Paying Attention
Notes from a Family Meeting, Vol. 2, No. 12
I’ve never been lost in the woods. I enjoy hiking but I stick to the marked trails. I have, however, been lost in the hospital. Any patient’s family member can empathize, but thankfully by the end of intern year, I knew all the quickest routes from the ED to any patient’s room. Even then, even when I could manage rounds like a rigged game of chutes and ladders, I spent a lot of time feeling lost. It would come over me like a wave of homesickness.
Debating over the best management of blood glucose for a dying patient, I wondered if there was some better direction in which we should be headed. Turning from that to my pager, I added another item to my to do list. The sheer number of tasks clamored for my attention. I triaged them, but the distress of triaging equally important tasks only added to the din. As I received yet another page to admit a patient, I found myself asking, “Why did this person have to get sick now? Why not just wait a few more hours until after my shift is over?” I wanted to believe I was this compassionate physician, but being lost saps that away.
It may be true what J.R.R. Tolkien wrote, that “not all who wander are lost.” So, too, not all who are lost wander. I spent very little time wandering in the hospital. I had this map given to me in medical school, and I kept adding in details in my residency. Still, even with the map, I became lost. I was venturing in different countries than what the cartographers anticipated. Like reading a real map, getting to where you want to know isn’t about knowing everything on the map. It’s about knowing the right path to get there.
Paying Attention
It’s no wonder then that information may now be a more valuable resource than gold or oil. Like other resources, many people access small quantities for daily activity, but only an elite few can leverage information to generate immense wealth. They do this mining the “attention economy.” Almost any website has cookies that track your behavior and gather data to use or sell. Giants like Facebook, Twitter, and Google invest millions to reap billions in the attention economy. These sites offer something to their users, or else people wouldn’t keep coming back, but at the end of the day, they’re very sophisticated machines used to harvest data by harnessing people’s attention. Our capacity to attend isn’t limitless though. Economist Herbert Simon saw a problem even before the advent of the internet and social media: “A wealth of information creates a poverty of attention.”
People are realizing their attention is a precious resource. We need ways to steward it so we don’t fritter it away by doom-scrolling. Ironically, the angst of the doom-scroller shows that access to more information doesn’t expand our choice in the ways we think it would (“more is better”). Neil Postman realized it stokes anxiety because we’re “faced with the problem of a diminished social and political potency. ... The news elicits from you a variety of opinions about which you can do nothing…” Rather than enhancing our agency, we have more information than we can possibly ever use.
Postman also recognized that social institutions provide a vital means of managing information. When they malfunction or fail, we don’t gain more independence; we’re forced to vet information on our own. This isn’t liberating. It’s homelessness:
“…any decline in the force of institutions makes people vulnerable to information chaos. To say that life is destabilized by weakened institutions is merely to say that information loses it use and therefore becomes a source of confusion rather than coherence.
Social institutions sometimes do their work simply by denying people access to information, but principally by directing how much weight and, therefore, value one must give to information. Social institutions are concerned with the meaning of information and can be quite rigorous in enforcing standards of admission.”
This is how religion and the state operate. This is also the business of prestigious medical journals, “evidence-based medicine,” medical school curricula, committees for academic appointment, promotion, and tenure, and so on. They (de)legitimize and (de)authorize types of information and sources of epistemic authority. Without them, we’re left to face the full brunt of information chaos on our own.
Clinicians are people just like anyone else, so we fall prey to the cultural strip mining so prevalent in the attention economy in the general ways I just summarized. Deeper and more specifically than that, though, when we can’t attend well, we lose sight of health.
Coming Into the Light
The philosopher James Williams, noticing how disempowering it can be to live in this attention economy, wrote Stand Out of Our Light: Freedom and Resistance in the Attention Economy. We might think that when we pay attention, we’re just focusing on a particular task at hand. I’m paying attention to the keyboard and the content of this newsletter as I write, for example. That is, as Williams describes, one type of attention, but there are at least three, which he helpfully frames in these ways:
Spotlight: “…our immediate capacities for navigating awareness and action toward tasks.” When you’re listening to a patient tell their story, or when you’re performing a surgery, you’re using a spotlight. This is what I’m doing as I type.
