On Screens and Surgeons
Atul Gawande has a fascinating article in the most recent issue of the New Yorker about the negative consequences of the electronic medical records revolution. There are many points in this piece that are relevant to the topics we discuss here, but there was one observation in particular that I found particularly alarming.
Gawande introduces the Berkeley psychologist Christina Maslach, who is one of the leading experts on occupational burnout: her Maslach Burnout Inventory has been used for almost four decades to track worker well-being.
One of the striking findings from Maslach’s research is that the burnout rate among physicians has been rapidly rising over the last decade. Interestingly, this rate differs between different specialities — sometimes in unexpected ways.
Neurosurgeons, for example, report lower levels of burnout than emergency physicians, even though the surgeons work longer hours and experience poorer work-life balance than ER doctors.
As Gawande reports, this puzzle was partly solved when a research team from the Mayo Clinic looked closer at the causes of physician burnout. Their discovery: one of the strongest predictors of burnout was how much time the doctor spent staring at a computer screen.
Surgeons spend most of their clinical time performing surgeries. Emergency physicians, by contrast, spend an increasing amount of this time wrangling information into electronic medical systems. Gawande cites a 2016 study that finds the average physician now spends two hours at a computer screen for every hour they spend working with patients.
Incomplete Solutions
Electronic medical records present a complicated case. As Gawande emphasizes, this technology undoubtedly represents the future of medical care — it solves many problems, and going back to ad hoc, handwritten systems is no more viable than the acolytes of Ned Ludd demanding the return of hand-driven looms.
The solutions Gawande outline include two major themes. The first is making these systems smaller, more agile, and more responsive to the way specific physicians actually practice, instead of trying to introduce massive, monolithic software that generically applies to many different specialities.
The second theme is introducing more administrative help to mediate between the doctor’s clinical work and interactions with the electronic systems (e.g., my recent article on intellectual specialization).
What caught my attention as I read this article, however, is that many knowledge work fields have experienced a similar shift where individuals now spend increasing amounts of their day interacting with screens instead of performing the high-value activities for which they were trained (just ask any professor, computer programmer or lawyer).
For us, it’s email and instant messenger instead of electronic medical systems, but there’s no reason to believe that the effect wouldn’t be the same: more ancillary screen time produces less well-being and, eventually, more burnout.
In the rarified and focused world of medical care, there are solutions to this screen creep problem. But where are the solutions for the rest of us? This is arguably one of the biggest problems facing our increasingly knowledge-based economy, and yet few currently take it seriously.
I am a business analyst, currently working on software development within the airline industry.
Part of the solution to the problem of user fatigue with IT systems is for development teams to pay closer attention to what a system’s users actually want to do, and help them to achieve it quickly, with a clear and streamlined workflow. In too many cases, the thinking starts with the system, rather than starting with the user’s *intention*.
For example, I am using the JIRA issue-tracking system. I have just spent several minutes failing to mark a ticket as Done, simply because it has to go back and forth through a complex (and irrelevant) workflow, carpet-bombing my colleagues with emails as it goes, rather than simply having a dropdown where you can choose the most relevant state for the ticket (or having a big button always available that says “Done”).
I think this is caused by the buyer of enterprise software not being the user. Engineering managers like JIRA partly because it’s so configurable so they can create the complex workflows you find frustrating, and they don’t have to use it day-to-day. I don’t think this will be solved by exhorting development teams to think about the user – they are probably under pressure from their management to add some feature that no end user wants, but will enable it to be sold better to whoever makes the buying decision.
This is probably a big part of why medical software is hard to use.
I’m software developer working in banking industry and I have positive experience with Jira. I guess a tool is not a problem here, but the way it is used. Jira is highly configurable, so you don’t have you use those fancy flows. You can create your own flow adjusted to your needs and modify it whenewer you want. And you can also highly limit amount of emails sent by jira
The problem predates mass use of computers.
The problem is FILLING IN FORMS — an activity long hated. I became an anarchist for a quarter century because I loathe forms so much. (But it is not just the government. Insurance forms, bank forms…you name it, I hate it.) With forms you need to map reality to someone else’s model, a model which does not fully conform to reality.
Medical record entry by computer is the equivalent of tax filing, where there are hundreds of possible forms, but you only have to fill a few of them. But figuring out which is another matter.
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There would be a simple solution if patients were paying instead of insurance providers: Just enter in what was done in plain old text. Let search engine technology flag the important bits for future doctors. For complicated case, there is always the option of reading the original text.
