Author + information
- Jarrod D. Frizzell, MD∗ ( and )
- Bina Ahmed, MD
- ↵∗Reprint requests and correspondence:
Dr. Jarrod D. Frizzell, Cardiovascular Disease, Division of Cardiology, Department of Internal Medicine, 1 University of New Mexico, MSC10-550, Albuquerque, New Mexico 87131.
Of all the labels applied to my generation, the “millennials,” there is 1 for which we are fully deserving: we are the “digital generation.” Born roughly between 1980 and 2000, we are the first to grow up with computers and video games in our homes. Surveys have shown that millennials may have difficulty fathoming a world without computers or cell phones (with owner rates of 97% and 94%, respectively) (1). Similarly, the penetration of texting has rocketed upward, now to the point where advertising campaigns must warn users against the dangers of texting during inappropriate times (e.g., while driving).
Millennials are the first generation to be a part of the pervasive use of multimedia messaging services as a transformative technology among health care providers. Nonetheless, it appears this change among providers has apparently gone largely unnoticed in the literature. Perhaps this is because of the “obviousness” of its use. When mentioning my interest in this topic among my peers, the general reaction was a blank stare, followed by: “Of course, we text.” Older attending physicians, particularly those proudly holstering a “flip phone” on their belt clip, evinced even more consternation on the topic.
The benefits of instant 2-way communication like texting in improving patient care are obvious in ways both large and small. Texting is simple and straightforward, with immediate results. In 1 sense, it is an extension of hallway conversations among clinicians that are often more fruitful than the more common method of communicating through patient medical charts. “It’s a digital extension of the corridor,” a colleague stated. In a similar vein, texting also expedites communication and relieves other shortcomings of 1-way communication systems. We have all experienced the uncomfortable silence after paging a consultant or the attending on call and have worried whether they received the page. Perhaps more frustrating is the endless ringing of the phone number to which we are urgently paged. With today’s smartphones, we are notified immediately if our messages are unable to be sent (e.g., poor reception), and in many cases, we can also see that a recipient has read the message.
Although data are limited, 1 survey of general surgery residents and faculty demonstrated the frequency and importance of text messaging as a typical component of patient-related care (PRC) duties (2). Among both residents and attending physicians, PRC was the most common reason for texting while at work, with a plurality supporting text as the preferred method for communicating “routine” PRC. A majority of all respondents were either “comfortable” or “very comfortable” texting about PRC. As one may predict, texting is more prevalent among residents than faculty. Granted, there is likely selection bias in such a study, and many of us have anecdotal evidence of an upward generational trend in text message usage.
The advantages of text messaging over traditional paging are evident across multiple clinical experiences. When on call, I am often awakened by a text. Before viewing the contents, the sound of receiving a text message compared with the jarring alert of a pager harkens a more pleasant experience. A text implies that it is someone I know personally enough to give them my number. Sometimes, it is along the lines of “Hey, could you give me a call? There’s a patient I’m worried about and I’d like to talk it over.” Frequently it is a photo of an electrocardiogram, with a short question like “VT? HD [hemodynamically] stable.” Knowing the question and having the opportunity to preview such information beforehand improves direct communication prior to returning the phone call. Another example came while admitting a young woman for syncope while she was driving. As is often the case with motor vehicle accidents, the history can be somewhat confusing. Whether the loss of consciousness preceded or succeeded the crash makes all the difference. Telemetry overnight sealed the diagnosis of long QT syndrome leading to torsades de pointes, and texting an image to our offsite electrophysiologist of the telemetry showing R-on-T causing torsades greatly enhanced the efficiency of additional care, workup, and treatment.