Starlight: “…our broader capacities for navigating life ‘by the stars’ of our higher goals and values…” When you’re trying to figure out the right thing to do, you’ll use all the many forms of starlight to guide you (e.g., rules, duties, principles, virtues, and so on).
Daylight: “…our fundamental capacities - such as reflection, metacognition, reason, and intelligence - that enable us to define our goals and values to begin with.” This is the whole context of a situation, perceived through those aforementioned capacities, that allows you to make sense of it so you can properly orient your behavior and plans. In medical terms, this might be understanding a patient’s H&P, including the oft-neglected appreciation for their baseline functional status, their family relationships, and their goals of care, as well as the possibilities and limits of what you can do to help them. You bring to bear on the issue your knowledge of the evidence, of your own past experience, and your present experience.
“These three lights of attention pertain to doing, being, and knowing, respectively.” These are the ways we navigate life. Corresponding to each of these forms of light are three forms of distraction:
Functional distractions: These “direct us away from information or actions relevant to our immediate tasks or goals.” An example might be a blaring alarm that keeps you from being able to listen to someone.
Existential distractions: These cause us to “lose the story of our identities, whether on individual or collective levels.” You can lose sight of important stars, or follow a wandering star into the wasteland. An example might be attempting to shift the purpose of medicine from health to autonomy and winding up with efficiency instead, which influences how we understand ourselves as clinicians.
Epistemic distractions: These involve “the diminishment of underlying capacities that enable a person to define or pursue their goals…” These make it harder to “integrate associations across many different experiences to detect common structures across them. … at its extreme, epistemic distraction produces what Harry Frankfurt refers to as ‘wantonness’ because it removes reflected-upon, intentional reasons for action, leaving only impulsive reasons in its wake.” An example here might be the “survival mode” that a burnt-out clinician is forced to inhabit, constricting their view of the clinical environment. Another example would be all the various biases that impinge upon our capacity to see rightly - e.g., when we anchor on a diagnosis, we might miss something otherwise obvious.
Williams argues that when we pay attention, we pay with something. “You pay with all the things you could have attended to, but didn’t: all the goals you didn’t pursue, all the actions you didn’t take, and all the possible yous you could have been, had you attended to those other things.” While some might take issue with this economic framing of attention, it helps me realize that sacrifice is necessary when we attend to anything.
We don’t have to venture far beyond Williams to see that these three forms of light are related. Where I direct my spotlight will eventually shape how I follow starlight and what I perceive in the daylight. The stars I follow will direct my spotlight. What I’ve seen in the daylight will shape how I chart my course under the stars and what I believe is available for me to spotlight. As I walk at night under the stars, dawn will find me in a new land. This seems to be a lifelong, iterative, and deeply formative process.
Distracted in Daylight and Starlight
Imagine being lost in the Alaskan wilderness. Probably most of the people reading this wouldn’t know how to survive. The natural world would assault us with information: sights, sounds, smells, and other sensations would buffet us, literally threatening our lives. Speaking for myself, I would interpret very little of it to my benefit. Throw someone competent in wilderness survival out there, though, and they can read the world around them to survive and make it back to civilization. The difference between someone who’s lost in the wilderness and someone who’s not is that the latter person knows how to remain oriented to where they are, where they’ve been, and where they’re going. They know where they should direct their attention and how. They don’t attend to everything; they attend to the right things.
When you’re lost, anything could be important, so you jump at every sound and ponder the nutritional value of every weed and berry. In medicine, the intern lives on checkboxes to get things done and manage the massive flow of tasks to care for their patients in the hospital. Just because the intern uses checkboxes doesn’t mean they’re lost, of course; it could be the opposite. But it could be symptomatic of a frantic attempt to manage epistemic distraction. This is more obvious when sitting with an intern who is attempting to help a patient make a complex medical decision: unsure of what’s important (The x-ray? The blood work? The home care? The patient’s desire to go fishing?), they ramble through everything. The key question here is, how do I attend to all this? The assumption is we should attend to it all because all of it’s important. We’re whole people, after all. We want whole person care.
