A Conversation With … Peter Cavanagh PhD, Former NASA Spaceflight Researcher, on “Patient” Observation

This month’s conversation will focus on patient observation, but not the sort that might first come to mind. It’s not about observing patients, but rather observing with patience, or observing patiently. Of course, if you’d like to use what we learn from this month’s guest—a pro at patient observation—to observe your patients more patiently, I won’t stop you. (And they’ll appreciate it.) Peter R. Cavanagh PhD (Fig. 1) would fit right in at any professional meeting at which you might find yourself as an orthopaedic surgeon. In fact, for 45 years, he attended those very meetings as a biomechanics researcher. His storied career was punctuated by receiving the Muybridge Medal from the International Society of Biomechanics, the Borelli Award from the American Society of Biomechanics, and NASA’s Distinguished Public Service Medal. Those are, respectively, the most prestigious awards given by the two leading professional societies in his discipline, and the highest civilian honor awarded by the world’s (and for all we know, the universe’s) leading civil space program.Fig. 1: Peter R. Cavanagh PhD shooting a Northern Gannet colony in Finnmark, Norway. © Peter CavanaghBut we aren’t going to talk about any of that. Instead, we are going to talk about rare birds and what it takes to observe them with sufficient patience and skill to capture them on film, while they are in flight, in a way that allows the resultant photos to be clear enough to convey the biomechanical principles of aerodynamics (Fig. 2), and beautiful enough to become coffee table books (Fig. 3) [1, 2] and museum exhibitions (Fig. 4) [3].Fig. 2: (A) A Bald Eagle (Haliaeetus leucocephalus) in a steep dive and (B) the approximate lift vectors from the right (L1) and left (L2) wings. Reorienting the lift vectors allows the bird to use its wings as multidirectional force generators. Key: Ly = vertical component of lift from the left wing; Lx = horizontal component of lift from the left wing. © Peter CavanaghFig. 3: A migratory Sandhill Crane (Antigone canadensis) during a winter stopover at Bosque del Apache National Wildlife Refuge in New Mexico, USA. © Peter CavanaghFig. 4: A Black-billed Mountain Toucan (Andigena nigrirostris) from Colombia with its brakes on, ready for a landing. © Peter CavanaghDr. Cavanagh has photographed birds on all seven continents, which certainly is impressive. But what impresses me far more is the patience with which he does so. He positions himself and waits like a sniper (an 18th-century bird reference, for those who know), for hours at a time, to capture the perfect combination of angle, light, optics, and flight mechanics. If you’re going to see 50 patients in the office tomorrow morning, it’s unrealistic that you’ll observe all of them with great patience. You won’t have that kind of time. But we all know when we’re in the room with a patient who is a puzzle—perhaps a diagnostic puzzle, or a shared decision-making puzzle whose situation calls you to bring all your empathy and care to the task of making a good choice in the context of that patient’s deeply held values. And we all know that those are moments in which we need to slow down, watch, and listen…even when there are 49 patients to go. We also all know that getting the tough patients right, even if doing so takes time, will save time in the longer run. It’s worth saying that close observation and careful listening also help in other settings, like getting to understand our own minds better and becoming more attentive to the people in our lives whom we love. Read the conversation that follows with Dr. Cavanagh, who’s got a thing or two to share about gaining the difficult-to-acquire skill of patient observation, and what we can learn about ourselves along the way. Seth S. Leopold MD:How have you changed over the years in terms of your ability to observe patiently? Is it getting easier? Harder? Peter R. Cavanagh PhD: First, I want to thank you for challenging me to introspect on something that has become a passion over the last decade. Passions rarely yield to an analytical approach, but, as I have pondered your questions, I think there are some underlying themes that may be useful to someone engaged in such a demanding and all-consuming profession as orthopaedic surgery. Let me start by defining the niche that I now inhabit as a bird photographer and author: I shoot and write about birds in flight. While there is great beauty in observing, recording, and capturing images of stationary birds perching or feeding, my professional background as a “quantifier” of human movement led to my desire to understand and record the phenomenon that has made birds so successful over the last 140 million years or so. Flying is the essence of “birdness”: Of the 11,000 or so extant species around the world, 99.5% of them can fly, and some use that ability to embark on astonishing feats of migration every year, such as the trans-Himalayan flight of Demoiselle Cranes (Anthropoides virgo) and the 8245-mile nonstop flight of a Bar-tailed Godwit (Limosa lapponica). The aerial maneuvers of birds are unmatched by even the most complex modern aircraft, with a prime example being the 200-mph stoop and prey-capture of the Peregrine Falcon (Falco peregrinus). Many of my avian encounters start by locating the target species on a perch, nest, or the ground, because I want to capture those first few fractions of a second as the bird launches into flight. This is when the process of patient observation and sometimes protracted waiting begins. I must address the technical issues of the shot (the shutter speed, the aperture, the ISO value) and modify these settings as weather conditions change, while keeping the eye of the bird at the center of my camera’s focus. I must be ready to start shooting at the instant movement