and cognitive overload How much is too much?

Richard L. Byyny, MD

e are in an age of information overload. The A 2012 survey found that average workers spend 28 , e-mails, apps, spam, tweets, social of their time managing e-mail,1 and a British study found media, texting, Facebook, Instagram, memes, we check our phones on average 221 times a day, or Wnews feeds, online videos, updates, and myriad other about every 4.3 minutes.2 A Stanford University School of forms of information have significantly increased the Medicine team found that nearly one in eight Americans information directed at us, as well as those in which we exhibit problematic Internet use.3 request to participate. In 2009, 50 billion e-mails were sent each day. In 2010, We have come to regard this overload of information, that number rose to 294 billion e-mails per day. and brain drain, as the norm. We accept this inundation Social norms have introduced a presumed require- as , learning, practice, performance, social ment to participate, and collaborate, in every message we and professional interaction, and decision-making, without receive. In contrast to the continuous growth in technol- ever considering our well-being, productivity, and sanity. ogy and information, our human capabilities are limited.

Illustrations (except for p. 4) by Jim M’Guinness. 2 The Pharos/Summer 2016 2 The Pharos/Autumn 2016 Our neurons don’t increase in numbers, nor do they and substantiated. Many so-called respond more quickly to this overdose of information. Our experts are more interested in serv- does not increase in capacity. We do not learn or ing their own egos, and enhanc- think faster, and this mismatch creates, contributes to, and ing their reputations than actually causes information, participation, and collaboration over- providing valuable information and load. The effort required to keep track of, and participate knowledge. Unfortunately, based on in, what is going on professionally, with family and friends, their biases, they presume that they and in the world requires an ever-increasing amount of know what we should know, and attention and time. think they know better than we know f o r We are continuously distracted from important priori- ourselves. ties—thinking, learning, reflecting, decision-making. The From a social perspective, this is compounded by a herd presentation of information has become an insidious influ- mentality that can characterize and influence the story and ence in the loss of our intellectual independence. We are information over time. As a society, we have come to let bombarded with jibber-jabber, rumor, and opinions that people we don’t know, and who are not always qualified, to are often biased with inaccurate or false information. decide what we need to know and when we need to know In the days of Walter Cronkite, there were only a few it. This creates an unintended consequence of impeding sources of information, and each had important filters — knowledge and learning. journalistic reviews, peer reviews in journals, and fact Increasingly, more people are becoming addicted to the checkers—that reviewed the information and plethora of information on the Internet, which can result verified its accuracy before it was presented in compulsive pursuits without any thought process. There publicly. With today’s 24/7 communica- is unsolicited information, task-relevant information, tion environment, it’s about posting well-known information, vaguely known information, and it on the Internet first, and fact information based on belief and opinion. It takes an inor- checking later. dinate amount of time and attention to participate in the Information is often preponderance of available sources of information. presented by self-claimed Information must be filtered and considered in the experts, colleagues, and context of the user—not the disseminator. It should a multitude of journal- be filtered for substance, significance, reliability, and istic-like outlets. Many completeness. Our critical thinking should make us wary media specialists, to completely trust what we read on the Internet. As bloggers, podcasters, Gerhard Fischer wrote, “We should focus on our need for and others have no the right information, at the right time, in the right place, professional training in the right way, to the right person.” 4 or background in Information overload is compounded by the accom- journalism, profes- panying participation overload, which consumes time, sionally-mandated attention, and brain power. It creates a poverty of attention. e t h i c s , o r communication. Cognitive overload We should wonder is the amount of if what we are read- mental effort being utilized in work- ing or hearing is valid ing memory at any given time. Human

