pimped on the job

[problem child]

I am 1 month into a new job in a new specialty. I am being fast-tracked in the SICU on a PA-run CT service with the goal of being fully trained to cover the ICU, the floor, consults, and 1st assist in the OR. it's a great job - really a well-paid residency, IMO - but one thing is difficult and weird: the chief PA is considerably younger than me, and while very experienced and knowledgeable, is causing me a lot of stress and distraction on the job by pimping me throughout the day, as well as micromanaging my every movement ("don't double click on that, left click and then right click"). the sound of screeching breaks occurs in my head every 20 seconds when she is "supervising me". each time I start to bring my thoughts together around a pt, she interrupts me and sends me in a new direction mentally. 12 hours a shift of this is nearly unendurable.

 

I don't know quite how I feel about it apart from stressed and irritated. on the one hand, I can look at it as some teaching I need in a new specialty. one is constantly interrupted on the job in an ICU, so maybe this will help me get up to speed on a new and busy service. on the other, her constant vocalizing and micromanaging me is causing me to be unable to think things through by myself, get a handle on the patents I am taking care of, and ask questions to fill in the blanks. I end up feeling I am looking stupid bc I can never have the mental space I need to process what I am learning. I know she comes from an 8 year background of preceptoring PA students through CT surg rotations. but I am not a student, I am staff.

 

I also might add that she has a very high-pitched, irritating voice, and that does not help.

 

does anyone consider this appropriate behavior for a chief PA? or am I being as overly-controlled as I feel?

[ventana]

Multitasking is really dangerous - it kills people

 

 

I would use this fact to have a discussion with her (likely best to talk to HR first so they are aware of the issue but don't ask for their help yet - protection against her getting revenge for challenging you if she is that insecure...)

 

 

I really think a polite short, not stressful discussion with her, maybe over lunch, about the fact that you are focusing very hard on learning and in order to do that you need to to allow you to do it wrong so you can learn it (on the computer stuff anyways). On patient care issues re assure her that you will ask questions....

 

Then try to gently guide and coach her to allow you to spread your wings and do it in peace......

 

maybe you can rotate to other shifts when she is not around? Maybe request different people to train you so that can get a different exposure?

 

 

You did not state your ages....... might help the advice......

[problem child]

I'm 55; she, (young) 30s. what you've already said, ventana, is very encouraging. please go on!

[ventana]

25 year age difference.... yikes that might be good or bad

 

I would think just setting clear parameters for when she can interrupt you is key - also, you need to show you clinical ability and use your age to your advantage, maybe even joke about the fact that you just need an extra second on the computer BEFORE she tells you how to do it...

 

That type of age difference could be tough if the younger person does not realize that they need to throttle it back a little bit and allow you to learn at your own pace. Try to mentor her a bit, gentle guidance and positive rewards might help, but I would avoid preaching or being a stern "parent" figure as you are all equals. Try really hard to find some common ground and start to build some positive bonds -

[gleannfia]

In my 26 years experience, I have found fellow PAs in general to be waaay worse than sup docs in terms of pimping.

[rcdavis]

On the other hand, ( coming from an Ed and critical care back ground), there is a ton of things that you need to learn.. And she is the one to teach you.

 

Your problem may be a combination of responding to the grate in her voice PLUS the slight resentment that you are not on top of the unit game yet, and in fact do need to learn these things.

 

Be concurrently studying bojars and Marion's.. Know them cold.

 

Learn the drugs, the step down protocols.

 

Practice the procedures.. ( my best and hardest mentor taught me by insisting on doing procedures " every one, the same same way, every day"and I had to relearn what I previously thought was an adequate technique into what was a stellar technique)

 

I went through my critical care training at 50.. And was the center of scrutiny and round the clock pimping by 30 year olds.. But only until it became apparent to them that I had learned what I needed to know.

 

Remember CTS guys are taught this way.. They constantly do it to one another.. Is one of the big differences between surgical personalities and medical personalities.

 

As far as multitasking: if you can not multitask, you are in the wrong business..

At one point ,you will be faced with needing to put in a ballon and starting a different patient on various pressors based on the numbers the nurse is giving you, while answering an attending call.. All simultaneously.

