An Unmeasured Variable in Modern Medicine

The supervising attending comes onto the ward passing the unit secretary, who is texting on her smartphone. She passes the nurse, who is surfing the Web. She then stops to watch the resident, who is gaming on his tablet.
As farcical as it might seem, this digital nightmare is increasingly common on hospital wards throughout the country and the world. Unfortunately, we have almost no data on how electronic distraction affects worker productivity and dedication to repetitive tasks in health care.
In my formative years of training during the late 1970s and 1980s, it was routine for residents to be barred from studying or reading in the operating room or on the ward. Journals and professional newsletters printed humorous cartoons of a physician skimming the financial news while alarms around him blared. Health care workers were routinely taught that their primary role was total dedication to patient care. It was an era of direct face-to-face or telephone communication between patients and the providers of that care. Distraction from given tasks was minimal, so caregivers were focused on the patient and directly collected and reviewed the data.
The modern hospital environment presents a radical departure from those days. The time-honored way we cared for patients, communicated among ourselves and answered questions is no longer the norm. The new health care model is one of electronic records and patient care data downloaded from a distant server. Generational changes mandate that we educate 20- and 30-year-olds about how to speak to patients—but these individuals have grown up communicating through secondhand electronic media without direct contact.
The health care workers of today rarely receive information directly from their patients. They review a downloaded health history on their computers. They do not speak to patients to get the subtle feeling for a disease in evolution or any new “minor” change that occurred since the patient was last seen. They must follow checklists that meet Medicare and other guidelines or risk billing challenges, reprimands from the department head, lawsuits and other opprobrium.
Individuals can argue that this type of medicine is better, but put yourself in the patient’s shoes: Your nurse or physician is looking into the computer screen while typing answers and cutting and pasting and filling out a checklist. What does all this have to do with your current complaint?
The environment, as patients observe it, also has changed. They no longer are at the center of their care—their data are. Their health care providers are fixated on computer screens; they might be doing medical work—or not.
And don’t think anesthesiologists are immune to digital diversion in the operating room. A study presented at the 2011 annual meeting of the American Society of Anesthesiologists found that nurse anesthetists and residents were distracted by something other than patient care in 54% of cases—even when they knew they were being watched! Most of what took their time were pleasure cruises on the Internet (abstract 1726).
An ever-growing body of evidence shows that the explosion of computers, smartphones, tablets and other devices, along with the omnipresent social media, has an addictive element. The psychology of this constant need to get information and be entertained has not been fully studied.
Whereas in the past, triggers for distraction in the operating room were relatively rare, technological changes and the accompanying societal shift have created an environment in which the health care worker constantly is tempted to surf the net, check social media and send emails. Our administrators and political leaders reinforce this behavior with their endless daily emails that must be answered, their regulatory hoops to jump through and the centrality of computers in hospitals.
So take a good look at that smartphone. How many of those emails need to be answered the moment they pop up on the screen? How about that long case last week? Was it really necessary to check the stock market, play the latest word game or do the daily crossword puzzle online?
Experts continue to lecture us on medical error rates that in many ways are computer models with made-up ranges of errors. (The endlessly cited 2001 Institute of Medicine report, “To Err is Human,” for example, rounded up the estimated number of hospital-related deaths from between 26,000 and 96,000 to a barely plausible 100,000.) They develop plans to address them based on shared responsibility and separate the health care worker from personal responsibility to protect their psyches. But no studies have looked at how the attentions of these protected clinicians are lured away by inescapable electronic distraction. Research has clearly demonstrated that the addictive quality of these devices has increased accidents each day on our roads. How can we ignore this phenomenon in health care workers as a component of errors and near misses?
Anesthesiologists have led the way in the past with our introduction of monitoring and best-practice guidelines, which have been the keystone of patient safety. We must help train the next generation of health care providers to deal better with the ever-growing explosion of electronic devices that have become so common in our modern world.

Dr. Papadakos is professor of anesthesiology, surgery and neurosurgery at the University of Rochester, in Rochester, N.Y., and a member of the editorial board of Anesthesiology News.