Attending

by Ronald Epstein

  A Zen story goes:

  Two monks were watching a flag flapping in the wind. One said to the other, “The flag is moving.”

  The other replied, “The wind is moving.”

  Huineng, their teacher, overheard this. He said, “Not the flag, not the wind; mind is moving.”12

  Seeing a situation from two perspectives simultaneously can reveal an even more profound truth. Of course the flag is moving and the wind is moving. What we don’t always appreciate is how our minds move between two or more views of the world. The ability to hold contradictory perspectives is not only a marker of a great clinician, it also characterizes great scientists. Physicist Niels Bohr is reported to have said “the opposite of a fact is falsehood, but the opposite of one profound truth might very well be another profound truth.” For him it was not intuitive to consider that light is both a wave and a particle—a paradox that boggles the imagination—yet the scientific evidence allowed no other explanation.

  HOLDING EXPERTISE LIGHTLY

  The failure of Gary’s clinical team to adopt more than one perspective may have had its roots in an inability to adopt a stance of “not-knowing.” Their expertise—or, better yet, the misapplication of their expertise—led to overcertainty, an arrogance in considering their provisional formulation to be an immutable fact. I can only speculate about what was going on in the minds of the clinical team at that time; haste and cognitive overload were likely at play, but there may have been more.

  Not-knowing is not the same as laziness. In Suzuki Roshi’s words, “Not-knowing doesn’t mean that you don’t know.” Not-knowing means not letting what you know get in the way. It means “to hold what you know lightly, so that you’re ready for it to be different.”13 In this way, knowing and not-knowing are not incompatible; they are two sides of the same coin.

  Living each moment recognizing that our understanding is incomplete—maintaining a sense of “unfinishedness” in the fast-paced, information-overloaded world of clinical medicine—is not easy. Once I make a diagnosis, I notice that I tend to see information in a different way; anything that conflicts with that sense of “truth” makes me uncomfortable, even more so if I’ve made a commitment by having declared that truth to someone else. It’s dangerous when you feel that it’s better to appear certain even if you’re wrong than to appear in doubt.

  The discomfort that happens when you are confronted by new information that conflicts with your existing beliefs, ideas, values, or behavior—“cognitive dissonance”—is amplified when your sense of certainty is disrupted.14 Faced with cognitive dissonance, we tend to seek consistency to lessen that sense of disruption. Traditionally, psychologists have identified two primary ways we relieve cognitive dissonance—by changing our ideas, values, beliefs, or behavior to accommodate the new information, or by plowing ahead, favoring information that confirms the old ideas and ignoring or rationalizing that which does not.15 Too often, we shape the facts to conform to our beliefs. In medicine, patients’ accounts of their illnesses are rich with inconsistencies, while chart notes are filled with seemingly coherent stories that confirm a diagnostic impression. Master clinicians find a third route, neither changing their viewpoint nor engaging in delusion. They practice living with the paradox. They accept that there might be two equally legitimate ways of viewing a situation, at least for the moment. Sometimes this paradox can be resolved as the situation evolves and new information becomes available. Other times, clinicians need to learn to live with uncertainties that might never be resolved.

  In medicine, up to a third of the symptoms that patients bring to their doctors defy our attempts at diagnosis, and despite doing all the right exams and tests, we aren’t able to provide a coherent explanation for the patient’s distress.16 Primary care physicians see scores of patients with leg swelling, which can sometimes be a sign of a life-threatening condition—a blood clot or heart failure—but most often is harmless. More than a third of patients whom cardiologists see with chest pain are found not to have heart disease. Neurologists’ offices are filled with patients who are dizzy, but extensive testing reveals no clear diagnosis. In those cases, good clinicians hold on to a sense of unfinishedness for months or years. They know that the next time the same patient reports a symptom, it may prove serious. Clinicians, however, are prone to divide patients into those with serious disease and those with “functional” distress. Some illnesses defy Western medical diagnostic categories and appear to be mind-body illnesses. However, classifying those forms of distress as “functional” can also be a trap; clinicians can miss seemingly similar symptoms that represent something more serious. For example, a patient of mine had chronic unexplained abdominal pain for years. She had undergone extensive diagnostic testing, and no treatments helped. Her pain worsened when she was depressed. I saw her on a Friday and reassured her that it was likely the same pain that she had had for years, even though she protested that the pain was different that day. Three days later she saw one of my partners, who sent her for an ultrasound. She had gallstones. I had completely missed the boat. After surgery, that pain resolved. But she still had the same unexplained chronic pain. She had pain that was both unexplained and explainable. This paradox—a patient with two similar symptoms—is common. After a heart attack, patients commonly have aftershocks—chest pains that prove innocuous. Patients with rheumatoid arthritis often have fibromyalgia, too—muscular aches and pains that are not associated with any joint destruction.

  DARING TO COME UP EMPTY

  Zen is rich with stories that contain evocative pearls of wisdom. One of those pearls is about emptiness. As Suzuki Roshi explains, “If your mind is empty, it is ready for anything.” The idea of emptiness is a radical, and somewhat disturbing, notion. One popular Zen story tells of a professor who once visited a Japanese Zen master to inquire about Zen.