begins. Sometimes, this process happens so fast that there is hardly enough time to ensure that my camera and I are ready to capture the shot, and other times, this process requires hours of absolutely unbroken concentration. Recently, in Kenya’s Rift Valley, I staked out the nesting tree of a Crowned Eagle (Stephanoaetus coronatus) for more than 8 hours, eventually capturing just one partially obstructed flight shot. There is no question that my skills and patience have improved over time. Now, I know the signs that suggest flight is imminent; I am more ready to take advantage of unexpected events; I am more centered in my waiting; and I am more successful in ignoring extraneous occurrences. But what has really made things “easier,” I would say, are recent advances in camera technology, which have had a huge impact on the quality and consistency of my results. My current camera (a Sony Alpha 1 Mk II, usually used in conjunction with a 600-mm f/4 lens) has firmware artificial intelligence (AI) that detects the image of a bird’s head in a predefined zone of the viewfinder. Once it has located the bird’s eye, it tracks and holds focus on the eye as the bird moves. This is nothing short of revolutionary. Every photograph in my first book [1] was taken with what is now a dinosaur of a SLR camera that required me to manually maintain a focus point on the bird as it moved across the sky (and with equipment that was nearly twice as heavy as my present gear). My current camera also has a feature called “precapture,” which enables images to be collected and saved before the shutter button is fully depressed. Once this mode is activated, images are temporarily saved in a circular buffer that, when full, is overwritten until the shutter button is fully depressed. At that time, the precaptured images are written to the camera card, and shooting continues at up to 30 pictures per second. For a flight photographer, this is a monumental development. Now, I am almost guaranteed a series of images from first movement to takeoff. It feels like cheating compared to my methodology of only 5 years ago! The lesson here is to grasp technological change with both hands, as the results can be astounding. Embracing change as an early adopter of new technology has revolutionized both my workflow and my images. Dr. Leopold:I understand what you're saying about the technology, but I'm wondering if you can comment a bit more about whathas helped you to continue to develop your patience and attention? Any tips you can recommend? Dr. Cavanagh: The process of being in a wild place searching for birds opens a space in my mind that verges on a meditative state that some eastern religions call samadhi, or “undistractedness.” A similar and more prosaic description in social psychology refers to the attenuation model, or “cocktail party effect,” where we can selectively attend to one set of stimuli while ignoring others. Such mechanisms allow me to assign the time—an hour or the entire day—to wildlife and nothing else. I ask myself the question: “Is there any other thing that I would rather be doing at this moment?” The answer “no” gives me permission to completely commit to the task at hand and ignore any competing thoughts and actions. Once I have made my mental commitment, there are a few practical steps I take to maintain the focus of my attention. I start by doing everything I can to minimize distractions in the current environment. Unless I am in one of the few places in the world where cell phones do not work (like Antarctica and parts of the Arctic), I turn off my phone so I am not tempted by the endless barrage of texts, emails, and notifications. When I am photographing birds in public places, the occasional person will drift by and want to engage in conversation, but I politely decline the interaction, explaining my need for vigilant attention without ever taking my eye from the viewfinder. Most passersby will respect this explanation. Some of the practical mechanisms I use to stay task-focused include working to anticipate the signals that action is imminent. Before they plan to depart, perching birds may stop preening to stretch their wings, lighten their takeoff weight, or they may rapidly scan the area for signs of danger or opportunity. They will invariably change their position to face the oncoming wind, because taking off into the wind increases the relative airflow over the wings and enhances aerodynamic lift. The biomechanics of takeoff in birds, as in humans, involves a countermovement in which the extensor muscles are activated eccentrically (the stretch-shorten cycle) to increase the takeoff force and power. So, watching for the countermovement as an early warning sign can be useful. However, nature is unpredictable, and I have missed many good photographs when none of the above signals were present. If I intend to take a photograph of an incoming bird, I pick up focus on the bird at soon as possible and follow it all the way in until it is positioned against the best possible backdrop. It is not uncommon for me to collect 50 to 100 images during a single flight encounter. When the wait is particularly long—as in watching a bird for several hours with my finger constantly on the shutter release—I sometimes resort to peculiar mind games to keep myself engaged. I imagine the interaction to be a competition between the bird and me. The bird wishes to conserve energy and fly only when it is advantageous to do so, whereas I want the bird to fly as soon as possible so that I can capture an image, and I am determined to outlast its hesitancy. This notion of a contest between “hunter and hunted” presumably has a deep evolutionary origin. As in any competition, the drive to win generates adrenaline, and that release keeps me engaged for a few more, possibly critical, minutes. Dr. Leopold:I fear that some readers will say something like, “this is all