Distracted doctoring

By Ruth Carol, contributing writer

There is a growing patient safety concern that is unrelated to a specific diagnosis, medication, procedure, or treatment, but it can impact all patients. If you have a personal electronic device or use an electronic health record (EHR) system, you are at risk. It’s called distracted doctoring.

The explosion of personal electronic devices coupled with the use of work-related technology, such as EHRs, computer tablets, and smartphones, not to mention beepers and pagers, have created the perfect storm for distraction. Spoiler alert: Multitasking only makes it worse.

Distraction is on the rise

Physicians are under greater pressure to do more with less time and fewer resources, said Steven Chinn, DPM, MS, MBA, administrative director, accreditation, regulations and quality management at Stanford Health Care, and clinical associate professor at Stanford School of Medicine. During shorter appointment times, they are required to diagnose and treat the patient while documenting everything they’ve done on the EHR. Studies suggest that distraction might be attributed to the volume of work that physicians must accomplish on a daily basis, he added. And it’s not just physicians; residents, nurses, pharmacists, and therapists are also impacted.

Distraction is a growing societal problem and health care is not immune to it, stated Jennifer Gardner, MD, assistant professor of medicine and dermatology at the University of Washington School of Medicine. “The only difference is that the stakes are higher in health care than in a lot of other realms of life, which is why it’s that much more important to address.”

Peter J. Papadakos, MD, author of Distracted Doctoring: Returning to Patient-Centered Care in the Digital Age, believes the pivotal event that brought this issue to the forefront in health care was the 2014 case of the Dallas anesthesiologist who was using his iPad during a procedure and failed to notice that his patient’s blood oxygen levels had dropped substantially until it was too late. The patient subsequently died. Organizations started questioning if their physicians were engaging in that type of behavior too, said the anesthesiologist who lectures around the country and internationally about distracted doctoring and how to interact with devices in the patient care setting. “I hear that errors are on the rise due to distraction at hospitals around the world,” he added.

Different than previous technologic advances, the recent onslaught of personal electronic devices has blurred the lines of work and home life, Dr. Gardner explained. “The perception is that we should be available 24/7 because we have the ability to respond to any issue any time of day via email and text — a perception promoted by employers,” she said. “That ‘always on’ mentality is underappreciated and draining our ability to focus.” Additionally, physicians are pressured to interact with their electronic devices to obtain medical information, review lab results and images, read patient notes, and document findings. Another difference is that in the past there was a physical barrier between people and technology, but today practically everyone carries their smartphone with them at all times.

While some believe that younger physicians are more susceptible to distraction because they have grown up being constantly connected with social media, others maintain that physicians of all ages are vulnerable. As proof of the former, Dr. Papadakos cited a 2012 study published in the Journal of Hospital Medicine in which smartphones were used during patient rounds by 85% of residents compared with only 48% of faculty. About 37% of residents compared with only 12% of faculty read and/or responded to personal texts/emails. Moreover, 19% of residents and 12% of attendings believed that they had missed important information due to distraction from smartphones. Residents are more adept at using this technology because it is part of their processes, Dr. Chinn said, but that doesn’t necessarily mean they are more vulnerable to distraction caused by it. Younger generations are not always aware of how connected they are, said Sarah Kasprowicz, MD, from Medical Dermatology Associates of Chicago, who relayed the story of a resident who took out her cell phone to respond to a personal text while in the room with a patient. When Dr. Kasprowicz later asked the resident if everything was okay and if she needed to leave to address a personal emergency, the resident wasn’t sure why the doctor was asking. “What the resident did is unacceptable on a number of levels,” Dr. Kasprowicz said. “But I don’t think she was even aware of her actions.”

Electronic devices are addictive

Chances are she probably wasn’t. “The tech world has hijacked our dopamine systems,” Dr. Gardner said. “That’s why we feel vulnerable when we don’t answer the cell phone or a text; the technology is working on a subconscious level.”

Dopamine causes people to engage in “seeking” and “wanting” behaviors, such as checking emails or social media. “We’re never quite sure when we’re going to receive a text message and from whom, so we keep checking,” said Shelley Rizzo, MSN, CPHRM, patient safety risk manager who presents across the nation about distracted doctoring for The Doctors Company, the nation’s largest physician-owned medical malpractice insurer. “When the device rings or vibrates, we know there’s a reward coming. Anticipation of the reward is sometimes better than the reward itself.” The instant gratification that one gets from receiving an email, text, or tweet encourages more seeking behavior. This is referred to as dopamine looping. Constant stimulation of the dopamine system, however, can be exhausting and cause lack of focus.

People typically use their devices right out of the box without adjusting their settings, Dr. Gardner said. “The devices are loaded with shiny, colorful flashing banners and notifications designed by tech developers to grab our attention, and it takes a lot more than will power to beat out this psychology,” she stated. To make matters worse, studies have shown that these devices can interfere with sleep. The blue light from cell phones and internet devices disrupts melatonin production, which can lead to insomnia and/or sleep deprivation.

