E-mail Anonymous: A Physician's Addiction

Abstract

DOI: 10.1200/JCO.2014.58.9705 The next time you are sitting in Grand Rounds, standing in the cafeteria line, rounding with your team, or giving a talk, take a look at your colleagues. Chances are, they are staring at a screen, and many are probably checking e-mail. E-mail has changed how physicians communicate. Whether related to patient care, academic pursuits, or administrative tasks, our interactions are now frequently conducted electronically. This form of communication has a new pressure attached: who would not prefer to collaborate with someone who responds within minutes? The patient-based aspect of e-mail reinforces the importance of a prompt reply—patient care is paramount, and therefore, checking e-mail frequently feels like something that good doctors should do. Whether the shift from live dialogue to e-mail has led to improved communication, enhanced productivity, or—most importantly—improved patient outcomes is unknown. The true extent and impact of daily e-mail use by physicians has also not been formally quantified. However, my own e-mail usage can be formally qualified. I am an e-mailaholic. It is hard for me to know exactly when the addiction began, but by the time I became an attending physician, I would check my e-mail at nearly every moment. The e-mail browser would be open in my office or clinic throughout the day, and when not at a computer, my e-mail would be just a few seconds away, accessible via the phone in my righthand pocket. Before going to bed and first thing on waking, while waiting for my coffee to brew or walking through the parking lot, I was checking e-mail. It was an action devoid of thought; it just became second nature for my thumb to push, slide right, enter password, and push once more—I can open e-mail with my eyes closed. Most of us can. A retrospectively self-administered CAGE questionnaire (the name of which is derived from questions used to screen for alcohol addiction; these questions involve the words cut down, annoyed, guilty, and eye-opener) would have easily produced three “yes” responses: I often thought about the need to cut down my e-mail usage and spend more time on the task at hand or with the people around me; my children were at times annoyed with me for not paying attention to our conversations; and I felt uneasy without a daily eye-opener: a check of my e-mail soon after waking up. Constant communication may have its benefits. Queries are answered more quickly, both by colleagues and patients (who may feel less intimidated getting in touch with their physician via e-mail), and perhaps projects and tasks are advanced a little faster. But e-mail also decreases spoken and face-to-face interactions, arguably eroding relationships. Questions answered by e-mail may result in misunderstandings that require many follow-up e-mails. This ongoing e-mailing leads to interruptions and multitasking: patient care, writing, reading, thinking, and generally being present in any given moment become fragmented. Many knowledge workers frequently multitask, but some believe that the term multitasking is a misnomer and that one is actually rapidly switching from task to task, which is a hindrance to creativity and intense focus. What is the cost of this constant switching of thought and attention? Although no prospective and unequivocal studies exist, e-mail has been associated with stress and loss of control, and in an academic environment, users spent approximately 23% of their time on e-mail, checking it up to 36 times per hour. In older adults, multitasking led to significant working memory disruption. When e-mail was shut off for 13 knowledge workers, they tended to multitask less and exhibited longer task focus; stress was also lower without e-mail. Interestingly, some companies are now asking their employees to shut off e-mail for certain lengths of time during the day to increase productivity. The gravitational pull of e-mail is strong and draws on the variable-interval reinforcement schedule concept—reward is unpredictable and e-mail becomes addictive. Furthermore, a recent study in default-mode processing (inward-directed thought) revealed that people not only do not seem to enjoy sitting quietly and thinking with no distractions, but that 43% (67% of men and 25% of women) selfadministered electric shocks rather than simply sit for 15 minutes without anything to do (all of them previously said they would pay money to avoid such JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 33 NUMBER 3 JANUARY 2