Hummingbird on flower


Jan 19, 2024

By Ron Epstein, MD

For the past two weeks, my son, daughter-in-law and two grandchildren have been visiting. Lenny is almost 2 and Summer is barely 4. Since we last saw them a couple of months ago, their perfect and beautiful selves have refined the art of distracting any number of adults. Of course, distraction is not their primary intention; their imperative is seeking the connection, love, and nurturance that they need to grow and flourish.

By total coincidence, I am due to revise a chapter that I wrote for a book on “Distracted Doctoring” several years ago, edited by a local ICU physician, Peter Papadakos.1 Of course, being distracted by the joyous exuberance of young grandchildren is quite different than the distractions that we face every day as clinicians and that pull us away from the most important things. But there are some common threads. Tasks begun and not completed, or taking twice as long as they should have. Communication lapses. Retreat to concrete, cognitively easy tasks (parsing through inane emails, ordering online things we don’t really need) that have simple, predictable, and not particularly satisfying results. Craving quiet, focus and sleep.

Distraction is about how we react to stimuli. In a busy overcrowded, noisy, smelly emergency room, as the visual, auditory, olfactory, and tactile stimuli increase in frequency and intensity, it takes increasing amounts of effort to stay focused. We might provide exquisite care but become increasingly exhausted and experience burnout. Or the care might not be so exquisite. Deep listening and deep thinking suffer. We might act only by protocol, not considering each patient’s unique context. We might only “hear” physical symptoms that point to a unifying diagnosis and ignore psychosocial aspects of the patient’s suffering. We might retreat into satisficing – being content with the first answer to a problem – and close the door to other possibilities. Or we might prioritize the i-patient2 – the administrative tasks dealt to us in the electronic health record – over the messy, suffering, flesh-and-blood patient. With each flash or warning sound emanating from the computer screen, our train of thought is either temporarily interrupted or permanently derailed.

Bringing the best of ourselves to our patients and colleagues is not always easy, especially in chaotic health care systems. Even more challenging is helping learners and trainees cultivate these same skills. First, and most importantly, those in leadership positions should recognize and act on the reality that clinicians can function only as well as their context allows. With the increasing centralization, bureaucratization, production-orientation and informatization of health care, health care organizations increasingly set the parameters within which optimal human functioning must occur. Yet, health care organizations fall short by not recognizing the limits of human cognition, and the emotional toll and secondary trauma experienced by health professionals. A whole new discipline of “organizational mindfulness” has emerged with guidelines that parallel those that individuals can cultivate:3 attentiveness to the most important things, critical curiosity, adopting a beginner’s mind, and being present rather than “phoning it in.”

Healthcare is increasingly a team endeavor and when teams develop a “shared mind,” they overcome many shortcomings of any individual team member.4 Shared mind involves emotional intelligence, curiosity, respectful questioning, and adopting new perspectives so that new ideas emerge from team interactions and expand the resourcefulness of the team.

And, for individuals, the first step is to cultivate awareness, regularly monitoring our own minds – Am I focused? Am I distracted and in what way? – before distraction evolves into distress and dysfunction. Awareness then allows for the possibility of adaptive self-regulation.5,6 Maybe all that is needed is to move to a quieter location when typing or dictating chart notes, recognizing that work will be more accurate, more efficient and less emotionally taxing. Often, though, we need to address the cognitive rigidity and emotional distancing that sometimes accompanies distracted doctoring: How stressed am I right now, and what toll is that stress taking on me and the care that I am providing? What am I assuming about this patient that might not be true? What is unique about this patient and their context? What might I not be seeing – and what might I be ignoring? What am I feeling? For those involved in teaching, those same questions can be directed toward learners.

All three avenues – organizational, team and individual mindfulness in healthcare –have been the subject of dozens of research studies over the past 10 years. They all point to the same outcomes – better care, better outcomes for patients, and better well-being for clinicians.

  1. Papadakos PJ, Bertman S. Distracted doctoring: returning to patient-centered care in the digital age. Springer; 2017.
  2. Verghese A. Culture Shock – Patient as Icon, Icon as Patient. The New England Journal of Medicine. December 25, 2008;359(26):2748-2751.
  3. Sutcliffe KM, Vogus TJ, Dane E. Mindfulness in organizations: a cross-level review. Annual Review of Organizational Psychology and Organizational Behavior. 2016;3(1):55-81.
  4. Epstein RM. Whole mind and shared mind in clinical decision-making. Patient Educ Couns. 90(2): 200-206.
  5. Epstein RM, Siegel DJ, Silberman J. Self-monitoring in clinical practice: a challenge for medical educators. J Contin Educ Health Prof. 2008 2008;28(1):5-13.
  6. Epstein RM. Attending: Medicine, Mindfulness, and Humanity. Scribner; 2017.


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