27 The idea of immaculate perception is hardly original. The concept had its origins in both Western and Buddhist philosophy, later to be confirmed with empirical studies. Buddhist philosophy emphasizes both the emptiness of all things including perceptions, and that through meditation one can strip away meaning, judgment, and bias, permitting us to see the world as it is. See F. J. Streng, Emptiness: A Study in Religious Meaning (Nashville, TN: Abingdon Press, 1967). Francis Bacon (1605) asserted that immaculate perception was necessary to see the world as it is, “keeping the eye steadily fixed upon the facts of nature and so receiving the images simply as they are.” Nietzsche, in Thus Spake Zarathustra, refuted that this would be possible, given that we have desires and wishes that will color our perceptions. Author Anaïs Nin reflected this sentiment in her oft-quoted passage on how we “do not see things as they are, we see them as we are.” See A. Nin, The Diary of Anaïs Nin, 1939–1944 (New York: Harcourt, Brace & World, 1969). The lack of immaculate perception has repeatedly been established in social psychology using studies of implicit (unconscious) bias and stereotyping, as noted in T. D. Wilson, Strangers to Ourselves: Discovering the Adaptive Unconscious (Cambridge, MA: Belknap Press of Harvard Universtiy Press, 2002). In medicine, these biases have been shown to influence clinical decisions. See A. R. Green et al., “Implicit Bias among Physicians and Its Prediction of Thrombolysis Decisions for Black and White Patients,” Journal of General Internal Medicine 22(9) (2007): 1231–38. A TEDx Talk by Jerry Kang exhibits this principle clearly: http://thesituationist.wordpress.com/2014/02/01/immaculate-perception. In this book, I propose that it is possible, through self-awareness, to access some of these processes that are normally below the level of awareness.
28 Scripts are internalized mental stories based on prototypical clinical scenarios—often learned during training. See B. Charlin et al., “Scripts and Clinical Reasoning,” Medical Education 41(12) (2007): 1178–84.
29 Patrick Croskerry, a Canadian emergency-medicine physician, describes “cognitive dispositions to respond,” intrinsic biases that affect clinical decision making. They are described well in J. E. Groopman, How Doctors Think (New York: Houghton Mifflin, 2007). Croskerry outlines dozens of sources of bias, stereotyping, and misapplied heuristics in a series of articles over the past fifteen years, from misplaced attribution, overconfidence, and premature closure. Most of these processes are below the level of awareness. For further reading, see P. Croskerry and G. Norman, “Overconfidence in Clinical Decision Making,” American Journal of Medicine 121(5) (2008): S24–S29; P. Croskerry and G. R. Nimmo, “Better Clinical Decision Making and Reducing Diagnostic Error,” Journal of the Royal College of Physicians of Edinburgh 41(2) (2011): 155–62; P. Croskerry, A. A. Abbass, and A. W. Wu, “How Doctors Feel: Affective Issues in Patients’ Safety,” Lancet 372(9645) (2008): 1205–6; P. Croskerry, “The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them,” Academic Medicine 78(8) (2003): 775–80; P. Croskerry, “Clinical Cognition and Diagnostic Error: Applications of a Dual Process Model of Reasoning,” Advances in Health Sciences Education 14(1) (2009): 27–35; and P. Croskerry, “From Mindless to Mindful Practice—Cognitive Bias and Clinical Decision Making,” New England Journal of Medicine 368(26) (2013): 2445–48.
30 A series of laboratory experiments confirming these observations were done by Mohanty’s lab. See A. Mohanty et al., “Search for a Threatening Target Triggers Limbic Guidance of Spatial Attention,” Journal of Neuorscience 29(34) (2009): 10563–72; and A. Mohanty and T. J. Sussman, “Top-Down Modulation of Attention by Emotion,” Frontiers in Human Neuroscience 7 (2013): 102.
31 Stereotyping in medicine clearly goes beyond individual patient behaviors and includes race, ethnicity, gender, sexual orientation, habits, obesity, lifestyle choices, and diseases, which I’ll discuss in greater detail later in the book.
32 The dermatologist Neil Prose describes a similar situation, in which a patient’s psychological distress was only apparent after he looked deeper than her skin. See N. Prose, “Paying Attention,” JAMA 283(21) (2000): 2763.
33 Carol-Anne Moulton calls this quality “attention in automaticity.” See C.-A. Moulton et al., “Slowing Down When You Should: A New Model of Expert Judgment,” Academic Medicine RIME: Proceedings of the Forty-Sixth Annual Conference 82(10) (2007): S109–S116.
