Attention

I’m going to talk about something going on placement highlighted for me, and that I see as symptomatic of a more general trend that exists in society, and that is the lack of attention.

Paying attention is extremely important, yet is so often seen as dispensable, or even a chore. You see the lack of attention everywhere — in lectures, in class, in the street, at the shop, and in conversations, when the person messaging you is suddenly infinitely more interesting than the real person sitting before you. It’s even built into our language: you ‘pay’ attention, because it’s valuable, like money. The things you pay attention to eventually grow. The things you don’t pay attention to eventually wither.

If you don’t pay attention in class, your grades will suffer, you won’t learn, and you’ll waste your time. If you don’t pay attention to people when they talk to you, your relationships with them will suffer. Attention paid or not paid to infants determines whether they develop Narcissistic Personality Disorder in later life. Everyone, whether they admit it or not, craves attention. We need attention to stay healthy; as social animals it’s biological. Social media is an economy built almost entirely on attention.

On placement I found that staff were keen to get exams done and didn’t really engage with patients on a personal level. I made a special effort to engage with them, because I know what it is like to be ignored or treated badly by professionals and I don’t want to subject others to that. I put myself in the patient’s shoes, because I acknowledge that they could be me – in fact, probably will be me in the future. I will be the old person being wheeled in to the x-ray room with pneumonia; fragile, on the brink of death, completely dependent on the attention and competence of the young people there.

The fundamental character and aim of health practice is service. We’re there to serve sick people. We’re not there to take out our personal psychological problems on them, or our colleagues, and yet this is so often what happens. I saw this on placement, and I see it all the time. I always wonder what people would rather be doing instead of being present and paying attention. Often they’d rather be somewhere else – on a tropical island, having a nice meal, or driving a nice car. What they don’t realise is that enjoying any of these activities requires that they pay attention to them. Doing anything well requires paying attention to.

The power of attention is evidenced by the success of the Mindfulness movement, which gained momentum in the West in the 1970s, when Jon Kabat-Zinn started the Mindfulness-Based Stress Reduction program at the University of Massachusetts Medical School. The program has been highly successful and recent research shows that meditation improves attention. The power of attention has been known in the East for thousands of years, yet it’s only now that the West is beginning to appreciate its power.

There is a very important and interesting philosophical distinction that I learned about years ago, and it describes the fundamental attitude that I think can transform our practice and our culture. It goes by different names, but in essence it’s really very simple. It is two different ways of relating to things or people. One way is the instrumental way, the other is the contemplative way. The philosopher Martin Buber called it the I-It and I-Thou distinction; in psychology there is intrinsic vs extrinsic motivation; Immanuel Kant referred to it as “seeing things as ends in themselves, rather than merely as a means”, and other philosophers call it the disinterested vs the interested relation to things. So for example, imagine you go to a gallery to see a painting. The first way of looking at this painting is the I-Thou way, which means you contemplate the painting, you appreciate it for its qualities, you admire it, it raises further questions in your mind, you behold it; you’re glad that it exists. You’ve had an experience with it that you haven’t had before, even with other paintings. The other way of looking at this painting is the I-It way, which is looking at it instrumentally, as an object. You might think “If I buy this painting today, how much can I sell it for in 5 years’ time?” You don’t care about the individual painting — all you are interested in is what you can get out of it. You might argue that being delighted by a painting, as in the first approach, you are still “getting something out of it”. This is true, but you’re getting something out of it in a way that doesn’t ignore the individuality of the painting — the attributes that make it unique and unlike any other painting in the world. It’s no longer fungible, like money: fungibility means my $5 note is the same as your $5 note; there is no practical difference between them. Not so with paintings, or with people.

I would encourage anyone to cultivate the I-Thou relation to things over the I-It. It can be applied to your relation with anything: a piece of music, a pet, a city, nature itself. It most definitely applies to patients. Rather than seeing patients as a nuisance, a source of money, things that interrupt your lunch break, a faceless throng — see them as individuals. Even if a person strikes you as particularly boring, just imagine that they’re not. Sometimes just positing this belief changes something in them, such that they do become interesting. They suddenly see that it’s okay to be themselves, however they are. I’ve seen this every time I give my undivided and judgement-free attention to someone. Thankfully, this is an ability that can be cultivated by anyone.

However, it’s not just paying attention that is required of us. It’s also knowing when and how to pay attention. I interviewed one of the dentists I used to work with and he highlighted an apparent conflict in clinical work, which is the one between clinical proficiency on the one hand, and compassion and empathy on the other. He pointed out that sometimes, in trying to remain compassionate, you fail to do your job in some way. Indeed, one area in which I struggle is where I allow the needs of individual patients to conflict, e.g. in allowing a patient to talk – which I do because maybe no-one has listened to them for a long time – it means the next patient, who is waiting, is made to wait longer. So in my aim to be compassionate to one person, I have done a disservice to another.

So there is a fine line here, and the key is judicious application. In Virtue Ethics, this is called practical wisdom, or phronesis in Greek (it’s Greek because Aristotle invented it). Basically it means knowing what to do, when to do it, and how to approach it. This can be mastered through practice, but even then you’ll sometimes miss the mark (which is fine, because that’s how you learn). The solution is to maintain one’s boundaries and communicate them in a tactful and understanding manner. Remaining patient-centred, you judge, based on the individual situation, when to stop the conversation and call the next patient in, or leave the room to set up the console or whatever you need to do.

Every tiny thing you do counts, no matter how inconsequential you think it is. Those few extra seconds of attention you pay someone — a patient, a colleague, a stranger — matter, and will make a difference to them, and everyone else they encounter. Positive acts beget positive acts, like ripples fanning out in a pond. The same goes for negative acts. In this way you can control, to quite a significant degree, how the world goes. It’s great that you don’t have to go anywhere, do anything, buy anything or be born into a privileged class to ‘acquire’ attention. You already possess it. It’s a matter of how you spend it.

Words and image by Diana Szabo