The ‘ecology of attention’ in health and social care

Apr 2, 2021

Every single transaction expends precious time of attention; time which is even more precious amidst the escalating claims on our attention. Those needing support and treatment are hoping to have their circumstances and problems understood, they seek attention, attention to the way their lives have been affected.

There is a constant barrage of calls on our attention, devaluing the quality of information and its validity. The theoretical physicist, Michael Goldhaber, described attention as the most precious and finite of all human resources (NYT report, February 2021).

The competing demands for attention can impair the delivery of health care. Increasing the time to process diagnostic and treatment decisions, interfering with memory recall, biasing decisions and creating insensitivity to changing clinical conditions. Clinicians want to be available for – shared patient information, feedback and advice – but “reachability” with its frequent contacts can degrade the quality of attention to patients’ needs and problem-solving.

These distractions in health care have been characterised by Mark Kissler and colleagues in the New England Journal of Medicine, Jan 25, 2021, as the medical “ecology of attention”.

Many factors can impede attention to patients – physical barriers, addictive computer screens, multiple screens, clunky electronic medical records, a plethora of advisory screens, guidelines and other non-critical demands besetting all levels of health care. Health care could learn from the airline industry. Safety depends on pilots devoting their undivided attention to flying the aircraft. Aviation regulators refer to the “sterile cockpit rule” which prohibits non-essential activities and distractions.

A shift to attentive care away from preoccupations with workload, time and resources, will improve the value, safety and satisfaction of patients and clinicians in their interactions. Moreover, it will address the disenchantment, withdrawal and ‘burn out’ in front-line clinicians. Clinicians are not engineers dealing with machines, they deal with bodies and persons. They need to be able to get on with the core work of healing.

Dr Rita Charon, a leader in ‘narrative medicine’ wrote:

“[attention] seems [to be] the most pivotal skill with which to endow a health professional who wants to be a healer.” And elsewhere, “…. We should think ambitiously about clinical environments that optimise attention. Such thinking can improve quality, efficiency, and patient and provider satisfaction and reduce the costs of care. Perhaps most important, it takes seriously the human elements that are necessary to produce high quality and meaningful work – a worthwhile goal for any care environment.”

Each one of us hopes, that in our own visits to the doctor and other professionals, we will have their undivided attention. But for many people this will rarely or never happen.

Disadvantaged people struggle to get attention in social/health services. The relationships speak of powerlessness and lack of agency. Expressed in voice, lack of eye contact, body language and physical barriers – protective screens, computer screens, the desk – unanswered telephone calls and clunky websites. Yet, their needs are desperate.

A man with several disabilities and long-term pain in Nowra, NSW, had re-applied for a Disability Support Pension including details of his medical condition. It was again rejected. He was distraught. The rejection letter had two phone numbers. I phoned the first, to Centrelink, but the call was unanswered. The second was to the Ombudsman’s Office where the response was a helpful.

It was lunchtime and we walked together to the Centrelink office. Eyes were raised. “I’m from the community clinic and this is my patient, I want his problem to be dealt with fairly.” After some negotiation between officers, the patient was ushered to senior officer behind a computer screen, while I waited at a distance.

As we left the building, the patient turned to me and said, “They never speak to me the way they speak to you.” (That says it all.)

I’ve watched, heard raised voices, as applicants for welfare or housing try to convey their circumstances and to be understood.

Much of the relationship of disadvantaged people with government is managed through Services Australia. Unsurprisingly they have been troubled by behavioural problems from applicants for welfare support in their public shop fronts. Their response was to canvas the idea of limiting staff contact with vulnerable ‘customers’. So they commenced the “vulnerable ‘customers’ innovation challenge” within the department, for ideas on how this might be achieved. As soon as the plans became widely known, they were abandoned.

There are examples of good performance by government agencies in dealing with  stressed and disturbed applicants.

During the pandemic, I saw staff at a Services NSW agency thoughtfully managing the queued and ‘socially distanced’ crowds of people – for car registrations, licenses, proof of identity and much more. Staff members reached out and spoke personally to everyone in the queues – managing their anxieties, language difficulties and disabilities.

Those needing support and treatment are hoping to have their circumstances and problems understood, they seek attention, attention to the way their lives have been affected.

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