Attending

by Ronald Epstein

  THE INNER MANAGER

  Bottom-up attention is capricious. Any fast-moving object or loud noise can act as a circuit breaker, even when it is a distraction. Think of what happens when an ambulance goes by while you’re trying to have a conversation at a café—you lose your train of thought even though the ambulance’s trajectory doesn’t intersect yours. And some things should be circuit breakers but aren’t. Bottom-up attention tends to fail when things change gradually—a kidney gradually turning blue, a slowly expanding mass, gradual weight loss, deepening depression.24 Here, only clinicians who are exquisitely attuned to salient cues (such as Mr. Laszlo’s night sweats) can see what is really there.

  For doctors, electronic health records are one of the most potent circuit breakers. Nearly every time I prescribe a medication, for example, warnings about drug toxicity or drug interactions flash on the computer screen in lurid eye-catching colors, whether the potential for trouble is trivial or life threatening. I lose my train of thought and my gaze is now captured by the computer screen, and the patient is left waiting.25 It’s impossible to investigate all of the warnings in detail; trying to do so would keep the average doctor up past midnight. Barraged with these warnings, it is understandable why clinicians ignore many of them and how they can set the stage for other errors due to fatigue and distraction. Designers of these programs, adept at computer operating systems, clearly were not taking into account the limits of clinicians’ inner operating systems.

  Executive attention is our “inner manager,” which helps us to prioritize one source of information over another. Consider what happens when Mrs. Rostro returns to talking about her itchy rash. My attention is divided between the signs and symptoms of heart disease and the signs and symptoms of eczema, far less serious. If it’s a normal day in the office, my visit with Mrs. Rostro might be interrupted by a knock on the door from my nurse, who informs me that the last prescription I wrote for a different patient is not covered by his insurance. I look at my mobile phone to find the phone number for the cardiologist to call regarding Mrs. Rostro, and I note a calendar alert to bring the car in for an oil change. When I hear the distant sound of a car alarm, which I’d usually ignore, I realize that I’d forgotten to bring the car in for the oil change. I sniffle, then become aware that I’m still fatigued, just having gotten over a cold. Executive attention triages stimuli and in the best of circumstances helps me pay attention to what matters—Mrs. Rostro’s concerns—and to ignore the rest.

  TWENTY MINUTES OF RED

  When I was in college in the 1970s, I took a course with Ken Maue, a visionary avant-garde musician. Ken wanted his musicians to experience beauty and harmony by inviting them to see the world differently, in unexpected and surprising ways. He composed a performance piece that was originally intended to last three days—hence the original title, Three Days of Red.26

  The instructions are simple: “For three days record in writing everything red that you see.” I actually did it once, back in 1973. Although the act of “seeing red” for three consecutive days for me was life changing (I could never again see the world in the same way), even a few minutes can be instructive (and far more pragmatic). You’re instructed to spend twenty minutes (or as long as an hour or as short as seven minutes) walking in the environment (often a hospital or conference center) in silence. I also ask you to notice what’s going on in your own mind during the exercise. This exercise directs your top-down, goal-directed attention to things red. While you’re observing your reactions, the exercise helps you be more aware of your inner experience, such as bottom-up impressions, emotions, and thoughts that enter your awareness. You might want to stop here and try it.

  TWENTY MINUTES OF RED

  For the next twenty minutes, record in writing the name of everything red that you see.

  The red exercise leads participants to realize that there is no “immaculate perception”—we don’t see things as they are as much as we see things as conditioned by our expectations and goals.27 People doing the exercise are frequently surprised at how many red things they now notice that had previously escaped their attention—even in a familiar environment. They ask themselves, “How red does something need to be to be called red?” They discern finer gradations of red, purple, orange, and pink. Some get competitive and try to list more red things, and more unusual red things, than their colleagues. Some get bored, some get excited, some get annoyed, and some worry if they’re doing the exercise correctly—all of these thoughts and feelings bubble up unbidden from their bottom-up attention.