 

Or you may reopening the sternal wires in a tamponading patient loosing RA pressure while another patient needs inadequate renal output addressed...

 

This is one of the most demanding but satisfying jobs.

 

You CAN do it.. Else they would not be wasting time on you.

[Guest JMPA]

On the other hand, ( coming from an Ed and critical care back ground), there is a ton of things that you need to learn.. And she is the one to teach you.

 

Your problem may be a combination of responding to the grate in her voice PLUS the slight resentment that you are not on top of the unit game yet, and in fact do need to learn these things.

 

Be concurrently studying bojars and Marion's.. Know them cold.

 

Learn the drugs, the step down protocols.

 

Practice the procedures.. ( my best and hardest mentor taught me by insisting on doing procedures " every one, the same same way, every day"and I had to relearn what I previously thought was an adequate technique into what was a stellar technique)

 

I went through my critical care training at 50.. And was the center of scrutiny and round the clock pimping by 30 year olds.. But only until it became apparent to them that I had learned what I needed to know.

 

Remember CTS guys are taught this way.. They constantly do it to one another.. Is one of the big differences between surgical personalities and medical personalities.

 

As far as multitasking: if you can not multitask, you are in the wrong business..

At one point ,you will be faced with needing to put in a ballon and starting a different patient on various pressors based on the numbers the nurse is giving you, while answering an attending call.. All simultaneously.

 

Or you may reopening the sternal wires in a tamponading patient loosing RA pressure while another patient needs inadequate renal output addressed...

 

This is one of the most demanding but satisfying jobs.

 

You CAN do it.. Else they would not be wasting time on you.

in agreement, multitasking is an absolute necessity of cts, if one cannot multitask then they should find another specialty. contrary to ventanas angle, multitasking in cts saves lives

[coloradopa]

On the other hand, ( coming from an Ed and critical care back ground), there is a ton of things that you need to learn.. And she is the one to teach you.

 

Your problem may be a combination of responding to the grate in her voice PLUS the slight resentment that you are not on top of the unit game yet, and in fact do need to learn these things.

 

Be concurrently studying bojars and Marion's.. Know them cold.

 

Learn the drugs, the step down protocols.

 

Practice the procedures.. ( my best and hardest mentor taught me by insisting on doing procedures " every one, the same same way, every day"and I had to relearn what I previously thought was an adequate technique into what was a stellar technique)

 

I went through my critical care training at 50.. And was the center of scrutiny and round the clock pimping by 30 year olds.. But only until it became apparent to them that I had learned what I needed to know.

 

Remember CTS guys are taught this way.. They constantly do it to one another.. Is one of the big differences between surgical personalities and medical personalities.

 

As far as multitasking: if you can not multitask, you are in the wrong business..

At one point ,you will be faced with needing to put in a ballon and starting a different patient on various pressors based on the numbers the nurse is giving you, while answering an attending call.. All simultaneously.

 

Or you may reopening the sternal wires in a tamponading patient loosing RA pressure while another patient needs inadequate renal output addressed...

 

This is one of the most demanding but satisfying jobs.

 

You CAN do it.. Else they would not be wasting time on you.

 

I'm going to agree and disagree on this one. We looked at this in our group a while ago. When we started a critical care residency we soon realized that the residents coming through had vastly different learning styles. Some were visual learners, some were verbal, some were kinesthetic. By the time you become a PA you probably know whats best for you. We found the simple expedient of asking the residents what kind of learner they were dramatically improved satisfaction on both the instructor and student side. In looking at the OP's post, I am guessing one thing that happens is that he has a different learning style than the other PA and she is not recognizing this.

 

Another issue is probably generational. Millenials treat the workplace environment vastly different than us "old" guys or gals. There is a raft of literature on this but it essentially involves forming loose knit task based relationships for a specific purpose which is different than the long term mentorship of the past.

 

Finally while I would agree that multitasking is important in critical care, you have to differentiate between multitasking and interruption. We had a series of procedural misadventures with the physician residents several years ago. When we did a root cause analysis, it was almost always interruptions during key portions of the procedure that were a major cause. What the OP describes to me is interruption not multitasking. We have changed our policy. One of our jobs is to ensure that residents follow unit policies and procedure (ie remove the wire as you insert the CVL). That's what I tell residents. I don't supervise physicians, I make sure they follow our procedures. If they are relatively skilled I don't gown and glove. Instead, I stand between the door and resident to intercept any interruptions. If I am part of the procedure I do the same thing from the bedside.

