Category: Medicine

Our daughter Margaret gave us a tour of the United States Capitol.

She is working as an intern for a congressman. One of her jobs as an intern is to give private tours. If know you are going to be visiting Washington DC, in advance you can try to book a tour of the Capitol building through your Congressman’s office. Or you can have a daughter who is an intern who can do it for you.

Margaret put on her ID badge and then walked us around a long line to another entrance. She took us past large groups of school groups in matching t-shirts. She showed us exactly where to go. She disappeared and came back with tickets for us. We watched the introductory movie and then as the large group of people started into the Capitol building, she guided us away from them. She took us down side hallways. We didn’t have to fight or jostle with the crowds to see things. She had plans for how we could see things. She told us about the different rooms and told us different stories as we went. 

It was really fun.

It was also really fun to feel like we were doing something special. It made it even better because it was our daughter who was making it happen for us. I felt proud to be her Dad. She had her pass that let us have a special tour.

It took me back to childhood. It made me think of my dad.

My dad was a High School math and science teacher. 

We were going to the high school basketball game. But we didn’t park in the main parking lot with everyone else. We drove past the school and around to the back of the school. We went through the back entrance and then through the wood shop. My dad had keys that could get us in through the back door. My dad had us take our coats off in the shop and leave them there. We didn’t have to drag all of our coats into the gymnasium and awkwardly hold them through the game. 

The wood shop was big. The equipment was huge and a little bit scary. I didn’t know what all of the equipment did. My eyes were big as I looked at everything.  I didn’t really understand what was happening. But my dad was taking us in that way. It was cool to do something that was different than what everyone else was doing. I felt proud to be his son. He was important. He had the keys to the back door.

I have never told him or anyone but this has been a long standing and powerful memory for me. I thought it was really cool that he had keys that could let us in through the back way. 

He taught school for almost 40 years. He taught kids who grew up to be important people. He taught the kids of kids he had taught. And at least a few times he even taught kids of kids of kids he had taught. He left a huge impact on his community.  He also had the keys to his classroom. And he had the keys to the back door.

My girls were little when I started working at the hospital. I had my hospital ID and the keys to my office. I could bring my family and park in the physician’s parking spaces. We could stop at my office and leave our coats as we went into the hospital. I could guide them through back stairways or elevators to where we were going. When I was a resident, they would come and visit me on call. In those days the hospital nursery had a viewing window. They used to like to go and look through the window at all the brand-new babies. 

I would take them to the hospital cafeteria. It was just a hospital cafeteria. But to a child it could be pretty cool. They could pick out anything they wanted. We would then go through the line together and I would pay for everything with a single swipe of my hospital ID.

As we walked around the US Capitol building, the pattern stood out to me. I remembered being 6 years old and walking through the back door and through the woodshop to the basketball game. I remembered Margaret being a little girl, taking her through the hospital and into the hospital cafeteria and letting her pick out anything she wanted. And I was happy that for a moment Margaret could show us part of what her current world is. 

What is this emotion? Some of it is pride. Pride can be both a good thing and a bad thing. In this case I think it is just fine. To be able to value each other and what we do is indeed a good thing. It is not saying that we are better than everyone else. But it is saying that our family members have value. They were created to create and contribute and bring value to their world. It is okay and good to recognize and celebrate those good things that they do.

Some of it is being able to share a little bit of what is important to us with the people that matter the most to us.

This happens every holiday season. In the large family gatherings, you are with the people that are most important in your life. You have the idea that you will be able to see them and reconnect and somehow let them know what is going on in your life. And yet, this often is so very hard to do. You have a whole host of things that are important to you. You have worries, hopes, failings, successes, and things that drive you and in which you are pouring your energy. It is only natural that you would want the people most important to you to understand. You feel like you should of course be able to catch them up on things. But that is not always easy to do. It is hard to summarize all of your current life with a few words. 

It is like trying to describe a painting or maybe a song. When you try to put it into words, it doesn’t capture the power or the deep meaning. It comes off sounding empty – forced – contrived. “I saw a painting of an old man walking through a field.” Yes. And? “It is really powerful.” Ok? I guess so. If you say so.

You cannot in words capture all the subtleties and complexities of your life. You cannot in an instance pull them into your world so that they can feel it all. You want to. You may try to. Don’t be disappointed if the translation from the intensity of your life to an expression in words doesn’t go well. It isn’t easy to do this. It is however good for you to try. But don’t stress about this. They care about you. It just may not be completely possible for them to capture all of it.  