  One of the reasons people find the red exercise so compelling is that they learn how their minds work; nearly all of them note that anything that is not red tends to be discounted. They literally see the world differently, and they see how inputs from the senses are filtered by their brains before they are apprehended as conscious perceptions. The red objects were always there, but now we notice them and notice how we notice them. It lays mental processes—normally in the background—in plain sight. These mental processes not only filter information that happens to come our way, they also drive our own information-seeking behaviors—we look, seek out, and even redefine objects as red.

  The red exercise has its counterparts in medicine. It’s common for medical students taking a dermatology rotation to begin to notice every freckle on each passerby. They might be more aware of the different brands of sunscreen on display when they go to the supermarket. During flu season, I see dozens of patients with influenza. I begin to divide the world of patients with respiratory symptoms into “flu” and “not flu.” I wonder how “flu-like” the patient’s symptoms need to be to consider it a case of flu—and not another respiratory virus or a bacterial pneumonia that would require antibiotics.

  But clinical medicine is more complex than simple pattern recognition; we not only see patterns, we enact scripts.28 In the emergency room, when an overweight middle-aged woman describes severe pain in the right upper quadrant of the abdomen, a physician’s “gallbladder script” is activated. The physician’s top-down attention is directed to listen for symptoms of pain and nausea after eating fatty foods, to consider whether a radiologist is available to interpret an ultrasound of the gallbladder, and to prepare to order intravenous fluids and pain relievers. This all happens in an instant.

  But scripts aren’t always reliable. For most physicians, the gallbladder script would be triggered by someone who has recently eaten a fatty meal and reinforced if the patient is “fair, fat, fertile, female over forty”—the five F’s mnemonic that medical students use to recall features of typical patients with biliary colic, the pain that occurs when a gallstone gets stuck, blocking the exit of bile. While this script would readily identify the “typical” patient, the majority of patients with biliary colic do not have all of these clinical features; if they’ve not eaten a fatty meal or if they are black, male, young, or thin, the physician typically takes longer to consider gallbladder disease. Or, conversely, patients with the five F’s might not have a gallbladder problem at all—they may have had too much to drink or have heartburn. By assuming that upper abdominal pain is due to gallbladder disease, the physician might not think to ask about other symptoms, such as shortness of breath, that might suggest something far more ominous (a heart attack). The same mental scripts that are helpful and efficient in straightforward situations can prevent us from seeing what is actually there in more complex ones.29

  The red exercise also has its counterpart in human relationships. If a doctor (or anyone else) has a preconceived idea about others—for example, their intelligence, the legitimacy of their symptoms, or their truthfulness—he will tend to discount evidence to the contrary. The effects of these expectations are even more powerful if the physician harbors unexamined negative emotions such as dislike, fear, guilt, anger, disgust, or annoyance.30

  Those expectations sometimes affect clinical care. I had a close call several years ago. Patricia Scarpa, a middle-aged woman whom I knew well, did not
come to the clinic often, but when she came, it always took a long time. She usually had a litany of aches and pains for which no cause could be found. She was not particularly distressed or depressed; this was just the way she was. Her voice was whiny, and she would elaborate in great detail about each item in her list of symptoms. As much as I tried to be attentive, after a while I couldn’t focus. I’d get impatient and annoyed.

