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Really, It’s Switch Tasking


 

It’s fitting that I’ve been interrupted many times while I’ve been writing this column. My topic is interruptions in the work of a hospitalist. I’ll leave it to you to judge whether the interruptions I suffered while writing have adversely affected the quality of this column. The more important question is how much the quality, efficiency and patient safety of hospitalists’ work suffers because of interruptions.

For the most part, the hospital where I worked as an orderly (how is that for an antiquated term!) in the 1970s was like a library; nursing stations usually were quiet and slow paced, well suited for concentration and focus. Today, the nursing station in a typical hospital looks more like the floor of the stock exchange, with many people trying to talk over each other and jostling for a position at a computer. People who study this kind of thing would say that we increasingly work in high-tempo settings with a high communication burden, and, as a result, our work has become increasingly “interrupt driven.”

My first, and generally ineffective, impulse is to try and decrease the noise and interruptions by doing things like asking others to page me less often, and only for time-sensitive clinical issues and not for routine things. But the problem is that promptly addressing many of these interruptions is our job, not simply a distraction.

It is tempting to say hospitalists (and emergency room doctors and others) have to do a lot of multitasking. But I think that we’re really “switch tasking” most of the time, rather than multitasking.1 Switch tasking means frequently changing tasks. With some regularity we stop in the middle of one task and switch our attention to another—and incur two costs in the process. One cost is the mental energy consumed and stress of frequently shifting our attention.

The other cost is that it is reasonably common that we fail to return to the original task, so it remains uncompleted. How often have you promised a patient you’d write a PRN order for a sleeping pill, but got interrupted and never circled back to write the order? And it is easy for most of us to think of similar errors with more significant consequences.

Kevin O’Leary and colleagues at Northwestern University in Evanston, Ill., conducted a time-motion study of hospitalists. It found hospitalists were interrupted by pages an average of 3.4 times per hour (+/- 1.5).2 Emergency room (ER) doctors face an environment similar to hospitalists, and one study found ER doctors were interrupted an average of once every 5 minutes, and two-thirds of the time did not return to the prior task.3

Interruptions vs. Sleep Depravation

I’ve found it difficult to adjust my work style and habits to keep up with the pace of change and the increasing frequency of interruptions. My first, and generally ineffective, impulse is to try and decrease the noise and interruptions by doing things like asking others to page me less often, and only for time-sensitive clinical issues and not for routine things. But the problem is that promptly addressing many of these interruptions is our job, not simply a distraction.

Even if we can’t make the interruptions go away, we can try to manage them. In 2005, I was thrilled to learn of an emerging field known as “interruption science.” For a really engaging look at this field, search the Internet for “Meet the Life Hackers,” an article by Clive Owen in the New York Times [Sunday] Magazine, October 16, 2005. It describes people who are devoting their research careers to understanding the best ways to manage interruptions and where our attention shifts next.

One workplace that has been studied extensively is the cockpit of fighter jets. They’re full of remarkable gadgets that provide constant information via lights and noisemaking devices, including one that sounds like the female voice on your car’s GPS navigator. But research showed that during times of high pilot workload, some of these alarms distracted the pilots from more important tasks and increased errors. One strategy has been to suppress some alarms when the jet is configured for a complex operation, such as dropping a precision bomb or landing.

Although I have absolutely no data to prove it, I suspect hospitalists’ high volume of interruptions increases the errors we make. In fact, frequent interruptions might lead to more problems and errors than the sleep deprivation that has received so much attention in the past few years.

Fixing the problem of sleep deprivation seems easy, at first. Just eliminate the long work periods. But that means moving toward more shift work, which decreases continuity and increases the potential for new problems, like fumbled handoffs. It is really tough to figure out how to optimally balance the competing needs of preventing sleep deprivation and maximizing continuity to the point that minimizes the errors and problems caused by each. And I think it’s even tougher to find solutions to reduce hospitalist interruptions and the adverse consequences.

Proactive Measures

Two strategies to minimize hospitalist interruptions have been used in a handful of places with some success. Neither is perfect, and both are difficult to implement. But each can serve as a starting place for brainstorming about where you could or should direct your efforts.

The first is to have a rounding assistant accompany each hospitalist throughout the day. This person:

  • Doesn’t need any medical training and functions much like a mobile receptionist.
  • Would hold the doctor’s pager and keep track of all incoming calls, some of which would be handled without involving the doctor. As an example, this assistant should be able to handle the “family is anxious and wants to know when you will be here” call without interrupting the doctor.
  • Could find charts, look up test results on the computer, page consultants, etc.

All these things could decrease the hospitalist’s interruptions with little impact on others.

Although it sounds wonderful, a rounding assistant ends up being very expensive and few practices use them. Some practices have case managers dedicated to the hospitalists, which provide some rounding assistant functions in addition to their case management work.

A second strategy that can significantly influence interruptions is to implement a system of unit-based hospitalists, in which a given hospitalist has most patients on a single unit of the hospital. This can decrease the number of pages to the hospitalist, as well as influencing communication in other ways that impact interruptions. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. He is also part of the faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

References

1. Crenshaw D. The Myth of Multitasking: How Doing it All Gets Nothing Done. Hoboken, NJ. Jossey-Boss; 2008.

2. O’Leary, KJ, Liebovitz DM, Baker, DW. How hospitalists spend their time: Insights on efficiency and safety. J Hosp Med. 2006;11(2);88-93.

3. Chisolm et. al. Emergency department workplace interruptions: Are emergency physicians “interrupt-driven” and “multitasking?” Acad Emerg Med. 2000;7:1239-1243.

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