December 20, 2011

Doctor Distraction Happens... It's Mandatory!

I admittedly snorted out loud when I read a New York Times article  earlier last week regarding increased physician distraction due to electronic devices, especially with the advent of the smartphone with its emails, text messages, calls, and other alerts that ping intermittently throughout a typical work day.

There is no question that electronic devices distract physicians as the article pointed out... But that's like complaining about a leaky faucet when there's a flooded basement and a hole in the roof.

The bigger problem that should be mentioned is hospital bureaucracy which probably creates just as much if not more unintended distractions for physicians and nurses.

What many patients and lay public may not realize is that there is a TON of paperwork that goes into the care of a patient. Regulatory bodies like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that accredits hospitals have made it mandatory in many cases though I suspect hospital administration often carries it a step above and beyond what is truly necessary.

What all this "mandatory" paperwork means is that nurses are calling physicians all the time just so they can check a box on a form... and there are a LOT of boxes to check.

Take a simple ear tube placement. A procedure that takes about 1-2 minutes to perform under sedation in the pediatric population.

It takes about 15-20 minutes to fill out all the nursing and physician forms (whether paper or electronic medical records). When the surgery actually begins, the nurse is too busy filling out even more forms rather than paying attention to the surgery... and often the surgery is already over... and the nurse is still busy filling out forms.

Talk about distraction... a registered nurse has been relegated to being a mere secretary rather than helping (or paying attention) in the care of a patient.

I recently asked a nurse how much time they spent on actual patient care versus how much time filling out forms during a typical shift.

It saddened my heart when I was told 60-70% of a nurse's time is spent on filling out forms (whether notes, chart documentation, medication reconciliation, etc) and only 30-40% on actual patient care. This time disparity was not always true in years past.

OR... ask any physician how many times they get called during a typical day because some form or paperwork was not completed or needs completion or just remind to get it completed by nurses who themselves are the main individuals who suffer under the crush of mandatory documentation in a hospital setting.

It is irritating to say the least to get a phone call during the middle of an operation, say dissecting a tumor off the facial nerve during a parotid cancer resection, by someone who wanted to remind me to sign off on a medication list on a patient I've already provided prescriptions for.

Another classic experience of mine was when the anesthesiologist had trouble intubating a patient who started to suffer a severe lack of oxygen. I was immediately called to the bedside and performed an emergency tracheostomy.

Of course, the nurse (well indoctrinated in form completion) involved in the case immediately instructed me to STOP performing the trach and to get consent as per the regulations... which is true 99% of the time... but never mind that. Heaven forbid we now can't check that little box that states "consent obtained prior to surgery." But in the interest of patient care, I did suggest that it would be better if the patient lived with an unconsented trach rather than died due to time spent obtaining consent.

Though electronic devices may be considered a "distraction" analogous to a mosquito buzz that comes and goes, one must not forget the avalanche of paperwork which is a much more pervasive and insidious distraction that DELIBERATELY takes attention away from the care of the patient. I understand the need for documentation, but at some point when the documentation itself dominates the majority of heathcare rather than the actual administration of care, there's something fundamentally wrong going on.

It's probably why medical missions are so gratifying to participating nurses and physicians where 90%+ of the time is in actual patient care.

Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.


Brindley75 said...

Great article. I love the comment about "a leaky faucet when there's a flooded basement and a hole in the roof".

One other element of distraction is the insurance companies. I can't remember the time I had a day when I didn't receive a prior authorization form from an insurance company about a medication I prescribed. And it seems like more and more often I am having to argue with insurance companies about why a patient's proposed surgery should be covered. A few weeks ago I tried to get approval for the SMILE technique for one of my patients (I like your video on this btw). I ended up spending more than 2-3 times as long as it takes to do the surgery arguing with Aetna. Did a peer to peer conference call with their "expert", wrote them a 2 page letter with references, and faxed them at least 10 peer reviewed articles dating back 10 years on tongue base reduction in OSA. After all of that, they still rejected it as being "experimental". All of this is a distraction from actual patient care.

Carolyn Thomas said...

Dr. Chang, you missed an opportunity here to enlighten your readers on the actual point of the New York Times piece.

While the necessity of filling out those annoying forms may warrant a separate post, I would have been far more interested in your take on the alarming results of the study reported in the Times, at least more than your rather flippant summary: "There is no question that electronic devices distract physicians" along with your dismissal of cellphone usage in the O.R. as merely "a mosquito buzz that comes and goes".

Tell that to the partly paralyzed patient cited in the Times piece whose neurosurgeon's phone records confirmed that at least 10 personal calls to his family and business associates took place during this patient's surgery.

Or consider the frightening survey results showing that HALF of perfusionists running bypass machines during open heart surgery had admitted texting, calling, browsing the internet or updating their social media accounts like Facebook and Twitter while working on cardiac procedures in the O.R.

Interestingly, Dr. Trevor Smith's research published in the journal 'Perfusion' noted a significant age difference between those in the O.R. who considered using one's cellphone for personal calls during open heart surgery inappropriate - and those (younger) respondents who saw nothing wrong with this trend.

When you write: "I understand the need for documentation", I'm assuming after reading your post that - based on results - you actually don't.

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