  On this particular visit, she mentioned worsening vague belly pain and bloating, not severe but noticeable. Finding nothing on her physical exam, I relegated this symptom to another one of her uncomfortable but nonserious concerns for which I could only hope to offer some empathy, reassurance, and symptom relief—and did. Later that evening, when I was completing my notes, my eye darted to the vital-signs portion of her chart. She hadn’t mentioned it, but she had lost nearly fifteen pounds since her last visit. The next day I called her and asked how she was doing. No better. I suggested that she come back in a few days. That time, I did a more careful physical exam, worried that she might have cancer. Although it was subtle, I thought I could feel fluid in her belly, not a normal thing. I hadn’t scheduled the time for a gynecologic exam, but I took the time to do it—and found a hard mass that proved to be ovarian cancer. Had I not called her in, or if I’d felt rushed or inattentive, the opportunity for a cure might have been lost.31

  WHAT MINDFUL ATTENTION LOOKS LIKE

  A colleague, a seasoned neurologist, greets a new patient. Watching the patient extend his hand for a handshake, something attracts the neurologist’s attention, something subtle in the patient’s movement—something that would not be noticed by a layperson. She cannot name that “something,” yet it triggers the thought “Watch out, be attentive, something is amiss.” The patient, previously thought to have Parkinson’s disease, just doesn’t have the type of hesitancy and difficulty initiating movements that would be expected if he did have Parkinson’s. Ultimately the patient is diagnosed with a small stroke, which prompts a different approach to treatment; the neurologist stops the potentially toxic medications for Parkinson’s and starts blood thinners to prevent another stroke.

  My hunch is that this neurologist—like other master clinicians—uses her whole mind to a greater degree than her less skilled counterparts. Master clinicians attend to the person in front of them while attending to their own mental processes. They don’t take for granted their initial impressions, or anyone else’s. They attend to that which they can explicitly describe, as well as the vague impressions that influence their judgment. They use their analytic minds—knowledge, evidence, and technical skills—as well as their intuitive and imaginative minds, the sensibilities that we typically associate with the humanities.32

  What does focused attention feel like? For an experienced cyclist, focused attention means maintaining balance while going around a sharp curve. For a musician, it is making exquisite each brief silence between two notes. For a surgeon, it is applying just the right amount of tension to a suture. For a neurologist, it is knowing when to let a first impression guide your thinking and when those impressions lead you astray. Attending in this way is the result of more than just experience. It takes practice to bring perceptions to awareness when needed, and to allow them to fade below the threshold of awareness at other times to avoid overloading the mental circuits,33 employing all three kinds of attention to perceive and respond to that which might otherwise have been missed.

  Applying focused attention is a moral choice, not just a skill. We pay attention to that which we consider important, and by virtue of paying attention to something, we make it important. All physicians take a vow to do their best to relieve suffering and not do harm. But unknowingly, sometimes we attend to some kinds of suffering—and some people who suffer—more than others. Attending to each patient’s concerns means more than just becoming more perceptive and attentive; it means being prepared to greet whatever concerns patients bring with curiosity and resolve.

  3

  Curiosity

  The sixty-year-old man lay motionless, and the whooshing sound of the ventilator was the only thing that broke the late-night stillness. He had had a large stroke and his condition hadn’t changed during the five days he had been in the hospital. His family was distraught; each day they came in and talked to him, rubbed his hand, wiped his face, desperately trying to establish contact, to see if he could respond in any way. Nothing. Then came their tears. On day number four, I was told, one family member thought that she saw him blink one eye in response to a question; otherwise he was flickerless. He had electrodes on his head for continuous EEG monitoring. The brain waves were normal, meaning that most likely he was “locked in”—able to think, but not able to move or respond in any way, a terrifying prospect. That morning, we rounded quickly. Still no change, no communication, zero. The intern wrote in the chart, “Unresponsive; prognosis poor.”