However, despite the positive applications of text messaging, it must be said that a conversation over text regarding a patient should not replace the need to fully evaluate a patient when that is what is required. As with any new technology, there are still many issues left to be resolved before encouraging unfettered adoption. Chief among these are privacy and security concerns. Despite the prevalence of text messaging in PRC in the above-mentioned survey, only a small minority of respondents agreed with the statement “texting is secure.” In the era of enhancements to the Health Insurance Portability and Accountability Act (HIPAA) as well as frequent headlines about secure data breaches, maintaining the privacy of patient data must be paramount. The fear of HIPAA violations, in particular, has driven some much-needed conversations (3,4). Secure messaging systems have been developed for use in health care, with at least 1 usage trial reporting success (5). Although promising, these systems have yet to reach the tipping point required by adoption of communication modalities to become mainstream. For now, deidentification of any PRC communicated via text messaging is what many should rely upon as a minimum.
Another aspect to bear in mind is the yet unconsidered medico-legal implications of recommendations made solely via text messaging. The traditional “curbside consult” was verbal communication, which left no trace. With “digital curbside” over text messaging, there is a digital footprint of a recommendation made without an actual evaluation of a patient by the consultant. The legal ramifications of such advice remain unclear and mandate cautious widespread use of “digital consults.” Last, contemporary culture continues to march toward digitizing the art of conversation and communication. Taking an actual history, being in a room with the patient, and conveying important details about a particular case to other consultants in person remain crucial to good medicine and optimal patient care. Overuse of digital communication may come at the cost of these foundations of modern health care and, therefore, must be considered before wider adoption.
A common joke is that only doctors and drug dealers carry pagers anymore. In fact, pagers and physicians are so synonymous that 1 was included in my toddler’s toy doctor kit—sounds and all —along with an electronic stethoscope. Much like the resistant old man in “Monty Python and the Holy Grail” (6), the use of a pager is not quite dead yet, despite insistence to the contrary in the nonmedical world. Nonetheless, the inexorable march toward easier communication continues unabated. It appears that my generation will be leading the way in cautiously turning the page, by turning the pagers off.
- Steven R. Steinhubl, MD ( and )
- Eric J. Topol, MD
RESPONSE: Time for the Pager to Enter Retirement
The practice of medicine is steeped in tradition. The use of pagers is 1 of them. In fact, 1 of the first paging systems ever developed was in 1950 for New York City physicians, representing 1 of the first commercial uses of the newly invented transistor (1). More recently, we recall receiving our first pagers as advanced medical students and admiring them with near reverence as another talisman, similar to our white coat and stethoscope, on our journey to becoming physicians.
A lot has changed in health care in the 65 years since the introduction of pagers. Yet, pagers have remained the cornerstone of all interprofessional communications in the medical field—routine, critical, or otherwise. This is despite a clear need for improved methods of communications. For example, the Joint Commission has identified communication failures to be 1 of the most common causes for sentinel events (2). In addition, another study found that nurses spend up to 7% of their already overstretched workday on tracking down physicians (3).
Of course, the staying power of the pager goes beyond just tradition. Cell signals, especially within hospital structures, can be weak and inconsistent. Phones lose power much more rapidly than a pager will. A busy night on call can both increase power drain and decrease charging opportunities. Most importantly, pagers offer greater security and less risk to privacy than do personal phones. For example, you cannot accidently send a page to a friend from college when awakened in the middle of the night with a patient-related question. Nonetheless, all of these issues have existing solutions, and as Drs. Frizzell and Ahmed aptly point out, the use of smartphones is so ubiquitous, and the advantages to both patients and providers are so numerous, the time has come to break from tradition and start implementing the solutions necessary to enable improved communications.
Just as the white coat has been shown to be a refuge for bacteria and infection risk for our patients (4), and the availability of pocket ultrasounds is transforming stethoscopes into little more than nonstylish neckwear (5), it is time for the pager to enter retirement along with these other vestigial hallmarks of an anachronistic doctor look and for our profession to break from tradition to do what is best for our patients.
- Ennis C.
- ↵The Joint Commission. Sentinel Event Data Root Causes by Event Type 2004–2013. Available at: http://www.jointcommission.org/assets/1/18/Root_Causes_by_Event_Type_2004-2Q2013.pdf. Accessed October 31, 2014.
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- ↵Gilliam T, Jones T, directors. Monty Python and the Holy Grail [DVD]. United Kingdom: EMI Films, 1975.