PookieMD's Blog: Where Physicians Learn About the Business of Medicine

It was a busy night at my local hospital.  I spent a lot of time in the ED, and the pager was in status.  The hospital I was at is a large tertiary hospital, and receives transfers from small mountain clinics that send us stuff like chest pain (easy) and hypertensive urgency/renal failure/barfing patients (hard.)  We get patched in to the Tiny Mountain Clinic Doctor, who gives us the skinny, and then we banter a bit about treatments etc, and then the helpful “connect” ombudsman arranges transport.

All good, so far. Except when the mountain doc wants to talk to me right as I am transferring a crashing patient to the ICU.  The helpful connect ombudsman calls me, and tells me that the Tiny Mountain Clinic Doctor needs to talk to me.  “I’m really busy,” I say, “I’m moving a patient to the ICU.  Can I call you back in 10 minutes?”  The helpful ombudsman agrees.  (BTW, our conversation is recorded, and we have all been warned to be polite as the powers that be will slap our hands if we are not.)

I’m busily assessing my patient, trying to get the transfer orders done, when the pager goes off again, not 5 minutes later.  It’s the helpful connect ombudsman.  “Tiny Mountain Clinic Doctor needs to talk to you,” she says.  Needless to say, Tiny Mountain Clinic Doctor takes first priority, even though I already said I would call back after the fire I’m putting out is taken care of.  (After all, we are being tape recorded!)

Oh how impatient we are.  But sadly, oh how impatient I am as well!  Could I just have a minute to think?

I sent an email to my colleagues with the information I posted previously about pagers and misuse/abuse.  Wow–what a maelstrom of emails I got back!  I found that I am not alone in my frustration at the over use of pagers for inconsequential items that can wait.

Here are some anecdotes and suggestions that came out of the email avalanche:

• One of our night docs counted the pages she got between 10:00 pm and 1:00 am. She got over SIXTY in three hours, many that could have waited, and were inconsequential.
• One doc suggested that all non essential items go into an in box on our EMR, that would pop up every 30 minutes and demand to be opened.   (I personally like this idea.)
• Another suggestion was that we carry Blackberrys that are linked to the EMR, and we get pages/texts that way. (Not bad in my book, but expensive.)
• A strong contingency advocated going to the Chief Nursing Officer and creating culture shift about paging early and often.  (Not likely to create a long acting,significant change.)
• One of the more radical docs thought that all pages should go through the charge nurse for each floor. (Wow, this would create friction!)
• More “prns” need to be added to the admission order set.  (This is a must do.)

And now, the best story of ‘em all:the case of the missing phone!

One of my fellow hospitalists was trying to reach a nurse on the phone that the nurse is required to carry.  The physician could here the phone ringing, but no answer.  He wandered over to the nursing station, and there was the nurse, sitting beside the ringing phone.  The hospitalist asked the nurse why the nurse wasn’t picking up the phone.

The reply: “I don’t answer the phone because it interferes with patient care.”

Yesterday, I was the admitting physician at one of the hospitals where I work.  I had a cell phone and two pagers hooked to my waist band.  In addition, of course, there were the over head pages.  All of these marvels of technology lead to mistakes, and can be particularly deadly in medicine.

As we all know, multitasking is a myth.  The human brain can not truly multitask–it can only hold one thought at a time.  As most attending physicians and all resident physicians know, a pager slows you down.  But how does it slow us down, and why is it dangerous?

When we are doing multiple tasks, we do none of them well.  That may be okay if you are knitting and watching TV, but when trying to manage a complicated case, interruptions can be deadly.  Take, for example a simple page, like the one I got yesterday, “Dr. So and So is not answering his pager?  Is he here today?”  Simple to answer, but what are the results?

1. I can’t complete my thought process, and it takes twice as long to get done what I was doing.
2. I forgot what I was doing, or planned to do.  I had to reorient myself to the complicated patient at hand and re-immerse myself in planning a diagnostic and treatment strategy.  Studies have shown that within 15 seconds of considering a new problem, we will forget the old problem.
3. It took me time to  get back in to the deep thinking mode that this very complicated patient required.
4. Multitasking leads to inattention blindness: we are so taken with one task we are inattentive to the other task, and ta da! mistakeville!  (Hmm, where could Dr. So and So be?  Is his pager battery dead?)
5. Multitasking leads to “task saturation”–becoming so engrossed in one problem that we forget the bigger problem at hand, that requires clear focus.  (Oh yeah, I was just about to move Mr. Very Sick to the ICU, but got involved in dead batteries!)

So how to fix this?  Sometimes, I deliberately do not answer pages instantly.  If I am in with a patient or putting orders in I will not call back right away.  I do look at the pager so I know where the page is coming from.  (For instance, I sometimes delay calling the ED back, as I know there is a physician on hand to handle emergencies.  I usually call the ICU back right away.)  However, this still requires me to look at the pager and figure out the level of importance, distracting me again.  Lastly, hospital groups, if they are busy enough, should have a designated admitting doctor, one that is not rounding.  Rounding, taking calls from the ED, and farming out admissions is a clear recipe for multitasking disaster.  Yes, I know, it’s the culture, but maybe it’s a culture whose time has come and gone now that hospitalists are busier than ever. 

It would help to have pages routed through a nurse practitioner, as some groups do.  In addition, it would be nice if I could get the nurses to assign a priority number to their pages.  And lastly, are all these pages necessary?  How about a formal study on how many errors pagers cause, and what kind of errors?  Motorola could fund it.

And yes, while I wrote this, I was interrupted three times–in twenty minutes–at home.

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