RHIP, doctors, and pagers
I've read this transcript from an NPR interview titled Why do doctors still use pagers?, from Planet Money. The interview talks to Mary Mercer, an emergency room doctor in San Francisco, and Christopher Peabody, another ER doctor at the same hospital, and who have run a pilot project to try and replace pagers.
They begin by covering what a pager is, exactly, because younger folks may have never encountered them: "it's a little black box with a little gray screen in it, and it emits a sound to alert you that you have a message." Someone calls your pager's number, which is converted to a message that goes over radio waves, and when the pager goes off, a number pops up on your pager screen, and you race to find a phone to call that number back. They used to be everywhere, particularly in the days before cellphones, but have since disappeared from pretty much everywhere except hospitals, specifically for doctors.
Mary Mercer was wondering why exactly is it that doctors still use pagers, why they are still putting up with them. A few years back, Mercer was in charge of a project to increase ER efficiency, and along with Peabody, she decided to see what could be done to replace them.
For an on-call doctor, the pager is a bit opaque. In San Francisco, the transcript says, you may be called for a patient with a rash, who has been in a car crash, or even in a sea lion attack. But all a doctor gets is a phone number on the pager, so there's no way to know if you're gonna be asked to write an order for some medication or to assist someone with a half-amputated limb. They have to call the phone number back, and get the story. Apps were being made available for medical personnel that do end-to-end encryption and allow read receipts while preserving patient privacy, but were not used. On the other hand, pagers are considered to be more reliable:
They have fewer dead spots. They run on entirely different networks than cellphones. If there's a big emergency and everyone tries to use their phones all at once, pager networks are less likely to be completely overwhelmed.
Mercer and Peabody still felt that the benefits of new apps would outweigh the negatives, and decided to prove it with a pilot program. For the pilot program, they enlisted one of these aforementioned apps to try it out, while still having doctors carry pagers as well, so they could see for themselves how it goes.
At launch, everyone seemed pretty enthusiastic, and the new stuff felt like a no-brainer: doctors could send each other photos from across departments, such as when dealing with open fractures:
So I took a secure photo and texted it to the orthopedic surgeon and just put the room the patient was in, no other information, and I got a response immediately that said, be right there. [...] So at that moment I was like, this thing's genius. We're definitely going to be implementing this technology system wide.
[...] Mary had the same experience. A patient came in with a seriously broken ankle. And instead of having to page someone and wait for them to call back and then describe to them exactly how the ankle was broken, Mary just texted over a photo. The orthopedic resident saw exactly what the problem was and came right down to take care of it.
[...] Everyone was high-fiving after that [...] The emergency resident and I high-fived. The patient high-fived. The orthopedic resident high-fived, you know?
(the interviewers do spend a bit going like "really, the patient high-fived?" and Cristopher going "they were thrilled!")
They did also find some issues with the system. Sometimes, doctors on-call would go to sleep, and while they had a strong, "Pavlovian" response to their pagers, some had their phone settings put such that the text messages wouldn't wake them up and they still had to be paged.
In fact, after a few weeks, Mary and Christopher started finding out that adoption was going down:
Toph was working in the ER. He had just texted one of the neurology residents, one of the young doctors on call. The resident walked into the ER wearing that, you know, Rambo belt of five or six pagers across their chest.
I turned to them, and I said, isn't this new system awesome, like, to just get this? You could get rid of all of those pagers you have. And they turned to me and said, it's awful. And I was, like, what? And he was, like, it's awful.
To explain how that unfolded, they introduce something called the RHIP, which stands for Risk, Habit, Identity, and Power:
- Risk: Doctors often felt cell phones didn't have enough battery to go through a full shift; Pagers had fewer dead zones than cell phones; During big emergencies, the pager network has less of a tendency to be overloaded than the phone network
- Habit: They were used to pagers, knew how to use it, and the new software was more of a pain.
- Identity: Pagers feel like a "symbol of doctorness"—a patient seeing a doctor look at their pager knows it's work related in a way they don't know it is when they appear to be texting someone else during a consult. This can end up changing how they feel about their own job as well.
- Power: This was the biggest, most disruptive one. Phones inverted the power dynamics, and this requires expanding a bit.
In the hospital where they ran the experiment, specific dynamics were in play:
Among the doctors at Mary and Toph's hospital, it was the residents who had the least power. They were the most junior doctors on their teams. And in specialties like orthopedics and neurology, one of their duties was to be on call, to respond to all those messages and photos and everything else that the ER doctors could now send instead of paging.
There's a whole team that's on call, but the junior-most person is usually the one that's in-house, you know, being the first line of defense.
They interview Abhinav Janghala, an orthopedics resident during the pilot program. He was one of those with a "Rambo" belt with a bunch of different pagers. He started up optimisitc, but ended up hating it. He mentions how people started texting him about minor things that wouldn't have been a page before—the threshold had been reduced. He'd find himself being pinged during surgery for minor questions, and even in group texts about patients he wasn't treating:
Let's say you're getting - normally, you would get 10 to 20 consults. Now you're getting 25 to 30 texts overnight, and only out of the 30 people, maybe 20 of them you actually needed to know about. [...] I started to see the pager as a way where it puts the person receiving the page in control of the communication.
That's the P in RHIP. By turning their phones off, doctors had the ability to control what they could be disrupted about, knowing that the pager would be used for really important stuff. Even when they were paged, they could decide when to call someone back. This went away with the app-based workflows, and would let the sender know if the on-call person had seen the message. This increased the demands on their attention.
During the experiment, residents started just flat out ignoring the app. The ER doctors only had the power to disrupt residents if the residents allowed it to happen:
At the end of the pilot program, when the three months were up, Mary and Toph got back all the data, and they were surprised to learn that their project had failed. Their big goal, you know, to use this efficient new communication technology to get their patients treated faster in the emergency room - none of that happened. [...] There was no statistically significant change in how long patients were spending in the ER.
Mercer and Peabody looked at the data, and it's not even that the app was or wasn't effective—it was just not being used: "By the end of the pilot program, traffic on the app had gone down 50%." The interviewers at NPR already do a perfect conclusion so I'll quote it directly:
For Mary and Toph, the moral of the story is, no matter how great a technology might be, how you implement that technology matters because even the shiniest new technology comes with some drawbacks. It might introduce new risks or disrupt old habits or call people's identities into question or maybe change the power dynamic in an organization. Now, any of these drawbacks can be overcome, so long as you do a good enough job of rolling out the new technology. Do what you can to foresee the drawbacks, and figure out ways to address them ahead of time.
[O]ne of the biggest unforeseen drawbacks was this paradox of increased communication. But sometimes having more communication doesn't improve communication, that it can just make people feel more powerless.
Overall, I found the RHIP framework to be really interesting as a way to frame the whole thing.