By SANJ KATYAL, MD
If you are like most doctors, you are sick of hearing about burnout. I know I am. There is a big debate on whether burnout is real or whether physicians are suffering from something more sinister like moral injury or human rights violations. That doesn’t matter. In the end, no matter what name we give the problem, the real issue is that physicians are in fact suffering. We are suffering a lot. Some of us—around one physician per day—are forced to alleviate their suffering by taking their own life. Each year, a million patients lose their physicians to suicide. Many more physicians suffer in silence and self-medicate with drugs or alcohol in order to function.
We are losing more physicians each year to early retirement or alternate careers. There are an increasing number of coaches and businesses whose single purpose is to help doctors find their side gigs and transition out of medicine. This loss comes at a time of an already depleted workforce that will contribute to massive physician shortages in the future. Perhaps even more troubling is that those physicians who remain in medicine are often desperate to get out. It is the rare physician these days that recommends a career in medicine to their own children. We now have a brain drain of the brightest students who would rather work on Wall Street than in a hospital.
As a physician trained in positive psychology, I have been committed to helping other physicians and students improve their well-being. The focus on well-being is a welcome change in medicine. But is it enough?
Many of us no longer experience the same levels of meaning and fulfillment that should be inherent to the practice of medicine. We want to spend more time with our patients but we trade presence for productivity. We crave meaningful connections with the sick but find ourselves hoping this will be their last complaint. We want to go home energized after a day of serving others but find ourselves too exhausted to play with our kids.
Physicians are among the most intelligent, hard-working and (yes) resilient people in the world. Do we really need more resilience modules to help us get through our days? We are suffering because we have lost our ability to focus on what matters most. We are suffering because we refuse to stand together in the defense of our colleagues and the ideal practice of medicine. It is time to reclaim the joy and meaning in our work and in our lives. It is time to live the kind of life we all dreamed of living when we were young. We may be suffering but we are not weak. We are strong. We are already resilient enough. It’s time that we started acting like it.
Rather than assume a passive victim role of an under-appreciated, burned out physician desperate to leave medicine, we can use our unique combination of intelligence, creativity and grit to take back control of our personal and professional lives.
So how do we do this?
Through the intentional cultivation and utilization of our most precious resource – our attention.
Attention is the new currency
I used to believe that time was our most important commodity. Financial freedom, early retirement and years of free time to travel was my goal. This common objective is shared by many others I know. What I have come to realize is that the problem in our lives is not the lack of money or time but the scarcity of our attention. We are filled with thoughts, worries, and to-do lists swirling around in our heads. We need more presence and more peace – yet we find ourselves thinking about work while playing with our kids, surfing the internet while talking to our spouse, or checking our phones at the first sign of solitude.
Most of us, myself included, spend large portions of our attention in a low quality, widely distributed manner. We are problem-solvers so we are ready to react and deal with issues as they arise each day. This is tiring, so we take much needed breaks by checking our phones or browsing the internet. We then get back to our “work” which most of the time, has built in low level tasks that further disperse our attention (EMR, charting, email). When we finally make it home, we look forward to relaxing and recharging. We want to unplug from the daily stressors but most of us never really do. We continue to check our phones, even while playing with the kids, often while watching TV, and collapse into bed exhausted, wondering where the time has gone.
We can do better. The cultivation of attention can have profound effects on both our personal and professional lives. There has been a rapid increase in overall unhappiness in physicians. Many studies have shown clear adverse links between physician well-being and cost of care, patient satisfaction scores, retention/recruitment and medical errors. Rates of anxiety, depression and suicide are higher in physicians and begin to rise in medical school. Many distressed physicians are leaving medicine early which will only exacerbate projected physician shortages. As we think about strategies to improve physician well-being, we need a comprehensive approach that addresses the root causes of suffering. It is not enough to make physicians more resilient or mindful (another popular buzzword) if they are thrown back into a negative, inefficient work environment every day. The key to this new approach is a focus on attention.