 

Part of our weakness as a profession is one of the same problems that nursing has. We promote people to leadership positions without giving them further training in leadership. I am guessing the the Chief PA in the OP's post does not have any training in leadership and is essentially parroting the way she was trained.

 

To the OP I would sit down with the chief PA and have a frank discussion about learning styles. Without being confrontational ask to be allowed to work your way through a problem with her available as a resource. Don't necessarily make it about the other person, just emphasize that your learning styles seem to be clashing.

[ventana]

in agreement, multitasking is an absolute necessity of cts, if one cannot multitask then they should find another specialty. contrary to ventanas angle, multitasking in cts saves lives

 

 

Sorry, the data does not support that. There is a difference between keeping many balls juggling in the air and true multitasking. Multitasking kills people. You need a clear, concise time to think through complexity of medicine.

 

It's funny as people think that they can multitask, but when you actually studied they find it dramatically increases errors.

[rcdavis]

Sorry, the data does not support that. There is a difference between keeping many balls juggling in the air and true multitasking. Multitasking kills people. You need a clear, concise time to think through complexity of medicine.

 

It's funny as people think that they can multitask, but when you actually started he find it dramatically increases errors.

 

I guess we are not saying different things.

 

A surgeon performing a complex procedure in the OR is on call. The unit or ED calls needing him or to tell him that there is another surgical patient needing his attention. My definition of multitasking is not that he continue the operation and answer the phone at the same time, but that he be able to stop the technical procedure for a minute, take Thenew information as input, re-priorities his schedule, and respond in kind, then return to the operation.

I am well aware that the human being actually cannot perform accurately more than one procedure, but any one in any business "juggles balls" ( think unit secretary answering 5 different telephone lines and making decisions/actions based on each one ( one on hold, one transferred to a patient's room, one transferred to an attending, one answered directly("who is on call?))) with several in the air at any time..

 

THat is multitasking, by my definition

 

Even microprocessors cannot really multitask .. They all process information serially.. One bit at a time, or act as an executor by relegating actions to other processors ( co-processing) or refering to previously well wrtitten sub routines.

 

We do the same.

 

I do not, when I refer to multitasking, actually mean that the surgeon has one hand in the belly of one patient, and one in the chest of another.

 

However, in both places I work( unit and ED),I am bombarded minute by minute with distractions, random bits of information ( some critical) about the 10-15 patients I am responsible for at any given time.. Some of them simultaneously critically ill.

 

I know that nursing has created "quiet zones" for nursing doing critical procedures ( mixing multiple Meds etc) which buffer them from other nurses, doctors, secretaries, etc, interrupting them while they are in the zone.

 

Unfortunately, if there are two seemingly equal critical pieces of information, that information needs to Be given to the most senior/appropriate health care provider.. Who, I maintain, is the best and only executor of that info, and will then prioritize those information bits into Sequential actions...

 

To be able to do that, in my world, is multitasking.

 

I live in a world where there Are multiple decisions which need to be processed and acted on ( even if it means holding off specific actions for awhile). I do not have the luxury of treating one.patient.at.a.time, and completing each encounter before considering the next.

 

So, maybe I need to redefine "multitasking" as "juggling balks"

 

Either way, an inability to receive, process, sort and act on disparate pieces of information is critical to both critical and emergency care.

 

David's points about learning styles are very interesting and infact intuitively seem spot on.

 

However, in the real world, data arrives in all forms: tactile, visual, written, aural, etc...

 

If you cannot process them that way, you end up being quickly overwhelmed and paralyzed.

 

As an aside, providers who have been in war or EMTs or firefighters or jet pilots, and have learned how to process, prioritize and respond to quickly arriving information in stressful situations, seem to do better than those who have not had those experiences, ... Or been stressed by the pimp

[Guest JMPA]

Sorry, the data does not support that. There is a difference between keeping many balls juggling in the air and true multitasking. Multitasking kills people. You need a clear, concise time to think through complexity of medicine.

