Increasingly physicians are experiencing greater demands and pressures in their roles as both clinicians and leaders. As demands increase, we are seeing many physicians moving more to multitasking strategies to cope. This paper outlines some of the myths and misconceptions around the benefits of multitasking and offers mindfulness-based approaches to minimize the impairments associated with distraction and bring greater focus to self-awareness, interpersonal relationships and innovative thinking.
Multitasking increases efficiency and effectiveness — Although this is one of the most prevalent and enduring myths about multitasking, research data do not support such claims. For example, researchers Cao and Liu (2013) present evidence that multitasking physicians demonstrate measurable delays in completing complex clinical decisions, such as making diagnoses.
This is not so surprising, if you consider that mentally switching tasks decreases cognitive processing efficiency by as much as 50% compared with tasks completed separately in sequence (Rubinstein et al. 2001). Dr. Gloria Mark and associates (2008) found that an average employee takes about 25 minutes to return to the same level of concentration with each interruption, and the average worker switches attention every three minutes (most of these interruptions are self-initiated). Each time you abandon a mental task to attend to an interruption, your emotional and cognitive engagement with the task immediately begins to decay. According to Basex, a business research company based in New York City, workplace interruptions lead to a productivity loss of about 28% for the average worker (Spira 2011).
Performance improves with greater multitasking proficiency — Clifford Nass, a prominent psychologist from Stanford University, led a study that assessed and compared light with heavy multitaskers on a battery of cognitive tasks (Ophir et al. 2009). Heavy multitaskers were less efficient at multitasking than light multitaskers. In particular, heavy multitaskers were worse at filtering irrelevant information and performed significantly worse at switching between tasks. They were also more distracted by irrelevant environmental stimuli, stored less content in their working memory and were unable to sustain concentration as long. Top
Technology saves time — Technology that is heralded as making our lives easier — email, the Internet, RSS feeds, short message service (SMS), instant messengers, Twitter — is, in fact, encouraging more multitasking behaviour and creating more distractions. For example, the average person now glances at his or her email 30–40 times an hour (Renaud et al. 2006). Recent studies with physicians have found that the use of personal devices, such as smart phones, also seems to be contributing to further distraction and, potentially, medical errors (Wallace et al. 2012). Professor Glenn Wilson, a psychologist from King’s College, London University, discovered that handling email can cause a 10-point drop in one’s IQ score, which is the equivalent of the cognitive impairment seen after the loss of a night of sleep (Wainright 2005).
More critically, chronic multitasking may be taking a serious biologic and psychologic toll on physicians and leaders. According to Dr. Edward Hallowell (2005), a psychiatrist specializing in attention deficit disorder, high multitasking environments are contributing to a clinical syndrome that he has termed attention deficit trait, or ADT. The core symptoms include distractibility, inability to sustain focus and impatience, and they lead to constant feelings of panic, irritation and guilt. People with ADT have difficulty staying organized, setting priorities and managing time. Moreover, Dr. Hallowell has frequently observed these symptoms in executives and leaders, who are more likely to multitask.
Over the past few years, evidence that multitasking is impairing our ability to sustain required attention and to learn has been mounting. Using magnetic resonance imaging (MRI) scans, Small and colleagues (2009) demonstrated that multitasking “overstimulates” the prefrontal cortex (the region of the brain responsible for directing attention) and, thereby, inhibits the processing of information in the hippocampus (the area of the brain responsible for the creation of memories), which impedes the learning of new items and the retrieval of memories. In particular, it appears that working memory, which is critical for focused attention and moving information into long-term memory, is compromised with multitasking. Top
Linda Stone (2009), a respected speaker, suggests that constantly switching between tasks has led to a pathologic state that she calls continuous partial attention. In this state, our minds habitually attend only partly to any given task, as other parts of the brain are busy scanning the environment for new stimulation. This constant need for stimulation contributes to heightened states of stress and anxiety by activating the more primitive limbic brain structures that are in part responsible for constantly scanning the environment for potential threats. These stress responses activate an adrenaline rush and other damaging stress hormones that, when prolonged, can damage cells in the hippocampus that contribute to the formation of new memories (Wetherell and Carter 2013). Prolonged stress states have been shown to contribute to and exacerbate various psychologic conditions, including depression, anxiety disorder and obsessive-compulsive disorder (Lucassen et al. 2013).