I think part of it is that we want them to know who we are now. You hope that they could understand, accept and value who you are in the context of your world. It is not possible to do this by just words. It cannot be achieved by just telling them about things or actions in your world. We try. It is not bad that we do this. But understand that in this flawed world you cannot in a few words pull them to a full understanding of who you are now.

We long for the kind of closeness where we truly understand and are understood. 

But it is a flawed world. There is only one who knows all of your inmost being. He is the one who has known you for all time. He is the one who knit you together in your mother’s womb. He is the one who saw all your pains and joys in childhood. He is the one who walked with you through the various friendships, crushes and relationships of adolescence. He is the one who went through the classes and the jobs and whatever has made the journey of your life. He is the one who knows all of you including the good and the bad, the lovely and the ugly, the successes and the failures. He is the one who stands by to grant you forgiveness and then acceptance (if you would ask Him and let Him), even with all of the flaws and scars of the past. He is the one and only one who can and does truly understand. 

But you want the approval and acceptance of your family. It may be your home, your relationships, your work, or the things that you have or even what you don’t have. You want them to see them. You hope that they can see parts of your life and be proud of you. That is only natural. It is okay.

I think it is great to think back even now with immense pride on who my dad was (is). That understanding has shaped a huge part of who I am, what I do and how I live my life. I am very proud that he (and my mother) chose to be teachers. I am proud that my dad chose to invest in others. I am proud of how much he is loved in their town. I am proud that he was always a good, kind and patient teacher. The way that he handled his classroom even now shapes how I handle myself at work. I am proud that he worked hard at everything he did. He cared about what happened. He thought about things. He did things. He did a lot of good. Those things also continue to shape and mold my decisions in everyday life. 

I am proud of so much that my father did and what he meant to so many people.

I am also proud that he was my dad who had the secret keys to the back door by the wood shop. 

What about you? What do you remember about your parents? Would you for just a minute celebrate the cool things that they did? Can you think back to a time when maybe they had the secret keys to a back door? Can you think about how that has shaped who you are? In your family gatherings can you look for what sort of back-door keys your other family members might have now? These might be important parts of their identity that they long for you to understand. Can you see them in your children? Can you look for what is important to them and celebrate it? Can you stand back and try to look at and appreciate the picture or the painting of the world that is their current world? Can you go beyond the words that they are trying to say to try to understand what they are hoping to communicate? Can you see and just a little understand and accept them and love them and their lives?

I am going back to Washington again tomorrow night. I am going to visit my daughter who is an intern for a congressman. She has an ID badge. She can take us on private tours of the United States Capitol. She knows her way around Washington, D.C. It is really cool. 

It is like she has the keys to the back door.

It is 10 am on a Sunday morning. I am rounding in the hospital. It is quiet. I can think. I find myself looking deeper at issues. I ask more questions. I dig in and look at the patient’s images and think not only about where he is but also trajectory. Where are things going? 

On to Monday. The whole team is back. Things are suddenly very busy and very congested. It takes effort to focus and think through things. There is a lot of filtering that I have to do. In that moment, I wonder about the resources and help that we invoke during the week. It can generate a lot of “busy-ness” around us.  There is a lot of noise on rounds that didn’t exist the day before. 

As I thought about this, I started calling it “cognitive noise.” 

I have tried to understand this and how to cope with it over the years.

The 1^st way that I thought about it was in regard to the “signal to noise” ratio.

We were at an event recently in a large auditorium packed with people. There was inevitably some level of background noise. One of the speakers got up to the microphone but did not speak loudly or closely enough to the microphone. We had to strain to hear him over the background noise of the people and the ventilation system in the room. One of the other speakers got up and spoke loudly into the microphone. The signal was a lot louder. We could hear him clearly. It was much easier and more satisfying to hear him. We didn’t really notice any of the background noise while he spoke. What the 1^st speaker said was important but got washed into the background by the noise.

Imagine listening to a radio broadcast but having a lot of static in the background. It makes it hard to hear the program especially if any of the voices are quiet or low pitched. We talk about this as the “signal to noise” ratio. If the signal (the program) is loud there is no problem. But if the noise (the static) is loud it makes it hard to hear. When there is a lot of noise, we cannot hear the more quiet or subtle signals. And in the situation where there is noise it frankly robs us of the joy of listening. 