 

It's funny as people think that they can multitask, but when you actually started he find it dramatically increases errors.

 

evidently you cannot manage more than one patient at a time, i have managed more than 30 critical care patients at one time, and yes management is considered multitasking. cts requires moments of multitasking with prioritizing. if you do not multitask (manage all patients on your service) than patients die, dead, gone, are no more. please don't mislead new pas or try to confuse elder ones. multitasking is not only necessary but does save lives. lets see the data

[Derbingle]

evidently you cannot manage more than one patient at a time, i have managed more than 30 critical care patients at one time, and yes management is considered multitasking. cts requires moments of multitasking with prioritizing. if you do not multitask (manage all patients on your service) than patients die, dead, gone, are no more. please don't mislead new pas or try to confuse elder ones. multitasking is not only necessary but does save lives. lets see the data

 

 

I have to agree with this. I never thought I would HAVE to manage multiple patients at the same time, which is stressful. But you do. No one else is available. You may be suturing or placing orders for DKA, hypotensive tachycardia and an RN comes to you with information on a patient not doing so hot 2 beds over. Low pressure, hypoxia etc. It would be foolish to say ill be there in 10 min or "can you just page my attending" or Just hold on. This is where your relationships make or break your performance. Of course you must prioritize and some times you do tell them to call the doc. Its like bleeding. You have to intervene. ED PA inner city.

[skyblu]

Agreed, multitasking in my specialty (EM) is absolutely key.

 

As rcdavis said, multitasking does not mean I am intubating someone with one hand while reducing a dislocated shoulder with the other. It simply means that while I am intubating, I also know in a part of my brain that my shoulder guy is recovering from procedural sedation and if a nurse tells me he is dropping his sats, I need to act or make a decision. Which patient is sicker? Do I finish what I'm doing or can this patient be on CPAP for a minute since RT is in the room next to me? Or is there an attending or another PA who can quickly respond to the shoulder dropping their sats?

 

I can't afford to say, "I can't hear about this now because I am intubating." I need to hear, re-evaluate my priorities, and shuffle my decisions as necessary.

 

It's my own internal triage system. This guy's discharge orders can wait because this other guy needs to be told he has a brain mass on CT. Or, sometimes, let me discharge this guy really quick so I can spend more time having the brain tumor conversation. Neither one emergent, but I have to constantly decide who and what I am seeing or doing next.

 

As far as the OP goes, I'd have a calm discussion with the Lead PA and explain you learn better by doing than hearing, so unless you're making a critical or dangerous mistake, she should give you a few minutes to process. When she asks something and changes directions before you answer, I'd say, "Wait a sec, let me think of what you just asked me for a minute before we move on."

[ventana]

evidently you cannot manage more than one patient at a time, i have managed more than 30 critical care patients at one time, and yes management is considered multitasking. cts requires moments of multitasking with prioritizing. if you do not multitask (manage all patients on your service) than patients die, dead, gone, are no more. please don't mislead new pas or try to confuse elder ones. multitasking is not only necessary but does save lives. lets see the data

 

 

Wow way to throw down... love the personal attacks right off the bat........

 

lets all take a breath and look at the data.... yes it is a studied issue and yes the data supports that multitasking causes errors and hence death...

 

I love the "I am better then that attitude that gets displayed by those that "think" they can do it.

 

Once again, multi tasking causes errors - look of hospital accreditation, looks over the industry buzz, look over risk management and they are all saying try not to multi task...

 

Now I am NOT saying not to manage multiple patients (and by the way in the studies I have seen the lowly internist also has high interruption rates! so it is not just the all might CTS guys that do it!) it is about focusing your attention fully to the task at hand. That means you might well finish the step of the task you are on and then answer the question..... but not (and this is a known issue) do 2-3-4 things at once.....

 

As for scaring off the new PA's --- again I would caution against multitasking to ANY PA's but Especially NEW pa's.....

 

Before you go out off and state that you are better then this, and that you do it all the time, and that everyone does it, (all very self inflating statements but not helpful in this discussion) I think you owe it to yourself to look at work flow design, sentinel event investigation, JACHO standards, industry standards, universal surgical precautions (not protective gear but the stuff all the surgeons are now doing to minimize risk of errors) This is what is driving procedure logs, proven standards, re credentialing issues.... It is an issue, multitasking (diverting your attention from the task at hand) is not good for your patients.