To believe that we should attend to everything because everything is mediated through our health isn’t holistic medicine; it’s an epistemic distraction. This is, as Jeff Bishop and others have warned, the totalizing gaze of medicine that subsumes everything into its analysis. Such omniscience just isn’t possible. Eventually we merely human clinicians succumb to information overload. There’s just too much to manage.1 But even for those things that are “managed” under such analysis, it’s painfully reductionistic.
Martin Heidegger remarked on a curious characteristic of technology, which I think applies more broadly to how Postman and Jacques Ellul framed technique and tells us something more about this reductionistic aspect of epistemic distraction in healthcare:
“If we inquire step by step into what technology, represented as means, actually is, then we shall arrive at revealing. The possibility of all productive manufacturing lies in revealing.
Technology is therefore no mere means. Technology is a way of revealing. If we give heed to this, then another whole realm for the essence of technology will open itself up to us. It is the realm of revealing, i.e., of truth.”
In short, when you have a hammer, everything’s a nail. That’s truth of the world revealed to you by your hammer. When everything’s a nail, you’ll try to figure out how to use your hammer more effectively. You’ll make a better hammer, a bigger hammer, a more efficient hammer. You’ll classify different kinds of nails and maybe have different hammers for each one. You might have different sub-specialists who use their hammers differently for those different types of nails. All this seems like a great way to go - if everything’s a nail. While the hammer is reliable at fastening two boards together by pounding on a nail, how reliable is it at showing us how the world works? What does it reveal?
I don’t think we live in such a world of “nails” yet, where our tools tell us entirely what we’re seeing. We’re in a period of transition. Clinicians are on the way to becoming technicians instead of being companions with their patients on a journey toward health. Symptoms of this transitional state include unease with the dominion of the electronic medical record and moral distress in caring for people in difficult circumstances where clinicians, patients, and families can’t see eye to eye about what to do. If we were fully in the realm of everything’s-a-nail, there’d be no EMR unease: we would submit entirely to being functionaries. There’d be no moral distress either: we would be satisfied to serve as tools in the hands of our patients or their authorized surrogate decision-makers. That we experience these symptoms suggest an immune response - that something within us resists the technical transformation of medicine.
We experience existential distractions during the transition too. Because we can’t follow stars that lead us in two separate directions, we either decide to travel together or part ways. The pandemic has brought this to the fore: for decades, patients and clinicians have followed the star of patient autonomy together. Now clinicians need to take into consideration public health and the common good while some patients still travel by the light of their own autonomy. The divergence in our paths has sown distrust and frustration, if not outright hostility.
When we try to replace health with autonomy and wind up aiming for efficiency instead, this doesn’t just change what we do. It changes who we become. As our practice is formed more by technique and less by virtue, we become something other than a clinician who pursues our patients’ health. With a severely impaired institution and tradition of medicine, facing information chaos calls for a different kind of person. It calls for a more efficient person. I like the language of distraction here because it can be momentary or chronic, which accords with my own experience. Sometimes I forget myself for an hour under the tyranny of the urgent, but I could also veer into the wilderness for a year and come out a different person.
Clearer Attention
There’s another way, framed by different questions: what is my attention for? Why does this warrant my attention? Not everything is important; indeed, some things don’t warrant our attention at all. Among those things that are important, they may warrant different kinds of attention: some a brief thought, others years of contemplation; some scientific analysis, others awe-struck wonder; some now, others later.
Like the expert survivalist in the Alaskan wilderness, we can discern those things we should attend to and those we can ignore only if we have a purpose to guide our reading of the environment. If we’re properly oriented toward health then some things just don’t matter while other things matter even more than we previously thought. Maybe the blood glucose matters now, maybe it doesn’t. Maybe the opioids matter now, maybe they don’t. Maybe housing matters, or substance use disorder treatment, or grief, or marital discord, or job loss. Not that medicine has the tools to address all of these, nor should it, but wise clinicians can discern the relationship between health and all of them. What is best for health now?