I started reading about cognitive noise.  This led to the 2^nd lesson. In a classic experiment by Iyengar and Lepper^[1]varieties of jams and coupons were put out in a store display. For one part of the experiment 6 varieties of jams were presented. For the other part, 24 varieties of jams were displayed. When 24 jams were displayed it attracted more people to the display. But when they analyzed purchasing, they found a surprise. When they had 24 jams displayed only 3% of consumers purchased a jam. When they displayed 6 jams, 30% purchased a jam.

It seems that when we are making choices, too much choice can create problems for us. 

I read another article that talked about buying a television. It explained how if you go into a store and they have 6 options you can work through them, decide what is important to you and then be satisfied with your selection and your purchase. If, however they have 40 televisions you rapidly get overwhelmed. In the end you either don’t purchase or end up not certain whether or not you made the best choice.

Too many options make it hard to think.  

One last concept makes up my understanding of cognitive noise.  The 3^rd lesson has to do with research that has been done on interruptions or multi-tasking. The truth of the matter is that human beings do not really multi-task. Instead we shift from one thing to another and then shift back. But we seldom do two things at the same time. The data suggests that we are indeed able to function in an environment of interruptions. But if we are interrupted it appears that we can get simple tasks done but not the more challenging and complex tasks.  An interrupted environment, or one with a lot of “noise”, keeps us at a superficial level.  The deep issues or problems go unresolved.

Let me explain that better. Imagine you have 5 things to do but one of them is a big deep issue that will take a lot of thought. If you are interrupted, you may get to the others, but you are unlikely to the 5^th one solved. You can get the easy things done. But the hard things go undone. My email inbox and “to do” list often convict me of falling prey to this one.

Let’s start pulling this together. It applies in clinical settings but also for our lives in general. Cognitive noise then is characterized by a triad:

1. Signal to noise problems: If you allow an environment that has a lot of noise, you end up functioning and responding to the obvious. You are more likely to miss subtle or more quiet signals. This means that you might just miss something that is very important, but which does not scream out at you. 
2. Jars of Jam (excessive choices): More is not always better. More options can make processing and decision making harder for us. We might think that the best thing is to be flooded with all the information and all of the options possible. But that often does not make for the best decision making. It also has a very strong tendency to make us irritable and unsatisfied.
3. Interruptions (failed multitasking): If you create (or allow or fail to fight against) an environment with multiple interruptions it will push you to a superficial level of functioning. You may not ask or solve the big or deeper questions. You may solve the simple but not the important. 

Bring on a quiet Sunday morning.  

The noise is reduced. Suddenly parts of the signal start to come through. It might be finding the subtle things that we missed before. We can go and look at the information that we want or need to look at rather than having information pumped at us.  We can process and think. We can ask the harder or bigger questions. 

And as much as I hate working on weekends or after hours, sometimes those are the most satisfying times. With the distractions pushed aside, the choices can become clearer. As I make clinical decisions, I feel better about them.  By the time that Monday comes, I feel like I have a much better understanding of my patients, where they are and the path forward.

It of course raises the question of whether we are doing things wrong in medicine. Do we put so many things around us to help us that we are actually making things harder? It is a valid question.  Maybe we need to think about simplifying things.

On one of our hospital units we implemented a process called “I-rounds” or “Interdisciplinary-rounds.” The concept was that we were to meet together and do all of our decision making at the patient’s bedside. We had patient, family, nurse, NP/PA, physician, pharmacy, and care management present. All discussion and decision making were to be made at the bedside, involving the entire team, including the patient.  It sounds like a great idea. We would be getting input from the entire team. The patients and family loved it. It did help to identify pieces of information that we might have missed. But it also generated a fair amount of cognitive noise. There was strong pressure to hear, process and make complex decisions in the moment. Many of us adapted and did “ok” with it. Some of the physicians hated it. I don’t know that any of them liked it.  By pulling together a “helpful” team we were actually making our job harder. 

There are ways to handle this.  I did so by refusing to let the “noise” control me. “You are complex,” I would tell the patient in front of the team. “You are here in the hospital despite the efforts of smart doctors. It would be foolish and arrogant of me to think that I could understand or solve things just in this moment. I am going to need to sit down and go over things in detail. We need to take some time to figure out what is best for you.”  

