Learning objectives
- 1)
Define distracted doctoring and how it influences patient safety outcomes.
- 2)
Describe the “iPatient” and its relationship toward patient-centered care.
- 3)
Identify issues relating to personal electronic device and computer addiction, noise, distraction, and contamination.
- 4)
Describe shared decision making, elements of effective listening, and elements of effective two-way communication.
- 5)
Define the “triangle of trust” and the elements of “the human level” mnemonic.
It’s scary out there
How patients view an organization can be directly connected to how we as physician assistants (PAs) are viewed. A patient or family member’s perception of an organization begins forming immediately upon entering an institution and can be shaped until discharge. Patients and their families trust their lives to our care. When patients and families see that you can convey their understanding of the problem by using strong communication skills and integrating electronic technology, they are comforted and feel secure about their well-being.
The introduction of the electronic medical record (EMR) has created an environment where best practices supported by evidence-based/peer-reviewed resources can be obtained with a few clicks on a keyboard. The gathering of lab data, radiologic readings, and other sources of information related to the management of each patient being cared for is literally at a finger’s touch. The Joint Commission (TJC) Sentinel Event Alert 58, which focuses on inadequate handoff communication, speaks to the misalignment in communication between providers. We realize that many sentinel events occur because of ineffective communication processes. Communication among members of the team and communication with our patients has become more and more of a concern because of the “lost art of listening.” Today there seems to be a large focus on the computer, sometimes known as the “iPatient,” and this focus seems to supersede interactions with the patient at the bedside. I have witnessed teams of caregivers discussing and reviewing information from a computer’s EMR, but paying no attention to the patient in the room in the bed. Often, a simple hello is all many patients are looking for. That greeting helps to establish trust and demonstrates a concern for their well-being. As Abraham Verghese notes, “The computer has become a good place to get a result, communicate with other people and in the interest of preventing medical error, it’s a good friend. The ‘iPatient’ is getting wonderful care across America, but the real patient wonders ‘Where is everybody?’”
The importance of “a doctor’s touch” (our touch) cannot be understated. The human hand is one of the most important tools of our career. The clinician-patient interaction is described as a ritual where patients trust our bedside interactions and examinations in order to heal. This is what a doctor’s touch can do. Instead, we are finding that rounds are moving from the bedside to the hallways and even to conference rooms. The discussions with teams without the patient are taking away the hands-on skills that are essential.
The focus of this chapter is on how to use technology without alienating patients, so I want to include an additional scenario. Have you ever stopped at a red light and watched pedestrians cross the street? Are they looking at the crossing or are they fixated on their personal electronic devices? Now let’s relocate to the hospital setting, where employees can be walking down a corridor with their electronic personal device in hand, oblivious to others or conditions in their oncoming direction. I say to myself, “What is so important that needs to be reviewed at this moment in time? Does what is being viewed have to do with patient management or does it have more to do with social media?” Overall “etiquette” with both personal and hospital electronic devices in health care is a great concern!
Matt Richtel, a Pulitzer Prize–winning New York Times reporter, in his article “As Doctors Use More Devices Potential for Distraction Grows,” speaks to the practice of “distracted doctoring.” Incidents include caregivers talking on phones when a surgical or bedside procedure was being performed. Others were found to be making personal phone calls or checking personal emails when their attention should have been directed toward their patient.
In 2017, Peter J. Papadakos and Stephen Bertman edited a textbook called Distracted Doctoring – Returning to Patient-Centered Care in the Digital Age . In the Forward section, “First, Do No Harm,” Matt Richtel describes how he received a tip from Dr. Papadakos that doctors were getting distracted using their phones and doctors were watching movies on their phones. Dr. Papadakos had a story to tell:
“He explained to Matt that the problem was showing up in hospitals, in medical schools, in the hallways and during rounds. He described doctors’ and nurses’ faces buried in phones as they rounded, sometimes bumping into things, sometimes worse…My gut feeling is lives are in danger…We’re not studying the problem and we’re not educating people about the problem and it’s getting worse.”
Noise, distraction, and contamination
The literature supports the use of electronic devices, smartphones, computers, and the EMR as having many advantages when it comes to a patient’s care and management. In our daily activities, we incorporate applications (apps) that align with healthy living styles, health education, and health management, but time spent with our electronic devices allows us less time to be applied toward person-to-person interaction. In addition, if the focus of an interaction results in a distraction, then “situational awareness” and even “clinical reasoning” can be altered. The EMR was designed to enhance patient safety and quality outcomes, but errors and poor outcomes can result in serious patient safety events.