Dr. Papadakos, director of critical care at the University of Rochester Medical Center, and his colleagues modified the CAGE substance abuse screening tool to help identify very high users of electronic devices who may benefit from getting additional help with preventing distraction from electronic devices in the operating room. During his lectures, he typically polls his audiences to determine whether they are addicted to electronic devices. “We have found that 50-75% of respondents, all of whom are health care professionals, are addicted,” Dr. Papadakos said.

Sources of distraction

“The smartphone is the most common distraction because it’s always with us whether it is used at work or not,” Dr. Gardner said. Just having it around is a distraction. “It’s playing on your mind because it makes you wonder, ‘What am I missing?’” she added.

The institutional reliance on email forces physicians to routinely check their smartphones, Dr. Papadakos noted. As a university-based physician, he receives more than 100 emails a day from the medical center, many of which he must respond to, despite their lack of urgency.

Next on the list is the EHR. Having all the patient’s health information in one place can be very helpful, Dr. Chinn said, but it also means that physicians have to filter through potentially thousands of entries to find information relevant to the patient’s current health issue. That can be very distracting and frustrating, he said. There is so much pressure to chart everything in the EHR that it inevitably feels like a distraction to the clinician and patient, Dr. Kasprowicz added.

None of the information in the EHR is prioritized; it just shows up, Dr. Gardner said. “You can’t look at all of the folders at once, so you have to scroll through them all.” Sometimes it takes scrolling through 30 charts to find the patient who should be seen right away. It’s assumed that if a patient calls that it’s a more urgent matter, but that’s not fool proof because younger patients tend to send email messages and they expect a quick response. This lack of prioritization creates an artificial sense of urgency and opportunities to miss truly emergent situations, she said.

Another significant source of distraction is not electronic. It’s the insurance hurdles that physicians and/or their staff must wade through. “What used to take a five-minute phone call now requires 80 emails to three different people,” Dr. Papadakos quipped. Nothing is more frustrating than to take the time to explain a treatment to a patient who can’t follow through because it’s not covered, the recommended referral doctor is out of network, or the medication is unaffordable, Dr. Chinn said. Ironically, this is one area where technology could pull its weight, Dr. Gardner said. If the EHR interfaced with insurance requirements, for example, the physician would know that the insurer prefers that an equivalent medication be prescribed or that the prescription must be sent to a specific pharmacy. “Then patients could get the medication they need when they need it and not to have to navigate the system themselves,” she said. “And it would eliminate a lot of back and forth between the insurance companies and physicians.”

IMPACT AND CONSEQUENCES OF DISTRACTION

“Distraction is a big patient safety issue,” Dr. Gardner said. “Any time you are distracted, errors can occur. They could be detrimental to your patient’s health as well as to your career because it puts you at risk for liability.” Both complex and routine tasks can be affected.

“It doesn’t take much if you’re interrupted by a ding from your cell phone to lose your situational awareness, and then you might not notice that something is out of place,” Rizzo said. Studies have shown there is a 60% increase in errors when a nurse is interrupted during medication administration preparation. Furthermore, interruptions lasting just 2.8 seconds double the likelihood of errors. “Among my colleagues, we often talk about medication errors that do occur and how many times this issue of distraction and multitasking is a factor,” Dr. Chinn noted.

It’s not uncommon for physicians to have multiple screens on their computer open at one time. “They can inadvertently put a prescription or test order into the wrong patient’s file,” he said. This very simple mistake could lead to adverse outcomes either by the correct patient not getting their medications or being referred for an unnecessary test. Other errors due to distraction could include delaying or missing a diagnosis, mislabeling a specimen, obtaining consent for a different procedure, not correctly identifying the patient prior to a procedure, and performing a biopsy or surgery on the wrong site, or worse.

Even if an error doesn’t occur, productivity may be affected. Staff at her office were checking their social media on their smartphones so often that this past February Dr. Kasprowicz’s office implemented an unpopular policy requiring employees to keep their cell phones in their personal lockers. In the case of an emergency, they could be reached via the main office number. “People were so connected that they were not hearing their name being called,” she said. They were making administrative errors and generally not following up on tasks or giving tasks the level of attention they needed. “Since implementing the policy, our productivity has improved and people appear to be more connected to their job,” Dr. Kasprowicz added. Cyberloafing, which is using internet access at work for personal reasons while pretending to be doing work, is a big problem in all workplaces, Rizzo said. It causes people to be pre-occupied, which in a physician’s practice could lead to delays in room turnover, incomplete or inaccurate recordkeeping, documentation errors, and delays in obtaining test results.

Patient satisfaction scores are highly dependent on the quality of the interaction between the physician and patient, Dr. Chinn said. Patients are very cognizant when the doctor isn’t paying attention to them, especially when the physician is looking at the EHR screen. A physician who is staring at their smartphone similarly gives the impression that they are not engaged. Many patients feel that they’re not being listened to when there is so much technology in the room, which Dr. Kasprowicz believes is a valid concern. The EHR takes the focus away from patients by creating the e-patient, the patient in the EHR, not the one in front of the physician, Dr. Papadakos said. “Instead of making eye contact and having basic human interaction with the sick person, the physician is checking automated boxes on the e-chart, checking lab results in the EHR, and typing notes. That’s a big breakdown in the physician/patient relationship.” It can lead to complaints, or in the case of an adverse event, a lawsuit. “We know there is a link between decreased patient satisfaction and increased medical malpractice claims,” Rizzo said.

