Distracted Doctoring and the iPatient

Distraction, in this profession, wouldn’t just meanan erasable mistake, it could cost a life.[i] — Runjhun Misra, MD, Medical resident, University of Connecticut

Mary Roseann Milne, 61, of Garland, TX, checked into the hospital on April 13, 2011 for an AV node ablation procedure to correct an irregular heartbeat. Although this cardiac procedure is not benign, it is not in the high-risk category of heart surgeries. But something went wrong, and ten hours later Milne was pronounced dead.[ii] As I write, the case is in the legal labyrinth. The family has filed a malpractice lawsuit against the hospital involved, the cardiac surgeon Dr. Robert Rinkenberger, and the anesthesiologist Dr. Christopher Spillers. The case is scheduled to go before a jury in September 2014.

Rinkenberger, the surgeon, says the anesthesiologist failed to notice Milne’s dangerously low blood-oxygen levels until “15 or 20 minutes” after she had turned blue. Up to that time, Rinkenberger states, Spillers had reported normal levels of oxygen in Milne’s blood.²

It was discovered that during the procedure anesthesiologist Spillers had been on his iPad while supposedly administering anesthesia and monitoring Milne’s vital signs. He admitted to occasionally texting, reading e-books, and accessing websites during procedures, but he claimed that “even when I’m doing so, I’m always listening to the pulse ox, always checking the blood pressure, always — you know, at least every five minutes.” In their interrogation, attorneys found he had also posted messages on Facebook during procedures. Phone records showed that one of his messages was, “After enduring the shittiest Friday I’ve had in a while, I just found out my next patient has lice. Freakin lice.” He had also published a photo of a patient’s vital signs during surgery, captioned, “Just sittin here watching the tube on Christmas morning. Ho ho ho.” The anesthesiologist admitted in his deposition he knew he shouldn’t have been doing any of these things.[iii]

None of these facts proves that Spillers was negligent in the Milne case; it will be up to jurors to decide. But it does reveal how smartphones, iPads, and other personal digital electronic devices are contributing to what’s being called “distracted doctoring.”

I was saddened to discover that this case occurred in Medical City Dallas Hospital, where I practiced internal medicine in the 1970s and 1980s, and served as chief of staff in 1982.

The Milne case indicates a pattern among anesthesiologists. At an annual meeting of the American Society of Anesthesiologists in 2011, survey data was reported that showed “nurse anesthetists and residents were distracted by something other than patient care in 54% of cases—even when they knew they were being watched.” Worse, “[M]ost of what took their time were pleasure cruises on the Internet.”³

It’s not only anesthesiologists. A case reported from Colorado involved a neurosurgeon whose patient became paralyzed during surgery. It was discovered that the surgeon had made no fewer than 10 phone calls while operating to his family and business associates. He used a wireless headset to do so.[iv]

Distracted nursing also occurs. An administrative director at an Oregon hospital reported disciplining a nurse caught checking airfares on a computer in the operating room.³

Nearly everyone on the healthcare team is involved — physicians, nurses, technicians, interns, residents. Peter J. Papadakos, MD, professor of anesthesiology, neurology, and neurological surgery and Director of Critical Care at the University of Rochester Medical Center in upstate New York, is a leading authority on distracted doctoring. “You walk around the hospital, and what you see is not funny,” Papadakos says. “My gut feeling is lives are in danger. Everybody’s addicted to their gizmos,” he says. When he goes onto the surgical wing in his hospital, Papadakos says the unit secretary “is texting on her smartphone,” the nurse “is surfing the Web,” and the resident, “is gaming on his tablet.” When he asked a group of physicians during a lecture whether they were concerned about distracted perioperative team members, 83 percent said they were. When he asked the physicians if they text while driving, 50 percent said yes. Another question posed to the audience was designed to mimic the test given to alcoholics: “Do you reach for your personal electronic device first thing in the morning?” More than half, 52 percent, answered in the affirmative. Drawing a comparison with airline pilots, whose job is equally crucial, he says, “Airline pilots don’t allow themselves to be distracted by social media, because they themselves do not want to die,” says Dr. Papadakos. “To replicate that in health care, we’d have to say, ‘If there’s a wrong-site surgery or other error, we will shoot everybody in the OR.’” ^{3, 4}

DISTRACTING ONESELF

In a recent essay, I reviewed evidence that the excessive use of personal electronic devices such as smartphones and laptops can be hazardous for one’s health, and can result in the actual shrinkage of brain tissue in the young.[v]^{, [vi]} Among the issues I discussed were distracted driving and distracted walking from talking and texting. Since the essay appeared, several readers have called my attention to distracted doctoring, which, the above examples show, poses a potential danger to anyone undergoing medical care.