 

As for my ability to manage patients, I will not degrade this to a personal level as I am exceptionally comfortable and capable of dealing with with own panel of high co morbidity patients (average in excess of 12 active dx) as is my SP, as well as the local medical community that I have stood tall in front of as I have broken new ground to establish an entirely new PA owned practice, in an entirely new field of home base primary care for the medically complex patient. Yes I juggle a lot every day, but as I am focusing on one task I try to remain 100% focused on that task alone to minimize my chance of errors.

 

I stand by my advice to newer PA's trying to learn a field - try to allow yourself to focus on the task at hand and not get interrupted...

 

 

 

 

 

The multitasking clinician: Decision-making and cognitive

demand during and after team handoffs in emergency care

Archana Laxmisana, Forogh Hakimzadaa

 

 

 

 

This states it better then I can:

 

For EPs, Multi‐Tasking is a Core Competency, but are Interruptions Safe for Patients?

 

Davidson, Steven J. MD, MBA

 

 

 

 

Article Outline

Author Information

 

 

 

Dr. Davidson is the chairman of the department of emergency medicine at Maimonides Medical Center, a professor of clinical emergency medicine at SUNY-Health Science Center in Brooklyn, NY, and a principal in Emerging Medical Concepts (www.emedconcepts.com), a medical leadership development and support consulting organization. He can be reached at davidson@pobox.com.

 

Recently, a all Street Journal article, “Pitfalls of Doing Too Much at Once,”¹ was posted in our ED, and several physicians and nurses gave me additional copies. In light of February's busy period, a bit of seasonal affective disorder, and a frigid and dreary winter, I can excuse my colleagues' efforts at trying to focus my mind on our challenging environment.

Family members who incessantly question staff about when their loved ones will be transferred to a unit, interrupting the care of other patients, remains a constant in our ED and probably yours as well.

The same eek, the New England Journal of Medicine's article, “Residents' Suggestions for Reducing Errors in Teaching Hospitals,”²hit my radar screen, citing as a problem “frequent interruption's with paging.” These articles about interruptions and multi-tasking provoked reflection and remembrance, and I turned to Academic Emergency Medicine's consensus conference on “Errors in Emergency Medicine” and “The Model of the Clinical Practice of Emergency Medicine.”³

I have no prescription after this reading, only an unsettled feeling that perhaps 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. Which high-risk activity? Driving.

Interruptions reduce efficiency and challenge the developing rapport with the patient

In New York and other states, holding a cell phone to your ear 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 recall caring for a patient with chest pain working through the history, reviewing the ECG, inquiring about contraindications to thrombolytics — when another patient requiring immediate endotracheal intubation presents.

 

Back to Top | Article Outline

Pride in Multi-Tasking (This is for JMPA and his "I Can do it" attitude)

 

We swagger a bit, and are proud of “pulling it off” even as these occurrences become more common. Yet, don't we have a collective responsibility to plan and implement systems that take into account human factors and resource constraints, particularly space and personnel, while maintaining our individual professional accountability?

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. “You chose the chaos,” they say.⁴

Indeed we did. We in emergency medicine have explicitly raised multi-tasking to the level of a professional skill requiring competency to complete residency and passing the certifying examination.

Perhaps it is 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 recall that 25 years ago I was able on most days and for most of a shift to see patients sequentially and write their history 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” in which he could eliminate interruptions and review patient data, look up clinical advice on diagnostics or therapeutics, and formulate a plan without interruption.

 

Back to Top | Article Outline

Reduce Efficiency

 

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, and results. Interrupt-driven 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 aren't going to diminish in coming years and that in an era of consumer-driven health care, 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 this doesn't mean only computer systems. Our fully electronic medical record includes user alerts; the clinician can set a timed alarm that pops up an icon and text message whenever he next logs in to the system.

But by and large, our staff 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 through the cracks. Their relative success undoubtedly includes components of personality and effort, but tools matter, too. Just as the Ne England Journal of Medicine 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 them. The Ne England Journal of Medicine piece should galvanize our residencies and all of us to our own efforts. I know it will in my hospital.