Noisy environments coupled with the use of mobile phones and electronic devices can cause distractions when clinical interactions are taking place. It was because of this concern that the Council on Surgical and Perioperative Safety (CSPS) developed a safety chart with an emphasis on a multidisciplinary team approach being required to reduce the level of noise to create a safer environment for both patients and teams. The chart is broken down further into three components. The first component reflects on the importance of minimizing noise and distraction. At certain points in time with decision making, all activities need to cease until the team has reached a unanimous decision about what to do next. The terms “sterile cockpit” and the “zone of silence” come out of the aviation industry and help to reinforce the importance of these concepts. The next component focuses on cellular devices in the operating room, but the same could be said for cellular devices found in procedural rooms or at the bedside. The chart states that: “1) care should be taken to avoid sensitive communication within the hearing of an awake or sedated patient, 2) the undisciplined use of cellular devices may pose and may compromise patient care, and 3) the use of cellular devices to take and transmit photographs should be governed by hospital policy on photography of patients and by government regulation.” Finally, the third component focuses on infection control: “The use of cellular devices or their accessories must not compromise the integrity of the sterile field. Bacterial contamination may pose a problem when using mobile phones in patient care” ( Fig. 15.1 ).
The Council on Surgical and Perioperative Safety (CSPS) includes the Association of Perioperative Registered Nurses, the American College of Surgeons, the American Society of Anesthesiologists, the American Association of Nurse Anesthetists, the American Society of Perianesthesia Nurses, the American Association of Surgical Physician Assistants, and the Association of Surgical Technologists. This terrific organization focuses on safe multidisciplinary approaches to create a safer surgical environment. CSPS asks “everyone to be prudent lest a bad event occur to patients and staff as a result of distraction.”
Communication
To foster a safe climate between clinicians, patients, and families, communication barriers need to be removed and shared decision-making approaches need to be incorporated. “Shared decision making occurs when a health care provider and a patient work together to make a health care decision that is best for the patient. The optimal decision takes into account evidence-based information about available options, the provider’s knowledge and experience, and the patient’s values and preferences.” Learning how to integrate decision aides, audio-visual devices, computers, and tablets is important when creating an appropriate environment for discussion and the communication process to take place. Many sentinel events are a direct result of ineffective two-way communication. When a person is being spoken to, the receiver may not fully understand important points posed to them. The receiver of the communication must be able to ask a question if they need further clarification. Various mnemonics can be applied to ensure that the most important content of the communication is received and understood. I-PASS (Illness severity, Patient summary, Action list, Situation awareness, and Synthesis by receiver) is a handoff initiative that focuses on “the patient summary, action list, situation awareness and contingency plans, and synthesis by the receiver.” To close the communication loop, a check back strategy ensures the message received can be implemented. Effective two-way communication skills that foster a “psychologically safe environment” can be implemented when effective communication tools and skills are applied.
The STEPPS in TeamSTEPPS TM stands for Strategies & Tools to Enhance Performance and Patient Safety. It incorporates teachable and learnable skills, such as leadership, situation monitoring, mutual support, and communication. Meanwhile, Ask Me 3 is “an educational program designed to improve communication between patients and health care providers, encourage patients to become more active members of their health care team, and promote improved health outcomes.” With a focus on health care literacy, patients learn the responses to three questions: 1) What is my main problem? 2) What do I need to do? and 3) Why is it important for me to do this? The tool is used to enhance effective communication between providers, patients, and family members. If one was to combine the TeamSTEPPS “check back” process with the concepts in Ask Me 3, then the sender would initiate the message, the receiver would accept the message and provide feedback, and, to “close the loop of discussion,” the sender would double check to make sure that the message had been received. The sender would then verify the communication by saying, “That’s correct.”
Addiction
In 2013, Dr. Papadakos published an article called “The Rise of Electronic Distraction in Health Care is Addiction to Devices Contributing.” He describes studies of residents missing important data on rounds or providers texting messages during critical portions of a procedure or interaction. Accepted social habits, such as smoking and alcohol intake, have become evident public health issues over time. Accidents as a result of texting and driving have drawn the attention of social media and especially insurance carriers. To that effect, the use of personal electronic devices are now being reviewed more and more when a sentinel event occurs. The utilization times can be extracted to see if there was usage during critical time periods in unfortunate clinical events. The concern goes back to how electronic devices are affecting one’s personal lifestyle and what the possible ramifications toward the patient are ( Fig. 15.2 ).
Songlie et al. note that “the mobile phone has gained a strong position in modern life and human society and is regarded as an indicator of communication technology. Despite its convenience for many people, the problems derived from overuse of the mobile phone lead to adverse consequences on an individual’s physical and mental health and social function.” “Nomophobia” is the term for the fear of being without a cell phone or beyond mobile phone contact. In a cross-sectional study conducted in a medical college in the city of Pune, “Nomophobia was found to be prevalent in first year MBBS [Bachelor of Medicine and Bachelor of Surgery] students.” A cross-sectional study with nursing students also found high levels of nomophobia, with many of them using their devices during clinicals. Other conditions associated with mobile phone addiction include low self-esteem, Facebook addiction. Internet addiction, and alexithymia (which is the inability to identify or describe emotions and is “common in individuals with psychiatric disorders”).
The University of Rochester modified a tool used for addiction and alcohol to investigate people’s addiction to electronic devices. This validated tool has helped to identify electronic addiction and support personal behavior modification. Although this example of the tool is being used in the OR setting, it can be applied in other settings as well. Please answer the questions in the tool and when you are completed ask yourself, “Am I addicted?” The University of Rochester Modified CAGE Questions are shown in Table 15.1 .