A recent study found that physicians self-reported greater psychophysical strain when multitasking (Weigl et al. 2013). Moreover, multitasking may be contributing to alarming rates of professional and personal distress, with up to 60% of practising physicians reporting at least one aspect of burnout syndrome: excessive emotional exhaustion, depersonalization or a low sense of accomplishment (Shanafelt et al. 2012). Top
A mindfulness approach to enhance focus
Given that multitasking contributes to increased distraction and stress and may culminate in burnout for physicians (Dunn et al. 2007), what strategies should physician leaders adopt to counter these effects? The obvious answer is simply to minimize multitasking. At face value, that makes sense, at least from the perspective of “containing” the problem (i.e., a “survival” strategy), but it may be incomplete given the pragmatic demands of leadership in the hectic, modern world of medicine. Given that demands and pressures will only continue to escalate for the physician leader, I suggest a more holistic strategy that is based on “thriving” — that approach is mindfulness.
Mindfulness, in a sense, is the polar opposite of multitasking in terms of behaviour and impact on one’s psychology and brain. Mindfulness refers to a quality of focus that includes the ability to sustain attention in a way that is intentional, in the present moment and nonjudgemental. It includes the ability to notice, observe and experience bodily sensations, feelings and thoughts as they arise. It reflects the capacity to adopt a particular orientation toward one’s experiences in the present moment (as opposed to ruminating about the past or fretting about the future) that is characterized by curiosity, openness and acceptance. It is about overcoming the natural tendency to be on “autopilot” and distracted, overcoming emotional reactivity to challenging experiences and suspending the need to label or judge them (Kabat-Zinn 2013). Top
Mindfulness is gaining credibility and wider acceptance in the medical and leadership communities (Ludwig and Kabat-Zinn 2008); for example, the University of Toronto Residency Wellness Program teaches mindfulness skills to medical residents. As a means of improving well-being and clinical performance, mindfulness has shown great potential in research trials with health care professionals.
For example, primary care physicians who participated in a program on mindful communication demonstrated improvements in various measures of well-being and enhanced personal characteristics associated with leadership, including emotional stability, empathy and conscientiousness (Krasner et al. 2009). More recently, Dr. Luke Fortney and colleagues (2013) looked at the effects of a short mindfulness course and found decreased levels of burnout, anxiety, depression and distress among doctors that lasted nearly a year later, even without any further mindfulness training sessions. Moreover, an investigation of internists found that their “ability to be present” correlated more strongly with finding meaning and a sense of control in their role as a physician than either diagnostic or therapeutic successes (Horowitz et al. 1995). Top
With respect to enhancing leadership capacity, the literature has identified several benefits of mindfulness training: expanded self-awareness, insight, receptivity, balance and clarity for oneself and others (Santorelli 2000, Kabat-Zinn 2013), greater leadership presence and authenticity (Santorelli 2000), improved interpersonal workplace relationships (Hunter and McCormick 2009) and increased creativity (Langer 2006). Boyatzis and McKee (2005) view mindfulness as an essential element of leadership and define it as the capacity to be fully aware of what is happening inside and around us.
Similarly, Daniel Goleman (2013), a popular author on emotional intelligence, identifies three crucial areas that leaders must heed to enhance their focus, what he calls the “triad of awareness”: awareness of one’s internal experience; awareness of one’s relationships with others; and awareness of the wider context that promotes innovation and creativity. Although he does not explicitly make the link, all of these attributes are central to mindfulness and leadership. These three attributes of focused awareness are further discussed below. Top
Recently, in a survey, 75 members of the Stanford Graduate School of Business Advisory Council rated self-awareness as the most important capability for leaders to develop (Toegel and Barsoux 2012). Self-awareness is about obtaining insight into why, how and when one thinks, feels and behaves in certain ways. It includes the ability to examine one’s emotional triggers, thinking patterns, assumptions, values, principles, strengths and limitations. As noted above, mindfulness training will enhance self-awareness. Further support comes from brain imaging studies conducted by Sara Lazar and her group at Massachusetts General Hospital. They compared experienced mindfulness practitioners with those with no meditation experience and found that parts of the cerebral cortex involved in self-reflection (right anterior insula) and empathy (Brodmann area 9/10) were significantly thicker in the meditators than in controls (Lazar et al. 2005).
Greater empathy and compassion are other benefits associated with mindfulness training in leaders. Goleman (2013) refers to three kinds of empathy: cognitive empathy — the ability to understand rationally another person’s perspective; emotional empathy — the ability to feel what someone else feels; and empathic concern — the ability to sense what another person needs from you. All three types of empathy can be developed through mindfulness training, as demonstrated by research conducted with physicians at Boston’s Massachusetts General Hospital (Riess et al. 2012). In this study, researchers trained physicians to monitor themselves by using deep, diaphragmatic breathing and to cultivate focus, rather than being lost in their own thoughts and feelings. They found this kind of training improved ability to decode facial expressions of emotion and achieve better patient outcomes. Top
Finally, another benefit of mindfulness practice for leaders is enhanced innovative and creative thinking. Carson and Langer (2006) describe mindfulness as a process of noticing and drawing novel distinctions that can lead to number of outcomes, including: enhanced sensitivity to one’s environment, greater openness to new information, the creation of new categories for interpreting events and enhanced awareness of multiple perspectives when problem-solving. Their research shows that when we are mindful, we are perceived as charismatic, genuine and authentic by those around us.