  The master served tea while the professor expounded about philosophy. When the visitor’s cup was full, the master kept pouring. Tea spilled out of the cup and all over the table.

  “The cup is overflowing!” said the professor. “No more will go in!”

  “Like this cup,” said the master, “you are full of your own opinions and speculations. How can I show you Zen unless you first empty your cup?”17

  On one level, this Zen story—and the concept of emptiness—is about making space so that we are ready for new ideas and can use our limited cognitive capacity more effectively.18 The educator and philosopher John Dewey captured this spirit in the early twentieth century. Dewey called for emptying the mind as “a kind of intellectual disrobing.” He said, “We cannot permanently divest ourselves of [our] intellectual habits. . . . But intelligent furthering of culture demands that we take some of them off, that we inspect them critically to see what they are made of and what wearing them does to us. We cannot achieve recovery of primitive naïveté. But there is attainable a cultivated naïveté of eye, ear and thought.”19

  As recently as thirty years ago, some psychologists believed that the message in this Zen story was nonsense. They believed that we had no risk of the cup’s overflowing because we only used a small part of our brains in everyday life and that the capacity of the brain was nearly limitless. This idea—that we only use 10 percent of our brains—has achieved urban-legend status and continues to be stated as fact in the media and pop-psychology publications. Despite its appeal, the 10 percent idea has been proved wrong; research has repeatedly demonstrated that we use all parts of the brain, and that the brain has limited capacity for attention, memory, and problem solving. Doctors, like other high-functioning professionals, need all of their cognitive capabilities—and then some—to deal with the complexity of patient care.

  The brain is prepared for overload, however. Your brain is always employing mental shortcuts; you categorize, summarize, see similarities, and aggregate information. That way, you achieve mental economy and process more information more quickly. But mental efficiency comes at a price; by characterizing a patient with a c
ertain set of symptoms as an “example of X,” doctors can miss a patient’s unique features. As I’ll discuss further in the chapter on decision making, efficiency can result in superficial solutions to complex problems.

  Emptiness is more profound than simply making space in an overcrowded brain. Emptiness is a way of understanding the world. While objects in the world are real, emptiness means that the theories, categories, and labels that we apply to them are constructions of the mind (or collectives of minds) and therefore lack substance. This idea comes from the Buddhist philosophy of emptiness (as I mentioned in chapter 1) and was also articulated by William James, the father of American psychology and a self-described “pragmatist.”20 James held that mental categories—such as diagnoses—can seem so real, but are fundamentally fragile. They have explanatory power but must be set aside in favor of other ways of seeing the world when their usefulness is tenuous and unproven. Expertise means knowing when to dare to come up empty.

  By now it should be clear that assigning a diagnosis can both illuminate and obscure clinicians’ thinking. A patient of mine was first considered a “classic” case of temporal lobe epilepsy, then, of borderline personality disorder, bipolar II disorder, post-traumatic stress disorder, and somatization disorder. Ironically, each of these explained her distress, but each was fundamentally unsatisfactory—the patient was all of these and none of them. This flux is true in all areas of medicine. Despite years of evidence that the underlying cause of stomach ulcer is a bacterial infection, doctors were reluctant to give up their notion that stomach ulcers were due to poor nutrition, stress, or excess acid production. Similarly, doctors took years to follow evidence-based guidelines to use beta-blockers to treat heart failure. Until the 1990s, we were all taught the lore that beta-blockers would weaken the heart, not strengthen it. It took over a decade for the medical profession to fully assimilate a new worldview.

  Doctors are trained to cling to categories. In medical school one of my professors said that there were 10,000 diseases. That was in 1984. In 2015, the International Classification of Diseases (ICD-10) listed over 170,000 different diagnosis codes. In medical school, students learn about “cases” of a particular illness before learning how to care for people who are ill. We learned to call diseases “diagnostic entities,” as if diagnoses were “things” that exist in the world, like a table or a kidney. You confuse the living, breathing human being in front of you with the diagnosis codes in a chart.

  TWO KINDS OF INTELLIGENCE

  There are two kinds of intelligence: one acquired,

  as a child in school memorizes facts and concepts

  from books and from what the teacher says,

  collecting information from the traditional sciences

  as well as from the new sciences.

  With such intelligence you rise in the world.

  You get ranked ahead or behind others

  in regard to your competence in retaining

  information. You stroll with this intelligence

  in and out of fields of knowledge, getting always more

  marks on your preserving tablets.

  There is another kind of tablet,

  one already completed and preserved inside you.

  A spring overflowing its springbox. A freshness

  in the center of the chest. This other intelligence

  does not turn yellow or stagnate. It’s fluid,

  and it doesn’t move from outside to inside

  through the conduits of plumbing-learning.

  This second knowing is a fountainhead

  from within you, moving out.