The term “distracted” doctoring, however, does not adequately describe healthcare providers who habitually use electronic devices for non-medical purposes during patient care. These doctors, nurses, and technicians aren’t distracted by outside happenings; they’re purposefully deciding to interact with Facebook friends or Twitter followers instead of the patient in front of them.

PATIENTS AS DISTRACTIONS

Sometimes it’s the patient’s use of a smartphone that constitutes a problem. This is commonplace, and is why medical and dental offices everywhere have signs saying NO CELL PHONE USE.   The following example was reported to me by Texas dentist Dr. Garry Dossey (yes, my twin brother):

Last week a 19-year-old young woman came to my office for extraction of four bone-impacted wisdom teeth.  She was accompanied by her grandmother. During the procedure, I could not get her to listen to what I was telling her because she refused to put down her cell phone and stop texting.  She was constantly taking selfies and photos of the procedure and me, and sending them to her boyfriend.  When I tried to convince her to set her cell phone aside, she became sullen. I managed to take out two teeth and then gave up.  I told the grandmother the procedure was terminated because of her granddaughter’s cell phone dependence, which I could not overcome.  This is not funny.  It is a serious happening in the medical and dental professions. Signs in the waiting room prohibiting cell phone use are completely ignored. I have battled this problem for four or five years, and it gets worse. I wonder what it is about these electronic devices that makes us take leave of all common sense. This is as big a problem for dentists, if not more, as for physicians. It cheapens all the healing professions. (Personal communication from Garry Dossey, DDS, April 28, 2014)

NATIONAL ATTENTION

In 2011, journalist Matt Richtel in the New York Times brought to the nation’s attention the dilemma posed by the undisciplined use of personal electronic devices in medical environments. He said, “Hospitals and doctors’ offices, hoping to curb medical error, have invested heavily to put computers, smartphones and other devices into the hands of medical staff for instant access to patient data, drug information and case studies. But like many cures, this solution has come with an unintended side effect: doctors and nurses can be focused on the screen and not the patient, even during moments of critical care. And they are not always doing work; examples include a neurosurgeon making personal calls during an operation, a nurse checking airfares during surgery and a poll showing that half of technicians running bypass machines had admitted texting during a procedure.”[vii]

Richtel’s article was a wakeup call. Soon after it appeared, professional societies in the United States and beyond began to address the issue through their annual meetings, safety committees, guidelines and studies.   Among them were the Association of Perioperative Registered Nurses, the American Academy of Orthopaedic Surgeons, Canadian and American respiratory therapists, the Congress of Neurological Surgeons, and the Emergency Care Research Institute.

THE iPATIENT

Abraham Verghese, a physician and professor at Stanford University Medical Center and the author of Cutting for Stone, says, “In the interest of preventing medical error, [the computer is] a good friend.” At the same time, he adds, the wealth of the data on the screen — what he calls the iPatient — gets all the attention. “The iPatient is getting wonderful care across America. The real patient wonders, ‘Where is everybody?’”7, [viii]

Several studies now show how iPatients are created. In one study designed to assess the negative effects of information technology on doctor-patient dialogue, researchers found that “the collaboration worked best when doctors were using a paper chart to communicate with their patients. They observed that personal digital assistants or laptops inhibited aspects of essential communication such as eye contact, gestures, visibility of actions, and verbal and non-verbal contact, which was a hindrance to quick and efficient information retrieval and communication.”[ix]^, [x]

I have known many physicians who are iPatient creators. They prefer to keep an emotional distance from their patients. During office visits they talk to their patient while peering at a computer screen and typing on a keyboard. Personal electronic devices are a refuge for them, a way of legitimizing a cool remoteness. Physicians who consciously or unconsciously resort to electronic devices as a wall between them and their patients might consider employment in another profession; the physician might be happier, and patients safer. Empathy and compassion are already hanging on by their fingernails in modern medicine. Patients do not deserve further dehumanization.

“IT’S ABOUT DINNER”

Medical educators are well aware of these issues. Yet, while medical schools are reminding students to focus on patients instead of gadgets, students are being given even more devices. For instance, at Stanford Medical School all students now get iPads, which they use to read medical texts. And they carry these devices into hospitals, while being cautioned not to let them get in the way of their one-on-one work with patients.⁷

It was not always this way, of course. Throughout the 1980s, most medical training programs banned residents from so much as studying in operating rooms or on the ward. Now doctors routinely do far more distracting things in these same settings, with no possible medical justification — from tweeting to texting to posting on Facebook.