 

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References

 

Shellenbarger S. New studies show pitfalls of doing too much at once. all Street Journal Feb. 27, 2003. Also available at http://online.wsj.com/article/0,SB1046286576946413103,00.html.

Cited Here...

 

Volpp KGM, Grande D. Residents' suggestions for reducing errors in teaching hospitals. Ne Engl J Med2003;348(9):851.

Cited Here...

 

Core Content Task Force II. The model of the clinical practice of emergency medicine.” Ann Emerg Med2001;37(6):745.

Cited Here...

 

Adams JG, Bohan JS. System contributions to error. Acad Emerg Med 2000;7(11):1189.

Cited Here... | PubMed | CrossRef

 

Chisholm CD, et al. Emergency department workplace interruptions: Are emergency physicians interrupt-driven and multitasking? Acad Emerg Med 2000;7(11):1239.

Cited Here... | PubMed | CrossRef

 

Kirmeyer SL. Coping with competing demands: Interruption and the Type A pattern. J Appl Psychol1988;73:621. model of the clinical practicet of emergency medicine. Ann Emerg Med 2001;37(6):745.

Cited Here...

 

Adams JG, Bohan JS. System contributions to error. Acad Emerg Med 2000;7(11):1189.

PubMed | CrossRef

 

Chisholm CD, et al. Emergency department workplace interruptions: Are emergency physicians interrupt-driven and multitasking? Acad Emerg Med 2000;7(11):1239.

PubMed | CrossRef

 

Kirmeyer SL. Coping with competing demands: Interruption and the Type A pattern. J Appl Psychol 1988;73:621.

View Full Text | PubMed | CrossRef

 

 

 

 

 

 

The multitasking clinician: Decision-making and cognitive

demand during and after team handoffs in emergency care

Archana Laxmisana, Forogh Hakimzadaa, Osman R. Sayanb, Robert A. Greenb,

Jiajie Zhangc, Vimla L. Patel a,∗

a Laboratory of Decision Making and Cognition, Department of Biomedical Informatics, Columbia University, 622 West 168th Street

Vanderbilt Clinic, Fifth Floor, New York, NY, United States

b New York-Presbyterian Hospital/Columbia University Medical Center, Department of Emergency Medicine, New York, NY, United States

c School of Health Information Sciences, University of Texas Health Science Center at Houston, Houston, TX, United States

a r t i c l e i n f o

Article history:

Received 19 April 2006

Accepted 27 September 2006

Keywords:

Handoffs

Interruptions

Multitasking

Medical errors

Cognition

Emergency care information

systems

a b s t r a c t

Several studies have shownthat there is information loss during interruptions, and thatmultitasking

creates higher memory load, both of which contribute to medical error. Nowhere

is this more critical than in the emergency department (ED), where the emphasis of clinical

decision is on the timely evaluation and stabilization of patients. This paper reports

on the nature of multitasking and shift change and its implications for patient safety in an

adult ED, using the methods of ethnographic observation and interviews. Data were analyzed

using grounded theory to study cognition in the context of the work environment.

Analysis revealed that interruptions within the ED were prevalent and diverse in nature.

On average, there was an interruption every 9 and 14 min for the attending physicians and

the residents, respectively. In addition, the workflow analysis showed gaps in information

flow due to multitasking and shift changes. Transfer of information began at the point of

hand-offs/shift changes and continued through various other activities, such as documentation,

consultation, teaching activities and utilization of computer resources. The results

show that the nature of the communication process in the ED is complex and cognitively

taxing for the clinicians, which can compromise patient safety. The need to tailor existing

generic electronic tools to support adaptive processes like multitasking and handoffs in a

time-constrained environment is discussed.

© 2006

 

 

 

 

or for the Harvard types:

[h=1]Multitasking—a medical and mental hazard[/h]POSTED JANUARY 07, 2012, 8:00 AMPatrick J. Skerrett, Executive Editor, Harvard Health

During a recent check-up, my doctor snuck a look at her phone a couple times. I don’t think it had anything to do with my health or care, so it was mildly annoying—but I didn’t say anything. After reading a report about a man who almost died because of a doctor’s “multitasking mishap,” next time I’ll speak up.

