The other day I was seeing a patient in my primary care office. A few minutes into the visit, I needed to look up a laboratory test result on the computer in order to share the results with her. Because the tests were done outside of our health care system, the search took longer. Then an error message popped up on the screen alerting me to a potential drug interaction, which I had to handle before proceeding. Eventually, I found the results and started to tell the patient, still looking at the screen. When she didn’t respond, I looked over to see that her chair was empty. She probably told me that she needed to go to the bathroom, but I just didn’t hear, and my attention was so focused on the screen that I didn’t see her leave even though she was sitting right next to me. I was talking as she walked back into the room. Realizing what happened, I was embarrassed. And, it made me wonder what I’d do if I were a patient, seeing that the doctor was looking at the screen and wasn’t really there.
Modern life places extraordinary demands on the brain and electronic media have only made the challenges more daunting. Cognitive load refers to how hard your inner operating system—your “working memory”—is working. If you’re doing a simple task, it’s not working very hard. If you’re doing a task that requires intense focus, it’s working harder. If you’re trying to do two complex tasks at the same time, you become cognitively overloaded and you ignore important details and make mistakes.
It’s safe to assume that your doctor’s cognitive load is always high and her working memory is stretched. Cumbersome electronic medical records and endless documentation requirements have added to physicians’ cognitive load, and they struggle to get back on track. They might try to simplify, and, in doing so, they miss potentially important nuances that can make all the difference. Like everyone, doctors try to compensate by multitasking. But humans are not capable of multitasking. We switch between tasks, first one, then the other. Especially if the tasks are unrelated—checking a patient’s medical record while trying to conduct a conversation; task switching doesn’t go smoothly. We don’t hear what was said, information gets lost, and we forget. Psychologists call it “interruption recovery failure.” It’s at those moments when we realize that the urban myth that we only use 10% of our brains cannot possibly be true and that we need every neuron that we have.
What should you do?
What should you do when you notice your doctor is trying to multitask, or not really listening? First, recognize that it’s not her fault—it’s the nature of medical practice. Then, make it easier for your doctor to listen. Use short sentences. Don’t repeat yourself unless she hasn’t understood. Most importantly, help the doctor focus on what’s most important. Prioritize your concerns and be willing to defer the less important ones to another visit. Sometimes, it’s best to wait a minute until you see that the doctor completes a task before introducing another. While she’s refilling your blood pressure medicine is not the time to talk about your chest pain or your depression. When she can make eye contact and is not distracted by a task that might be essential to your care is the time to start.
Some words, images, and sounds capture our attention more than others. Many of these mental “circuit breakers” are innate, such as loud noises, bared teeth, and red blood. Other attention-grabbers are learned. Doctors pay more attention to words that suggest a serious condition (chest pressure, high fever) than words that suggest less serious conditions (an itch, a runny nose), appropriately so.
Unfortunately, though, doctors, through their training, learn to ignore things that they shouldn’t, such as emotional expressions; if a patient expresses a fear or a worry, there’s only a 10% chance that the doctor will respond. Doctors also prioritize specific, localized symptoms over non-specific, global symptoms (“It hurts all over”). In short, doctors learn to favor the biological, the physical, the specific, and the concrete.
So, if you’re a patient, how can you help your doctor know that you’re worried? That you do hurt all over? Here, clarity and gentle persistence pay off. Emphasize that your concern is important. Be specific when you can, and if your concern is emotional, nonspecific, or vague, preface your statement with “I wish I could be more specific, but it’s distressing and concerning to me and I’d like to understand what’s going on.” It may be possible that there is little that can be done, but at least you’ll be more likely to get a clear answer.
Everyone daydreams. In fact, there’s a whole body of research on the merits and perils of daydreaming. Daydreaming is a manifestation of the brain’s “default mode” in which we aren’t focused on anything in particular and the brain is scanning its internal landscape and the outer landscape for dangers, opportunities, and affiliations.
As a patient, though, the default mode doesn’t do you much good; it has little to do with information coming from the outside world. Sometimes, we can tell when someone else is daydreaming—a far-off look, perhaps. That’s where refocusing comes in. If your question or concern hasn’t been addressed fully and the other person seems like he is elsewhere, gentle redirection is helpful. You might say to your doctor, “I’m not sure I understood what you’re planning to do about my elbow.” Or something else, short, specific, respectful, and that helps the doctor get back on track. Of course, as a patient, it’s not your “job” to help the doctor think, but, in reality, we all help each other think, all the time—it’s part of being social beings. It’s what I call “shared mind.”
When everybody’s distracted, no one is listening. You’d think that would result in continual disaster in medicine. Fortunately, not. Because health professionals speak a common language and have shared mental models for managing straightforward illnesses, we compensate for the lack of communication by invoking protocols.
This approach works for simple, routine, and predictable problems, but it can all fall apart when dealing with more complex situations. With the vast amounts of information available in the electronic health record, doctors frequently suffer under the illusion that there has been communication that in fact has not really occurred. It’s like drinking out of a firehose; the important messages often impossible to find. One solution might be “open notes,” doctors’ notes in the medical record that patients can see and review. Even then, sorting through your own medical records works only if you’re not critically ill and if you’re medically literate.
When you’re sick, your attention should be on your illness and not the doctor’s mental state. Here, three minds are better than two—bring a family member or a friend along who can advocate for you and be at your bedside when you’re at your most vulnerable. Case managers, guides, coaches, and navigators (if they’re available) can also help everyone focus on what’s most important.
Minding your own mind
There are many more ways in which distraction plays out in healthcare and other endeavors in which small errors can spell large consequences. As a patient, you should be mindful, too. Being mindful of your own mind—your state of attention or distraction, your cognitive load and your emotions—helps you be mindful of others’ minds, too. I believe that mindfulness is contagious. The more you can be aware of attention-grabbers, cognitive load, daydreaming, and collective distraction in your own life, no matter what you do, the more focused you can be when you’re in the doctor’s office. This awareness is also the key to good relationships and to knowing yourself better in general.