Attention Capital Theory in Medicine: The Key to Professional Fulfillment
In an information-rich world, the wealth of information means a dearth of something else: a scarcity of whatever it is that information consumes. What information consumes is rather obvious: it consumes the attention of its recipients. Hence a wealth of information creates a poverty of attention and a need to allocate that attention efficiently among the overabundance of information sources that might consume it.
—Herbert Simon (1971)
For physicians, the most meaningful aspects of medicine are the time spent using their talents to alleviate suffering. At the heart of our profession is the daily contribution of hard work, knowledge and experience that can heal someone who is hurting. These interactions are what bring us joy. They provide meaning and impact to our lives. In the end, they are the reasons we went to medical school. But they are increasingly hard to experience. They are dwindling in both frequency and duration in the current practice of medicine. These small but rewarding interactions are what I call “physician zone” and we must learn to optimize our time spent in them. What makes up this zone is unique to each specialty. For internists, family docs, emergency physicians, it may be face-to-face interactions with a patient to formulate the best treatment plan. For surgeons, it may be the key moments in an operation. For radiologists and pathologists, it may be the actual time spent viewing and interpreting the images or slides. When we are in this physician zone, we are using our highly trained skills to meet the diagnostic challenge before us. To fully experience these “peak” interactions, we should be relatively free of distractions, fully immersed in the task at hand, and connected to the suffering before us.
The path to reclaiming joy and meaning in medicine is to cultivate the ability to direct our attention on valuable activities while minimizing the rest of our tasks. When we can design environments and create habits that enable us to spend more focused time in our physician zone, we will be more productive, more connected, and more fulfilled.
Modern healthcare and the current practice of medicine is increasingly complex with advances in technology, research, regulatory/payment models and of course more complicated patients and disease processes. We are bombarded with massive amounts of information and stimuli on a daily basis. Our ability to process large amounts of data, however, has remained constant. This imbalance between higher and more complex inputs and our stable processing ability has led to increasing fatigue, error, and overall lower satisfaction among physicians.
Attention capital theory, coined by Cal Newport, states that our ability to cultivate and direct attention is our most precious resource. To better understand how to apply this approach to the daily practice of medicine, we must explore key principles from the science of attention – cognitive load theory.
According to cognitive science, new information is handled and processed through our working memory (formerly called short-term memory). This information is then stored in long-term memory and can be retrieved as needed by our working memory. All of our formal and informal education is handled in this manner. Our working memory is a high performance engine that processes both new information coming at us and retrieving old information stored in our long term memory. Working memory capacity has a higher correlation with academic success than IQ in children. Optimizing our working memory can have profound effects on the quality of our output (high productivity, low error) and more importantly on our overall well-being.
The key insight from cognitive load theory is that while our working memory is essentially unlimited in its ability to retrieve old information stored in long term memory, it has a fixed capacity to handle new information from our environment. Additionally, our working memory is highly sensitive to the complexity (cognitive load) of the information being presented. This cognitive load is comprised of intrinsic load (the inherent difficulty of a problem) and extrinsic load (the environment and the manner in which the information is presented). Think of intrinsic load as signal and the extrinsic load as noise. In order to optimize our working memory performance, we need to improve the signal/noise ratio in our work (and in our lives).
Since we cannot often change the complexity of the problem before us (patients with multiple chronic diseases, cancer follow-up CT scan with extensive abnormalities), we must focus most of our efforts on reducing noise. To simplify our efforts, we can think of noise as synonymous with distractions. These distractions can be in the form of external distractions or workflow distractions. External distractions are found in our environment and our habits. These include smartphones, email notifications, and other low value activities. Workflow distractions include the disorganized manner in which the problem is presented (EMR with key information on multiple screens) or additional tedious steps that we are required to perform to complete the main task (data entry during patient encounter). As we often encounter both types of distractions throughout our daily work, we can face exponentially increased levels of noise. In either case, the cognitive price we pay to handle these distractions is through decreased performance (of our working memory).
