Paul Dubbins, MBBS

If my wife is right, I am, in fact, a woman. She and other women in my life all maintain that only women can multitask. Yet there is published evidence that I and all of my male associates work in an environment that is interrupt-driven with high multitasking loads.1 Superwoman, eat your heart out.

It is not just my professional life that is interrupt-driven. I am interrupted when I’m watching soccer to go and mow the lawn, interrupted when I am doing online research (what is the best site for French wine?), interrupted when I am deep in thought on how to resolve the economic crisis-and no, I was not asleep!

Now I have ample evidence to explain why the other behavior driving complaints leveled at all males (we never listen!) is designed specifically to reduce error.

“Multitasking is bad for patients and interruptions even worse,” I can tell my wife, noting that observations on clinicians demonstrate that doctors are interrupted between six and seven times an hour, that this causes them to spend less time on any given task, and that they fail in nearly 20% of cases to return to the task when they have been interrupted.2

I use this to explain to my wife why the garden gate still consists only of the surrounding frame. And I can tell the chief that I failed to meet my targets because I was interrupted and that I forgot to return to the reporting work list after that idiot from the emergency department burst in to show me his latest triumph of FAST scanning.

The “no interruptions” sign has gone up on the office door and anyone who enters had better watch out. I can now relax in solitude and silence, dim the lights, adjust the ambient temperature, make sure the viewing station is at the right height, modify the mouse and keyboard to minimize repetitive stress injury, swear at the voice-activated transcription, and I’m ready for a high-volume, low-error workload.3,4 And just to show that I view my consultant responsibilities seriously, the sign also says I am available for consultation between 8:30 and 9:00 a.m. each day (i.e., during the daily ward round).

Some radiologists have adopted this stance. Apparently supported by the literature, they lock themselves away, free from distraction, to carry out their primary role of reporting images. They argue that surgeons would not tolerate interruptions during surgery and that a gastroenterologist would complain vigorously if we were to discuss the finer points of a chest x-ray in the middle of a sigmoidoscopy.

They miss the point. While I agree that to be interrupted compromises patient safety and/or privacy, the value of a radiologist, as of all doctors, is the ability to multitask, to work under pressure. Much of our work is to deal with urgent and emergency conditions, to respond rapidly and accurately to complex and evolving problems. If I am scheduled for image-guided intervention in the afternoon, I wish to discuss the indications and the state of the patient’s health in advance of the procedure. And if this doesn’t happen when I am reporting, then when?

What about the “radiologist of the day” approach? This has many advantages, but if I have reported a study, the clinician may to wish to discuss the report with me. If the study falls within my area of expertise, it would be inappropriate to discuss it with anyone else. And if I am sticking a needle, tube, or stent into anyone, I owe it to the patient to be briefed properly prior to the procedure.

The stance also ignores other evidence for the causes of reporting inaccuracies including workload, lack of clinical details, poor image quality, and, indeed, attention span. Those reviewing x-rays at airport security spend only 20 minutes at a time in front of the screen. Could it not be argued that interruptions, if managed well, might improve our performance?

Until patients form an orderly queue outside my office at the proscribed time, with their ailments properly triaged, then interruptions will be an inevitable part of medical and radiological practice. We must seek to manage such interruptions firmly and effectively, finishing the review and reporting of a study, if the report is almost complete, prior to diverting our attention, or setting aside the study with a brief note of what had and had not been reviewed so that we can return to it later without cutting corners.

If we are not able to demonstrate skills in multitasking, time management, and effective communication, as well as great accuracy in image interpretation, then our roles, as some would suggest, can be divided into individual competencies and performed by an ever growing flock of task-orientated technicians.

And the garden gate? Don’t tell my wife that it is hidden under a pile of car magazines in the garden shed! I like interruptions but my shed is sacrosanct…

Articles

If my wife is right, I am, in fact, a woman. She and other women in my life all maintain that only women can multitask.

Women have no right to monopoly over multitasking

If my wife is right, I am, in fact, a woman. She and other women in my life all maintain that only women can multitask. Yet there is published evidence that I and all of my male associates work in an environment that is interrupt-driven with high multitasking loads.

“Multitasking is bad for patients and interruptions even worse,” I can tell my wife, noting that observations on clinicians demonstrate that doctors are interrupted between six and seven times an hour, that this causes them to spend less time on any given task, and that they fail in nearly 20% of cases to return to the task when they have been interrupted.

The “no interruptions” sign has gone up on the office door and anyone who enters had better watch out. I can now relax in solitude and silence, dim the lights, adjust the ambient temperature, make sure the viewing station is at the right height, modify the mouse and keyboard to minimize repetitive stress injury, swear at the voice-activated transcription, and I’m ready for a high-volume, low-error workload.

