Attending

by Ronald Epstein

  4 Philosopher Michael Polanyi calls this subsidiary awareness, that which is just beneath the surface, accessible to consciousness, but which is kept tacit so that we do not stumble. A pianist, for example, if asked to constantly be aware of each finger movement, would stumble more than if those movements were maintained outside awareness. See M. Polanyi, Personal Knowledge: Towards a Post-critical Philosophy (Chicago: University of Chicago Press, 1974); and M. Polanyi, The Tacit Dimension (Gloucester, MA: Peter Smith, 1983). A related construct is pre-attentive processing, in which the brain “selects” which of many sources to attend to. See J. H. Austin, Zen and the Brain: Toward an Understanding of Meditation and Consciousness (Cambridge, MA: MIT Press, 1998). Another related construct is process knowledge, knowing how to do things, often tacit when it involves learned behaviors such as tying knots for a surgeon, riding a bicycle, playing scales for a pianist, etc., a useful construct in education. See M. Eraut, Developing Professional Knowledge and Competence (London: Falmer Press, 1994).

  5 C.-A. Moulton and R. M. Epstein, “Self-Monitoring in Surgical Practice: Slowing Down When You Should,” in Surgical Education: Theorising an Emerging Domain, ed. H. Fry and R. Kneebone (New York: Springer, 2011), chap. 10, 169–82; and 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.

  6 In all fairness, I don’t know whether Mehta was curious or not. Perhaps he was, in which case it was an internal experience that he didn’t share. Reich’s curiosity was visible.

  7 I am grateful to Randy Huntsberry, PhD, the professor for this course and others I took while at Wesleyan University. He had a strongly positive transformative effect on me and others.

  8 J. Kabat-Zinn, Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life (New York: Hyperion, 1994).

  9 More accurately, Nagarjuna, the second-century Buddhist philosopher, would propose a fourfold paradox—to see yourself as fallible, to see yourself as infallible, to see yourself as both fallible and infallible, and finally to see yourself as neither fallible nor infallible. See F. J. Streng, Emptiness: A Study in Religious Meaning (Nashville, TN: Abingdon Press, 1967).

  10 G. L. Engel, “The Need for a New Medical Model: A Challenge for Biomedicine,” Science 196(4286) (1977): 129–36.

  11 G. L. Engel, “The Clinical Application of the Biopsychosocial Model,” American Journal of Psychiatry 137(5) (1980): 535–44; and G. L. Engel, “From Biomedical to Biopsychosocial: Being Scientific in the Human Domain,” Psychosomatics 38(6) (1997): 521–28.

  12 In the 1950s, British psychiatrist Michael Balint pioneered a group format in which general practitioners would discuss difficult cases. Through deep inquiry, Balint would help the GPs uncover otherwise hidden emotional reactions to patients that could affect the care they provided their patients—positively and negatively. He firmly believed that the person of the physician was as important a therapeutic agent as the drugs physicians could prescribe. See M. Balint, The Doctor, His Patient, and the Illness (New York: International Universities Press, 1957); I. R. McWhinney, “Fifty Years On: The Legacy of Michael Balint,” British Journal of General Practice 49 (1999): 418–19; and L. Scheingold, “Balint Work in England: Lessons for American Family Medicine,” Journal of Family Practice 26(3) (1988): 315–20.

  13 Family-of-origin groups explore the influences of one’s own family—history, values, beliefs, use of language, degree of cohesion, etc.—on one’s clinical work. See S. H. McDaniel, T. L. Campbell, and D. B. Seaburn, Family-Oriented Primary Care: A Manual for Medical Providers (New York: Springer-Verlag, 1990); R. M. Epstein, “Physician Know Thy Family: Looking at One’s Family of Origin as a Method of Physician Self-Awareness,” Medical Encounter 8(1) (1991): 9; S. H. McDaniel and J. Landau-Stanton, “Family-of-Origin Work and Family Therapy Skills Training: Both-And,” Family Process 30(4) (1991): 459–71; and M. Mengel, “Physician Ineffectiveness due to Family-of-Origin Issues,” Family Systems Medicine 5(2) (1987): 176–90.

  14 Personal-awareness groups, developed by the American Academy on Communication in Health Care, are a group format for physicians to explore their inner lives and relationships, based on the work of psychologist Carl Rogers. D. H. Novack et al., “Calibrating the Physician: Personal Awareness and Effective Patient Care,” JAMA 278(6) (1997): 502–9; T. E. Quill and P. R. Williamson, “Healthy Approaches to Physician Stress,” Archives of Internal Medicine 150(9) (1990): 1857–61; and R. C. Smith et al., “Efficacy of a One-Month Training Block in Psychosocial Medicine for Residents: A Controlled Study,” Journal of General Internal Medicine 6(6) (1991): 535–43.

