The art of attention

I was called into the ICU around 4:00 a.m. to see a patient who was not doing well. His blood pressure was low, he was breathing erratically, and he had started having fevers after a prolonged ICU stay. When I arrived at the hospital, the residents apologized for calling me in so early. “No problem,” I said. “This is actually my favorite time of day.” They were surprised by my optimism. I told them that during meditation retreats in Thailand, we usually wake up around 4:00 a.m. It is a beautiful time. The air is fresh and cool, and the sounds of the forest and the meditation bell resonate clearly through the silence. I like to refer to it as “the time before the world wakes up.” I cherish these early morning hours because they allow me to step into a space of timelessness and spaciousness. I rest in simplicity as I watch the arising and passing away of thoughts, feelings, sensations, and identities. When I arrive at the meditation hall, I join the other meditators in the flow of walking meditation. Each of us has found a small path to walk back and forth, mindful not to interrupt others. Lifting–stepping–placing. Lifting–stepping–placing. One foot and then the other. Slowly and mindfully. The contrast with my life in the hospital is stark. I reflect on how much of my training and work in medicine has felt rushed, how often I have felt like I'm being pulled in multiple directions at the same time. It is now around 6:00 a.m. in the ICU, and I can see the first flickers of sunlight streaming through the windows. The patient who I came in to see is doing slightly better after we adjusted the ventilator settings and changed his blood pressure medications. We spoke with the nephrologist and made a decision to start him on dialysis in order to remove fluid and correct his acidosis. A few minutes later, the charge nurse asked me about another patient—a young man in his 30s with severe COVID-19 pneumonia who has been on maximal ventilator settings all night. We talk about putting him on ECMO, the last line of treatment available for his severe respiratory failure. After talking to my attending, we decide to proceed with the ECMO cannulation. I prepare to place a central line in the patient's left internal jugular vein. The hospital is still quiet and his room feels unusually spacious after the furniture has been removed to make space for the ECMO equipment. The nurse quietly goes about her tasks in the room while I gather the necessary supplies and position the patient for the procedure. I pause, gather my attention in the present moment, and begin. Cleaning—draping—placing the needle—threading the wire—inserting the catheter—suturing—dressing. In the still quiet hours of the early morning, my work in the ICU becomes my meditation. My body and mind are fully integrated into this single task. From this place of presence, joy arises. “Attention is a moral choice” said my mother, resolutely. She was referencing a well-known quote by author, psychiatrist, and philosopher Iain McGilchrist (“attention is a moral act”). I do not recall precisely what we were talking about before she said this. It doesn't matter. What matters is that this statement changed how I think about my life and the practice of medicine. It made me wonder: If attention is a moral choice and medicine is a moral enterprise, then what are the implications of distraction in modern medicine for patients, clinicians, and society? I was reminded of a discussion that I had last year with one of my colleagues. He was preparing for his board exam and said, jokingly, that if the examiners really wanted to test our clinical abilities, they would not simply give us access to UpToDate. The real test would be to interrupt us repeatedly with pages, secure chats, texts, emails, and questions from people nearby as we tried to take the exam. I imagine most of you can identify with this scenario. When I shared this story with a friend who does not work in healthcare recently, he seemed terrified. He wondered how clinicians can make good decisions in an environment filled with so much distraction. I wonder this, too, sometimes. And I worry. I worry about the fragmentation of attention in modern healthcare environments. I worry that it contributes not only to emotional exhaustion and unfulfilling personal connections among clinicians but also to lower patient satisfaction, reduced efficiency, and even medical errors. Numerous research studies have shown that medication errors increase when nurses are interrupted. In my experience, distraction separates us from our deepest values, prevents us from truly listening to our patients, and makes it difficult to recognize and attend to our own needs and the needs of those around us. So, what are we to do? Personally, I believe that the solution lies both within and outside ourselves. I started this essay with a story about meditation practice. Meditation is one of many practices that can be used to cultivate present moment awareness. Modern neuroscience research has shown that meditation and other contemplative practices not only improve focus and mental clarity but can also help us to cultivate prosocial qualities that are valued in healthcare, like compassion. By increasing self-awareness, these practices can also teach us how to work more skillfully with distraction, thereby minimizing the impact on patients. I have found this to be true in my own life and wonder if these evidence-based practices could be integrated more into modern medical training. In addition to minimizing inner distractions, we need to better understand how our modern work environments contribute to distraction. Can we design environments that support presence, connection, safety, and healing? Are there specific systems-level change we can make to ensure that distractions are minimized, especially in high-risk situations? For example, a colleague recently shared that oncologists at his hospital wear noise-cancelling headphones and work in a separate area when placing chemotherapy orders. Currently, there is limited research on distraction in healthcare and much of it is restricted to specific settings such as the operating room. We need additional research in this area, ideally done in collaboration with experts in organizational psychology, social psychology, and neuroscience. We need to ask some important questions. What are the conditions under which healthcare providers can focus and flourish? Can we use technology to rediscover simplicity rather than what feels like unending complexity? If attention really is a moral choice and medicine is a moral enterprise, then why are we not paying more attention to our attention? The author declares no conflicts of interest.