 And just to show that I view my consultant responsibilities seriously, the sign also says I am available for consultation between 8:30 and 9:00 a.m. each day (i.e., during the daily ward round).

I didn’t know it until now but if my wife is right, I am, in fact, a woman. She and other women in my life-family, coworkers, friends-all maintain that it is only women who can multitask. Yet there is published evidence that I and all of my male colleagues work in an environment that is interrupt-driven with high multitasking loads. Superwoman, eat your heart out.



 There is no doubt that it is not just my professional life that is interrupt-driven. I am interrupted when I’m watching football to go and mow the lawn, interrupted when I am doing online research (what is the best site for French wine?), interrupted when I am reading about the Murcielago I will never own, interrupted when I am deep in thought on how to resolve the economic crisis-and no I was not asleep! 

 Now I have ample evidence to explain why the other behavior driving complaints leveled at all males (we never listen!) is designed specifically to reduce error. No longer can she exclaim, when I point to the errors occasioned in the airline or nuclear power industries as a consequence of interruptions and distractions, “Haven’t seen you piloting too many planes of late. And although you may generate a lot of hot air, we still seem to have pay utility bills!” 

 “Aha!” I can reply. “Multitasking is bad for patients and interruptions even worse.”

 Observations on clinicians demonstrate that doctors are interrupted between six and seven times an hour, that this causes them to spend less time on any given task, and that they fail in nearly 20% of cases to return to the task when they have been interrupted. 

 Not only can I use this to explain things to my wife-why the garden gate still consists only of the surrounding frame-but also to the chief-I don’t meet my targets because I was interrupted: I forgot to return to the reporting work-list after that idiot from the emergency department burst in to show me his latest triumph of FAST scanning (“Look! An ectopic pregnancy causing ureteric obstruction!!” he shouts before rushing on to the next emergency, my response, “….or a corpus luteum and parapelvic cysts…” lost in the whir of arms and legs-he really should get a cape!). 

 So. No more interruptions for me! The sign has gone up on the office door and woe betide anyone who enters! 

 And this is really nice: relax in the solitude and silence, dim the lights, adjust the ambient temperature, make sure the viewing station is at the right height, modify the mouse and keyboard to minimize repetitive stress injury, swear at the voice-activated transcription, and I’m ready for a high-volume, low-error workload. 



 And just to show that I view my consultant responsibilities seriously, the sign on the door also says that I am available for consultation between 8:30 and 9:00 a.m. each day (it’s important that this is during the daily ward round rather than after it has finished!). 

 There are those within radiology who have adopted this stance. Apparently supported by the literature, they lock themselves away, free from distraction, to carry out their primary role of reporting images. They argue that surgeons would not tolerate interruptions during surgery, that a gastroenterologist would complain vigorously if we were to discuss the finer points of a chest x-ray in the middle of a sigmoidoscopy. 

 I think they miss the point. While I agree that to be interrupted during a radiology procedure compromises the safety of the patient or during an intimate examination compromises their privacy, the value of a radiologist, as of all doctors, is the ability to multitask, to work under pressure. Much of our work within hospitals is to deal with urgent and emergency conditions, to respond rapidly and accurately to complex and evolving problems. If I am scheduled for image-guided intervention in the afternoon, I wish to discuss the indications and the state of the patient’s health in advance of the procedure. And if this doesn’t happen when I am reporting, then when? During a prostate ultrasound? A joint injection? A defecating proctogram? 

 What about the “radiologist of the day” approach? I am sure this has many advantages, but if I have reported a study, then it is usual for the clinician to wish to discuss the report with 

, unless a second opinion is sought. If the study falls within my area of specialist expertise, then it would be inappropriate to discuss it with anyone else. And if I am to be asked to stick a needle, tube, or stent into anyone, then I owe it to the patient to be briefed properly prior to the procedure. If I am to supervise experienced trainees, I can either pace up and down outside the procedure room like an expectant father or I can do something else productive and recognize that I will be interrupted if the trainee encounters something unexpected that is beyond his or her competence or level of training. 

 The stance also ignores other evidence for the causes of reporting inaccuracies including workload, lack of clinical details, poor image quality, and, indeed, attention span. Those reviewing x-rays at airport security spend only 20 minutes at a time in front of the screen. Could it not be argued that interruptions, if managed well, might improve our performance? 

 Until patients form an orderly queue outside my office at the proscribed time, with their ailments properly triaged, then interruptions are an inevitable part of medical and radiological practice. 

 We must seek to manage such interruptions firmly and effectively, finishing the review and reporting of a study, if the report is almost complete, prior to diverting our attention, or setting aside the study with a brief note of what had and had not been reviewed so that we can return to it later without cutting corners. 

 If we are not able to demonstrate skills in multitasking, time management, and effective communication, as well as great accuracy in image interpretation, then our roles, as some would suggest, can be divided into individual competencies and performed by an ever growing flock of task-orientated technicians. 