We need strategies to help us focus our limited working memory on the intrinsic cognitive load rather than waste part of it to address extraneous loads (distractions). In medicine, that means focusing our attention on the critical moments and interactions each day that bring us the most satisfaction and meaning. In order to do this with the most concentration, the most presence, and the most connection, we need to eliminate anything that seeps away any of our precious attention or limited working memory. Anything that is not related to the actual problem we are trying to solve—the patient we are trying to heal, the study that we are trying to interpret, the operation we are trying to perform—is all wasted effort that leads to error, fatigue and diminished performance. Ultimately, it leads to a loss of meaning and joy in our profession.
How to focus: Improve S/N
Increase Intrinsic Cognitive Load (Signal):
The cultivation of attention (improved working memory performance) can actually be made easier by increasing the difficulty of our work (increased signal). When the challenge of what we are doing matches our skill, it is easier to become engaged. Increased engagement has been correlated with higher levels of productivity, quality and well-being. Too little difficulty for our skill level (think EMR clicks, pre-authorization paperwork, or self-editing reports/charts) causes fatigue and boredom. This is often relieved by seeking out distractions. When our work is above our skill level (under-prepared for a lecture), we become anxious and overwhelmed—both of which are also relieved by distractions.
The degree of difficulty of our professional work is especially relevant to the current practice of medicine. In a 1992 study Survey finds Low Office Productivity linked to Staffing Imbalances, economist Peter Sassone found that technological advances allowed tasks previously done by humans to be completed with computers. The elimination of clerical positions resulted in short term economic improvement for the companies through lower overall staffing costs. What he found was that executives were now spending a larger percentage of their time on tasks that used to be completed by lower level employees. He believed that productivity enhancing computer systems were largely responsible for the shift to lower complexity work. These systems replaced some support staff and made clerical work available to everyone in the office. The decrease in the amount of time spent on high value, complex work resulted in an overall less efficient, higher cost, and lower productivity work environment. It also led to lower rates of engagement, higher rates of fatigue, and lower professional fulfillment. Sound familiar? This exact same phenomenon, the law of diminishing specialization, is occurring in health care. Voice recognition systems have replaced entire transcription departments of hospitals resulting in radiologists and cardiologists self-editing their reports. Now instead of focusing eyes on the image screen, most function as high price bobble-heads going back and forth between images and their VR screen. This has led to nonsensical errors, decreased “eyes on image” time, and lower productivity. We have shifted the cost of transcription from relatively low cost FTEs to some of the highest paid FTEs in the hospital. Other specialties have encountered similar results with the “death by a thousand clicks” of electronic medical records (EMR). These EMR systems, really designed for billing purposes, have automated the much of the clerical order entry that was previously performed by support staff. The remaining “automated” work is now largely performed by physicians. The underlying theme in the practice of medicine is that physicians are increasingly performing tasks that are well below their skill level. While the reduction in support staff may save a small amount of money, the corresponding decrease in “intellectual specialization” as Sasson reported, is actually more expensive in terms of productivity, quality, and well-being of physicians.
Decrease Extraneous Cognitive Load (Noise): Workflow distractions and low level tasks
So what is the solution? On a professional level, we can focus our attention to do the things that only we can do. I call this the “physician zone” and it may be the most important contributor to physician well-being. For the internist or ED physician, this may mean having a scribe in the room to take notes in the EMR so there can be direct face-to-face communication with the patient during the examination. This face-to-face interaction is the physician zone – most of the other tasks that physicians perform mainly support ancillary functions required to get paid. Currently, many of these tasks are sprinkled throughout the physician zone time, in between these critical interactions or added on to the end of the day (charting). For the radiologist, this may mean offloading tasks in the reading process to editors to be able to stay in the interpretive zone (radiologist version of the physician zone).
There is another reason to focus our attention on the key aspects of the physician zone that utilize our highly trained skill set. According to cognitive load theory and split-attention effect, distributing our attention between different information sources and trying to mentally integrate them produces extra load on our working memory. Splitting our attention between the patient and the EMR or between the voice recognition screen and the images increases the extraneous cognitive load which in turn increases fatigue and lowers performance. Multiple studies have shown that when physicians are able to optimize their physician zone time through more focused attention and delegation of clerical tasks, they are more productive, more accurate, and happier.