Some students simply don’t comprehend the problem. Sarah Forgie, MD, and Shelly Ross, PhD, of the University of Alberta, report the experience of a 39-year-old man suffering from multiple facial contusions and a head injury after a water-skiing accident. He came to the emergency department accompanied by his wife. The resident began taking a history, then stopped mid-sentence, pulled out his phone, read the screen and began to text. The spouse of the patient said, “What are you doing?” The resident replied, “I have to answer this. It’s about dinner.” He turned his back, continued to text, waited for a response, then texted again. Replacing his phone, he started again with the history. When the wife complained about the interruption, the resident looked at her blankly, and again stated, “I had to answer it. It was about dinner.”[xi]

DISTRACTION AND MULTI-TASKING

Medical and surgical errors were major killers in American hospitals long before the smartphone era. Epidemiologist Barbara Starfield reported in 2000 that around 200,000 Americans die in U.S. hospitals each year because of the side effects of medications and medical errors.[xii] Adding errors due to smartphones to this already grim toll is going in the wrong direction.

Research on multitasking and divided attention consistently shows that learning and memory are impaired when too many distractions are present. In a study at an Australian hospital, researchers found that each interruption to medical care workflow was associated with a 12.1 percent increase in procedural failures and a 12.7 percent increase in clinical errors.[xiii] In one case, a medical resident forgot to stop an anticoagulant medication for a post-op patient. The resident was distracted by a text message on her smartphone, and she forgot her primary task.[xiv]

Remedies exist. In one study designed to prevent distracted nursing, researchers implemented a “no interruption zone” by placing red tape on the floor around the site of drug preparation to act as a visual “do not disturb” sign. With this simple intervention, there was a 40.9% reduction in the number of interruptions during medication preparation.¹¹ This simple, inexpensive, and effective intervention illustrates the ingenuity that nurses often bring to challenges in patient care that need solving.

DIRTY DEVICES

Distraction aside, using smartphones in healthcare facilities presents risks of contamination and infection.

Nearly all studies show that mobile devices have a high level of bacterial contamination.[xv] In one, 96 percent of cellphones tested were contaminated, 15 percent by bacteria known to cause significant infections.⁹

Another study examined 390 cellphones and 390 hands that used them. Overall, the researchers found that 92% of hands and 82% of phones showed some type of bacterial contamination. In16 percent of subjects, both hands and phones were contaminated with E. coli, which is fecal in origin. The likely reason for the contamination is that people don’t wash their hands after using the toilet. About a third of hands and a quarter of phones contained Staphylococcus aureus.[xvi]

In an additional study of the hands of 200 healthcare workers and their mobile phones, 94 percent of the phones were found positive for some type of bacterium. Of particular concern was that about a third of the Staphylococcus aureus isolated from both hands and phones were methicillin resistant (MRSA).[xvii]

Cellphones have come to be regarded as an indispensable appendage. People use them almost unconsciously, including healthcare workers who should know better. As a concerned husband reports:

During a hospital visit to my wife, I observed the following: A nurse arrived to hang another bag of antibiotics. She washed her hands, but before she could complete the task, her phone rang. She pulled it out of her pocket and began talking, stepping into the hall to finish her conversation. When she returned to the room, she dropped her phone in her pocket and hung the antibiotics without washing her hands. It happened so quickly, I did not intervene, but it is frightening.[xviii]

Hands can be easily cleaned with soap and water, but if their next stop is a smartphone the contamination cycle begins all over again. Guidelines on how to clean your smartphone and its carrying case, as well as laptop keyboards, can be found at a variety of websites.[xix]^, [xx]^, [xxi]^{, [xxii]}

PRIVACY AND ETHICS

Physicians and nurses often say the main reason they use electronic devices is to check medical records or look up relevant information, but this more limited than sometimes realized. Because SMS, the Short Message Service component of mobile communication systems, does not meet criteria for protecting privacy under the stipulations of HIPAA, the Health Insurance Portability and Accountability Act, smart phones, strictly speaking, should not be used for communicating with or about patients. Note that in the Milne case above, anesthesiologist Spillings sent a photo of his patient’s electronic data in a casual message to a friend. This is a flagrant violation of patient privacy.³

The decision to use a device, for any reason not immediately relevant to the patient, may not be defensible, if for no other reason than it is a choice to compromise one’s attention to the patient. Some medical insiders believe the voluntary decision to engage in distraction is a violation of medical ethics. Runjhun Misra, the medical resident at the University of Connecticut quoted in the epigraph, says, “To adhere to [the Hippocratic] oath, it is critical to be mentally present during all clinical encounters or you may miss a critical, life-impacting piece of information.”¹ Quite simply, physicians should pay attention; if they are texting, tweeting, or reading, their attention is compromised.

