The Klein Associates team began by interviewing professionals who worked in extreme settings, such as firefighters, military commanders, and emergency rescue personnel. Many of those conversations, however, proved frustrating. Firefighters could look at a burning staircase and sense if it would hold their weight, they knew which parts of a building needed constant attention and how to stay attuned to warning signs, but they struggled to explain how they did it. Soldiers could tell you which parts of a battlefield were more likely to be harboring enemies and where to focus for signs of ambush. But when asked to explain their decisions, they chalked it up to intuition.
So the team moved on to other settings. One researcher, Beth Crandall, visited neonatal intensive care units, or NICUs, around Dayton, near where she lived. A NICU, like all critical care settings, is a mix of chaos and banality set against a backdrop of constantly beeping machines and chiming warnings. Many of the babies inside a NICU are on their way to full health; they might have arrived prematurely or suffered minor injuries during birth, but they are not seriously ill. Others, though, are unwell and need constant monitoring. What makes things particularly hard for NICU nurses, however, is that it is not always clear which babies are sick and which are healthy. Seemingly okay preemies can become unwell quickly; sick infants can recover unexpectedly. So nurses are constantly making choices about where to focus their attention: the squalling baby or the quiet one? The new lab results or the worried parents who say something seems wrong? What’s more, these choices occur amid a constant stream of data from machines—heart monitors and automatic thermometers, blood pressure systems and pulse oximeters—that are ready to sound alarms the moment anything changes. Such innovations have made patients safer and have remarkably improved NICUs’ productivity, because fewer nurses are now needed to oversee greater numbers of children. But they have also made NICUs more complex. Crandall wanted to understand how nurses made decisions about which babies needed their attention, and why some of them were better at focusing on what mattered most.
Crandall interviewed nurses who were calm in the face of emergencies and others who seemed on the brink of collapse. Most interesting were the handful of nurses who seemed particularly gifted at noticing when a baby was in trouble. They could predict an infant’s decline or recovery based on small warning signs that almost everyone else overlooked. Often, the clues these nurses relied upon to spot problems were so subtle that they themselves had trouble later recalling what had prompted them to act. “It was like they could see things no one else did,” Crandall told me. “They seemed to think differently.”
One of Crandall’s first interviews was with a talented nurse named Darlene, who described a shift from a few years earlier. Darlene had been walking past an incubator when she happened to glance at the baby inside. All of the machines hooked up to the child showed that her vitals were within normal ranges. There was another RN keeping watch over the baby, and she was observing the infant attentively, unconcerned by what she saw. But to Darlene, something seemed wrong. The baby’s skin was slightly mottled instead of uniformly pink. The child’s belly seemed a bit distended. Blood had recently been drawn from a pinprick in her heel and the Band-Aid showed a blot of crimson, rather than a small dot.
None of that was particularly unusual or troubling. The nurse tending to the child said she was eating and sleeping well. Her heartbeat was strong. But something about all those small things occurring together caught Darlene’s attention. She opened the incubator and examined the infant. The newborn was conscious and awake. She grimaced slightly at Darlene’s touch but didn’t cry. There was nothing specific that she could point to, but this baby simply didn’t look like Darlene expected her to.
Darlene found the attending physician and said they needed to start the child on intravenous antibiotics. All they had to go on was Darlene’s intuition, but the doctor, deferring to her judgment, ordered the medication and a series of tests. When the labs came back, they showed that the baby was in the early stages of sepsis, a potentially fatal whole-body inflammation caused by a severe infection. The condition was moving so fast that, had they waited any longer, the newborn would have likely died. Instead, she recovered fully.
“It fascinated me that Darlene and this other nurse had seen the same warning signs, they had all the same information, but only Darlene detected the problem,” Crandall said. “To the other nurse, the mottled skin and the bloody Band-Aid were data points, nothing big enough to trigger an alarm. But Darlene put everything together. She saw a whole picture.” When Crandall asked Darlene to explain how she knew the baby was sick, Darlene said it was a hunch. As Crandall asked more questions, however, another explanation emerged. Darlene explained that she carried around a picture in her mind of what a healthy baby ought to look like—and the infant in the crib, when she glanced at her, hadn’t matched that image. So the spotlight inside Darlene’s head went to the child’s skin, the blot of blood on her heel, and the distended belly. It focused on those unexpected details and triggered Darlene’s sense of alarm. The other nurse, in contrast, didn’t have a strong picture in her head of what she expected to see, and so her spotlight focused on the most obvious details: The baby was eating. Her heartbeat was strong. She wasn’t crying. The other nurse was distracted by the information that was easiest to grasp.
People like Darlene who are particularly good at managing their attention tend to share certain characteristics. One is a propensity to create pictures in their minds of what they expect to see. These people tell themselves stories about what’s going on as it occurs. They narrate their own experiences within their heads. They are more likely to answer questions with anecdotes rather than simple responses. They say when they daydream, they’re often imagining future conversations. They visualize their days with more specificity than the rest of us do.
Psychologists have a phrase for this kind of habitual forecasting: “creating mental models.” Understanding how people build mental models has become one of the most important topics in cognitive psychology. All people rely on mental models to some degree. We all tell ourselves stories about how the world works, whether we realize we’re doing it or not.
But some of us build more robust models than others. We envision the conversations we’re going to have with more specificity, and imagine what we are going to do later that day in greater detail. As a result, we’re better at choosing where to focus and what to ignore. The secret of people like Darlene is that they are in the habit of telling themselves stories all the time. They engage in constant forecasting. They daydream about the future and then, when life clashes with their imagination, their attention gets snagged. That helps explain why Darlene noticed the sick baby. She was in the habit of imagining what the babies in her unit ought to look like. Then, when she glanced over and the bloody Band-Aid, distended belly, and mottled skin didn’t match the image in her mind, the spotlight in her head swung toward the child’s bassinet.
Cognitive tunneling and reactive thinking occur when our mental spotlights go from dim to bright in a split second. But if we are constantly telling ourselves stories and creating mental pictures, that beam never fully powers down. It’s always jumping around inside our heads. And, as a result, when it has to flare to life in the real world, we’re not blinded by its glare.
When the Air France Flight 447 investigators began parsing cockpit audio recordings, they found compelling evidence that none of the pilots had strong mental models during their flight.
“What’s this?” the copilot asked when the first stall warning sounded.