By redesigning our physician workflow, we can focus our attention on the critical steps that only we are trained to do. This does not imply that physicians should refuse to do things that are “beneath” them. For many of us, the most satisfying interactions of the day come from non-interpretive tasks when we leave our chairs or office. The way to maximize these rewarding interactions is to increase their frequency and our ability to be fully present. This can only occur if our workflow is efficient and does not require us to do tasks that will increase fatigue and stress. We can then function at the top of our licensure, better focused to perform our specific high value work while in our physician zone – so that we have more time and attention to have lunch with our technologists, a cup of coffee in the physician lounge or a few extra minutes (fully present) with an anxious patient.
Decrease Extraneous Cognitive Load (Noise): External Distractions and the Power of Rules
We have discussed how to improve intrinsic cognitive load (signal) by focusing our attention on meaningful work that requires our highly trained skill set and decreasing extraneous load (noise) by delegating low level tasks to eliminate workflow distractions. Another significant contributor to poor S/N and lower performance of our working memory capacity are external distractions, mainly found in our pockets.
Our minds are biologically wired to focus on anything that is threatening, pleasurable or novel. Many of the distractions found on our phones combine all three aspects and can be very difficult for us to resist. It is estimated that we spend less than 20% of our time actually present in each moment. While this has always been a difficult problem, the issue has become significantly worse with the advent of smartphones. Large social media conglomerates have hijacked our attention using behavioral psychology and addiction principles for their own profit. There will eventually be a backlash against these apps, ironically with more apps designed to keep us free of distraction and help us focus our attention. In the meantime, we can incorporate some simple strategies that can allow us to be more intentionally present and engaged in each moment.
The first place to start is to turn off all notifications except text messages – no sounds or messages on our lock screen or computers. The next step is to leave your phone in your office or backpack during the workday. Check it only after working in short sprints of 60-90 minutes. Another effective strategy is to leave your phone in a central place while at home (charging drawer) rather than in your pocket. Put it in airplane mode at least an hour before bed. No phones at the dinner table or at restaurants. All of these strategies are even more important to teach our kids because these digital natives do not know a world without their phones; we need to model the correct behavior for them. For kids, some common rules could be to leave phone in another room while studying (also in short sprints). While driving kids to activities, do not allow phone use in the car. This can be a time for conversation and may be the only uninterrupted time you have with them that day. Set daily limits for yourself and for your kids. Have a rule of how much social media time can be consumed each day. Don’t check your email for the first two hours of every day and only after you have completed an important task (exercise, meditate, creative work etc). There is an entire new field called digital well-being with a host of strategies to help us control these intentionally addictive devices. None of these rules or constraints will make you popular among your kids (trust me) but here is the underlying key principle: constraints create freedom and attention. By limiting our choices at each moment and not habitually turning to our phones at every chance, we are actually free to choose what to focus on with more attention and with more presence. This increased presence enables us to really connect with our patients, our kids, our spouse, and most importantly, with ourselves.
Attention to time
It is easy and tempting to blame all of the busyness and discontent many of us feel on distractions and excessive phone use (especially among our kids). While certainly a large contributor, distractions (phones) are not the entire problem. There have always been and always will be tempting forms of distractions that we can turn to (although perhaps not as intentionally addictive). The root of the problem is understanding the reason we seek distraction in the first place? It is usually to relieve some inner discomfort that we feel. Learning to identify this initial uncomfortable trigger is the key. So why do I feel like checking my email again or looking at my phone in the car? What is happening inside that I turn to this behavior – am I bored? Am I afraid of missing something important? Am I tired of being alone with my thoughts? The answer is usually habit and boredom.
