Mental mayhem: The peril of multitasking in medicine

Elizabeth Harry, MD, and Rich Joseph, MD, MBA

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 theJournal 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.

Underappreciated, or perhaps less discussed, is how maddeningly difficult it is to get “in the zone” while practicing medicine nowadays.

Harry and colleagues conducted the first large scale study to interrogate the intuitive link between cognitive load and burnout in health professionals. The investigation used the Task Load Index from NASA to evaluate the cognitive load of work environments as determined by four main subscales: mental demand, physical demand, temporal demand, and effort. As hypothesized, the sum Task Load Index scores were strongly and independently correlated with emotional exhaustion, depersonalization, and the overall risk of burnout across specialties. 

Solutions to reduce cognitive load must target both the individual and the work itself. Techniques like meditation, breathing exercises, and other stress reduction techniques help to enhance working memory in high-demand environments. Learning how to manage stress and anxiety is a core competency for any professional in today’s frenzied work environment.

On a system level, we must devise mechanisms and tools to reduce extraneous cognitive load. Checklists, for example, help automate and streamline workflow and enhance patient safety. Storing patient data in one reliable location on the EHR would reduce the redundancy, and hence cognitive load. We should reduce the extraneous cognitive load on trainees by limiting the number of patient charts that can open simultaneously, restricting interruptions during dedicated education sessions, triaging alerts and nursing requests based on clinical severity, and using one dedicated platform to communicate about patient care with consulting services.  

These solutions, albeit critical, chip at the margins rather than cutting to the core question-how do we rediscover a sense of flow in the work of doctoring? Harry recounted a recent episode that may provide a clue. While sharing the concept of cognitive load with a group of surgeons, many of them noted the “sacred” space of the OR, in which they do their craft with minimized interruptions, limited pages, and no email.

The National Physician Burnout, Depression & Suicide Report 2019, conducted by Medscape, discovered that the highest rates of physician burnout by specialty occurred among urology (54 percent), neurology (53 percent), physical medicine and rehabilitation (52 percent), internal medicine (49 percent), emergency medicine (48 percent), and family medicine (48 percent). Conspicuously absent are many fields-surgical specialties, in particular-with notoriously brutal hours that we would hypothesize to experience more burnout than those with less hours on call, more sleep, and better “work-life balance.”

To be clear, many surgeons are suffering from intense burnout. But perhaps when they are able to access flow in the operating room-one of the few remaining workspaces that prioritizes and facilitates intense focus-this may confer some protective effect. This begs the question of how we create environments that support “deep work” for all physicians? For internists and others who primarily do cognitive work, consider designing workflows that batch the endless communications about patient care in order to free up protected blocks of time to actually think and devise the best possible care plans. For emergency medicine doctors, consider skill-based shifts, where one trainee is exclusively doing procedures, one is taking histories, and one is triaging patients based on acuity. For radiologists, one might be assigned to field requests for wet reads and imaging protocols such that the others may focus intensely on reading films.

Medicine is a heterogenous profession with diverse personality types and a complex division of labor. But the desire to experience flow in work is universal. Solutions to physician burnout must enable us to spend time, energy, and focus immersed in the essence of our craft.

Rich Joseph, MD, MBA, is a senior resident in primary care-internal medicine at Brigham & Women’s Hospital in Boston, Mass. His clinical practice going forward will focus on Weight Management and Obesity Medicine.

Elizabeth Harry, MD, is the assistant medical director for the Brigham & Women’s Physician Organization and director of faculty development and wellbeing. She practices as a hospitalist.