud noises activate bottom-up attention in everyone—these stimuli steal away our attention, whether or not they are relevant to the task at hand. Bottom-up attention can also be triggered by internal stimuli from the body itself, such as a pain in the back or a grumbling in the stomach. Other stimuli are “salience dependent”—things that stand out because they are meaningful to us in some way. An everyday example is how we perk up when we hear our name mentioned at a cocktail party. Or, in medicine, the words chest pressure.
I saw Jane Rostro in the office—a woman in her seventies whom I’ve known for years. Like many older patients, she would bring several concerns to each visit, some trivial and some more serious. On this visit her list included hemorrhoids, an arthritic knee, and an itchy rash. Then she mentioned, almost as an afterthought, a funny sensation “right here” while climbing stairs, motioning with a broad gesture encompassing most of her chest and abdomen. It had been worsening over the past several days. A pressure, but not a pain. My attention was diverted by the words pressure and climbing stairs because of their salience—they might be indicators of angina, a potentially life-threatening situation. Not quite aware I was doing so, I suddenly demoted the itchy rash discourse and put myself on a new set of tracks in a different direction. Once I had made a bottom-up shift in focus, I switched back into top-down mode, now going through a sequence of questions asking about indicators of heart disease—short of breath? puffy legs? family history?—having completely abandoned the itchy rash.
When I told the emergency department about her impending arrival, I mentioned Mrs. Rostro’s “chest pain,” even though she had called it “pressure” and never used the word chest. Unwittingly, I filled in the blanks. I described her symptom to the nurse differently from the way Mrs. Rostro experienced and described it, perhaps because in medical school I learned a category of symptoms called chest pain and not this funny sensation kinda around here. And I know that chest pain tends to capture the attention of the emergency room staff and that the patient will be seen more quickly. If my bottom-up attention had been malfunctioning completely, had I persisted with her itchy rash and hemorrhoids and ignored her vague feeling that something was amiss, the outcome might not have been as good. She was found to have a blockage in her right coronary artery, which was stented, resulting in relief of her symptoms, perhaps saving her life.
Bottom-up attention activates several neural networks. One of those networks resides on the right side of the brain, the side most often associated with intuition, novelty, creativity, hunches, and artistic expression.21 This makes sense because bottom-up attention is more impressionistic and intuitive. Bottom-up attention also involves the limbic system, which regulates emotions such as fear. Perhaps this is why people often struggle to explain why their attention gets redirected; I find myself saying, “Well, she just looked sick,” and only later do I put together the pieces of what might have contributed to that impression (pale skin, shallow breathing, lying still). The just looked sick intuition, for me and other clinicians, is not innate; it is a product of experience and my ability to assimilate patterns over time. If you’re not observant and have trouble educating your intuition, you’ll become what educators Carl Bereiter and Marlene Scardamalia call an “experienced non-expert”—someone you wouldn’t want to have as your doctor.22
By the time doctors finish medical school, certain signs and symptoms become incorporated as salient. They reliably elicit bottom-up responses—for example, if the patient mentions chest pain or has slurred speech, most doctors drop what they’re doing and shift gears. Bottom-up attention tends to act like an “involuntary circuit breaker,” quickly turning off a top-down process and diverting attention to something more immediate. Other equally important signs and symptoms don’t trigger physicians’ circuit breakers as consistently. Recently, a capable resident took me to see a patient, in his mid-fifties, who was receiving treatment for kidney cancer. The cancer was potentially curable. He was in the hospital because the chemotherapy was making him sick. He seemed a bit flat, perhaps despondent. This is
not unusual for patients in the hospital—no one likes being there and no one sleeps well. But then he said that he was thinking of taking early retirement.
I completely missed the salience of that patient’s statement; in fact, when I discussed the case with the resident, I couldn’t recall having heard it at all, nor did I register the patient’s mood. I was totally focused on prescribing medications for pain and nausea. But for the resident, it sounded an alarm. The resident felt a sinking feeling, a sadness. He wondered whether this feeling was triggered by the patient—whether the patient might be depressed or even suicidal—which then tripped his internal circuit breaker and captured his attention. In fact, the patient was depressed. We referred him for psychotherapy and he responded well. The resident’s ability to pick up on this signal was a direct result of his awareness of his own emotions—the heaviness he felt only grew stronger the more he talked with the patient. This particular resident had good teachers and role models who helped him learn how to be more sensitive to patients’ depression. He used his own emotions to inform his care of the patient. But he was exceptional; not all clinicians would have picked up on these clues.23