Remember how time seemed to be endless when we were children? Summers lasted forever and years felt like decades. As we get older, time seems to fly by faster each year. The days seem like minutes and years seem like days. What is happening? Time is still the same for all of us. Our ability to pay attention to our time is the main thing that has changed. When we were young, everything was new and captivated our attention. We were fully present as we learned about ourselves and the world around us. As we got older, however, we settled into comfortable routines and mental models of life. The simple wonders of each moment were no longer enough to hold our attention. Play was replaced by work, close conversations with friends were replaced by quick texts and each day started to feel the same. There was not much new to learn or experience in our daily routines so we began looking forward to the weekend, our next vacation or even retirement. This only served to speed up time even more. Many of us are bored with our lives. We seek adventure and new experiences, even if only found on our phones. We can do better. We can slow time down while also fully experiencing the joy and wonder in each day.
The solution to boredom and routine is to cultivate attention, constraints and novelty about everything we do. If we can really pay attention to what we are doing (and we do this by imposing some constraints that force us to focus), we can find new things about the task, different ways to do things, and notice something we never noticed before. This provides novelty which in turn infuses a sense of wonder/fun into our lives. Playing catch again with my son? How can I throw the ball even harder or ask different questions to have a deeper conversation while catching? Reading another 100 cases today? Can I identify a subtle finding that explains the patient’s symptoms? Can I read the imaging study like it was my mom’s scan? Can I be thankful that I am able to read a complicated CT and think back to my training when things like this seemed so hard? Seeing my 30th patient in a ten minute slot? Can I treat this patient like I would my close friend? What suffering of theirs can I alleviate? Feel stuck in my career? What skills can I acquire to help solve important problems in the world? By increasing and focusing our attention to questions that matter, we can notice and appreciate the new in the old, the good in the mundane, and the minutes as they are passing by.
Pay attention to each other!
One other area in our professional life that demands our focused attention is the physician-physician relationship. Throughout our lives, we have grown up in a competitive culture that pits us against each other. Moreover, we have become accustomed to this “lone wolf” culture as a normal way of life. We hide our insecurity and vulnerability so we can maintain our edge. We bury our emotions and self-medicate to hide the pain. This approach has not served us well in training and continues to sabotage our attempts to practice medicine. Even worse, our lack of cohesiveness and collegiality has been exploited by hospital administrators and insurance executives profiting from our labor. To them, we are a fragmented, overpaid and whiny group who must be “taught” how to run the business of healthcare. It gets even worse. Physicians in general are reluctant to discuss mental health issues and are fearful (rightly so) of licensure/credentialing restrictions. Many feel that non-physician mental health professionals don’t “get what they are going through.” As physicians, now more than ever, we desperately need to do a better job of supporting each other. While a confidential formalized peer support for physicians by physicians is finally in place, we all have an opportunity each day to help our fellow colleagues. Rather than grinding through the workday, racing to retirement or our side gigs, we need to turn our attention to the suffering around us – in our patients, colleagues, and ourselves. It starts with simple acts of attention. After discussing a case with a colleague, ask them how they are doing? How are things at home? What sports are their kids playing and do they get to the games? Working with a troubled physician who appears to be struggling? Spend some regular time with them and encourage them to seek confidential professional help. Let them know that they are not alone. Ultimately, these are the moments in life that matter and we must learn to pay more attention to them.
Learning how to pay attention to our attention (meta-attention) can be transformative. Using principles from cognitive science, we can create a comprehensive approach (attention capital theory in medicine) to reclaim the meaning and joy that has been depleted from our profession. Increasing the difficulty of our work to match our skill level, delegating low-level tasks to help us focus on critical steps in our physician zone, creating rules to eliminate distractions, and noticing both the wonder and suffering around us may be more important than resilience training or wellness modules. Although well-intentioned, the majority of these solutions are band-aids and do not address the underlying root cause: our increasing inability to pay attention to what matters in life. Optimizing our ability to focus, perform meaningful deep work, and be fully present along the way are the keys to reclaim joy and meaning in our personal and professional lives. Instead of paving the way out for unhappy physicians, we can create a stable platform that attracts the best and brightest into the field, enables doctors to stand tall, thrive personally and professionally, and ultimately heal the world. It all starts with our attention.