  15 I am grateful to David Sperber, who led a personal-awareness group for family medicine residents for thirty years, and to David Seaburn, Susan McDaniel, Pieter LeRoux, and others, who led family-of-origin reflection groups during my fellowship training.

  16 Concepts that I explored included personal knowledge, procedural knowledge, process knowledge, tacit knowledge, self-reflection, reflective practitioner, reflection-on-action, reflection-in-action, knowledge-in-action, intersubjectivity, enaction, and more, all cited in Epstein, “Mindful Practice.”

  17 Publications in the late 1990s began to focus on the interior lives of physicians and the impact of self-awareness on clinical practice. See S. L. Shapiro, G. E. Schwartz, and G. Bonner, “Effects of Mindfulness-Based Stress Reduction on Medical and Premedical Students,” Journal of Behavioral Medicine 21(6) (1998): 581–99; S. L. Shapiro and G. E. Schwartz, “Mindfulness in Medical Education: Fostering the Health of Physicians and Medical Practice,” Integrative Medicine 1(3) (1998): 93–94; R. C. Smith et al., “Teaching Self-Awareness Enhances Learning about Patient-Centered Interviewing,” Academic Medicine 74(11) (1999): 1242–48; D. H. Novack, R. M. Epstein, and R. H. Paulsen, “Toward Creating Physician-Healers: Fostering Medical Students’ Self-Awareness, Personal Growth, and Well-Being,” Academic Medicine 74(5) (1999): 516–20; D. H. Novack et al., “Personal Awareness and Professional Growth: A Proposed Curriculum,” Medical Encounter 13(3) (1997): 2–7; and Novack et al., “Calibrating the Physician.”

  18 Epstein and Hundert, “Defining and Assessing Professional Competence.”

  19 The Comprehensive Assessment program for medical students emphasizes the skills of diagnosis and treatment but also the capacity of students to reflect and be self-aware. Students continue to say that it is one of most formative parts of their medical school career, and it gives me hope that students are hungry to know themselves more deeply. See R. M. Epstein et al., “Comprehensive Assessment of Professional Competence: The Rochester Experiment,” Teaching and Learning in Medicine 16(2) (2004): 186–96.

  20 Epstein, “Mindful Practice.”

  21 M. C. Beach et al., “A Multicenter Study of Physician Mindfulness and Health Care Quality,” Annals of Family Medicine 11(5) (2013): 421–28. Beach assessed physicians’ (lack of) mindfulness using a standard mindfulness survey that included items such as “I tend to walk quickly to where I am going without paying attention to what I experience along the way” or “I find myself listening to someone with one ear, doing something else at the same time” or “I frequently forget a person’s name shortly after we meet.” Although it is odd to think that one could self-rate one’s own mindfulness, the surveys do predict what most would consider to be mindful behaviors and correlate with more experience with meditation. P. Grossman, “On Measuring Mindfulness in Psychosomatic and Psychological Research,” Journal of Psychosomatic Research 64(4) (2008): 405–8.

  22 I discovered a like-minded colleague in Rochester, Dr. Mick Krasner, and the two of us spearheaded workshops and seminars in mindful practice for physicians, residents, students, and medical educators in Rochester. These have blossomed into programs on six continents. Several foundations funded us to help make those ideas a reality. The 1999 JAMA “Mindful Practice” article has been cited in the medical literature over a tho
usand times.

  23 We published the results in JAMA in 2009 and a follow-up study in Academic Medicine in 2012. See H. B. Beckman et al., “The Impact of a Program in Mindful Communication on Primary Care Physicians,” Academic Medicine 87(6) (2012): 1–5; and M. S. Krasner et al., “Association of an Educational Program in Mindful Communication with Burnout, Empathy, and Attitudes among Primary Care Physicians,” JAMA 302(12) (2009): 1284–93.

  24 We assessed their personalities using the NEO five-factor scale, the most widely used assessment of personality. See P. T. Costa and R. R. McCrae, “NEO PI-R: Professional Manual, Revised Neo Personality Inventory (NEO PI-R), and Neo Five-Factor Inventory (NEO-FFI)” (Odessa, FL: Psychological Assessment Resources, 1992); R. R. McCrae and P. T. Costa Jr., “Personality Trait Structure as a Human Universal,” American Psychologist 52(5) (1997): 509–16.

