Attending

A few separate passages I’ve combined from Dr. Ronald Epstein’s Attending: Medicine, Mindfulness, and Humanity:

Altogether, I saw too much harshness, mindlessness, and inhumanity. Medical school was dominated by facts, pathways, and mechanisms; residency was about learning to diagnose, treat, and do procedures, framed by a pit-of-the-stomach dread that you might kill someone by missing something or not knowing enough.

Good doctors need to be self-aware to practice at their best; self-awareness needs to be in the moment, not just Monday-morning quarterbacking; and no one had a road map.

The great physician-teacher William Osler once said, “We miss more by not seeing than by not knowing.”

The fast pace of clinical practice—accelerated by electronic records—requires juggling multiple tasks seemingly simultaneously. Although commonly thought of as multitasking, multitasking is a misnomer—we actually alternate among tasks. Each time we switch tasks we need time to recover and, during the recovery period, we are less effective. Psychologists call this interruption recovery failure, which sounds a bit like those computer error messages we all dread. We increasingly feel as if we are victims of distractions rather than in control of them.

Outside of the OR (and not always even then), it’s rare to find an environment that promotes the space for deep focus and self-awareness. Mindfulness, insofar as a daily approach to medical practice, is something that goes against the grain of one’s surroundings.

Good doctors need to be self-aware to practice at their best; self-awareness needs to be in the moment, not just Monday-morning quarterbacking.

I like that. Medicine is generally ripe for Monday-morning quarterbacking (and radiology in particular due to the permanent, accessible, and objective nature of the imaging record).

But doctors don’t work in vacuums. We are humans.

Consider for a moment the discipline of human factors engineering:

Human factors engineering is the discipline that attempts to identify and address these issues. It is the discipline that takes into account human strengths and limitations in the design of interactive systems that involve people, tools and technology, and work environments to ensure safety, effectiveness, and ease of use. A human factors engineer examines a particular activity in terms of its component tasks, and then assesses the physical demands, skill demands, mental workload, team dynamics, aspects of the work environment (e.g., adequate lighting, limited noise, or other distractions), and device design required to complete the task optimally. In essence, human factors engineering focuses on how systems work in actual practice, with real—and fallible—human beings at the controls, and attempts to design systems that optimize safety and minimize the risk of error in complex environments.

(I first found that passage plagiarized on page 8 of the American Board of Radiology’s Non-interpretive Skills Guide.)

Despite the rise of checklists and evidence-based medicine, humans have been almost designed out of healthcare entirely. Rarely is anything in the system–from the overburdened schedules, administrative tasks, constant messaging, system-wide emails, the cluttered EMR, or the byzantine billing/coding game–designed to help humans take the time and mental space to sit in front of a patient (or an imaging study, for that matter) and fully be, in that moment, a doctor.