  I was still at the hospital late at night and I had just finished my notes. I peered into the patient’s darkened room and was surprised to see Dr. Fisher. I was a medical student, fortunate to have been assigned to a renowned senior neurologist, C. Miller Fisher, for a month-long rotation. Fisher was an observant and thoughtful man, but I saw him doing things in the room that struck me as, well, odd. Flashlight in hand, he illuminated parts of the room, then shone it on his own face while talking to the patient, gesticulating wildly and making grotesque facial expressions—sneers, grins, frowns—almost clownlike. Then he’d stop and check the EEG machine for any spike in the visual cortex or the auditory cortex when he was talking and gesticulating—hoping to see what was still working in the patient’s brain and to connect in some way with the patient as a person. Fisher assumed that the patient had an inner life and wanted to see if he was capable of a two-way connection with the world. He assumed that “unresponsive” merely meant that he had not found the correct channels for communication. Fisher didn’t know what he would find. Ultimately, he noted a flicker of movement around the patient’s eyes, just like what the family had described. Fisher noted a simultaneous EEG spike in the visual cortex—confirming the family’s impressions that the message was getting through. The patient, otherwise barely showing signs of life, was responding. We communicated this news to the family the next day. Even though we will never know what impact that human gesture had on the patient—his ability to communicate never improved—the family found solace knowing that their messages of love and caring were getting through.

  Fisher’s curiosity was palpable. Like the late Oliver Sacks, he had perfected the art and joy of observation. Like others who are curious, his gratification was intrinsic; when being curious, we explore new things for their own sake with no extrinsic reward.1 Inevitably, this kind of exploration yields unexpected surprises.

  Curiosity is a fundamental human quality and is essential for survival; during a famine, those who seek out novel sources of food and shelter are likely to fare better (Who would imagine that the inside of a prickly thistle could be a delicacy or that cold slippery ice could be made into a warm cozy igloo?). Curiosity is “wonderment,”2 a realization that there is always more; personality researchers consider curiosity a manifestation of a psychological trait, “openness to experience.”3 In medicine, curiosity means seeking to know what makes each person tick. An attraction to the unknown, the unusual, and the unexpected is also what makes great physician-scientists. Whereas most scientists were throwing away moldy petri dishes, Alexander Fleming, an inquisitive but otherwise undistinguished scientist, discovered the mold that would be synthesized into penicillin.

  Throughout medical school, residency, and clinical practice, doctors are socialized to be authoritative, knowledgeable, and self-confident. Saying “I don’t know” is not an option. Perhaps curiosity is seen as immature or even dangerous. Students’ probing questions—a sign of curiosity—are not always well received by supervising physicians.

  Curiosity is sidelined by what Jerome Kassirer, former editor of the New England Journal of Me
dicine, called a “stubborn quest for certainty.” Being too certain—never being in doubt—paradoxically results in lower-quality care through overtesting, premature conclusions, and tunnel vision.4 Psychologically, when doctors (or anyone else) are barraged with information and in a hurry, we find it harder to be curious, to explore outside the box, to entertain doubt. The pressure to solve problems quickly leads doctors to rely on rules and mental shortcuts rather than to consider each situation afresh. In their more mindless moments, doctors do tests “just to be sure,” then abandon their curiosity when a test confirms their initial impressions. Content with a solution that is expedient and not necessarily optimal, they don’t explore a full range of options. They tacitly assume that being open or curious takes too much time and energy, not recognizing that putting on blinders will cost them time later. In a word, they satisfice.

  Faith Fitzgerald’s 1999 essay on curiosity should be required reading for all health professionals.5 An internist, Fitzgerald was dean of students at the University of California, Davis, School of Medicine. Typically, on rounds, senior physicians ask trainees to present the most interesting patients admitted overnight. Interesting—in medical discourse—is code for rare diseases (usually incurable) or atypical manifestations of more common ones, things that are easy to miss. Or, sometimes, a “classic” presentation of a serious disease—the loud murmur signaling a ruptured heart valve or bruises on the abdomen signaling severe pancreatitis. Interesting is in contrast to the typical day, which for most clinicians is filled with things that, on the surface, seem quite ordinary; for cardiologists it’s chest pain, for neurologists it’s headache, for dermatologists it’s acne. Fitzgerald, in a brilliant educational exercise, would turn the question on its head; she would ask residents to present their most boring patient. Her goal was to promote curiosity by demonstrating that every patient’s story was unique, interesting, and vital to her care.