The previous comment is hilarious: CARL filled a form to make it !
Without disrespecting the previous comments, I wouldn’t disagree more. Cal exposes an problem that goes beyond the technology used to fill the the forms. It’s as profound as:
– Are we really genetically prepared to watch a screen for hours without human interaction?
– Human species have evolved for centuries being social animals, this behaviour has shifted dramatically in recent years. Increase in the rate of depression might be related to the same issue.
Great post / thought Cal – Thanks for sharing!
One of the most powerful “performance tips” I offer my executive coaching clients is the simple strategy of taking frequent walks, breaks and spending time in nature (walking 1-on-1 meetings, outdoor team meetings, etc.). While in theory a properly trained and mindful “mind” can operate in a distracted/distracting environment without much negative impact on performance (imagine what a Buddha would be like in the office!), it’s helpful to cultivate this mindful nature by spending more time in nature and less interruption driven spots.
What’s nice to see, is that the mind naturally settles down (and becomes more insightful: i.e. capable of fresh ideas, thinking and innovation) when we do this.
Ravi, I agree with your approach. I’ve seen significant benefits from doing as much work as possible outdoors. I called my 1 on 1 meetings/walks “management by walking around the block.”
I am a computer programmer whose ideas come to fruition entirely with on screen time. Its rare that I have to look away in order to refer to a paper diagram or notes.
My issues are the same as what you might find with someone who is a chronic gamer: physical immobility for many hours. The mental burnout issues are not there for me as a programmer because the rewards come often enough to encourage perseverance.
Great post!
And very aligned with the idea of the importance of honoring your brain dominance instead of falsifying type. What makes doctors good at their work is typically dominance in the front quadrants of their brain. In particular ER doctors generally have front right dominance. Administrative activities are easiest for individuals with back left dominance (polar opposite brain strength). According to the book “Thriving in Mind: The Natural Key to Sustainable Neurofitness,” this means administrative activities are 100x harder for a natural ER doctor than a natural admin.
This mismatch of activities with brain dominance leads to fatigue, immune system issues, depression, etc.
It’s so important to honor our strengths instead of stifling them.
To your brilliance!
Elizabeth Grace Saunders
I have had the pleasure of having had top-shelf administrative assistants support my and other peoples’ work. These individuals had some type of pre-destined knack for administrative organization beyond anything I could attempt. There was hardly anything we threw at them that they could not handle, and handle well. In fact, in a few instances I can recall, it almost became a game to see if we could stump them. So for as long as I can remember I have been a strong proponent of organizations employing administrative assistants – they pay for themselves in spades! They seem to enjoy their work, and I/we can enjoy ours. And I have always paid them very well, in addition to perks and bonuses. Had I not had these individuals supporting me along the way, I, too, would have likely suffered burnout of paperwork. Here’s to the admins!
another great article.
I have experience in healthcare and with multiple EMR systems. Both good and bad.
Long story short. EPIC Systems has to die.
Your post is so spot on. I’m a pharmacist who just took early retirement due to burn out. 12 hour days on one’s feet are bad enough, but for the last few years 11-1/2 of those hours were spent working on the computer and patient interaction became an interruption. Of course, the company I worked for claimed it was all about the patient, but evaluations all came down to computer metrics of time/task. I finally left the profession completely and couldn’t be happier.
it’s really helpful for me. Thanks Bro
I have seen this same situation during my 25+ years of teaching high school. The amount of data teachers are expected to input into computers is mostly useless and completely draining.
I have read Deep Work and loved the book. However, I have started asking myself whether it is really realistic to have what people would consider “reasonable” 8-hour working days and be able to perform even half of those hours in a state of deep concentration. For example, as a software developer, I am expected to spend 90% of my time in front of a computer, which is absolutely draining which affects my work and life satisfaction. Ideally, I would organize my time in 1 hour and a half chunks and then go for a long walk, but that just doesn’t work with most companies.
Hi,
Thank you for sharing this information. Here we provide one Conference related to Physician Well-being. The Conference details are given below.
9th Annual Coalition for Physician Well-Being Conference is organized by Coalition for Physician Well-Being, Inc. and will be held from July 29 – 31, 2019 at Swissotel Chicago, Chicago, Illinois, USA. This conference has been approved up to 13.25AMA PRA Category 1 Credit??.
For more information please follow the below link:
https://www.emedevents.com/c/medical-conferences-2019/2019-coalition-for-physician-well-being-conference