In a case report for the federal Agency for Healthcare Research and Quality, Dr. John Halamka, the chief information officer at Harvard Medical School, described the so-called mishap, which happened to a 56-year-old man with dementia who was admitted to the hospital to have a feeding tube placed in his stomach.

One of the man’s doctors increased the dose of the blood-thinner warfarin the man was taking. Warfarin helps prevent clots from forming in the bloodstream. The next day, the doctor decided to evaluate whether the man needed warfarin at all, and asked a resident (junior doctor) to temporarily stop the order for daily warfarin.

Using her cellphone, the resident began to make the change via a computerized order entry system. Part way through, she received a text message from a friend about a party. She responded to the text, but forgot to go back and complete the medication order canceling warfarin. As a result, the man kept getting a high dose of warfarin. His blood became so “thin” that, two days later, blood was spontaneously filling the sac around his heart, squeezing it so it couldn’t pump properly. He needed open-heart surgery to drain the blood and save his life.

[h=3]The hazards of multitasking[/h]Many people take pride in how well they multitask. But new research suggests some big downsides to it.

I spoke with Dr. Paul Hammerness and Margaret Moore, authors of Organize Your Mind, Organize Your Life, a new book from Harvard Health Publications. They said that multitasking increases the chances of making mistakes and missing important information and cues. Multitaskers are also less likely to retain information in working memory, which can hinder problem solving and creativity.

Instead of trying to do several things at once—and often none of them well—Hammerness and Moore suggest what they call set shifting. This means consciously and completely shifting your attention from one task to the next, and focusing on the task at hand. Giving your full attention to what you are doing will help you do it better, with more creativity and fewer mistakes or missed connections. Set shifting is a sign of brain fitness and agility, say the authors.

(To learn more about Organize Your Mind, Organize Your Life, visit the Harvard Health Publications website.)

[h=3]Time to focus[/h]Doctors, nurses, and other health-care professionals are busy folks. It’s understandable that they resort to multitasking. But it doesn’t guarantee the best medical care. Dr. Halamka, who has helped pioneer the use of electronic medical records and doctors’ use of handheld devices, writes that hospitals and other health-care settings need to help doctors and other providers cope with the distractions that come with the use of new technologies.

We can all help, too. Doctors may need a little assistance learning, or remembering, how to focus. So next time mine is doing several things at once, I’ll speak and up and ask him or her to do just one thing—be my doctor.

[skyblu]

ventana, I'm not saying anyone is better than anyone else. I'm saying that giving 100% focus to one thing and one thing only is not possible in all cases or all specialties.

 

Not only do I manage complicated patients in the ED, I manage them ALL AT THE SAME TIME. Meaning, I can't "just get back to you when I finish this LP" if my other guy arrested. Or is septic and dropped his pressure. I might need to interrupt the LP when I get the information.

 

A nurse will not wait to tell me somebody is very sick, or a lab value was returned and is critical, until I finish the task at hand. They will tell me when it needs to be told, and sometimes, that is right now.

 

It is then up to me to decide what to do with that information. So I do have to consider my options. And no, I'm not gonna stop squeezing the bag-valve mask on my unresponsive patient so I can give the new thoughts 100% of my attention. Nor am I going to ignore the guy dropping his pressure or the CT that tells me someone is dissecting his aorta because I'm giving 100% of my attention to squeezing the BVM. Sorry, doesn't work that way in EM.

 

And not all of this is critical stuff. I cannot tell you how many times I chart with one hand and eat a sandwich with the other. Or I'm on the phone with a consultant while I'm signing a work release note. It just happens. Just like, yes, I occasionally change the radio station or have conversations with my kids when I'm driving.

[ventana]

ventana, I'm not saying anyone is better than anyone else. I'm saying that giving 100% focus to one thing and one thing only is not possible in all cases or all specialties.

 

Not only do I manage complicated patients in the ED, I manage them ALL AT THE SAME TIME. Meaning, I can't "just get back to you when I finish this LP" if my other guy arrested. Or is septic and dropped his pressure. I might need to interrupt the LP when I get the information.

 

A nurse will not wait to tell me somebody is very sick, or a lab value was returned and is critical, until I finish the task at hand. They will tell me when it needs to be told, and sometimes, that is right now.