Can we recover what we see of the human person in broad daylight - their emotions, their humanity, their families, and the landscape of the human condition over which they travel? We can learn about those things by reading great stories, watching great films, and fostering narrative competence. However, their rightful place in how we appreciate health as part of the human condition is best appreciated if we recover and sustain a tradition of practice in caring well for the body. That tradition can help us face a world full of otherwise chaotic information and glean the information we need to situate health in relation to other good things in life. If we just collect information for its own sake, though, we’re at risk of becoming distracted by mere technique.
Attending to Health
Remarking on the power of systems to beat an individual’s best intentions, Williams quotes The Grapes of Wrath by John Steinbeck, wherein farmers were being kicked off their land by the bank:
“Sure,” cried the tenant men, “but it’s our land ... We were born on it, and we got killed on it, died on it. Even if it’s no good, it’s still ours ... That’s what makes ownership, not a paper with numbers on it.”
“We’re sorry. It’s not us. It’s the monster. The bank isn’t like a man.”
“Yes, but the bank is only made of men.”
“No, you’re wrong there–quite wrong there. The bank is something else than men. It happens that every man in a bank hates what the bank does, and yet the bank does it. The bank is something more than men, I tell you. It’s the monster. Men made it, but they can’t control it.”
Clinicians, burnt out and frustrated, may feel this same helplessness before the power of the machine of modern healthcare. But the healthcare system isn’t more than the persons who make it up, it’s less. In order to do more together, we sacrifice important aspects of our humanity to make this system that, on the one hand, can wield almost magical technology to great benefit, but on the other, offers sleep without rest, blankets without warmth, and food without fellowship. It isn’t a community the way a family is. Nor should it be, I suppose. But our hope that we can do, even be, more together than when we’re alone is an echo of a promise that it’s good to be work in rich, deep, meaningful community with others.
So, as Stanley Hauerwas observed, “Medicine is but a gesture, but an extremely significant gesture of society, that while we all suffer from a condition that cannot be cured, nonetheless neither will we be abandoned.” Even when medicine loses its humanity, even when it seeks machine-like efficiency, there are glimmers of goodness, shining forth from those meetings between mere humans.
This is the tragedy of real monsters, which aren’t totally evil but instead broken in their goodness. As Mary Shelley’s Frankenstein teaches, the monsters we make are monsters because of our own misdirected foolishness. Brendan Foht observes:
“Frankenstein notably achieves his success almost entirely in isolation from the actual scientific community — an individual, who thinks of himself as a genius and savior of mankind, toils away in isolation, not needing or heeding either the scientific or moral judgments of anyone else. He learns from them, at the university, but in the passive manner of an apprentice picking up skills and learning recondite secrets, rather than in the active manner of a colleague engaged in a common enterprise of research. Certainly, no one learned anything from Frankenstein about the secret of conferring life on inanimate tissue. It was a profoundly individualistic effort, an expression of an individual’s genius and dedication rather than the collective effort of a scientific community.
From the lofty heights of genius to which Frankenstein elevated himself it can be impossible to see the moral demands that are near at hand. With the creation of a whole new species, or the salvation of mankind, or the casting of light into the darkness of ignorance seemingly within reach, Frankenstein sees the creature on which he is toiling not as a person whose happiness or misery will depend on him, but as mere dirt on which his hands are dabbling to perform miracles.
…
Frankenstein’s sin was not that in abandoning his creature he failed to control it. It was that in abandoning his creature he failed to love and provide for it. It is the pain that follows from this abandonment that warps the creature’s morality and leads him to the disasters that follow.”
I’m not suggesting we should learn to love the healthcare system we’ve made. Love is integral to our task, though. We should understand that this system is a tool that will shape us through its monstrous technique unless we direct our attention, individually and collectively, toward a good end. If we follow the stars of love, yes, and wisdom, patience, and humility in using our tools, then we can avoid the paths down which the tools themselves tempt us. We can avoid such temptations when we aim at the better purpose of using medicine for health. It’s seems obvious, but the digital age has shown us we can become distracted even from the obvious. Sometimes it’s the most obvious things that help you get back on track.
Working in a world of distraction is difficult. Sometimes we’ll look up and see a star that could guide us home, and it lights the faces of our companions in ways we haven’t seen before. Then the clouds drift across the sky and cast our path and friends in shadows once again. Can we refocus our attention and chart a better course for the journey?
