“She doesn’t look like a person with an addiction problem to me,” replied the physician to the psychiatrist, referring to a patient who was admitted to the hospital for confusion. She was found at home amidst an array of bottles containing various controlled substances, and a toxicology screen positive for cannabis. She was in a higher socioeconomic bracket having retired from a professional job. The psychiatrist explained that addiction crosses all social lines, and there was no typical “look,” but there was an ongoing reluctance by the physician to concede that addiction was an issue. Cognitive rigidity, an affliction we are all vulnerable to, is the inability to appreciate another perspective. Gary Klein, in Streetlights and Shadows: Searching for the Keys to Adaptive Decision Making, described cognitive rigidity as “holding onto initial explanations despite the subsequent accumulation of contrary evidence.” It’s a tendency to adhere to a set of beliefs, or an unwillingness to consider a viewpoint that does not fit a person’s own narrative.
Take this puzzle as an example. To solve it, connect all nine dots by using no more than four continuous lines, and the pen cannot be lifted from the paper once drawing begins. The solution will be discussed later.
Cognitive rigidity in medicine can interfere with our ability to work effectively. It causes us to put present and future encounters in boxes from past experiences. While building on previous experience is essential to our foundation of knowledge, sometimes it can hinder us from thinking outside that proverbial box. Similarly, automatic responses and muscle memory are needed in situations in which a quick assessment of the situation and a quick response is critical. But sometimes, automatic and habitual responding can narrow our options because we have difficulty considering alternatives.
Some common symptoms of depression can be insomnia, low mood and difficulty concentrating. During one encounter, a patient endorsed the above symptoms but also casually mentioned her longtime hobby of working with beads and making jewelry.The patient’s niece softly expressed concern about the jewelry products possibly containing lead. So we worked up the patient for lead poisoning, the symptoms of which can also be insomnia, low mood and difficulty concentrating. If I were working on autopilot, I might have been in a rush to dismiss the family member’s concern and would have proceeded to solely attribute this patient’s symptoms to a psychiatric disorder. Did she actually have lead poisoning? No, but I’m glad that I considered it a possibility and could safely rule that out. The purpose of being more cognitively flexible is not to approach every single patient with the aim of discovering a rare illness, but to avoid habituation which may blind us to subtle clinical cues that present an opportunity for further exploration.
There are several ways to develop cognitive flexibility, but one way is mindfulness. It’s like Pilates for your brain. And as with any exercise, it takes repetition and persistence to develop those mindfulness muscles. While mindfulness is an integral part of meditative practices, it does not require taking time out to meditate. Mindfulness is the human capacity to pay attention to the present, on purpose, without judgment and can happen on the move. It happens when we pay attention to our walk from the car to the office (without thinking about the day’s schedule). It happens when we notice the flavors of the pasta at lunch (without thinking about the load of laundry waiting at home). It happens when we intently auscultate a patient’s heart (without thinking about the previous patient’s test results.) If we’re paying attention in the moment, we’re practicing mindfulness.
We can all remember being medical students and our first patient encounters. We tended to be so focused on the questions we needed to ask that we weren’t always fully attuned to the patient’s responses. Sometimes, after missing what the patient said, we may have had to repeat questions. By being present and paying attention, we can efficiently register patient’s responses, without precious seconds being used to repeat questions or overlook information the patient may have already volunteered. Dr. Ronald Epstein, author of Attending: Medicine, Mindfulness, and Humanity, often talks about the “doorknob method” of reminding ourselves to be more mindful. Before entering a patient’s room, as the hand touches the doorknob, gently bring the attention to the present moment, quietly count three breaths and then enter the room.
Mindfulness asks we see people or situations with a “beginner’s mind.” It’s seeing a problem as if it’s the first time it’s ever been seen. If the fifth patient of the day presents with chest pain, it requires reliance on expertise and a foundation of knowledge built from years of experience, but also requires releasing any preconceived notions about this fifth patient and releasing assumptions as to the potential source of their chest pain. Avoiding working on autopilot and avoiding assumptions opens the mind to possible subtle clinical clues that can alert a clinician to a different diagnosis.
Furthermore, research shows that mindfulness helps us to be more attentive, strengthens our ability to focus and tune out distractions and improves working memory. Goleman and Davidson wrote about the science behind mindfulness in their new book, Altered Traits. Even three ten-minute sessions of breath counting in subjects improved scores on a battery of cognitive tests. Mindfulness practices have also been shown to improve adaptation to novel and non-habitual task requirements.
Back to that puzzle. It’s common to feel restrained by the dots, despite instructions saying nothing about drawing lines that go outside the margins of the dots.
We were drawn to the field of medicine because of our desire to take care of our patient’s health and well-being, and because we were drawn to the intrigue of solving medical puzzles. Cultivating cognitive flexibility can help us to work efficiently and help us avoid missing details so that we can be better diagnosticians, and ultimately better healers.
Smitha Murthy is a psychiatrist and can be reached on Twitter @smithgirl0906.
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