 

It is then up to me to decide what to do with that information. So I do have to consider my options. And no, I'm not gonna stop squeezing the bag-valve mask on my unresponsive patient so I can give the new thoughts 100% of my attention. Nor am I going to ignore the guy dropping his pressure or the CT that tells me someone is dissecting his aorta because I'm giving 100% of my attention to squeezing the BVM. Sorry, doesn't work that way in EM.

 

And not all of this is critical stuff. I cannot tell you how many times I chart with one hand and eat a sandwich with the other. Or I'm on the phone with a consultant while I'm signing a work release note. It just happens. Just like, yes, I occasionally change the radio station or have conversations with my kids when I'm driving.

 

 

 

but this thread is about a pa struggling in a new field

 

I too "keep a lot of balls in the air with a juggling act that sometimes seems crazy" but the fact of the matter, and what I was bringing up, is that this is not a good thing.

we all "think" we can multitask, but the data - and is this not the gold standard that we all should aspire to follow? EBM? - is saying strongly that it is not a good idea. i am not talking do multiple things throughout a shift, or managing multiple patients, but instead the interruptions (what the OP was asking about) and how this functions on the human brain. We do not have to re - invent the wheel here - we need to look at ways to improve our systems... yeah I have been interrupted while doing a crazy hard Vascath insertion on a crumping patient by a nurse that wanted permission to go to lunch and a family member that wanted to talk and many other trivial issues......... the system needs to prevent these stupid mental interruptions.... also, the providers need to realize that this is a dangerous time for the patients.... mental interruptions are not a good thing and we need to work on getting them held to a minimum so that we can be the best we can be. Boy that sounds like a commercial. There will ALWAYS be interruptions, but to allow a PA struggling in learning the time to focus and form solid thoughts and learn new things interruptions like "click on that button" need to be eliminated.

 

 

I would like to hear from people that have either worked on work flow process or have gone through a few sentinel event investigations pipe in here.... I have gong through a few on both sides and they were very educational and revealing in the information...... How about someone that has studied it and can comment on the data?

[greenmood]

I don't think multitasking is the point here, really. There is a big difference between expecting a PA to truly multitask and rudely interrupting another provider's thought process for no reason. The latter is disruptive and causes anxiety and tension, even in the best multitaskers.

 

There is a way to balance necessary teaching in a new position and respect for another provider's methods and knowledge. It sounds like your supervisor is used to the balance between PA student and preceptor. I don't think it's wrong of you to expect a higher level of respect for your abilities/independence given where you are in your career as long as you understand you may not even know what you don't know. I have a number of more experienced PAs responsible for my orientation in my new job and they all approach it a little differently, and it's more difficult with some than others. Maybe find out what she expects from you, exactly? I'm thinking of that computer example you gave... with her directing every click of the mouse. If you sat down with her and reported your frustration, and then asked her (sincerely) if the service really prefers that you do these things in this precise way... sometimes hearing how silly it sounds out loud does the trick.

[problem child]

yeah, these last two posts kind of hit the nail on the head in terms of what I originally wrote. this esp to the point "There will ALWAYS be interruptions, but to allow a PA struggling in learning the time to focus and form solid thoughts and learn new things interruptions like "click on that button" need to be eliminated".

 

I fully expect in a cardiac SICU I will be interrupted with pt issues, and have to rotate who is top priority sometimes many times and within minutes. it is the micromanaging, and interrupting while I am trying to lock down clinical concepts that is highly irritating, anxiety-inducing, and, IMO, dangerous for patients (as was stated above).

 

she seems to have backed off, so she may have realized how ridiculous it is to be breathing down my neck while I navigate a new EMR, watching for every joggle of the mouse and correcting me before I have even arrived at my own destination on the screen, that was causing my mind to lock and then meltdown. it caused me to be unable to form whole concepts about patient care. I don't think right-clicking vs double-clicking is even a remotely relevant issues. my priority is to get clinical concepts tight, and I'm sure I will discover more shortcuts as I go to shave those precious seconds of my documenting and ordering (#mild sarcasm).

 

I appreciate the feedback here and will look for opportunities to set gentle boundaries as needed. micromanaging just does not work for me. I need the mental space to connect dots that eprtain to disease processes and patient care.