Vigilant Awareness

In hospitals, clinicians constantly encounter conflicting and ambiguous information,” says Ronald M. Epstein, MD, professor of family medicine, psychiatry, and oncology at the University of Rochester Medical Center (URMC) N.Y. “This information often gets processed tacitly, outside of awareness, and often results in various undesired consequences. For example, premature closure of diagnostic thinking or ordering a test rather than inquiring further of the patient.” In the average hospital, distractions and sensory inputs, including smells, sights, sounds, and tactile sensations, as well as multiple tasks to complete, can all seem pretty overwhelming. Faced with so much data, says Dr. Epstein, the tendency of the mind is to simplify and reduce it in some way. And that’s when error can rear its ugly head.

“Simplification is often arbitrary and unconscious,” he says, and thus “the trick of working in hospital is to develop a vigilant awareness of the ambient stimuli that are all around you, making choices as to what you attend to, relegating other stimuli to the background, and in that way avoiding becoming overwhelmed or controlled by them. In that way, you have the capacity for making better judgments.”

Some clinical decisions can be made fairly easily and routinely (low-level decisions), he says, whereas other patient situations require a fair bit of deliberation (high-level decisions). (See Tables 1 and 2, right.) The human mind tends to avoid the unpleasant and to give more attention to what is compelling. Also, the ambiguity of role and responsibility—especially in large hospitals—may further confound a hospitalist’s mental capacity. Keen attention to each moment also boosts physician well being.

“Hospitalists are often working in crowded, stressful, high-paced, windowless environments in which there is no natural form of respite,” says Dr. Epstein. Therefore, all physicians need ways of keeping themselves from being overwhelmed by the challenges of sensory input and intense emotions caused by exposure to suffering, conflicts, imperatives for critical thinking, and so on.

“If practitioners were able to be more mindful,” he says, “they might experience greater well-being, because they would be able to make more choices about what they attend to and how they react to them.”

Dr. Epstein and his colleagues at the University of Rochester Medical Center—Timothy Quill, MD, Michael Krasner, MD, and Howard Beckman, MD—have studied the qualities of mind required to exercise that awareness extensively, especially as they relate to clinical practice and education.2 They were recently awarded three complementary grants to teach mindfulness to physicians: one from the Arthur Vining Davis Foundations, another from the Physicians’ Foundation for Health Systems Excellence, and the Mannix Award for Excellence in Medical Education.

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