3 Information and cognitive overload

memory is limited in its capacity to effectively utilize and Sensory memory perceives, and briefly retains, visual learn from cognitive input. Cognitive psychologists and and auditory information. Sensory information is stored scientists often categorize memory into three primary long enough to be transferred and utilized in short-term subsystems—sensory, working, and long-term memory. memory allowing for the retention of impressions of sensory information, after the original stimulus has been processed. Working memory is constrained by a small storage capacity. It is vital to learning, and performing tasks. Working memory retrieves relevant knowledge possessed and stored by the learner in long-term memory. It orga- nizes the new with the existing information to facilitate efficient storage of the new information in a modified schema. In a seminal paper in 1956, George Miller, Princeton University, demonstrated that most individuals can only hold seven +/- two units of information in working memory at any given time, and can organize, compare, and contrast no more than two to four elements at any given time.5 That means working memory is very limited in capacity, which creates an inherent constraint on our ability to process and store information in long-term memory. Long-term memory has nearly unlimited storage. Retrieving information is constrained by use rather than limits on capacity. In order for information to be used and applied it must be stored in long-term memory and be recalled and applied when necessary. Memory retains and stores infor- mation learned into file drawers or schemas of accessible learned information. We retrieve the information using retrieval cues to open the right drawers, and transfer that information into working memory. The long-term sche- mas give rise to expertise. Cognitive load has also been categorized as intrinsic load, which depends on the number and complexity of information elements, and the interaction of the elements in the learner’s knowledge—the load associated with the task. Extraneous load is not essential to the task, but induced by design of the task, and how information is presented in the environment. It includes thoughts about non- emergent and unimportant work items—, transient digital information, etc. Germane load is devoted to the processing, construction and automation of schemas in working memory so they can be integrated into existing knowledge and long-term memory, and retrieved and used for and decision-making. Dr. Jerome Kassirer (AΩA, Jacobs School of Illustration by Bruno and Anne Vaes.

4 The Pharos/Autumn 2016 Medicine and Biomedical Sciences at the University of We are also increasingly burdened by just-in-case Buffalo, 1956) found that, “to develop expertise in prob- learning rather than just-in-time learning. Studies on lem-solving and decision-making, it is not enough to learn heavy media multi-taskers compared to light media how to find information. We also need to remember the multi-taskers found that heavy media multi-taskers have information and know how to use it.” 6 Cognitive learning a reduced ability to filter out interference from irrelevant theory is based on understanding and diverting cognitive information, and they are more likely to pay attention to processing power toward germane cognitive load. a large scope of information rather than focusing on any We have a harder time learning new things when particular piece of information. Heavy multi-taskers are our brains are distracted. This is also complicated when less selective in filtering information and tasks they should inaccurate information is stored for retrieval into work- attend to, and accomplish, in a defined time period. They ing memory, resulting in faulty reasoning and decision- are more likely to interpret all information as equal, or making ability. nearly equal, in importance. In addition, it is harder to learn and remember new important information when Multi-tasking is not all it’s cracked up to be frequently distracted by many activities.10 Information overload is also related to multi-tasking. Chronic multi-tasking is rapidly becoming nearly ubiq- Many people take great pride in being a multi-tasker, uitous, creating challenges and adversely affecting human and see multi-tasking as an accomplished skill. However, cognition, thinking, and learning. evidence indicates that multi-tasking does not improve work, decision-making, or productivity, but it does contrib- New disorders ute to cognitive overload and its associated consequences. Neuroscientists and psychologists have identified The average young adult moves between media plat- new maladaptive behaviors including Internet Addiction forms 27 times per hour, which can lower IQ by as much as Disorder (IAD), Problematic Internet Use (PIU), and 15 points.7 As a contrast, studies that have shown an eight Addiction Deficit Disorder (ADD).3 The layper- percent decrease in IQ for regular marijuana smokers who son may know this as Information Fatigue used heavily from adolescence onward.8 Syndrome, but it can, and often does, evolve Multi-tasking adversely affects emotional intelligence, into a full-blown disorder. and cognitive functions. We know that the brain cannot Although the definitions and criteria pay attention and process more than one thing at a time, lack standardization, and are not yet but multi-tasking requires rapid and repeated switching of recognized in DSM-5 as psycho- attention from one thing to another, and back again. This logical disorders, they do seem results in ignoring important information, faulty or incor- to be part of a continuum of rect reasoning, and slower completion of tasks that are technology addiction. Due to the done less well than if done one at a time with a thoughtful prevalence, and potential adverse approach. effects and outcomes, it appears to Multi-tasking creates decreased attention span, a state be analogous to other compulsive use of inaction, and negatively impacts the ability to make disorders. smart decisions. It adversely affects work performance, Officially named disorder, or not, excessive involvement and the time to get the task done, thereby limiting innova- and use of and social media can tion, ingenuity, and creative thinking. have serious effects, affect memory, and influence every- It has been shown that it takes day life. It is still unknown how much use and involvement an average of 25 minutes to is too much to cause adverse emotional, functional, and return to a work task after health outcomes. an e-mail interruption, and What can, and should, we do about this new and workers who completed the increasing phenomenon? Let’s start with increasing aware- same tasks in parallel took ness of the problematic side of information and cognitive 30 longer and made twice overload. As physicians, teachers, educators, and writ- as many errors as those ers, we strive to contribute to others’ learning about new who completed tasks things, including unintended adverse consequences. sequentially.9 As physicians, it is our job to understand and influence

