Wednesday, May 14, 2003

For Emergency Physicians Multi-tasking is a Core Competency, but is it Safe for Patients?

Recently, a Wall Street Journal article about the “Pitfalls of Doing Too Much at Once”[1] was posted in our ED and physician and nursing staff forwarded me multiple copies. In light of the end of February busyness accompanied by a bit of generalized seasonal affective disorder and a rather frigid and dreary winter, I can excuse my colleagues efforts at concentrating my mind on our challenging environment. The incessant questioning of family members about when their loved one would go upstairs interrupting the care of still other patients remains a constant in our ED and probably yours as well.

The same week the New England Journal Sounding Board article on patient safety, “Residents’ Suggestions for Reducing Errors in Teaching Hospitals”[2] hit my radar screen citing as a problem, “Frequent interruptions with paging.” These public press and peer-reviewed citations of interruptions and multi-tasking provoked reflection and remembrance and I decided to read further and turned to the proceedings of the Academic Emergency Medicine sponsored consensus conference on “Errors in Emergency Medicine” from November 2000 and “The Model of the Clinical Practice of Emergency Medicine.”[3]

I have no prescription after this reading; only an unsettled feeling that perhaps those colleagues who have asserted that multi-tasking is a dysfunctional response may have a point. While we are all doing more and under ever-greater scrutiny, other segments of society are demanding that we focus on high-risk activities. Just what high-risk activity? Driving. In New York and other states holding a cellphone while driving is now illegal. Yet looking at your pager or half-listening for an overhead page while eliciting a patient’s history is not. And we all can tell the tale in caring for a patient with chest pain of working through the history, reviewing the ECG, inquiring about contraindications to thrombolytics when another patient—requiring immediate endotracheal intubation—presents. Yes, we swagger a bit and are proud of “pulling it off” even as these occurrences become more common. Yet, don’t we collectively have responsibility to plan and implement systems that while still maintaining our individual, professional accountability; take into account human factors and our resource constraints—particularly space and personnel? Blaming the patient for seeking “unnecessary” care is merely our displacement of the pressures we feel from elsewhere in the system—from those who ignore the proximity bias of our presence in the ED and blame us for our own circumstances.[4] “You chose the chaos.” They say.

Indeed we did. We in emergency medicine have explicitly raised multi-tasking to the level of a professional skill that requires evidence of competency for completion of residency and indeed successful completion of our certifying examination.

It’s perhaps unrealistic to imagine that emergency physicians will ever merely move from one patient to the next, completing a patient encounter before moving onto the next one. Yet, I do recall that 25 years ago I did work for awhile in a hospital where most days, for most of a shift, I was able to see patients sequentially, write my history and physical and orders before moving onto the next patient, reviewing results or engaging with a consultant. Time for reflection, review and consideration of patient needs was built into that process. Today, we no longer have that opportunity. One of my colleagues longs for a “pod” into which he could slip to close out the interruptions and allow for a controlled environment—not to relax—but rather to review patient data, look up clinical advice on diagnostics or therapeutics and formulate a plan without interruption.

Interruptions of our primary task reduce our efficiency and challenge the developing rapport with the patient in front of us. Forcing multi-tasking on an already busy clinician results in distraction and consequent oversights—of patient complaints, findings, results, etc. Interrupt-drive computer systems can mindlessly return to the tasks waiting in the queue; humans cannot and efficiency and patients may suffer the consequences.[5]

Given that patient acuity and volume isn’t going to diminish in coming years and that in an era of consumer driven healthcare, access for family and bedside visiting will likely become more common; interruptions and multi-tasking will be with us for the foreseeable future. How then can we all stay on track and minimize errors?

Exhorting individual clinicians is not the answer; changing systems, not people is the only way—and no, this doesn’t mean only computer systems. Yes, we have a fully electronic medical record. It includes user settable alerts—the clinician can setup a timed alarm—just like setting an alarm clock—that will result in an icon popping up and display of a text message when the clinician next logs in to the system.

But our staff—by and large—still use handwritten paper lists. We’re all familiar with colleagues who manage their shift with lists, cards or other memory aids. Some of them have fewer episodes of patients or information, “falling into the cracks.” Their relative success undoubtedly includes components of personality and effort, but tools matter too. Just as the NEJM article sought residents’ ideas for error reduction in the teaching hospital environment, focus your staff on addressing the problem of interruptions in the ED environment.

Interruptions and the loss of control they portend is a contributor to clinician stress, which “has important consequences for productivity, quality of task performance, workplace anxiety, fatigue and job satisfaction” according to Kirmeyer.[6] We know these things and bemoan them, yet as a specialty we have barely any research on how to mitigate the effects of interruption on both clinician and patient. The NEJM piece should galvanize our residencies and all of us to our own efforts. I know it will in my hospital.

[1]Shellenbarger, S: “New Studies Show Pitfalls of Doing Too Much at Once.” Wall Street Journal February 27, 2003 in Work & Family Section. Also available at,,SB1046286576946413103,00.html

[2]Volpp KGM and Grande D: “Residents’ Suggestions for Reducing Errors in Teaching Hospitals.” NEJM 348(9):851-855, 2003.

[3]Core Content Task Force II: “The Model of the Clinical Practice of Emergency Medicine.” Ann Em Med 37(6):745-770, 2001.

[4]Adams JG, Bohan JS: "System Contributions to Error." Acad Emerg Med 7(11):1189-1193, 2000

[5]Chisholm CD, Collison EK, Nelson DR, Cordell WH: "Emergency Department Workplace Interruptions: Are Emergency Physicians 'Interrupt-driven' and 'Multitasking'?" Acad Emerg Med 7(11):1239-1243, 2000.

[6]Kirmeyer SL: “Coping with Competing Demands: Interruption and the Type A Pattern.” J Appl Psychol 73:621-9, 1988.