  25 A 2014 study at the University of Pennsylvania reaffirms that physicians find their relationships with patients to be the most meaningful and rewarding aspects of their work. The researchers asked students and residents to identify physicians who exemplified humanistic patient care. These physicians reported attitudes, such as humility, and habits, such as self-reflection and mindfulness practices, that contributed to their effectiveness as healers and a reduction in burnout. See C. M. Chou, K. Kellom, and J. A. Shea, “Attitudes and Habits of Highly Humanistic Physicians,” Academic Medicine 89(9) (2014): 1252–58.

  26 See A. Verghese, “Culture Shock—Patient as Icon, Icon as Patient,” New England Journal of Medicine 359(26) (2008): 2748–51.

  27 Initially, the concepts of population health and evidence-based medicine ignored individual patients’ perspectives and needs or developed quantitative models to incorporate “values” into algorithms that would guide treatment. The limitations have fortunately been addressed in the more recent conceptualizations of evidence-based medicine, which now incorporate elements of patient-centeredness. See D. Bassler et al., “Evidence-Based Medicine Targets the Individual Patient. Part 2: Guides and Tools for Individual Decision-Making,” ACP Journal Club 149(1) (2008): 2; V. M. Montori and G. H. Guyatt, “Progress in Evidence-Based Medicine,” JAMA 300(15) (2008): 1814–16; and G. Guyatt et al., “Patients at the Center: In Our Practice, and in Our Use of Language,” ACP Journal Club 140(1) (2004): A11–A12.

  28 My personal experience has been with the Zen and the Vipassana meditation traditions. These and other contemplative practices have in common a moment-to-moment attention to one’s experience, cultivation of focus, and/or receptiveness and a nonjudgmental attitude. For some, martial arts or running or playing music serve similar ends. The important features are dedication, consistency, perseverance, and a sense of community. See chapter 11 and the appendix for more details.

  2. ATTENDING

  1 This quote is attributed to the late (and great) American baseball hero and philosopher Yogi Berra.

  2 Sadly, Emil did not do well. His oncologist assured us, though, that the outcome would have been the same even if he had been diagnosed a month earlier.

  3 This observation is now the title of a bestselling book, The Invisible Gorilla, which explores the phenomenon in all of its depth. C. Chabris and D. Simons, The Invisible Gorilla: How Our Intuitions Deceive Us (New York: Crown, 2011). For one version of this video, see http://www.youtube.com/watch?v=47LCLoidJh4.

  4 The gorilla is in the upper-right portion of the (black) lung fields. See T. Drew, M. L. Vo, and J. M. Wolfe, “The Invisible Gorilla Strikes Again: Sustained Inattentional Blindness in Expert Observers,” Psychological Science 24(9) (2013): 1848–53.

  5 I am not sure why others did not speak up. Perhaps they too did not notice, or were afraid of the surgeon’s reactions.

  6 J. S. Macdonald and N. Lavie, “Visual Perceptual Load Induces Inattentional Deafness,” Attention, Perception, and Psychophysics 73(6) (2011): 1780–89.

  7 D. Kahneman, Thinking, Fast and Slow (New York: Farrar, Straus and Giroux, 2013).

  8 I thank David Leach, formerly the head of the Accreditation Council for Graduate Medical Education, for introducing me to this Aristotelian concept in the context of medical practice and the literature that supports it. To understand better how expertise is more than just being experienced, see C. Bereiter and M. Scardamalia, Surpassing Ourselves: An Inquiry into the Nature and Implications of Expertise (Chicago: Open Court, 1993).

  9 W. Levinson, R. Gorawara-Bhat, and J. Lamb, “A Study of Patient Clues and Physician Responses in Primary Care and Surgical Settings,” JAMA 284(8) (2000): 1021–27; and A. L. Suchman et al., “A Model of Empathic Communication in the Medical Interview,” JAMA 277(8) (1997): 678–82.

  10 D. S. Morse, E. A. Edwardsen, and H. S. Gordon, “Missed Opportunities for Interval Empathy in Lung Cancer Communication,” Archives of Internal Medicine 168(17) (2008): 1853–58.

  11 More about this later in the discussion about the contribution of emotions to decision making in chapter 6.

  12 Physicians provided informed consent to participate in the study and agreed to see two “unannounced standardized patients” during the subsequent year. See 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; and D. B. Seaburn et al., “Physician Responses to Ambiguous Patient Symptoms,” Journal of General Internal Medicine 20(6) (2005): 525–30.

  13 R. M. Epstein et al., “Awkward Moments in Patient-Physician Communication about HIV Risk,” Annals of Internal Medicine 128(6) (1998): 435–42.

