Medical training has drained my brain.
Not in the good way—that satisfying cognitive fatigue after hours of deep, engaged work. Just the opposite. My attention span is scattered. My focus is fuzzy. My brain is fried from the fire of incessant disruptions. My monkey mind meanders amok. Purportedly, the average attention span for humans is now reportedly less than that of a goldfish. Goldfish-level attention feels aspirational for me nowadays.
Many of the reasons that residents suffer distress and burnout are evident and well-characterized. Causes include physical and emotional fatigue, the imbalance between effort and reward, and a lack of control. Now, in my last week of residency, I recognize another, more insidious culprit—years of distraction eroding my ability to focus. The struggle to concentrate and single task underlies much of my dissatisfaction, stress, and burnout.
Data is now validating my lived truth—the multitasking demanded in our work is likely an under-appreciated, but substantive factor in physician burnout. Cognitive Load theory, articulated by John Sweller, relates to the amount of information that working memory can hold at one time. Short-term working memory describes our capacity to store and manipulate information in service of complex tasks. A limited resource, short-term working memory shrivels under physiologic or emotional stressors. The greater the cognitive load, the more difficulty we experience when trying to pay attention, rehearse, and remember. Learning new information requires minimizing distracting—so-called extraneous cognitive load—to maximize the transfer of important information into long-term memory.
Multitasking is a myth, or better yet, a misnomer. When we multitask, we actually shift our attention rapidly between multiple tasks. Our brains are built to single task. When we task-switch, we interrupt ourselves and lose time in the process. Often touted for hyper-efficiency, multitasking actually reduces productivity, increases mistakes, and contributes to information overload, according to a study in the Journal of Experimental Psychology: Human Perception and Performance. With each switch, a so-called “residue” of attention remains stuck thinking about the original task.
Studies find that frequent multitaskers have reductions in grey matter in areas that control empathy and emotions and exhibit weakness in both working memory and long-term memory. We become increasingly distractible and may even be more prone to depression and anxiety. The chronic stress inflicted by multitasking restricts our available resources for attention and working memory.
Burnout emerges when the stresses of a job outstrip one’s ability to cope effectively. A systematic review of job burnout and cognitive functioning shows a clear correlation between burnout and a decline in three major cognitive functions—executive functions, attention, and memory. In medicine, the increasing cognitive load is a function not only of a mounting work load, but the complexity and pace of the work flow. The high-stakes environment adds another layer of anxiety. Beneath this festers a corrosive culture and the “hidden curriculum” of medical training, still rife with mobbing, bullying, and harassment. This overwhelming cognitive load heightens stress and likely accelerates burnout by clouding attention and working memory.
In contrast, our brain works most efficiently when it can focus on a single task—even if boring or frustrating—for a longer period of time. Focus is foundational for job satisfaction. As originally described by psychologist Mihaly Csikszentmihalyi, “flow” is “a state in which people are so involved in an activity that nothing else seems to matter; the experience is so enjoyable that people will continue to do it even at great cost, for the sheer sake of doing it.”
Elements of flow include:
- present moment concentration on a singular task,
- a clear objective with immediate feedback, an intrinsically rewarding experience,
- a sense of effortlessness,
- an appropriate balance between perceived challenge and skill,
- a sense of control, and
- an absence of time and self-consciousness.
We might refer to this colloquially as being “in the zone.” This heightened sense of awareness of the here and now is inaccessible if distractions interfere.
Excessive cognitive load is understandably perilous for patient safety. “The ability to obtain new information, store that information, and subsequently retrieve it is a critical component of safe and effective patient care,” explain Harry and Sweller. Do you remember entering the wrong medication for a patient while toggling between multiple patient charts on the electronic health record? Or perhaps you accidentally forgot to note that critical task for a patient amid the deluge of questions, pages, and alarms? Many of us have been there, tiptoeing along the precipice of medical error.
Mental overload can bring us to the edge of catastrophe.