secretNeuron overload and the juggling physician

Neuron overload and the juggling physician

Danielle Ofri

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Patients often complain that their doctors don't listen. Although there are probably a few

doctors who truly are tone deaf, most are reasonably empathic human beings, and I wonder

why even these doctors seem prey to this criticism. I often wonder whether it is sheer neuron

overload on the doctor side that leads to this problem. Sometimes it feels as though my brain

is juggling so many competing details, that one stray request from a patient

—

even one that is

quite relevant

—

might send the delicately balanced three-ring circus tumbling down.

One day, I tried to work out how many details a doctor needs to keep spinning in her head in

order to do a satisfactory job, by calculating how many thoughts I have to juggle in a typical

office visit. Mrs Osorio is a 56-year-old woman in my practice. She is somewhat overweight.

She has reasonably well-controlled diabetes and hypertension. Her cholesterol is on the high

side but she doesn't take any medications for this. She doesn't exercise as much as she should,

and her last DEXA scan showed some thinning of her bones. She describes her life as stressful,

although she's been good about keeping her appointments and getting her blood tests. She's

generally healthy, someone who'd probably be described as an average patient in a medical

practice, not excessively complicated.

Here are the thoughts that run through my head as I proceed through our 20-min

consultation.

Good thing she did her blood tests. Glucose is a little better. Cholesterol isn't great. May

need to think about starting a statin. Are her liver enzymes normal?

Her weight is a little up. I need to give her my talk about five fruits and vegetables and 30

min of walking each day.

Diabetes: how do her morning sugars compare to her evening sugars? Has she spoken with the

nutritionist lately? Has she been to the eye doctor? The podiatrist?

Her blood pressure is good but not great. Should I add another BP med? Will more pills be

confusing? Does the benefit of possible better blood pressure control outweigh the risk of her

possibly not taking all of her meds?

Her bones are a little thin on the DEXA. Should I start a bisphosphonate that might prevent

osteoporosis? But now I'm piling yet another pill onto her, and one that requires detailed

instructions. Maybe leave this until next time?

How are things at home? Is she experiencing just the usual stress of life, or might there be

depression or anxiety disorder lurking? Is there time for the depression questionnaire?

Health maintenance: when was her last mammogram? PAP smear? Has she had a colonoscopy

since she turned 50? Has she had a tetanus booster in the past 10 years? Does she qualify for a

pneumonia vaccine?

Ms Osorio interrupts my train of thought to tell me that her back has been aching for the past

few months. From her perspective, this is probably the most important item in our visit, but

the fact is that she's caught one of my neurons in mid-fire (the one that's thinking about her

blood sugar, which is segueing into the neuron that's preparing the diet-and-exercise

discussion, which is intersecting with the one that's debating about initiating a statin). My

instinct is to put one hand up and keep all interruptions at bay. It's not that I don't want to

hear what she has to say, but the sensation that I'm juggling so many thoughts, and need to

resolve them all before the clock runs down, that keeps me in moderate state of panic. What

if I drop one

—

what if one of my thoughts evaporates while I address another concern? I'm

trying to type as fast as I can, for the very sake of not letting any thoughts escape, but every

time I turn to the computer to write, I'm not making eye contact with Mrs Osorio. I don't want

my patient to think that the computer is more important than she is, but I have to keep

looking toward the screen to get her lab results, check her mammogram report, document

the progress of her illnesses, order the tests, refill her prescriptions.

Then she pulls a form out her of bag: her insurance company needs this form for some reason

or another. An innocent

—

and completely justified

—

request, but I feel that this could be the

straw that breaks the camel's back, that the precarious balance of all that I'm keeping in the

air will be simply unhinged. I nod, but indicate that we need to do her physical examination

first. I barrel through the basics, then quickly check for any red-flag signs that might suggest

that her back pain is anything more than routine muscle strain. I return to the computer to

input all the information, mentally running through my checklist, anxious that nothing

important slips from my brain's holding bay.

I want to do everything properly and cover all our bases, but the more effort I place into

accurate and thorough documentation, the less time I have to actually interact with my

patient. A glance at the clock tells me that we've gone well beyond our allotted time. I stand

up and hand Mrs Os

orio her prescriptions. “What about my insurance form,” she asks. “It

needs to be in by Friday, otherwise I might lose my coverage.” I clap my hand against my

forehead; I've completely forgotten about the form she'd asked about just a few minutes ago.

Studies have debunked the myth of multitasking in human beings. The concept of

multitasking was developed in the computer field to explain the idea of a microprocessor

doing two jobs at one time. It turns out that microprocessors are in fact linear, and actually

perform only one task at a time. Our computers give the illusion of simultaneous action based

on the microprocessor “scheduling” competing activities in a complicated integrated

algorithm. Like microprocessors, we humans can't actually concentrate on two thoughts at

the same exact time. We merely zip back and forth between them, generally losing accuracy

in the process. At best, we can juggle only a handful of thoughts in this manner.

The more thoughts we juggle, the less we are able to attune fully to any given thought. To

me, this is a recipe for disaster. Today I only forgot an insurance company form. But what if