  14 One recent review of the influence of patient-clinician communication and relationships in clinical care is J. M. Kelley et al., “The Influence of the Patient-Clinician Relationship on Healthcare Outcomes: A Systematic Review and Meta-analysis of Randomized Controlled Trials,” PLoS ONE 9(4) (2014).

  15 R. J. Baron, “An Introduction to Medical Phenomenology: I Can’t Hear You While I’m Listening,” Annals of Internal Medicine 103(4) (1985): 606–11.

  16 Philosopher Michael Polanyi coined the term subsidiary awareness, a prerequisite for the capacity to slow down when you should; and attention in automaticity was described by surgeon Carol-Anne Moulton and physician Annie Leung. See M. Polanyi, The Tacit Dimension (Gloucester, MA: Peter Smith, 1983); and A. S. O. Leung, R. M. Epstein, and C.-A. Moulton, “The Competent Mind: Beyond Cognition,” in The Question of Competence, eds. B. D. Hodges and L. Lingard (Ithaca and London: Cornell University Press, 2012), chap. 7, 155–76.

  17 D. D. Salvucci, N. A. Taatgen, and J. P. Borst, “Toward a Unified Theory of the Multitasking Continuum: From Concurrent Performance to Task Switching, Interruption, and Resumption,” Proceedings of ACM CHI 2009 Conference on Human Factors in Computing Systems—Understanding UI 2 (2009): 1819–28.

  18 There is a large literature in education and psychology on the effects of manipulating extraneous cognitive load (that which is not related to the problem at hand) and germane cognitive load (that which is related) on problem-solving capacity. See J. Sweller, “Cognitive Load During Problem Solving: Effects on Learning,” Cognitive Science 12(2) (1988): 257–85; N. W. Mulligan, “The Role of Attention during Encoding in Implicit and Explicit Memory,” Journal of Experimental Psychology: Learning, Memory, & Cognition 21(1) (1998): 27–47; and C. Stangor and D. McMillan, “Memory for Expectancy-Congruent and Expectancy-Incongruent Information,” Psychological Bulletin 111(1) (1992): 42–61. For a more nuanced understanding of how attitude and motivation can “undo” this effect and promote recognition of inconsistent data, see J. W. Sherman, F. R. Conrey, and C. J. Groom, “Encoding Flexibility Revisited: Evidence for Enhanced Encoding of Stereotype-Inconsistent Information under Cognitive Load,” Social Cognition 22(2) (2004): 214–32.

  19 For a more detailed exploration of top-down and bottom-up attention, see M. Corbetta and G. L. Shulman, “Control of Goal-Directed and Stimulus-Driven Attention in the Brain,” Nature Reviews Neuroscience 3(3) (2002
): 201–15.

  20 Rashes are common in innocuous viral illnesses, but some kinds can signal something more serious—measles, meningitis, or severe medication reactions.

  21 For a discussion of the structure and function of the right frontoparietal network, and the importance of the right-sided lateralization, see Corbetta and Shulman, “Control of Goal-Directed.” The right-left hemispheric differences are oversimplifications often promoted by popularized neuroscience. Current research suggests there are more similarities in function than differences, yet clearly some dysfunction is localized. For example, depression is associated with overactivity of the right prefrontal cortex compared to the left; those who have had right-sided strokes tend to be oblivious of their deficits, etc.

  22 See Bereiter and Scardamalia, Surpassing Ourselves.

  23 Attending to everything important is not always possible or desirable at any given moment, especially in emergency situations.

  24 Psychologists describe “change blindness,” in which gradual or unexpected changes in an image go unrecognized. For examples of gradual change blindness, see http://www.youtube.com/watch?v=1nL5ulsWMYc.

  25 Drug warnings occur an average of sixty-three times—one every eight to ten minutes—during a typical physician’s workday. See A. L. Russ et al., “Prescribers’ Interactions with Medication Alerts at the Point of Prescribing: A Multi-method, In Situ Investigation of the Human-Computer Interaction,” International Journal of Medical Informatics 81(4) (2012): 232–43.

  26 The original source is K. Maue, Water in the Lake: Real Events for the Imagination (New York: Harper & Row, 1979). Ken Maue taught at Wesleyan University in the 1970s, and his brilliant ways of bringing awareness to the ordinary were stunning. A musician by training, his avant-garde “pieces” became gradually less concerned with sound and more about how we can experience any environment as “music.” His pieces reveal our inner lives in ways similar to those of formal contemplative practice—they sculpt our capacity for awareness.