Breaking the Interruption Cycle in Clinical Practice

Researcher Suggests Cognitive Strategies That Can Help

December 20, 2017 09:22 am Sheri Porter

Interruptions happen in life, and they happen a lot in the workplace. But when physicians are interrupted during an important task at work, it can result in considerable frustration and, in some cases, potential patient harm.

[physician holding hourglass sign]

As a busy family physician, wouldn't it be nice to have some guidance on how to prevent interruptions, as well as tips on how to safely get back to the previous activity when they do occur?

Look no further than an article published( in the November issue of Annals of Emergency Medicine titled "Emergency Physician Use of Cognitive Strategies to Manage Interruptions."

According to the AAFP's 2017 member census, about 3.4 percent of active members who participated in the census said they work primarily in an ER setting; a further 5.4 percent listed the ER as their secondary work setting. In total, 3,620 AAFP respondents said they work full- or part-time in an ER.

But the study is relevant to all family physicians, said lead author Raj Ratwani, Ph.D., in an interview with AAFP News.

Story Highlights
  • Physicians in all medical specialties face the daily frustration of frequent interruptions during clinic hours or ER shifts.
  • Interruptions can sometimes jeopardize patient safety.
  • New research published in Annals of Emergency Medicine urges physicians to explore the causes of interruptions and suggests tactics to help physicians to resume initial tasks quickly when distractions do occur.

"This specific study happened to be with emergency physicians, but we did a similar study looking at radiologists, and another at interruptions with nurses," said Ratwani, who serves as acting center director and scientific director at MedStar Health's National Center for Human Factors in Healthcare in Washington, D.C.

"The basic principles of how to handle interruptions are quite generalizable across clinicians and across subspecialties."

Study Design, Key Findings

For this particular study, researchers conducted a time and motion study in three urban academic ERs with annual patient volumes ranging from 36,000 to 91,000.

They recruited six ER physicians from each institution and observed each of the 18 participants for two hours across morning, afternoon and night shifts, balancing observation times between the beginning, middle and end of their shifts.

Physicians being observed were engaged in a variety of activities including computer-based work, paper-based tasks such as documentation, direct patient care, and telephone or face-to-face conversations with other physicians and clinicians.

According to authors, "An interruption was defined as any event initiated by an outside stimulus requiring the physician to direct his or her attention away from the current task."

When interrupted and asked to perform a new task, physicians used strategies that included immediately starting the new task, rejecting the task, delaying the request, or multitasking by working on both the task at hand and the new request.

Researchers found that physicians were interrupted a total of 457 times in 36.6 hours of observation. They noted an average of 12.5 interruptions per hour, with a mean length of 31.8 seconds.

The majority of interruptions (87.2 percent) came from other staff members, including physicians, residents, nurses and technicians, with the remainder of interruptions stemming from phone calls, patients, pages and devices.

Physicians were most often working on a computer when interrupted, a situation that accounted for 44.5 percent of interruptions.

Regarding physician action taken after those 457 interruptions, observers noted that physicians most often stopped what they were doing and engaged in the new task (75.4 percent), followed by multitasking (22.2 percent), delaying the interruption (1.7 percent) or rejecting the interruption (0.8 percent).

Authors noted the existence of interruption management strategies that could be used "to better mitigate the disruptiveness of interruptions," and said that such strategies could be "particularly useful in high-risk environments such as the ED (emergency department) to reduce the likelihood of error and possibly patient harm."

In addition, researchers noted that despite frequent interruptions in the ER, physicians "rarely used management strategies such as delaying or rejecting interruptions."

Strategies to Employ

In a phone interview, Ratwani took some time to discuss concrete strategies family physicians can employ to deal with interruptions in practice.

At the top of his list was preventing interruptions in the first place. He noted that basic studies in cognitive science and cognitive psychology show a five- to 10-fold increase in the number of errors when an interruption occurs mid-task.

"In health care, it's harder to quantify the increase in error rates because of complexity of the domain," said Ratwani, but errors take on more significance when they jeopardize patient safety.

"Take some time to look at when you get interrupted. Think about the source of those interruptions and if there is a way to mitigate the problem," he suggested.

For instance, sometimes a lack of communication causes a staff person to "interrupt you again later on because they need more information." And issues can also arise when a health information technology system doesn't appropriately convey information.

Once physicians have considered the "why," they should learn how to prepare for interruptions. Most physicians immediately accept an interruption and move away from their primary task, but the problem comes when they get back into that initial task, said Ratwani.

"Your memory for what you were previously doing is being erased by this new task. So, at the very moment you get interrupted, you have a couple of seconds to make some important decisions that will actually help you when you resume the task," he said.

Instead of automatically engaging, use a tactic called a "course break point," said Ratwani. "Buy yourself a little time to get to a good stopping point in the task that you're involved in." For instance,

  • when reading, continue to the end of the sentence or finish the paragraph before you acknowledge the interrupter, or
  • when engaged in electronic prescribing and entering the dosing information, add that final digit for the 10 tablets you're ordering before leaving the screen.

A second tactic in the preparation phase is the use of "environmental cues," said Ratwani. For example, when entering information in your electronic health record, stick a note right on the screen -- literally on the field where you were last entering information -- to grab your eye when you return to the screen.

A third tactic is simply taking a second or two to repeat the main task to yourself -- just as people do when repeating the name of a new acquaintance several times after meeting so it sticks in the memory.

"The same thing applies here; you're just about to enter dose information and you get interrupted. Mentally say to yourself, 'entering dose, entering dose, entering dose' to improve your ability to come back to that task when you resume," said Ratwani.

There's also a tactic called "memory rehearsal" that involves mentally recalling your previous activity, such as "I was doing dosing information," while engaged in the interruption.

Ratwani stressed that some situations require intense focus. "If you are in the middle of prescribing a high-risk medication, there's absolutely nothing wrong with telling the individual starting to interrupt, 'Wait a moment while I finish what I'm doing.'"

In closing, Ratwani said metacognition is an important process for physicians to consider.

"I'm always amazed at these incredibly bright people who are thinking deeply about really complex clinical problems but sometimes neglect to think about the way they do their own work," he said.

More From AAFP
Emergency Medicine/Urgent Care Member Interest Group