  —Jellaludin Rumi (1207–1273)

   translated by Coleman Barks

  The poet Rumi provides a compelling description of beginner’s mind. Rumi lived in thirteenth-century Persia, and his writings have enjoyed a well-deserved renaissance in the past few decades; his words are often amazingly timely. In an often-quoted poem,21 Rumi describes the familiar analytic kind and another kind of intelligence—a “fluid” intelligence and a “freshness” that comes from within. This other intelligence is first-person knowing, the kind of knowledge that emerges from stories rather than textbooks, from reflection rather than analysis, from immediacy rather than categorizing. The “freshness” that Rumi summons is beginner’s mind—avoiding being blinded by theories, facts, and concepts, and living a truth, not just describing it. Only eight hundred years later has cognitive science caught up with Rumi’s prescience, and now medical educators and psychologists affirm that these two approaches are necessary for good clinical judgment, being complementary and not incompatible.22

  Prior to the twentieth century, doctors commonly talked about diagnosing the person; only later did doctors talk about diagnosing diseases. In ancient Greece, and in traditional Chinese medicine, disease was seen as an ever-changing dynamic imbalance of humors.23 I am not advocating abandoning modern medicine in favor of ancient practices (although some of these too may be effective). Rather, we can learn from those older traditions in the way that they recognize that people are dynamic, their symptoms and experiences change, and their illnesses have trajectories—making the case for clinicians to ask themselves, “Is there something new or different with this patient today?”

  Unfortunately, diagnosing people in this dynamic way is not reinforced in current clinical practice. The force in medicine that drives billing is the codable diagnosis—sadly, a billing category. Until beginner’s mind is supported by the structure of health care organizations—and I believe that it can be (more on this later)—it needs to come from within, no small task.

  THE WATER JAR TEST

  Those who engage in meditation have claimed that in doing so they can promote beginner’s mind. The trick is in how to prove it. Psychologists had to find a way to observe and measure beginner’s mind, or its opposite, the tendency of the mind to be “blinded by experience,” known as the Einstellung effect—when rigid thought patterns get in the way of identifying more adaptive and creative solutions to a problem.

  A team of Israeli researchers came up with a way to measure the Einstellung effect—the Einstellung water jar test.24 Typically the water jar test is in two phases. In this experiment, volunteers were trained to solve several problems (dividing water in different ways among several jars of different sizes), each of which required the same complex formula. Then the volunteers were given a new problem, which could be solved using a much simpler approach, and were left to their own devices to figure it out. Those who had prior mindfulness practice figured out the simpler solution more readily. As a researcher, though, I wasn’t convinced. For example, the same qualities that led someone to undertake meditation practice might also be the ones that led to better performance on the test.

  The researchers then took people who had never done any contemplative practice, meditation, or attention training and divided them randomly into intervention and control groups. An eighteen-hour intervention program over seven weeks introduced five different practices—attention training (focusing on the breath), body scan, open awareness, walking meditation, and compassion meditation—plus various awareness exercises, dialogues, and home practice.25 Those in the intervention group scored better on the test, less likely to be blinded by experience and more likely to find simpler and creative solutions. They had learned to adopt a beginner’s mind.

  IN THE CLINIC

  Over the years I have developed a habit of pausing momentarily before entering any patient’s room. With my hand on the doorknob, I quietly take a breath to help me become more present in preparation for the visit—I mentally set aside everything that has happened with the patient I have just finished seeing and other events of the day so that I can be fresh and available. I let go of expectations. It takes just a second or two and invites the freshness that Rumi describes.

  I am not the only one to discover ways of achieving mindfulness-in-action. Julie Connelly, a physician colleague at the University of Virginia, writes eloquentl
y about how poetry can promote beginner’s mind.26 Rumi’s poem and other poems that invoke the same openness of mind are now on my computer’s screen saver, a reminder to balance my view of each patient, to see through an analytic lens, bringing all of my knowledge, expertise, and experience, and also to cultivate a “freshness” within.

  Reflective questions keep me on track and out of trouble. I habitually ask myself, “Is there another way to view this situation? What am I assuming that might not be true? How are prior experiences and expectations affecting how I view the situation? What would a trusted peer say?” These “opening-up” questions help me identify my cognitive rigidity and blind spots, some of which are the consequence of the expertise I worked so hard to develop. Reflective questions are not about factual recall; rather, they are questions that open up one’s awareness, raise doubts, and expose uncertainty. Anyone who works in a complex environment (and who doesn’t?) will find that questions such as these do lead to greater mindfulness. I use the same questions with students and colleagues. Although I rarely talk about it in this way to students, reflective questions promote what the educator Donald Schön called reflection-in-action;27 they take little time—a few seconds here and there—and save time in the long run. It’s a way of remembering that while I might be good at finding answers, it’s more important to know that I’m asking the right questions.

  5

  Being Present

  I delivered babies for many years as part of my family practice. At first, I found it difficult to look directly at the face of women experiencing the intensity of labor. Reflexively, I’d avert my gaze. Witnessing raw and unfiltered expressions of pain made me feel uncomfortable and inadequate. I’d busy myself with a task—check the electronic fetal monitor, talk to the patient’s partner, talk to the nurse. When I was doing something—prescribing a medication, actually helping a newborn glide into the world—I felt calm and confident. But I foundered when the situation didn’t demand action—or demanded inaction. Perhaps patients noticed, or perhaps they didn’t.