3. CURIOSITY
1 Some of the content of this chapter is drawn from an article I wrote with Larry Dyche: L. Dyche and R. M. Epstein, “Curiosity and Medical Education,” Medical Education 45(7) (2011): 663–68. Also see D. E. Berlyne, “Novelty and Curiosity as Determinants of Exploratory Behaviour,” British Journal of Psychiatry 41(1–2) (1950): 68–80.
2 From Erich Leowy, quoted in F. T. Fitzgerald, “Curiosity,” Annals of Internal Medicine 130(1) (1999): 70–72.
3 Here I’m referring to the five-factor model of personality. See R. R. McCrae et al., “Nature over Nurture: Temperament, Personality, and Life Span Development,” Journal of Personality and Social Psychology 78(1) (2000): 173–86.
4 Uncertainty in medicine and physicians’ reactions to uncertainty have been explored in depth since Renee Fox’s seminal 1959 book. Here is a selection of perspectives, but space does not allow inclusion of a comprehensive set of references: R. Fox, Experiment Perilous: Physicians and Patients Facing the Unknown (Glencoe, IL: Free Press, 1959); J. P. Kassirer, “Our Stubborn Quest for Diagnostic Certainty: A Cause of Excessive Testing,” New England Journal of Medicine 320(22) (1989): 1489–91; F. Borrell-Carrió and R. M. Epstein, “Preventing Errors in Clinical Practice: A Call for Self-Awareness,” Annals of Family Medicine 2(4) (2004): 310–16; G. Gillett, “Clinical Medicine and the Quest for Certainty,” Social Science & Medicine 58(4) (2004): 727–38; K. G. Volz and G. Gigerenzer, “Cognitive Processes in Decisions under Risk Are Not the Same as in Decisions under Uncertainty,” Frontiers in Decision Neuroscience 6(105) (2012): 1–6; R. M. Epstein, B. S. Alper, and T. E. Quill, “Communicating Evidence for Participatory Decision Making,” JAMA 291(19) (2004): 2359–66; R. M. Epstein et al., “ ‘Could This Be Something Serious?’ Reassurance, Uncertainty, and Empathy in Response to Patients’ Expressions of Worry,” Journal of General Internal Medicine 22(12) (2007): 1731–39; M. S. Gerrity, R. F. DeVellis, and J. A. Earp, “Physicians’ Reactions to Uncertainty in Patient Care: A New Measure and New Insights,” Medical Care 28(8) (1990): 724–36; G. H. Gordon, S. K. Joos, and J. Byrne, “Physician Expressions of Uncertainty during Patient Encounters,” Patient Education & Counseling 40(1) (2000): 59–65; C. G. Johnson et al., “Does Physician Uncertainty Affect Patient Satisfaction?,” Journal of General Internal Medicine 3(2) (1988): 144–49; and J. Ogden et al., “Doctors’ Expressions of Uncertainty and Patient Confidence,” Patient Education & Counseling 48(2) (2002): 171–76.
5 Fitzgerald, “Curiosity.”
6 In 1912 the Titanic hit an iceberg on its maiden voyage, killing the majority of those on board.
7 Just out of curiosity, I checked my own medical chart. There were thirty problems listed, most of which had resolved decades ago. Only two were actually relevant to my current health.
8 E. Baumgarten, “Curiosity as a Moral Virtue,” International Journal of Applied Philosophy 15(2) (2001): 23–42; J. Halpern, From Detached Concern to Empathy: Humanizing Medical Practice (Oxford: Oxford University Press, 2001); Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century (Washington, DC: National Academies Press, 2001); R. M. Epstein et al., “Measuring Patient-Centered Communication in Patient-Physician Consultations: Theoretical and Practical Issues,” Social Science & Medicine 61(7) (2005): 1516–28; and C. M. Chou, K. Kellom, and J. A. Shea, “Attitudes and Habits of Highly Humanistic Physicians,” Academic Medicine 89(9) (2014): 1252–58.
9 See M. Polanyi, “Knowing and Being, the Logic of Tacit Inference,” in Knowing and Being: Essays by Michael Polanyi, ed. M. Grene (Chicago: University of Chicago Press, 1969), chaps. 9 and 10, 123–58; and
M. Polanyi, Personal Knowledge: Towards a Post-critical Philosophy (Chicago: University of Chicago Press, 1974).
10 V. F. Reyna, “A Theory of Medical Decision Making and Health: Fuzzy Trace Theory,” Medical Decision Making 28(6) (2008): 850–65.
11 For interesting discussions about informed intuition in expert practice, see M. C. Price, “Intuitive Decisions on the Fringes of Consciousness: Are They Conscious and Does It Matter?,” Judgment and Decision Making 3(1) (2008): 28–41; V. F. Reyna and F. J. Lloyd, “Physician Decision Making and Cardiac Risk: Effects of Knowledge, Risk Perception, Risk Tolerance, and Fuzzy Processing,” Journal of Experimental Psychology: Applied 12(3) (2006): 179; and D. Kahneman and G. Klein, “Conditions for Intuitive Expertise: A Failure to Disagree,” American Psychologist 64(6) (2009): 515–26.