Trajectories
Following a meandering reading-path, sharing some brief commentary along the way.
“A negative effort: Simone Weil and the ethics of attention in palliative care”
Aldis Petriceks attends deeply to the nature of attention in the clinical encounter. Noise, from within and without, can crowd out the practice of good medicine. Relying on reflections from Simone Weil, Petriceks notes that rather than redoubling our effort to attend more carefully, we should rather strip away those things that get in the way of attending. Namely, “attention in palliative care [is] the unforced process of becoming less aware of yourself and more aware of the patient and what they are going through, while holding onto the skills, knowledge, and compassion that will benefit the patient and respond to their particular needs and context.” This is an attempt to avoid coercing patients and pushing our own agendas on them. But there’s an error in the other direction: by draining as much of ourselves, as clinicians, from the encounter, we actually dehumanize the encounter as we become mere functionaries. “Compassion,” for example, can be an abstract term, but it’s always locally, specifically embodied by a human person. I can’t just show compassion without relying on my own embedded, embodied humanity with its own peculiar history. Any attempt to do so will reduce compassion and other virtues into techniques that bend not toward serving the patient’s health but toward customer service.
“How far do you go when the alternative is death?”
Daniela Lamas writes of the challenges that face patients and their families who pursue a “right to try” medications for terminal conditions that haven’t yet been approved or even fully studied. This is so-called “compassionate use,” allowing these patients to have one more long-shot at a treatment that may or may not offer them some more time. She reflects on the journey of one man and his wife as he faced cancer and, while waiting for one such intervention, died. His wife ends the piece on a hopeful note, glad that they spent his remaining time working so hard pursuing this. It’s very hard, if not impossible, to do two things at once here: to fight through a bureaucratic pathway toward what is so often a technological mirage, or to prepare for death. Lamas wonders what harm might befall someone who is dying and that could have been the focus of her piece, but in order to ponder it, we need to discern when along the journey with a disease someone is “dying.”
“New JCO paper - surrogate validation”
I’m not an oncologist, but I appreciate listening to Vinay Prasad critique cancer studies. His discernment is sharp and always oriented toward helping patients. He’s earned a negative reputation due to some of his stances on COVID policy, so that may have turned some away from all of what he has to say, but you’re missing out if you do that. In this particular podcast, he tears into a paper that is afflicted by some under-recognized conflicts of interest and then goes on to push back against how that went about validating the surrogate end-point they want to support. We should all be suspicious of surrogate end-points because they’re easier for research groups to use and may not track with any outcome that’s meaningful for patients (e.g., longevity, function, comfort).
“Conceptual competence in psychiatry”
Awais Aftab and G. Scott Waterman are concerned that a conceptual malaise has fallen the field of psychiatry resulting from a neglect of its philosophical underpinnings. They notice, as I have, that trainees struggle with philosophical problems but lack the necessary tools and skills (and sometimes, I would add, virtues) to properly approach, or even see, those problems. So they propose conceptual competence, which includes conceptual assumptions and questions, conceptual tools, conceptual discourse, and conceptual humility (a little nod toward virtue ethics there). Their ideas could be expanded to include all of medicine: what if we approached medical school not from a fundamentally biological frame, but from a philosophical frame? Would it even be possible?
We can’t be 100% efficient in our work. If we aim for that, we ossify and are unable to adapt to changes that our work and environment require. So, we need slack to remain flexible. We see the healthcare system had very little slack to accommodate the blow the pandemic would deal to staffing: both because of burnout and because of illness itself. But just like “self-care,” we can bend slack to efficient purposes. Ultimately, we need unquantifiable margin in our lives not only to adapt, but to breathe.
Closing Thoughts
“Learn from me, if not by my precepts, at least by my example, how dangerous is the acquirement of knowledge, and how much happier that man is who believes his native town to be his world, than he who aspires to become greater than his nature will allow.”
Mary Shelley, Frankenstein
There’s something to be said here for the utility of artificial intelligence (AI) in healthcare. I think that, too, makes bigger promises than it can deliver, but it’ll have to be a discussion for another time.