Patients and families get that. They love that. They are not demanding snap in the moment answers. 

Lest those of you outside of medicine get worried or despair – physicians get pretty good at filtering out the noise. Medical training leads through a development process of teaching physicians to handle the “cog noise” problem. Most get quite skilled at filtering through the noise to see the important. The crowded noisy ICU with beeps, alarms, floor sweepers, families talking, nurses giving report and then a big team rounding is the norm. We get effective at handling that. Many of us can even get a bit proud of our ability to function in chaos.

I went through two months of flight school in the US Navy as a part of the flight surgeon training. When I was learning to fly, they told us that we were going to need to learn how to multitask. They told us it was not a normal thing to be able to do. We were told that we should practice learning the emergency procedures at the same time as we were doing two other things.  We were told that we should try to listen to music, shoot baskets and recite our emergency procedures. I don’t recommend this – but I would drive my car (in non-congested areas), have the radio on, have the window open with wind blowing at me, and bounce a ball with one hand, and at the same time recite the emergency procedures. I was working to ingrain the important so that I could still use them even with a lot of distractions. “Maintain, check, feather, clean, look, lock,” was the engine failure emergency procedure. I learned it so well that it is immediately available to me now 26 years later.

So, we can practice and study and learn and condition ourselves to handle the noise problem. We can train ourselves to identify the important from among the clutter.

But what about for higher thinking? What about new things?

What about trying to write a blog post? 

For me it is generally very early in the morning. I settle into a favorite chair in the quiet empty silence of the morning. In these moments my brain begins to work in an uninterrupted manner. It allows me to really think and process. It allows me to feel and then somehow to try to pull these feelings into my awareness. The blog writing is an extension of that process. Seeing things in writing helps me process and makes them real. In those moments emotions and feelings within me become real. They go through the evolution from background thoughts to thoughts understood to thoughts written.

But in order for me to have any of this happen I need to eliminate the cognitive noise. 

And so, what am I trying to say?  I think there are several lessons:

1. Recognize the problem of cognitive noise in your world. That may be the 1^st step to being able to deal with it. Social media + text messages + snapchat + television + emails popping on your screen + jabber or Microsoft teams messages are all helpful tools. They also will leave you as a superficial human being who only deals with the simple. If you long for depth and complexity and the ability to solve the hard problems, you must recognize and then fight against the cognitive noise that fills your world. 
2. Train yourself to be able to handle the noise of your world. You cannot always eliminate the noise. You can get better at discriminating the signal in the midst of the noise. The human mind has an amazing capacity to learn and process. It can filter if you train it to do so.  Like learning an emergency procedure practice this skill so that you get good at it. Can you see and read the deeper things that are happening in the moment? I am proud of my ability to stand in an ICU room and have huge amounts of data coming at me but then to be able to quickly filter through it all to find the important.  I tease through it so that I can deal with real issues.  Can you push yourself to see the important rather than just the loud? In work, but also in your relationships and your life can you train yourself to see and hear in spite of the noise?
3. More is not better. More will not generally make you happier. Having 24 varieties of jam available is likely to just make you frustrated. If you only have a choice of 6 jams to choose from you are likely to be more satisfied. Resist the urge to complicate your life. Simplify whenever possible. If you feel irritable or frustrated maybe it is because you are filling your world with too much.
4. Enjoy the quiet moments. Do not so quickly give these up. Carve out times for reflection, study, or prayer. As you do this you may quickly find that even a few minutes of such time become the most valued minutes of your entire day.

These lessons apply in the clinical world. Understand that the noise of our environment will tend to make you a superficial and algorithmic thinker. Fight against it. Push deeper. Think. Look. Listen. Feel.

These lessons apply to your life (to my life).  Can we take this to an even deeper level?  

Who are you? Do you have depth? Do you really hear? Do you really love? Do you really feel? Can you hear and know God? Or will you allow even Him to be crowded out by the cognitive noise in your world? Do you long for depth and realness to your life? Then you must rebel – you must fight – you must rebuild or restructure your enviornoment – to work against the cognitive noise in your life. It is waiting for you. There is clarity that can come in the simple, the uninterrupted and the quiet.

There is joy in a quiet weekend morning.

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^[1] Journalof PersonalityandSocial Psychology, 2000, Vo7l.9, No.6, 995-100