I sat in the workroom on a busy cardiology service during the first month of my residency training, listening to the drone of distant elevator music through the phone. My fingers raced across the keyboard as I waited for a free pharmacist to answer my call.
Buzz. I felt the rumble of the pager on my left hip as it vibrated to let me know that Ms X was requesting pain medication. I thought fast: “OK, I will get to her as soon as I finish the orders I am typing for Ms. Y and the pharmacist can clear the medications for Ms Z. Everything is under control.”
“Dr. George,” a nurse called as she entered the door to my right. “I can tell you look busy, but when you have a chance, Mr. C just came back from his procedure and is requesting a meal order. He is pretty hungry.”
Buzz. This time the gentle vibration of the pager on the opposite hip chimed in to remind me that Mr. B’s family would like to see a doctor about the plan for his discharge.
Then from my left: “Dr. George,” a second nurse mumbled shyly. “Mr. A has nausea again and I think he vomited up some blood. Could you come take a look?”
Between the computer orders, the phone, two nurses and two pagers, I counted six separate switches in patient care that my brain juggled within the span of less than 60 seconds, all while I sat in the middle of a bustling workroom. Six inputs, six different patients, each with important needs.
Experiences such as this drive my impression that modern residency training is as much about multitasking as it is about medical knowledge, and as much about prioritization as it is about procedural skill. Perhaps even more than traditional skills, these non-clinical competencies directly impact on the effective and safe delivery of care. In isolation, all the knowledge in the world would have difficulty overcoming inadequate triaging of patient needs or inability to respond to stressful situations.
I offer this experience here not because it is exceptional, but, rather, because it is so commonplace that we tend to accept it as the norm. Of course this is not a new phenomenon; if anything, it is a tradition and a recognized right of passage. However, I wonder if technology is now adding new variables to the equation.
Technological distractions
On top of my typical clinic visits, patients now regularly e-mail me or contact me through a health portal that is accessible 24 hours a day. In the hospital, I never seem to be further than 10 feet from a computer terminal or telephone, often carry two pagers, and overhead announcements are ubiquitous.
These technological distractions and interruptions have increased in concert with the implementation of the electronic health record (EHR) and a recent study showed that the transition to EHRs has as much as doubled the time residents spend performing patient documentation.[1] Yet, the challenges extend far beyond increasing time burdens. A study in this issue of Medical Education examines the negative impact of EHRs on trainee development and clinical reasoning.[2] Varpio et al. suggest that use of the EHR requires a new way of working and thinking because the modality changes both our cognitive workload and our acquisition of clinical reasoning skills.[2] Despite this, there has been little research into the impact of technology on medical education.
Beyond limiting face-to-face direct patient care, I find that EHRs require me to navigate through several screens of disconnected data. There are varied window views and unanticipated pop-ups, and I must simultaneously manage several electronic patient charts with limited onscreen discrimination between each patient. Unnecessary clinical data are automatically integrated into the chart and my notes, situated to meet reimbursement measures and satisfy regulatory requirements. Interruption by these data, on top of the sensory overload already imposed by task switching, often obscures key findings and challenges otherwise straightforward pathways of clinical reasoning. Truly, opportunity for interruption is pervasive.
Counter to these increasing interruptions in the medical world, research on effectiveness demonstrates that the highest performers are those who are able to focus on one task at a time. Meanwhile, it seems that multitasking tends to have exponentially diminishing returns as additional priorities are added.[3, 4] The key disruptor, from a cognitive performance standpoint, appears not to be the interruptions themselves, but rather the act of repeatedly switching from task to task that blunts the ability to respond.[5] The business community has largely responded to these revelations by developing training on how to respond to interruption and implementing protected work time for specific tasks.[6, 7] This may challenge the entrenched model of traditional in-patient care, but is worth consideration.
One recent study observed that residents can be paged as frequently as every 8.7 minutes and are paged on average once every 13 minutes.[8] Given the suggestion that interns spend upward of 40 percent of clinical time in front of a computer and less than 15 percent in direct patient care,[9] it is possible that we are moving away from health care training and toward health care triaging.
Challenges in communication, teamwork and adapting to changing circumstances
Reflecting upon my own training to this point, I feel the true tests of residency lie not in any textbook, but within the challenges of communication, teamwork and adaptation to changing circumstances. Therefore, although I do not foresee a short-term shift in training or practice to eliminate interruption, I do hope that our academic community is sufficiently inspired to prepare our trainees for these episodes of necessary task-switching. This may offer additional and unanticipated benefit in responding to the growing challenge of cynicism and burnout in medicine.
Although the development of clinical knowledge and experience will always remain the priority of training, our academic communities should look to prevent these increasing interruptions. Perhaps busy in-patient services might examine models based on successful work management strategies in business. One method might be to devise a medicine rounding team with a schedule that allows for protected work time for residents.
For instance, teams might utilize interdisciplinary rounds in the early morning hours to bring as many care providers, including nurses and care coordinators, up to speed on the plan for each patient. Following rounds, junior residents might use a two-hour block of protected work time to minimize interruption and maximize efficiency. All team members on the ward would be aware of this protected time, although emergencies would remain a priority. Upper-level residents could manage any pressing matters, and the protected work time might conclude with open rounds and communication with nurses and care coordinators to address any interim issues. This, along with purposeful training in effective management of task switching, might go a long way toward reducing error and preventing the onset of burnout.
It has been my experience that the most challenging aspects of residency training have pertained to the ability to adapt to change, multitask and prioritize, and to the need for resiliency in the face of adversity. Despite this, I had very little guidance on how to appreciate and hone these skills during my formative training years in college and medical school. I urge that we respond to the increasing imperative of purposeful teaching in these non-clinical skills. Ultimately, I cannot foresee a training program that removes the pager from the hip, but I can envision success for those who prepare trainees to manage the task of responding to the buzz.
Aaron George, DO, is a recent graduate of the Duke Family Medicine Residency Program. He now works at Summit Health Primary Care in Chambersburg, Penn. Contact Aaron George at aaronegeorge@gmail.com.
This article was republished with permission from John Wiley and Sons. The article was first published online April 18, 2015. Read the full text of the article.