5 Information and cognitive overload

harmful behaviors, and support positive change. We have others couldn’t answer when asked. Every Thursday night, patients who can benefit from changing their perceptions, his family knew that he would be away studying, and not attitudes and regimen with regard to Internet and social home for dinner. He would go to the county medical associ- media use. We have family, friends, colleagues, and are a ation library, because he wouldn’t know anyone there who member of organizations where our awareness and knowl- might disrupt his attention and concentration. He would edge can be of benefit to those suffering from information research the questions he had written down in his note- and cognitive overload. book. Upon leaving, he would tear up the list of notes, and In 1967, Peter Drucker noted in “The Effective start over for the next week. He was the smartest and best Executive” that effectiveness in accomplishing tasks informed of any of my teachers, mentors, and colleagues. requires a focus of attention on one problem at a time, and As another example, when I started my first job as a devotion of the time needed to complete the task.11 In our faculty clinician, I had an open door policy in my non- profession, we have developed task and clinical office. I was repeatedly interrupted by almost approaches and strategies, but often by habit rather than anyone for almost anything, and couldn’t complete tasks, thoughtful planning. We also know that some approaches study and write. I obtained a study carrel in the university work better than others. library, and scheduled time on my calendar to be away for We need to respond and adapt to behavioral changes, a half day each week. I didn’t carry a beeper during those and modify our thinking and behaviors. We can do things times, and wouldn’t have carried my cellphone if I had one. differently, make changes, better manage our time, and No interruptions, and my productivity soared. I found that reduce interruption and unanticipated distractions. the problems that were waiting for my return had usually Developing a time management protocol requires a been solved without my input. modest investment and focus for one week to analyze Time management strategies include setting short- current time use. By keeping an hourly time log for a typi- and long-term goals; setting priorities for responsibili- cal week, with all hours and activities logged, including ties; planning and organizing activities; and minimizing sleep and non-work-related activities recorded, we can activities that waste time. It is more about behaviors than determine how, when, where, and why we spend our time. time; and matching time with priorities and goals. Time At the end of the assessment week, time should be subclas- management takes time to learn, practice, and master. sified into categories, e.g. medicine, education, meetings, Effective time management is one of the most important idle/wasted, family, etc. This helps determine changes that competencies for physicians. We must learn to say no in a can be initiated to better manage time. professional and justifiable way. We must learn to delegate, The next step is to set personal goals categorized by and minimize interruptions and distractions. We should interest, necessity, work, education, health, etc. This will schedule time on our calendars—professional and private— develop an awareness of requirements, electives, unneces- for our predetermined priorities and important tasks. sary activities, and others, to create a plan to make effec- Stephen Covey’s “7 Habits of Highly Effective People” tive changes. provides Covey’s Time Management Grid (see illustra- After personal goals comes daily goals, also categorized tion).12 The grid is used to manage information and by what can be achieved each day, then prioritized. Goals responsibilities into classifications: urgent; non-urgent; that are achieved are checked off. Strategies to achieve important; and not important. Quadrant I is urgent goals and eliminate time-wasting activities will become and important for the immediate and imperative dead- apparent, and the ability to take control through choices lines. Quadrant II is non-urgent and important will become achievable. for long-term strategizing, priorities, tasks Time is our greatest asset and must be used wisely. and responsibilities that require time and Parkinson’s Law states that there is a human tendency to attention. spend effort and time on more insignificant tasks that are Quadrant III is urgent and not impor- perceived as important rather than on those of true impor- tant. It represents unimportant time tance. For example, Dr. Pete Reynolds, one of my mentors pressured distractions, but someone and professors, felt compelled to keep up his continuing wants it now or soon creating an illu- education, but found difficulty in pursuing his education sion of importance and a stress response because of constant interruptions. When on rounds, he had mentally with an adrenergic/dopaminer- a notebook in which he would record questions that he or gic reaction (many information and

