Sometimes we hear only what we're listening for, and if we divide attention, we can miss critical information. We must strive to Iisten with the "third ear" to hear not only what's said, but also what's unsaid.
Clinicians suffer in terms of information overload and burnout, while patients can feel neglected, rushed, and unheard in clinical interactions. If we’re only giving the patient part of our attention, we’re only practicing partial medicine. Slowing down, turning off technology, not typing while we listen—paying full attention can help clinicians feel more fulfilled, patients feel heard, and lead to an improved practice of medicine.
Information overload is the norm
The practice of contemporary medicine is as much managing information overload as it is being a clinician. For instance, in my work in a triage service in primary care mental health, I do what I’m sure you do too—I reply to emails, view alerts in the EMR, follow multiple instant message threads from our team and other providers, answer and return phone calls—oh, and don’t forget the patient. Our brains are deluged in communication, information, and distraction while we’re trying to listen to our patients and give excellent care.
Continuous partial attention
We live in what has been called the Age of Information, although Thomas Friedman has suggested that we’re really living in the Age of Interruption.1 We’re all multitasking all the time, often interrupting as much as we’re communicating.
Linda Stone, a former tech company executive coined the term “continuous partial attention” and differentiates it from multitasking. She distinguishes between multitasking (“motivated by a desire to be more productive and more efficient”) and continuous partial attention (as a desire for connection.) Originally, Stone saw mostly the positive in continuous partial attention, making it sound almost like some kind of flow state or peak experience. This isn’t my experience of monitoring multiple technologies while trying to listen to a patient! Stone later coined the term “continuous continuous partial attention” and pointed out some of the negative aspects of always paying partial attention to things.
Ellen Rose, a professor of education, has studied the impact of technology on student learning and points out that the larger question is whether continuous partial attention is “an inevitable adaptation to a new reality or a dysfunctional state of distraction, a form of cognitive dexterity or a cognitive deficit…—is it an essential job skill or the primary cause of employee stress and burnout?” Can we really pay attention to multiple things at once?
Sustained inattentional blindness
A series of studies by Simons and Chabris were about sustained inattentional blindness, in which focusing on one thing can block out our awareness of another thing, particularly if it is unexpected. For instance, counting how many times a team passes a basketball while a person dressed in a gorilla suit walks up. You can watch the video used for this study at the author’s website “The Invisible Gorilla.” When I first learned of this experiment, I immediately thought of our contemporary practice of medicine—where counting the passes is all the technological communication we’re attending to and the patient could end up being the gorilla that we miss—right in our midst!
In fact, the concept of sustained inattentional blindness was repeated in a medical setting. A gorilla image that was 48 times the size of an average lung nodule, was inserted into chest x-rays—83% of radiologists didn’t see the gorilla. To me, these studies tell us that we need to be very cautious thinking that we can multitask or have continuous partial attention. In fact, the way we’ve set up constant technological information input in clinical settings may just be interrupting us rather than informing us.
My experience as a cancer patient with doctors engaged in continuous partial attention
As a cancer patient, I see doctors trying to balance so many attentional demands. I try to gauge when the doctor is really listening to what I’m saying before I say something important. I pause or slow down when the doctor is looking at labs or notes. I’m tempted to stop talking altogether when the doctor is typing during my/our appointment, but I’m also aware of the limited time I have to get potentially critical information across. I’ll often write out a summary of symptoms and side effects since the last visit. I know the doctor will only have time to read one page, at most, so I edit it down to bullet points. Then I make sure I put the most important questions at the top of the list.
As a doctor, I know the challenges of managing multiple attentional demands while trying to listen to and be present with a patient. As a patient I know how difficult it is to convey a complex set of multiple symptoms and side effects to a doctor—I can see the pressure toward reductionism and inside-the-box styles of thinking. This kind of listening seems to come out of a continuous partial attention that is scanning for a way to reduce the complexity and uncertainty into a well-defined box or science factoid. Instead of a complex presentation with difficulty standing, feelings of weakness and shakiness in the legs, a feeling that I’m struggling to stand in one place, as if my low back is engaging and struggling to make up for my legs feeling weak and leading to low back strain, paresthesias from head to toe, perioral tremor, and cognitive symptoms, the doctor repeats back to me that he’s giving me a medicine that can help “tremor” and “pain.” I already feel misunderstood and that somehow, I’m a “bad” patient because of my bewildering array of complex side effects following immunotherapy, but now I feel that I need to continue pushing for the medical system to not come to a sense of premature diagnostic closure by reducing these symptoms to “tremor” and “pain” which really seem secondary to some larger neurological issue.
Listening with the third ear
I remember my psychotherapy training when I was discouraged from even taking notes on a clipboard because it could interfere with truly listening to a patient. Psychodynamic psychotherapy values deep listening, listening with our whole selves. Theodor Reik called this “listening with the third ear.”
Now in medicine we have partial listening—my experiences as a doctor and a patient lead me to conclude that partial listening is only partial medicine. We cannot provide good care if we aren’t fully there, if we aren’t giving continuous full attention. Maybe it’s too much to ask in today’s healthcare ecosystems to listen with the third ear, but maybe we could at least try to remember to use two ears when listening to patients, instead of only one.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.