FIRST THING IN THE MORNING

Some users claim they are addicted to their electronic device. But even if true addiction to these devices exists, this does not excuse their misuse. As journalist Rebecca Buckwalter-Poza writes, “A surgeon addicted to alcohol or an illegal drug wouldn’t be allowed to operate while drunk or drinking — so why are physicians addicted to their iPhones and technicians given to texting still allowed in the operating room?”³

The University of Rochester has developed a tool with which to address addiction to a personal electronic device (PED) such as smartphones, tablets, or small mini-computers. It is based on CAGE, a highly validated questionnaire used to screen for alcohol addiction (CAGE is an acronym of its four questions). The University of Rochester Modified CAGE Questions are:

1. Have you ever felt you needed to Cut down on the use of your PED?
2. Have people Annoyed you by criticizing your use of PED?
3. Have you felt Guilty about your overuse of PED at work?
4. Do you reach for your PED first thing in the morning?

The survey, says Papadakos, self-validates to the participant his or her own shortcomings and is a springboard to starting a dialogue and correction of behavior in the professional environment.[xxiii]

NEXT STEPS

The morbidity and mortality in healthcare settings associated with electronic device abuse have brought healthcare workers face to face with the dark side of the digital explosion. This dark side has already been encountered by other segments of our society, such as the 3,000 American teens killed annually in car crashes while texting and driving, and the tens of thousands of brain-injured survivors who will require millions of dollars for care and rehabilitation, whose lives will never be the same.⁵ But electronic devices are not going to disappear from the medical landscape, nor should they, just because they can be abused. They are, after all, neutral; the abuse lies with us.

Anesthesiologist and neurosurgeon Papadakos asks, “So, where do we stand? The signs are encouraging. Medical centers throughout the country have started to develop guidelines and recommendations on the use of electronic devices and professional behavior. Hospitals, medical schools and clinical departments have addressed the issue through grand rounds and staff education.”²³

Even though these are early days, it is encouraging that the problems with distracted digital doctoring are being identified, and that specific guidelines are being delineated for the use of smartphones by professional societies and safety committees around the country.^{9, 23} Lessons learned in the medical world should be shared with our society at large. As Papadakos states,

As health professionals, we already have become leaders in self-correction of this behavior and developing ways of addressing these technology issues. I call on each of us to begin educating both our families and communities. Hospitals and health professionals should educate young people in the schools of the dangers of overuse of this technology. We should pressure our elected officials on the dangers of not only texting and driving, but on distracted pedestrians…. Through education, we can effect great, positive change in how we interact with these new technologies.²³

The challenges raised by distracted, digital doctoring may seem unprecedented, but in essence they have been around a long time. They deal with whether we will control, or permit ourselves to be controlled by, machines. We have already struggled with many iterations of this issue. For example, every day we must decide whether to devote the time and attention required to take a detailed history from a patient and perform a thorough physical exam, or cut short face time in favor of expensive tests and scans. The digital gadgets and gizmos are only the latest in a flood of inventions to come between our patients and us.

Or not. The choice is ours.

References

[i] Misra R. Distracted doctoring — is it really a concern? UConn Today. 6 February 2012. http://today.uconn.edu/blog/2012/02/distracted-doctoring-—-is-it-really-a-concern/. Accessed 24 April, 2014. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437811/. Accessed 24 April, 2014.

[ii] Nicholson E. Dallas anesthesiologist being sued over deadly surgery admits to texting, reading iPad during procedures. http://blogs.dallasobserver.com/unfairpark/2014/04/dallas_anesthesiologist_cops_t.php. 1 April, 2014. Accessed 22 April, 2014.

[iii] Buckwalter-Poza R. Treat, don’t tweet: the dangerous rise of social media in the operating room. http://www.psmag.com/navigation/health-and-behavior/treat-dont-tweet-dangerous-rise-social-media-operating-room-79061/. 16 April, 2014. Accessed 21 April, 2014.