6 The Pharos/Autumn 2016 URGENT NOT URGENT IMPORTANT Quadrant I: Quadrant II: Urgent & Important Not Urgent & References Important . Sunshine J. Workers Spend One-Fourth of Workday Reading, NOT Quadrant III: Quadrant IV: Responding To : Survey. Huff- IMPORTANT Urgent & Not Urgent & ington Post.  Aug . http://www. huffingtonpost.com////email- Not Important Not Important workday_n_.html. . Rucki A. Average smartphone user From Steve Covey’s 7 Habits of Highly Effective People. checks device  times a day, according to research. EveningStandard.  Oct cognitive distractions fall into this quadrant). . http://www.standard.co.uk/news/techandgadgets/average- Quadrant IV is not urgent and not important for activi- smartphone-user-checks-device--times-a-day-according- ties that have little or no value, but are often used for taking to-research-.html. a break or distraction from other important activities. . Young KS. CBT-IA: The First Treatment Model for In- Most activities fall into Quadrants I and III, while ternet Addiction. J Cog Psychotherapy. ;(): –. Quadrant II is most important because one must work . Fischer G. BMBF Report: Conceptual Frameworks with attention and allocated time to accomplish the task. and Innovative Computational Environments In Support Of The lesson here is to quit spending time and attention on Self-Directed and Lifelong Learning. http://ld.cs.colorado. unimportant tasks and activities, and do the important edu/~gerhard/reports/bmbf.pdf. things first. . Miller GA. The Magical Number Seven, Plus or Minus Two: Some Limits on Our Capacity for Processing Informa- Improving our well-being tion. The Psychological Review. ;: –. Information and cognitive overload lead to a loss . Kassirer JP, Kuipers BJ, Gorry GA. Toward a theory of of control over much of our professional and personal clinical expertise. Amer J of Med.  Aug;(): –. lives. This creates undo stress and unimportant distrac- . Mohan I. Multi-tasking millennials are costing us bil- tions which may adversely affect our work and lives and lions. Boston Globe.  Aug . https://www.bostonglobe. contribute to professional dissatisfaction and burn out. A com/business////multi-tasking-millennials-are- thoughtful understanding of this problem, and implement- costing-billions/agiigCDaEMVFeIAI/story.html. ing effective approaches and strategies can help to regain . Bebinger M. As More States Consider Legalizing, control of many, if not most, responsibilities, work, and Questions About Pot And The Brain. National Public other activities. Radio.  Sept . http://www.npr.org/sections/health- We are exposed to too much unimportant information shots/////as-more-states-consider-legal- that leads to cognitive overload. We are depleting our izing-questions-about-pot-and-the-brain. brain power with babble, drivel, foolishness, gibberish, . Wong K. How Long It Takes to Get Back on Track and balderdash. The expectation that we will participate After a Distraction. lifehacker.  Jul . http://lifehacker. and respond to copious unimportant sources of informa- com/how-long-it-takes-to-get-back-on-track-after-a-dis- tion is unreasonable and impracticable. We must become tract-. experts at managing our time, expectations, and the . Ophir E, Nass C, Wagner AD. Cognitive control in influx of information that we seek out, and in turn, seeks media multitaskers. Proc Natl Acad Sci U S A.  Sept ; us out. If we recognize and understand this new intrinsic (): –. element of the modern era, we can adapt, make behavioral . Drucker PF. The Effective Executive: The De- changes, regain control, and improve our professional finitive Guide to Getting the Right Things Done. New roles, personal and professional lives, and our overall York:HarperBusiness; . well-being. . Covey SR.  Habits of Highly Effective People. New York:Free Press; .

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