12 The body scan can be done lying down or sitting, or even standing. The instructions are simple, and guided body scans are readily available on the Web if you want to try it yourself. An audio-recorded guided body scan can be accessed at http://www.urmc.rochester.edu/family-medicine/mindful-practice/curricula-materials/audios.aspx.
13 Thanks to Laura Hogan for this story.
14 E. J. Langer, The Power of Mindful Learning (Reading, MA: Perseus Books, 1997); and G. C. Spivak, L. E. Lyons, and C. G. Franklin, “ ‘On the Cusp of the Personal and the Impersonal’: An Interview with Gayatri Chakravorty Spivak,” Biography 27(1) (2004): 203–21.
15 More about doubt and uncertainty in chapters 4 and 6.
16 J. Greenberg and N. Meiran, “Is Mindfulness Meditation Associated with ‘Feeling Less’?,” Mindfulness 5(5) (2014): 471–76.
17 C. R. Horowitz et al., “What Do Doctors Find Meaningful about Their Work?,” Annals of Internal Medicine 138(9) (2003): 772–75.
18 See T. B. Kashdan et al., “Curiosity Enhances the Role of Mindfulness in Reducing Defensive Responses to Existential Threat,” Personality and Individual Differences 50(8) (2011): 1227–32; and C. P. Niemiec et al., “Being Present in the Face of Existential Threat: The Role of Trait Mindfulness in Reducing Defensive Responses to Mortality Salience,” Journal of Personality and Social Psychology 99(2) (2010): 344–65.
19 C. Kidd and B. Y. Hayden, “The Psychology and Neuroscience of Curiosity,” Neuron 88(3) (2015): 449–60.
20 J. Gottlieb et al., “Information-Seeking, Curiosity, and Attention: Computational and Neural Mechanisms,” Trends in Cognitive Sciences 17(11) (2013): 585–93.
21 Dopamine drives exploration behaviors in humans and animals and also affects memory and intelligence. In the prefrontal cortex, which processes executive decision making, impulse control, and other cognitive processes, one particular dopamine receptor is strongly expressed, the D4 receptor. Catechol-O-methyltransferase is an enzyme that breaks down dopamine and other neurotransmitters and is also active in the prefrontal cortex. Thus, the current model is that both genes for dopamine D4 receptor and COMT may affect curiosity. R. P. Ebstein et al., “Dopamine D4 Receptor (D4DR) Exon III Polymorphism Associated with the Human Personality Trait of Novelty Seeking,” Nature Genetics 12(1) (1996): 78–80; and C. G. DeYoung et al., “Sources of Cognitive Exploration: Genetic Variation in the Prefrontal Dopamine System Predicts Openness/Intellect,” Journal of Research in Personality 45(4) (2011): 364–71.
22 Here, and everywhere in this book, I apologize for the oversimplifications of complex multidimensional biological processes with complex control mechanisms that have been coalesced into pathways for heuristic value, but diminish the marvel of their interconnections. In particular, social epigenetics is in its infancy as an area of scientific pursuit, and while the basic principles—that the social environment affects gene expression—will prove enduring, the details of how this happens will undoubtedly undergo radical revisions.
23 Dyche and Epstein, “Curiosity and Medical Education”; and L. K. Michaelson, A. B. Knight, and D. Flink, Team-Based Learning: A Transformative Use of Small Groups (New York: Praeger Publishing, 2002).
24 P. Fonagy et al., Affect Regulation, Mentalization, and the Development of Self (New York: Other Press, 2002); and D. W. Winnicott, The Maturational Processes and the Facilitating Environment (Madison, CT: International Universities Press, 1965).
25 E. J. Langer, Mindfulness (Reading, MA: Addison-Wesley, 1989); Langer, Power of Mindful Learning; D. A. Schon, The Reflective Practitioner (New York: Basic Books, 1983); N. H. Leonard and M. Harvey, “Curiosity, Mindfulness and Learning Style in the Acquisition of Knowledge by Individuals/Organisations,” International Journal of Learning and Intellectual Capital 4(3) (2007): 294–314; J. P. Fry, “Interactive Relationship between Inquisitiveness and Student Control of Instruction,” Journal of Educational Psychology 68(5) (1972): 459–65; and B. Roman and J. Kay, “Fostering Curiosity: Using the Educator-Learner Relationship to Promote a Facilitative Learning Environment,” Psychiatry: Interpersonal and Biological Processes 70(3) (2007): 205–8.