To conclude, physician leaders who cultivate mindfulness will not only counter the negative impact of their highly distracting and stressful multitasking environment, but they will also strengthen their ability to focus attention on their own internal state, more likely listen deeply to others and be better able to consciously respond rather than react. At the same time, mindfulness practice can support a more disciplined and directed approach to the steady stream of thoughts that prevent us from being in the present moment, where true innovation and foresight emerge. Top
Paul Mohapel, MSc, PhD, Mohapel Consulting Ltd., Victoria, B.C.
Boyatzis R, McKee A. Resonant leadership: renewing yourself and connecting with others through mindfulness, hope, and compassion. Boston: Harvard Business School Press, 2005.
Cao S, Liu Y. Medical decision making performance in dual-task scenarios. Proceedings of the Human Factors and Ergonomics Society Annual Meeting 2013;57(1):733-7.
Carson S, Langer E. Mindfulness and self-acceptance. J Rational Emotive Cogn Behav Ther 2006;24(1):29-43.
Dunn PM, Arnetz BB, Christensen JF, Homer L. Meeting the imperative to improve physician wellbeing: assessment of an innovative program. J Gen Intern Med 2007;22(11):1544-52.
Fortney L, Luchterhand C, Zakletskaia L, Zgierska A, Rakel D. Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: a pilot study. Ann Fam Med 2013:11(5):412-20.
Goleman D. The focused leader: how effective executives direct their — and their organizations’ — attention. Harv Bus Rev 2013;Dec:51-60.
Hallowell, EM. Overloaded circuits: Why smart people underperform. Harv Bus Rev 2005;Jan:55-62.
Horowitz CR, Suchman AL, Branch W, Frankel RM. What do doctors find meaningful about their work? Ann Intern Med 1995;138(9):772-6.
Kabat-Zinn J. Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. New York: Bantam, 2013.
Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B, Mooney CJ, Quill TE. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 2009;302(12):1284-93.
Langer E. On becoming an artist: reinventing yourself through mindful creativity. New York: Ballantine Books, 2006.
Lazar SW, Kerr CE, Wasserman RH, Gray JR, Greve DN, Treadway MT, et al. Meditation experience is associated with increased cortical thickness. Neuroreport 2005;16(17):1893–7.
Lucassen PJ, Pruessner J, Sousa N, Almeida OF, Van Dam AM, Rajkowska G, et al. Neuropathology of stress. Acta Neuropathol 2013; Dec. 8.
Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. JAMA 2008;300(11):1350-2.
Mark G, Gudith D, Klocke U. The cost of interrupted work: more speed and stress. In Burnett M, Costabile MF, Catarci T, De Ruyter B, Tan D, Lund MCA (editors). Proceedings of the SIGCHI conference on human factors in computing systems. New York: ACM Press, 2008:107-10.
Renaud K, Ramsay J, Hair M. “You’ve got email’ Shall I deal with it now?” Inter J Hum-Comput Int 2006;21(3):313-32.
Riess H, Kelley JM, Bailey RW, Dunn EJ, Phillips M. Empathy training for resident physicians: a randomized controlled trial of a neuroscience-informed curriculum. J Gen Intern Med 2012;27(10):1280-6. Available: www.ncbi.nlm.nih.gov/pmc/articles/PMC3445669/ (accessed 19 Jan. 2014).
Rubinstein JS, Meyer DE Evans JE. Executive control of cognitive processes in task switching. J Exp Psychol Hum Percept Perform 2001;27(4):763-97.
Santorelli S. Heal thy self: lessons on mindfulness in medicine. New York: Three Rivers Press, 2000.
Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012;172(18):1377-85.
Small GW, Moody TD, Siddarth P, Bookheimer SY. Your brain on Google: patterns of cerebral activation during internet searching. Am J Geriatr Psychiatry 2009;17(2):116-26.
Spira JB. Overload! How too much information is hazardous to your organization. Hoboken, N.J.: Wiley, 2011.
Wallace S, Clark M, White J. ‘It’s on my iPhone’: attitudes to the use of mobile computing devices in medical education, a mixed-methods study. BMJ Open 2012;2(4). Available: http://bmjopen.bmj.com/content/2/4/e001099.long (accessed 19 Jan. 2014).
Weigl M, Müller A, Sevdalis N, Angerer P. Relationships of multitasking, physicians’ strain, and performance: an observational study in ward physicians. J Patient Saf 2013;9(1):18-23.
Wetherell MA, Carter K. The multitasking framework: the effects of increasing workload on acute psychobiological stress reactivity. Stress Health 2013; May 30.