Interacting with electronic devices increases a physician’s risk of medical malpractice. Whenever there’s a medical malpractice claim and an allegation that the adverse event was caused by distracted practice, the physician’s cell phone records can be subpoenaed, Rizzo explained. All of the quality care that was provided by the physician can be overshadowed if there is hard evidence that they, for example, were surfing the Internet during a procedure. The mere suggestion that a physician was distracted can make it more difficult to defend a defensible case.

MULTITASKING IS A MYTH

People often brag about how they can multitask, but studies have shown that it’s not such a good thing after all. Multitasking causes people to make more mistakes and retain less information, the latter of which can hinder one’s ability to problem solve and be creative.

“Approximately 2% of us are super taskers who can truly multitask and the rest of us are just in denial,” Dr. Gardner said. “We’re really doing serial mono-tasking, not multitasking.” The problem is that every time people shift their focus to do a different task, they get as much as 40% less efficient and more tired. For complex tasks, the percentage is even higher. “Studies have shown that it can take upwards of 30 to 40 minutes to get back to where you left off when you are distracted,” she said. “The more you’re distracted, the harder it is to return to the task at hand.”

While humans can focus on more than one auditory cue at a time, they can’t focus on more than one visual cue at a time, Dr. Papadakos added. “We can’t change our evolution. So instead of doing one task well, we do 10 tasks poorly.”

AVOID OR MANAGE DISTRACTIONS

More and more, hospitals are educating their physicians about the dangers of distracted doctoring and how to interact with the patient and technology simultaneously. For the past several years, Dr. Gardner has presented two annual workshops on the topic, one for residents and one for faculty.

Some institutions are developing e-etiquette programs and protocols. For example, Kaiser Permanente developed guidelines for clinician-patient communication (see sidebar), and UCLA Health System developed an educational video to demonstrate how to use computers while maintaining patient-centered care. Along those lines, when Dr. Kasprowicz is in the exam room, she positions herself so that she is focused in front of the patient. “Take the time to look up from the computer screen and make eye contact,” she said. “I often pause when I need to document a physical finding and I will tell the patient what I’m doing so the patient knows that the moment is about him or her.” To engage patients, best practices suggest that physicians should explain step-by-step what they are doing, Rizzo noted.

Dr. Gardner advocates for physicians to put boundaries between them and their technology to minimize distractions. For example, turn off notifications and social media apps. Allow only certain individuals’ texts or calls to get through. “Do not bring your cell phone into the exam room with the patient,” she said. “Keep it in a work bag, not on the desk.” Dr. Papadakos recommends using separate devices for personal and professional use, making it easier to maintain focus on patient care uses while at work. Dr. Kasprowicz recently purchased a smartwatch that she uses only at work. Dr. Kasprowicz programmed the settings to allow a handful of information to come through and the rest gets categorized as noise that she scrolls through at the end of the day. It has helped her disconnect from things that are not the primary focus at work.

To avoid multitasking, Dr. Gardner schedules her day by deciding how much time to devote to the various tasks she needs to accomplish. Designate a certain time to check emails, and don’t try cramming that in on the elevator or between patients because the latter is not good use of your time or attention, she said. “Humans tend to underestimate how much time it’s going to take to do a given task,” Dr. Gardner added. “Give yourself the time and space you really need to focus. If you’re really present and mindful and do the task at hand, you will do it better.” Dr. Chinn recommends a “team huddle” or “reset,” that is taking a momentary pause before starting a new procedure or task.

Smarter not harder

Read more about strategies for time management atstaging.aad.org/dw/monthly/2019/march/smarter-not-harder.

The Doctors Company has recently developed presentations, continuing medical education courses (https://thedoctors.rievent.com/a/29625P3wtKXq), and videos (www.youtube.com/watch?v=MZyGhBOuIg4&list=PLs0-nKqwogxIa6OypS3vQa_wA5Q6-R59T) to help educate its members on the topic. It suggests mitigating distraction by employing mindfulness techniques, organizing your work space, using a checklist for more complex activities to ensure no steps are missed, training yourself to verify patient orders or documents using two identifiers, and slowing down to check your work. Mindfulness training has been shown to increase cognitive performance.

“There is the perception that work is controlling us,” Dr. Gardner concluded, “but we still have the ability to control how we interface with our technology.” Dr. Papadakos added, “The technology has moved forward faster than the human brain has, so we never had the chance to educate people how to interact with it. When I first started talking about this in 2011, people thought I was crazy. How can doctors and nurses become addicted to their phones? Now nobody would ask that.”

Experts discuss a growing health care concern