Takeaway
Healthcare professionals can help counteract "sustained inattentional blindness" and faulty clinical reasoning by integrating Zen principles into their practice. This may allow clinicians to more fully perceive the patient’s reality, as well as avoid overlooking crucial details.
Passion in the Medical Profession | January 3, 2025 | 5 min read
By David Kopacz, MD, University of Washington
The editorial team fell in love with this piece and played with many different fun title ideas that we hope you enjoy: “Zen mind, physician’s mind; Now and Zen; Ask not what Zen can do for you, but what Zen can do for your patient; Got Zen? “
Before I studied Zen, mountains were just mountains and rivers just rivers. When I started studying Zen, mountains were no longer mountains and rivers no longer rivers. But now that I’ve gained some understanding of Zen, mountains are once again mountains and rivers are once again rivers. (Zen saying quoted in Renée Weber, “Dialogues with Scientists and Sages.”)
The Zen teacher Shunryu Suzuki wrote a book called “Zen Mind, Beginner’s Mind,” about how the practice of Zen is a way of capturing and preserving the freshness of seeing things for the first time, as a beginner. I’ve read and re-read this book over the years to the point where my wife thought I had no understanding of Zen because I couldn’t get past the beginner stage! Beginner’s mind, in our culture, and particularly in medical culture, is something that we strive to lose as quickly as possible.
I remember as a medical student my own internal pressure, as well as the external pressure, to become an expert, to narrow down the diagnosis, and give the right answer. The introductory quotation about mountains and rivers captures the paradox around certainty and uncertainty—when we study something, we can lose sight of the forest for the trees, so to speak. In Zen, this quotation tells us that we have some grasp on the truth as beginners, we lose this truth as we immerse ourselves in study, but if we study long enough, we can come back to this “beginner’s mind” in approaching life and problems.
A human being seeks healthcare because they are suffering. A beginner starts with the individual suffering of this human being; a more advanced technician might quickly look past the human being to look for biochemistry and pathology and treat these without ever returning to the human. The beginner sees the obvious, the technician sees the obscure, the Zen physician sees both and never loses sight of either.
How doctors think
Dr. Jerome Groopman, in “How Doctors Think,” alerts us to common cognitive errors doctors make in their thinking. For instance, premature diagnostic closure happens when a physician decides on a diagnosis without exploring other possibilities which then sets into motion an incorrect course of treatment. While our clinical algorithms can guide us in our treatment protocols, Groopman cautions that they can also “Discourage physicians from thinking independently and creatively. Instead of expanding a doctor’s thinking, they can constrain it,” (5). He further warns that physicians are “Being conditioned to function like a well-programmed computer that operates within a strict binary framework,” (6).
Groopman and Suzuki both seem to be telling us is that the mindset we have when we approach a problem can shape the answers that we get.
Sustained inattentional blindness
Studies by Chabris and Simons showed that if subjects were involved in an attention task, such as counting how many passes a basketball team makes, that 50% of the time they would not see someone in a gorilla suit walk on to the court! This study has implications for healthcare as our default is to multitask: listening to a patient, looking up labs, reading the electronic medical record, typing a note while interviewing the patient, and also attending to a series of beeps and alerts from pages, cell phones, instant message systems, emails, overhead hospital alerts, and wall phones. Drew,Vo, and Wolfe have done a follow-up study placing an image of a gorilla (48 times the size of a typical lung nodule) in chest CT scans and found that 83% of radiologists did not see the unexpected finding. This phenomenon is called “sustained inattentional blindness.” We tend to see what we expect to see and overlook what we do not expect to see.
Zen mind, beginner’s mind
“In the beginner’s mind there are many possibilities, but in the expert’s there are few.” Suzuki. Zen teaches us to be open to possibilities and not to jump to quick conclusions of applying algorithms to our lives. The “expert” that Suzuki seems to be speaking of here is not the accomplished Zen teacher, but rather someone who is more like a technician whose cognitive schema limit and structures their reality. “The true purpose,” Suzuki writes, “is to see things as they are, to observe things as they are, and to let everything go as it goes.” This requires a beginner’s mind in order to open to the many possibilities of reality. Further, Suzuki tells us that, “As long as you have some fixed idea or are caught by some habitual way of doing things, you cannot appreciate things in their true sense.”
Zen mind, physician’s mind
What can we learn from Suzuki and his Zen teachings for the practice of medicine? While we often hear about mindfulness meditation as a way of managing stress and burnout, Suzuki tells us that we can use the practice of Zen as a way of more truly perceiving reality to be better diagnosticians, technicians, and physicians. We are over-trained to follow algorithms and protocols without even thinking about them. It’s this automatic projection of cognitive structures on to reality that opens the door to cognitive, diagnostic, and treatment errors, even as these same algorithms can help us implement evidence-based medicine. We cannot stop being good technicians, but we can also practice being good Zen physicians, cultivating beginner’s mind alongside our training in expert/technician’s mind.
Zen physician practices
1. Start with the person, end with the person.
2. Pause for a moment before reaching diagnostic certainty. Imagine other possibilities—can you come up with five differential diagnoses before deciding on the first hypothesis to pursue?
3. When things aren’t working, go back to the beginner’s mind—try looking at the situation for the first time, ask the patient what their thoughts and feelings are, review the history again, ask more about family history.
4. Start with the person, end with the person.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.