26 Strong attachment to friends and family during adulthood influences curiosity and exploration in the work environment. Those whose work environments are unsupportive, though, are forced to derive support exclusively from their relationships with family and friends. However, family and friends quickly tire of medical talk and the difficult situations that doctors face. See A. J. Elliot and H. T. Reis, “Attachment and Exploration in Adulthood,” Journal of Personality and Social Psychology 85(2) (2003): 317–31.
27 E. R. Kandel, “A New Intellectual Framework for Psychiatry,” American Journal of Psychiatry 155(4) (1998): 457–69.
4. BEGINNER’S MIND
1 S. Suzuki, Zen Mind, Beginner’s Mind (New York: Weatherhill, 1980).
2 Suzuki Roshi died three years before I arrived in San Francisco, yet his teachings about beginner’s mind were and remain guideposts of practice at the center.
3 Stewart and Hubert Dreyfus observed chess players and professionals in a variety of fields to understand how experts get that way. They developed a model of a hierarchy from novice, advanced beginner, competent, proficient, and expert, only later adding a level for master. See H. L. Dreyfus, On the Internet (Thinking in Action) (New York: Routledge, 2001).
4 C. G. Shields et al., “Pain Assessment: The Roles of Physician Certainty and Curiosity,” Health Communication 28(7) (2013): 740–46.
5 M. Hojat et al., “The Devil Is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School,” Academic Medicine 84(9) (2009): 1182–91.
6 A series of neuroimaging studies conducted by a research group in Taiwan provides some clues as to how this happens. The researchers prepared a set of brief videos in which one set of actors was touched by Q-tips and another set underwent acupuncture. They showed the videos to doctors who practice acupuncture. The control group was nonclinicians, matched for age and educational level. The brain activity of both doctors and nonclinicians was monitored using a variety of functional neuroimaging techniques (initially MRI scanning, with follow-up studies using magnetoencephalography and electroencephalography) to demonstrate how doctors’ expertise modulates how they perceive the pain of others. Among nonexperts, witnessing a patient undergoing acupuncture (as compared to being touched by a Q-tip) produced responses in the sensory and emotion-processing parts of the brain, reflecting some degree of emotional resonance and empathy. However, among physician-acupuncturists, those areas were deactivated, and instead, other areas of the brain were activated—particularly those involved in regulating emotions and a cognitive understanding of (but not emotional resonance with) the patient’s experience (so-called theory of mind); their growing expertise leads them to see the world differently. This ability—to regulate emotions and categorize illness into disease categories—is fundamental to good care. Yet, there is an unnecessary imbalance, and it doesn’t have to be that way—we can have both technical expertise and human understanding. See J. Decety, C. Y. Yang, and Y. Cheng, “Physicians Down-Regulate Their Pain Empathy Response: An Event-Related Brain Potential Study,” NeuroImage 50(4) (2
010): 1676–82; and Y. Cheng et al., “The Perception of Pain in Others Suppresses Somatosensory Oscillations: A Magnetoencephalography Study,” NeuroImage 40(4) (2008): 1833–40.
7 P. Goldberg, The Intuitive Edge: Understanding and Developing Intuition (Los Angeles: J. P. Tarcher, 1983).
8 Karl Ditters von Dittersdorf was a well-respected eighteenth-century composer, whose music is faultless but clearly without the inspiration of Haydn, Mozart, or Bach.
9 P. Croskerry, “From Mindless to Mindful Practice—Cognitive Bias and Clinical Decision Making,” New England Journal of Medicine 368(26) (2013): 2445–48.
10 The source is F. S. Fitzgerald, “The Crack Up,” in The Crack Up, ed. E. Wilson (New York: New Directions, 1945). However, the idea is not new. The poet John Keats considered creativity to spring from the rejection of constraining philosophies and absolute truths and the seeking of mystery and doubt. Keats influenced pragmatist philosophers such as John Dewey, and perhaps also Fitzgerald.
11 While this quote has been attributed to Einstein, the source has never been found and many others have made similar observations.
12 This Zen story is quoted in many sources, originally from a Zen classic now in translation as K. Yamada, The Gateless Gate: The Classic Book of Zen Koans (New York: Simon & Schuster, 2005).
13 From a talk by G. Fronsdal, “Not-Knowing,” http://www.insightmeditationcenter.org/books-articles/articles/not-knowing.
14 L. Festinger, “Cognitive Dissonance,” Scientific American 207(4) (1962): 93–107.
15 The many ways in which physicians can deceive themselves during diagnoses is explored in J. E. Groopman, How Doctors Think (New York: Houghton Mifflin, 2007).
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