Medicine Archives - Page 18 of 27 - Man, Medicine, and Mike

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:

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.
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.
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:

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.
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?
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.
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.

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

I needed curtains for my examination room.

I was working at the Sewell’s Point clinic. It was in the early 90s when I was an active duty U. S. Navy doctor. The problem was that the exam table was visible as I opened the door. Every time I entered the room, I exposed my undressed patient to everyone in the hallway.

I needed a curtain that could be pulled between the exam table and the door. It seemed like such a simple thing.

They sent the person in charge of facilities and requisitions to me. He had me fill out a form (“chit” in military jargon). It was 5 layers thick with carbon paper between each layer. I had to press hard to fill in all of the spots on the form. I worked through the lengthy form. When I had it finished, I gave it back to him and asked him to look it over. He told me that it looked fine.

“You will never see these curtains by the way.”

I asked him, “Why not?”

“You will like be out of the military or moved on before this request is processed and approved. That is just the way things work.”

“Is there anything I can do to accelerate this? I really just need one curtain.”

“Nope!” he said as he walked away.

I spoke with one of my corpsmen to explain what happened. “Don’t worry doc, I’ll take care of it,” HM1 Jones reassured me. The next day I came to work and there was a very nice little moveable divider wall in my exam room. It was quite effective. It did exactly what I wanted.

“Where did this come from?” I asked him.

“Don’t ask doc. Just be happy with it.”

He did tell me that he had overnight watch and that sometimes you just need to conveniently reappropriate things from one area to another in the military.

I didn’t ask any more questions and went on working. All was good for about 2 years. I had my divider and I was happy. And then one day a crew of people showed up with tape measures and tools. The next thing I know my divider was gone and in its place was a very nice and new curtain. In fact, all the exam rooms on the hallway now had nice curtains up.

I asked what had happened. Perhaps my requisition had done some good.

Nope.

It was all about an impending Joint Commission visit. The CO of the clinic had staged a mock visit using the clinic staff. They walked around the clinic and watched operations. As they went through the clinics, they watched the naked patients being exposed to the hallway when the doors were opened. Suddenly there was a crisis. This was an emergency. They could not have this problem when the Joint Commission came through in the next week. Immediately the money was approved to go outside the normal pathways and to go to a local store and buy the supplies and just get the curtains up.

And so, I had a very important lesson into change management.

The lesson has been repeated over and over through the years. As an agent of change, it is hard to get things moving. But change management teaches us that the first step is to, “Create Urgency.” You need to get people to feel the strong need for change. Sometimes you just have to invent a crisis. But you need to somehow get people to move out of the inaction that keeps positive change from happening. There is a momentum that inhibits us. We need to overcome that.

Sometimes this is referred to as a “burning platform.”

That term comes from a tragic disaster on an oil platform in the North Sea. At 9:55 pm on July 8, 1988, an explosion occurred and the entire platform was engulfed in flames. More than 200 workers were trapped on the platform. Ultimately 167 people died. Andy Mochan was one of the men trapped on the platform. He jumped into the icy waters more than 150 feet below. He knew that he would only survive about 30 minutes in the water unless he were rescued. When he was asked about his decision, he said he was faced with little choice. He either needed to, “jump or be fried.” As much as he didn’t want to jump, he was forced to make a change because he had to.

It is this sense of a strong and pressing need that can force people from the status quo to what needs to be done to counter change.

It reminds me of the history of heart transplant. On December 2, 1967, Christian Barnard performed the world’s first heart transplant. The patient was Louis Washansky and he lived for only 18 days before he passed away from complications. In talking about the patient’s decision to get a heart transplant, Barnard later wrote, “For a dying man it is not a difficult decision because he knows he is at the end. If a lion chases you to the bank of a river filled with crocodiles, you will leap into the water, convinced you have a chance to swim to the other side.”

All stories aside, it is an important principle to understand. It is amazing to me how the impossible becomes possiblewhen a crisis arises. Resources and abilities become available that you can be told absolutely don’t exist until there is a strong motivation for change.

The military had messed up my pay. In fact, they had messed up a lot of people’s pay. In order to get the problem resolved, I had to leave the hospital and walk a 10-15 minute walk across the military complex to the pay office. There a civilian contract worker was responsible for sorting out the pay issues. He had me fill out a bunch of paperwork and told me to come back the next week. I came back the next week and he told me that he still could not get my issue resolved. There was just too much work and he had not gotten my forms processed. I was frustrated. I was on call every 3^rd night and even on non-call days I worked 12-hour days. As I left to go back to the hospital, I saw him leave his desk to walk outside with his buddies to smoke for a while.

When I got home, I told my wife. She was really frustrated! She remembered that in orientation the doctor’s wives met the wife of the Admiral in charge of the hospital. She had told them to call any time if there were problems. She picked up the phone and called. I did not want Sarah to do this. This went outside of the chain of command and was not the way the military was supposed to work. Helen (the Admiral’s wife) didn’t mind. She told her that they had messed up her husband’s pay also. She called her husband’s aide. The aide called the pay office. Within 5 minutes I had the same civilian contract worker calling me and apologizing. He had my pay fixed that day.

Funny thing about it being too much work and too complicated to get it fixed.

Seems it all depends on how motivated people are for change.

Ok – so here are the lessons I have taken away from this and similar experiences:

Sometimes you have to create, invent, declare or make a crisis to get movement to get what ought to be done.
Most of the time your job is to be able to communicate what you are feeling or thinking. Why do you feel the need for change? Is there really a pressing need? You cannot expect to get what you want if you cannot make other people feel the need as strongly as you do. The 1^st step might be for you to spend time thinking about what is driving your desire for change. Until you can explain that clearly, you may not be able to move things forward.
External regulation and review can be a tool for good. In this case the Joint Commission turned out to be a very helpful thing for me. Maybe the best thing you can do is to submit yourself or your organization to some kind of external scrutiny to get them to listen and respond and change.
If that all fails – perhaps you need an HM1 Jones to creatively “fix the problem” while he is on watch overnight! At least that could be an interim solution!

Share this:

Share this: