Sixteen years after the famous phrase “one more thing” was uttered by visionary Steve Jobs while introducing the iPhone, smartphones are nearly ubiquitous, both inside and outside of the hospital. A few years after the iPhone’s launch, a New York Times article about “distracted doctoring” famously drew attention to the issue of smartphones serving as potential threats to patient safety (asamonitor.pub/446Iej9). While computer workstations and personal devices can be used to access case-specific institutional protocols, medical references, and intraoperative teaching resources, they can also serve as distractions.
In a 2012 study on non-record keeping computer activity during anesthesia care, Wax and colleagues found that such activity comprised 16% of procedure time and occurred more often during longer cases, during general anesthetics, with patients having lower ASA Physical Status scores, and by attending anesthesiologists working solo (Anesthesiology 2012;117:1184-9). Interestingly, the study found no significant differences in measures of hemodynamic instability occurring during periods of non-record keeping computer use. In an editorial discussing these findings, Domino and Sessler explained that vigilance, a key component of safe anesthesia care, declines with prolonged activity, during which boredom and low arousal can lead to poor performance (Anesthesiology 2012;117:1156-8). They further suggested that, considering task switching has been shown to enhance vigilance and monitoring activity in some circumstances, it is conceivable that non-record keeping activity could improve performance during periods of declining vigilance, as may occur during maintenance of anesthesia.
“It is important to note that excessive use of PEDs is not synonymous with addiction; the time spent on the device must be problematic in the user’s daily life. Furthermore, it can be difficult to determine when a behavior transcends habitual usage into an addiction.”
Even if this is the case, the use of personal electronic devices (PEDs) could be problematic during less routine cases or when caring for sicker patients, and such use is likely more common among anesthesia providers who exhibit addictive behaviors with electronic devices such as smartphones. Indeed, though Domino and Sessler presented evidence from the railroad and aviation industries supporting the notion that vigilance suffers during monotonous tasks, they also noted a known train derailment and accidental deviation from a flight path resulting from an engineer and pilots distracted by their PEDs (Anesthesiology 2012;117:1156-8).
Like many addictive behaviors, excessive or problematic PED use is not a character flaw, but rather the behavioral manifestation of individual differences in neurobiology and their interactions with the environment. A study using positron emission tomography to quantify striatal dopamine synthesis capacity found a negative relationship between dopamine synthesis capacity and proportion of subjects’ smartphone use dedicated to social media applications (iScience 2021;24:102497). In another study examining fronto-striatal-limbic structures using MRI in users of the popular messaging app WeChat, excessive use was associated with smaller gray matter volume in the ventral anterior cingulate cortex, and greater use of WeChat’s payment feature (which allows for in-store, online, and peer-to-peer transactions) was associated with smaller gray matter volumes in the nucleus accumbens (Sci Rep 2018;8:2155). These regions are implicated in regulatory control of reward mechanisms and responsible for the dopamine release that is instrumental in behavioral response to reward-predictive cues, respectively (Neuroscience 2005;135:1025-33). While these findings together suggest that social media and perhaps device use in general are driven by aberrant reward processing, the cross sectional nature of the studies precludes making conclusions about whether such aberrancy precedes or results from excessive use. Regardless, it has been theorized that the variable reward schedules in the form of notifications of “likes,” comments, and other engagement on social media platforms lead to rewarding dopamine release similar to that seen in other addictive behaviors such as gambling, keeping the user engaged in compulsive use via positive feedback loops (J Neurol Neurophy 2020;11:1-2).
It is important to note that excessive use of PEDs is not synonymous with addiction; the time spent on the device must be problematic in the user’s daily life. Furthermore, it can be difficult to determine when a behavior transcends habitual usage into an addiction. Griffiths operationalized addictive behavior as that which includes six fundamental components of addiction: salience, mood modification, tolerance, withdrawal symptoms, conflict, and relapse (J Subst Use 2005;10:191-7). Even without the presence of all six components, conflict is an important element to consider when discussing phone usage in the OR. Griffiths stated, “Continual choosing of the short-term pleasure and relief leads to disregard of adverse consequences and long-term damage.” While for many people, the long-term consequences of using one’s phone at work may be disciplinary action or the eventual severing of employment, for a physician these consequences could be morbidity or mortality of the patient (J Subst Use 2005;10:191-7).
As of May 2023, the American Psychological Association does not consider PED addiction to be a diagnosable disorder. Perhaps as a result, research on and specialized treatments for device addiction are relatively limited. However, there are several evidence-based treatment methods that have been shown to be effective in addressing different behavioral addictions. Cognitive behavioral therapy, for example, is considered to be an effective treatment protocol for addiction. Twelve-step programs such as Internet and Technology Addicts Anonymous offer an effective peer-support option (Curr Psychiatry Rep 2011;13:382-9).
Though many people may wish to use their phones less than they do, it can be difficult to make real and lasting changes to PED usage due to its relative habituality. Furthermore, suppressing a habit is even more difficult while under cognitive load, as a physician may be in the OR (Br J Soc Psychol 2009;48:507-23). Formed from a strong situation-behavior association (i.e., “my patient is stable during maintenance and my tasks are completed, so I sit down and get out my phone”), habits can become automatic and may feel uncontrollable. Additionally, impulsivity has been found to be positively associated with cell phone addiction (conscientiousness, conversely, is negatively associated with the addiction) (Pers Individ Differ 2015;79:13-19). The omnipresence of our PEDs allows impulsivity and habit-forming behavior to flourish; RescueTime, a mobile application that tracks cell phone usage, found that in 2018 the average American picked up their phone 58 times per day, frequently within minutes of having previously put it down (asamonitor.pub/3CE3Bwl). While the reported number of average daily phone pick-ups varies by survey, the number frequently exceeds 50 (with one 2021 survey reporting a staggering average of 344 phone pick-ups per day) (asamonitor.pub/3CFtHiy).
One of the few methods known to break habits once they are formed is to remove the necessary stimulus. However, this may not be possible in the case of perioperative PED usage, as physicians may need to keep their phones with them for work purposes. Thus, it is important for individuals to be able to self-regulate their impulsive and habitual response to access their PEDs. A promising strategy involves the use of implementation intentions – straightforward statements of how one plans to implement an intended behavior (Pers Soc Psychol Bull 2011;37:502-13). Instead of saying, “I want to use my phone less,” an implementation intention specifies the exact scenario in which one intends to do this, such as, “If I am in the OR and I sit down because my patient is stable, then I will review a topic relevant to my cases instead of getting my phone out.” Research indicates that the similarity of this if-then structure to that of a formed habit allows new links to be developed between situations and behaviors, weakening the old behavior and facilitating the breaking of habits (Br J Soc Psychol 2009;48:507-23; Pers Soc Psychol Bull 2011;37:502-13). The ease of utilization makes this strategy appealing; one can repeat an implementation intention to themselves with minimal effort and in any setting, including in an OR. All that is needed is the desire to lessen one’s PED usage and the intentionality to employ this technique.
How else can an anesthesia professional intervene if they notice their smartphone use may be impacting their vigilance, efficiency, and conscientiousness? One possible solution could involve having a second device without any gaming, social media, news, finance, or other distracting applications, especially when physicians are given the option of an employer-financed work phone. By leaving one’s personal device in the locker room and using the second device in the OR, the user would have a forcing function in place that would allow a moment to pause and interrupt the impulse to use the entertaining application of their choice – they would need to intentionally download the application before using it. Users without a second device could turn off notifications from distracting applications or turn on the “do not disturb” mode when caring for a patient. Mindfulness practice could facilitate resisting the impulse to check one’s phone or to more quickly redirect one’s attention to the case after picking up their PED.
“Instead of saying, ‘I want to use my phone less,’ an implementation intention specifies the exact scenario in which one intends to do this, such as, ‘If I am in the OR and I sit down because my patient is stable, then I will review a topic relevant to my cases instead of getting my phone out.’”
While there is still a dearth of data capturing the effects of PED use and related addictive behaviors in the OR, anesthesia professionals should carefully consider their own smartphone and other device use while engaging in patient care activities, including monitoring. Even if not pathological, distractions posed by the use of personal devices could have significant detrimental effects on patient safety. It can also place health care professionals at legal risk in malpractice lawsuits in which phone use records and application metadata could be used to argue they were not vigilant. The relative novelty and wide social acceptance of smartphone ubiquity means that the field of psychology has not yet formalized a framework for a personal device use disorder, and no widely established gold standard of treatment exists. In the meantime, all members of the anesthesia care team have a responsibility to honestly self-evaluate their use of personal devices, find effective ways of curtailing distracting use in the OR, and seek professional help if they feel they are exhibiting addictive behaviors.