[iv] Richtel M. As doctors use more devices, potential for distraction grows. http://www.nytimes.com/2011/12/15/health/as-doctors-use-more-devices-potential-for-distraction-grows.html?pagewanted=all. 14 December, 2011. Accessed 21 April, 2014

[v] FOMO, digital dementia, and our dangerous experience. Explore: The Journal of Science and Healing. 2014; 10(2): 69-73.

[vi] Yuan K, Qin W, Wang G, Zeng F, Zhao L, et al. (2011) Microstructure Abnormalities in Adolescents with Internet Addiction Disorder. PLoS ONE 6(6): e20708. doi:10.1371/journal.pone.0020708. Abstract available at: http://www.plosone.org/article/info:doi/10.1371/journal.pone.0020708. Accessed October 30, 2013.

[vii] Richtel M. As doctors use more devices, potential for distraction grows. http://www.nytimes.com/2011/12/15/health/as-doctors-use-more-devices-potential-for-distraction-grows.html?pagewanted=all. 14 December, 2011. Accessed 21 April, 2014

[viii] Verghese A. Cutting for Stone. New York, NY: Vintage; 2010.

[ix] Gill PS, Kamath A, Gill TS. Distraction: an assessment of smartphone usage in health care settings. Risk Manag Healthc Policy. 2012; 5: 105-114. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437811/. Accessed 25 April, 2014.

[x] Alsos OA, Das A, Svanæs D. Mobile health IT: the effect of user interface and form factor on doctor-patient communication. Int J Med Inform. 2012 81(1):12–28. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21996624. Accessed 25 April, 2014.

[xi] Ross S, Forgie. Distracted doctoring: Smartphones before patients? http://www.cmaj.ca/content/184/12/1440. Accessed 21 April, 2014.

[xii] Starfield B. Is US health really the best in the world? JAMA. 2000;284(4):483-485.

[xiii] Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010;170(8):683–690.

[xiv] Halamka J. Life as a healthcare CIO: safe wireless practices. http://geekdoctor.blogspot.com/2007/12/safe-wireless-practices.html. Accessed 21 April, 2014.

[xv] Al-Abdalall AHA. Isolation and identification of microbes associated with mobile phones in Dammam in eastern Saudi Arabia. J Family Community Med. 2010 17(1):11–14. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3195068/ . Accessed 25 April, 2014.

[xvi] Song S. Study: 1 in 6 cell phones contaminated with fecal matter. Healthland.time.com. http://healthland.time.com/2011/10/17/study-1-in-6-cell-phones-contaminated-with-fecal-matter/. 17 October, 2011. Accessed 25 April, 2014.

[xvii] Ulger F, Esen S, Leblebicioglu. Are we aware how contaminated our mobile phones are with nosocomial pathogens? Ann Clin Microbiol Antimicrob. 2009; 8: 31. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2655280/. Accessed 25 April, 2014.

[xviii] Graedon J, Graedon T. Cellphones a potential source of contamination; wash hands after use. http://www.tristateneighbor.com/entertainment/country_living/your_health/cellphones-a-potential-source-of-contamination-wash-hands-after-use/article_3c4bbc0a-1d34-11e1-a61b-001871e3ce6c.html. Accessed 25 April, 2014.

[xix] Roos D. How to clean your cell phone. home.howstuffworks.com. http://home.howstuffworks.com/home-improvement/household-hints-tips/cleaning-organizing/how-to-clean-your-cell-phone.htm. Accessed 25 April, 2014.

[xx] Viren T, Crosby D. How to clean your cell phone. Wikihow.com http://www.wikihow.com/Clean-Your-Cell-Phone. Accessed 25 February, 2014.

[xxi] How to clean a laptop. electronics. howstuffworks.com. http://electronics.howstuffworks.com/how-to-tech/how-to-clean-laptop.htm. Accessed 25 April, 2014.

[xxii] How to thoroughly clean your keyboard. howtogeek.com. http://www.howtogeek.com/65073/how-to-thoroughly-clean-your-keyboard-without-breaking-anything/. Accessed 25 April, 2014.

[xxiii] Papadakos P. Digital distraction: signs of improvement, but more focus needed. Anesthesiology News. January 2014: 40(10). http://www.anesthesiologynews.com/PrintArticle.aspx?A_Id=24703&D_Id=449&D=Commentary. Accessed 24 April, 2014.

Image by NEC-medical-51, courtesy of Creative Commons licensing.