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Can You See the Gorilla?

  • Jessica W. Tsai
    Correspondence
    Address correspondence to Jessica W. Tsai, MD, PhD, Boston Children's Hospital, Hunnewell Building, Pavilion 129, Housestaff Lounge, 300 Longwood Ave, Boston, MA 02115 ().
    Affiliations
    Boston Children's Hospital, Boston, Mass

    Department of Pediatrics, Boston Medical Center, Boston, Mass
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Published:February 03, 2018DOI:https://doi.org/10.1016/j.acap.2018.01.013
      It's a simple video, really. There are 6 people, 3 people wearing black shirts and 3 wearing white shirts. The viewer is instructed to count how many times the players wearing white pass the basketball. The correct number is 15. However, while viewers remain intently focused on the number of passes, most viewers fail to see a person in a gorilla costume dance through the basketball game.
      • Simons D.J.
      • Chabris C.F.
      Gorillas in our midst: sustained inattentional blindness for dynamic events.
      Somehow, while most people get relatively close to counting the right number of passes, they miss the gorilla in the room.
      This video has been used to study inattentional blindness, the lack of attention in the absence of true visual deficits, and poignantly demonstrates that we often miss some of the most obvious things despite the best of intentions. This kind of tunnel vision is far too commonplace in medicine, and even experts are susceptible to it. In a 2013 study, radiologists were asked to perform a lung nodule detection task on computed tomography images. An image of a gorilla, 48 times larger than the average nodule, was inserted in the last case, and 83% of radiologists failed to identify this gorilla despite eye tracking data showing that most of them looked directly at it.
      • Drew T.
      • Vo M.L.H.
      • Wolfe J.M.
      The invisible gorilla strikes again: sustained inattentional blindness in expert observers.
      My team was called on a weekend to the surgical recovery area for a patient that was having massive hemoptysis. The patient was quickly stabilized, and we emergently called multiple teams in the hospital, including the intensive care unit, general surgery, otolaryngology, interventional radiology, and anesthesia, not to mention multiple nurses, technicians, and pharmacists. The scene was chaotic, but fortunately the patient's vital signs remained stable. When I looked around, there were at least 15 people huddled together, chatting in a hurried and animated fashion, excitedly discussing the patient and possible next steps.
      As the intern, I had been relegated to a computer on wheels in the corner, where I had been instructed to place STAT orders for numerous medications, page different specialists in the hospital, pull up radiographic images, and recite lab values as soon as the laboratory returned the results. As I got to work, I noticed the patient's father, cowering in the corner of the room. His eyes were glassy. He was clearly and understandably horrified by the situation unfolding in front of him.
      I peered over my computer screen, glancing first at the father, quiet and confused, then at the group of physicians huddled together, excitedly discussing the patient—and I observed an incredibly striking disconnect. I saw these thoughtful, well-intentioned physicians who had completely forgotten that a frightened parent had just witnessed his previously healthy child cough up nearly a liter of bright red blood. “Sir?” I called to him. “I'm Jess, one of the resident doctors. All of these people are here to help you and your family.” He asked me who everyone was. I pointed out to him the fellow and attending from each of at least 5 different services. I explained why each person was there and what his or her role was. Interventional radiology could potentially see a bleeding vessel and make it stop bleeding. In the worst-case scenario, general surgery would take out part of his child's lung if we could not get the bleeding under control, but this was unlikely. The intensive care unit would likely be the safest place for his child, given the ability to have 1:1 nurse-to-patient ratios. As we chatted, the individual consultants dispersed until we were the only two people remaining in the room. At what point did everyone forget about this father?
      As physicians, inattentional blindness is ubiquitous. Odd, rare, high-acuity events have morphed into routine, rote occurrences. We forget that patients and their families do not experience these situations with the same regularity that we do. We rightfully pay close attention to vital signs and provide a laser-sharp focus on derangements in physiology, but we sometimes fail to provide humanity. In short, we miss the gorilla in the room. We miss the opportunity to provide care, empathy, understanding, and kindness. We miss the chance to listen. We miss the whole point of why many of us went into medicine in the first place.
      In 1927, Francis Peabody
      • Peabody F.W.
      The care of the patient.
      wrote in an essay published in JAMA, “There are moments, of course, in cases of serious illness when you will think solely of the disease and its treatment; but when the corner is turned and the immediate crisis is passed, you must give your attention to the patient.…Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.” I think of these words often, as they resonate tremendously with me. Familiarity with illness is precisely why our patients and their families trust us with their care. Yet this same familiarity can make physicians seem detached, distant, and unapproachable. As a soon to be pediatric hematology/oncology fellow, I know there will be many instances where my patients will be extremely ill, pushing the boundaries of my medical knowledge and experience. Yet during these times I must not see the patient as an intellectual exercise. Rather, I have to see the gorilla, to remember that I have the remarkable privilege of guiding patients through diagnosis, through therapy, through remission, and sometimes through relapse. I will have to ask myself, as we all ultimately do: “Can I see the gorilla?”

      Acknowledgments

      To my patients and their families for helping me maintain my humanity.

      References

        • Simons D.J.
        • Chabris C.F.
        Gorillas in our midst: sustained inattentional blindness for dynamic events.
        Perception. 1999; 28: 1059-1074
        • Drew T.
        • Vo M.L.H.
        • Wolfe J.M.
        The invisible gorilla strikes again: sustained inattentional blindness in expert observers.
        Psychol Sci. 2013; 24: 1848-1853
        • Peabody F.W.
        The care of the patient.
        J Am Med Assoc. 1927; 88: 877-882