 ….and the garden gate? Don’t tell my wife that it is hidden under a pile of car magazines in the garden shed! I like interruptions …. just not during the World Cup! 




DR. DUBBINS is a consultant radiologist at Derriford Hospital in Plymouth, U.K. 

Coiera E. Clinical communication – a new informatics paradigm. Proc AMIA Annu Fall Symp 1996:17-21.

Westbrook J, Coiera E, Dunsmuir WT, et al. The impact of interruptions on clinical task completion. Qual Saf Health Care 2010 May 12. [Epub ahead of print].

Berlin L. Defending the ‘missed’ radiographic diagnosis. Am J Roentgenol 2001;176(2):317-322.

Stephens S, Martin I, Dixon AK. Errors in abdominal CT. J Med Imaging 1989;3:281-287.

Radiologist discovers his female side as multitasking demands escalate

Living in England has inevitable consequences, ones shared with most of Northern Europe. The winter is long and dark, and, in South West England, also wet and cold. We are unable to wait until spring to lighten our spirits. We seek more daylight, more sun. So along with the French, the Dutch, the Belgians, the Germans, and the Scandinavians, we make the long pilgrimage south.

Being radiologists, the “SAD syndrome” is particularly severe. We travel to work in the dark, spend all day in the dark, and travel home in the dark. And being radiologists, we are blissfully ignorant of the warnings of our dermatology colleagues about the dangers of solar energy. Yes, of course I use factor 15 to 20 sunblock and I wear a hat. But I also lie in the sun and soak up its warming rays. I need to relax. The journey to the sun was already too stressful; I have already worried myself half to death about issues much closer to my own specialty.

Like many left-of-center conservatives, I was convinced that the media were right: the world had become a dangerous place. Terrorists are around every corner, and slightly left-of-center radiologists are almost certainly their prime target. I was comfortable with the introduction of full-body scans at airports. I am a scientist and have read in detail about the nature of the radiation. Apparently they use one of two different types of scanning systems:

 that produces lowlevel radiofrequency energy with values measured in terahertz (tHz). Unlike x-rays and UV rays, mm-wave photons do not carry enough energy to break chemical bonds or ionize atoms and molecules; they possess even less energy than visible light photons.

 To a radiologist, this is even more straightforward. Understanding the Compton Effect was an early lesson of physics lectures, and the absorbed dose is extremely low.

The U.S. Environmental Protection Agency offers further reassurance: “Most of the scanners deliver less radiation than a passenger is likely to receive from cosmic rays while airborne.” Scanned passengers are likely to absorb only 0.1 to 5 μSv of radiation. So my only worry was whether half an hour in the gym would be enough to avoid an outbreak of giggles among airport security staff as my somewhat less than Adonis-like physique presented itself for review. That is, until our family debate about the Shock Doctrine.

Always more susceptible after a good dinner and a few glasses of wine, the argument that my son presented of the use of global threat and disaster as a means of manipulating society seemed compelling.

How much did I really understand about mmwave technology? After all, it is measured in tHz and that in itself is fairly scary. My cursory review of the literature was shown to be exactly that, and a rather more in-depth assessment revealed some legitimate health concerns.

Mathematical modeling studies show that tHz fields may interact with double-stranded DNA in a way to produce nonlinear reactions or resonances. These have the potential to unzip DNA, creating bubbles in the double strand that could significantly interfere with processes such as gene expression and DNA replication.

I was not reassured by the somewhat bland platitude that currently deployed body scanners operate in an mm-wave region above the submillimeter or tHz region investigated in the study I was looking at. So, coming from a country where individual choice is paraded as a human right, I was mulling over whether to request mm-wave or x-ray backscatter.

There is little doubt that the doses from the backscatter x-ray systems being proposed for airport security purposes are said to be very low, but by now I was calculating the cumulative dose for a frequent flyer. I was weighing up the pros and cons of refusing the body scan altogether and submitting myself to an intimate body search, but the very thought of the rubber glove induced a serious attack of irritable bowel syndrome. I resolved to pack a lead coat in my carryon luggage-although this left only enough room for a tiny pair of Speedos dating back to the 1970s.

In the event, it was only my wife who was searched and neither of us was submitted to a body scan. She has this innocent smile that is always interpreted as an attempt to hide evil intent. Nobody was the slightest bit interested in the lead coat, although the Speedos produced barely stifled giggles not only at airport security but also throughout the holiday...

Living in England has inevitable consequences, ones shared with most of Northern Europe. The winter is long and dark, and, in South West England, also wet and cold.

Paul Dubbins, MBBS

Articles

Women have no right to monopoly over multitasking

Women have no right to monopoly over multitasking

Radiologist discovers his female side as multitasking demands escalate

Airport scanners raise the ceiling on a fear of flying