fine if you’ve got all day to spot a bird, but I’ve got to see 50 patients before I can call it quits today; what possible use could this have for me?” I believe your skills in this area can transfer directly to surgeons, but I’m more curious for your thoughts on this—both as someone who has worked with lots of surgeons, as well as, perhaps, someone who has been a patient occasionally. Is there a way for people to use what you know even if they have to move at a certain pace in a surgical practice? Dr. Cavanagh: I certainly understand if many readers discount my experiences and observations as irrelevant to their busy and stressful lives. Successful surgeons cannot dwell for long on the many possible approaches to a problem—they need to see, act, and move on. But this is why I think the notion of undistractedness is relevant to orthopaedic surgeons, who must deal with the professional pressures of practice politics, scheduling difficulties, financial stress, staffing, and the like, along with all of the personal distractions that are lurking, ready to drain their attention from the most important task. Then, when a procedure is underway, the surgeon must divide his or her focus between the mechanics of the surgery and the incoming information on the status of the patient from numerical and observational cues. These inputs must be weighted, and decisions must be made quickly to achieve the desired results. These periods of prolonged watchfulness and attention to external conditions are normal occurrences in your lives, as in mine. While the importance of undistractedness is obvious during surgery, it is other aspects of a patient-surgeon interaction that influence the patient’s mindset. Most patients will respond negatively to an encounter that feels rushed, focused on external factors such as the EMR, or driven by general assumptions rather than information derived from thoughtfully observing and listening to the patient. In other words, patients tend to react negatively when they feel as though their surgeon is focused on the mechanics of a visit rather than on listening. This is where surgeons can work on achieving samadhi—within the context of patient interactions. Think of it this way: A surgeon has devoted decades of his or her life to education and training to gain the knowledge and skills necessary to serve one purpose: providing benefits to patients. That vast investment of time and intellectual energy leads to a given moment with a given patient: every patient, every moment. So why, in the middle of an interaction or surgical procedure, would a surgeon possibly want to think of anything but the task at hand? Before entering a room, asking the question, “Is there anything else I would rather be doing at this moment?” may be useful. Acknowledging that this moment is not the ideal time to address the many distractions lurking in one’s mind can result in a valuable reset. Dr. Leopold:To what degree are looking and listening carefully different activities? If one comes easier to someone than the other, how can we shore up our soft spot? Dr. Cavanagh: Listening is an important component of comprehensive observation. A couple of wildlife experiences come to mind by way of illustration. I was traveling in South Africa’s Kruger National Park some years ago with a guide who was acutely attuned to the sounds of the bush. It was a matter of survival for him, because he often led walking safaris in areas where Big 5 animals (lions, leopards, elephants, buffalos, and rhinos) were abundant. We were sitting in camp after a game drive when he called my attention to a distant commotion. “The monkeys are warning that eagles are hunting,” he said. From the cacophony of bush sounds, he recognized the specific alarm calls that of aerial who to their (Fig. The of as a different he A Crowned Eagle (Stephanoaetus coronatus) heavy to bring the of a to its in Kruger National South As a the Crowned Eagle may face in the but it does not for a such as or © Peter that we into a with a series of bird the guide an “The birds are that there is a the before in a as a by the birds, made its birds by their and many such encounters in their of birds But on this to I was to be in the of an who had taken the skill of listening to a that few other He had the of and birds, which his (and the of those he The this might have been to the and birds that were but not the of their These observations from the are relevant to our of close observation. The here is that when we with we may know who is but we may not be attuned to the and of his or her to fully understand the of what is being For the being when someone am in can someone who is listening carefully how or that A will the the patient’s and engage in to learn This is a but it that listening is more than Dr. to a though that you do more in than many of do during periods of it’s had to have been a change for you. I can see the of the in the you’ve been the of the change, and your best for Dr. Cavanagh: It is a but to say that both a and an opportunity. The could be to continue your in a different like rather than or working in rather than in The is to use as a to a completely new I that and deeply engaged in the and of avian flight. The of this kind of change is the that to a that is by people who have made it their If you can imagine the of an photographer to become an orthopaedic you can the My own to these was to a deep dive into the of avian The that my of during space flight to of on avian flight. I made it my to as many as I could and set up for new on avian My The and of refers to the work of more than working in this I could not to new in avian I could help what was in new my use the skills during my professional career to and help the of others. I share this to who are that there are many skills one over the of a professional career that are directly to in completely different And for a new of has been