I have been naïve. I am not stating that I completely failed to recognize the extent to which our phones, the internet, and social media permeate our lives. Until now, however, I have dismissed the impact of screen time. After finally watching the 2020 Netflix documentary The Social Dilemma, I am shell-shocked by the realization that a vast majority of us are addicts. Aptly noted by professor emeritus of political science, statistics, and computer science at Yale University Edward Tufte, “there are only two industries that call their customers ‘users’: illegal drugs and software.”
Watching the film, I found myself becoming defensive, rationalizing my usage, justifying the need for excessive use given my vocation, or applauding my own paltry parental restrictions with our children. Upon reflection, I came to admit the similarities between my device usage and some of my patients’ struggles with alcohol and opiates. By way of example, primary care providers regularly perform a CAGE screening for alcohol abuse:
- Have you ever felt you needed to cut down on your drinking?
- Do people annoy you by criticizing your drinking?
- Have you ever felt guilty about drinking?
- Have you ever felt you needed a drink first thing in the morning (eye-opener)
When it comes to screens, I possess all four of the CAGE criteria, and I am willing to bet most readers of this article do as well. Immediately, I go back to the justifications: “I need perpetual phone access for my job”, “I have to stay up to date on my email and recent hospital data” and “so what if my phone and laptop use is excessive, I’m not hurting anyone”. Therein lies my naïveté.
Let us go beyond some of the potential consequences of being hyper-focused on our screens that include motor vehicle accidents and becoming an insufferable internet troll. Social media creates an avenue for behavior manipulation and truth distortion. These platforms leverage confirmation bias, implicit bias, salacious fake news, and calculated algorithms designed to optimize our interest and seduce us into a technologically induced trance. There is a reason that so many of us have our smartphones in our hands most of the day and within arm’s-reach at night. As explained brilliantly in The Social Dilemma, billions of people worldwide have been manipulated into becoming extremely dependent users.
We are not just the product of manipulation; we are the product itself. Data about our preferences, our search histories, and our shopping choices, are an incredibly valuable commodity. As Aza Raskin, formerly of Firefox and Mozilla, said, “Advertisers are the customers. We (users) are the thing being sold.” It is not just our data for sale, however. As noted by Jaron Lanier, pioneering computer scientist and founding father of virtual reality, “It’s the gradual, slight, imperceptible change in your own behavior and perception that is the product”. Thus, you, your colleagues, your clients, your patients, your friends, and your family are victims of powerful persuasion. Persuasive technology has altered our thoughts, our feelings, and our reality without many of us ever being cognizant of the manipulation.
At Colquitt Regional Medical Center, we have a robust training program for the recognition of bias. It is paramount to not trivialize bias. We must recognize our subliminal attitudes regarding race, sex, obesity, sexual preference, etc. to ensure that we never make sub-optimal healthcare decisions as a consequence of our own biases. Problematically, social media has a tendency to create division by escalating bias. Social media algorithms exploit tribalism and our human need for affiliation to herd us into niche groups that can intensify our implicit biases. Our customized news feeds then deliver content that persistently amplifies whatever prejudices or preconceived notions we may unknowingly possess.
All healthcare organizations should teach the bias potential promulgated by social media usage. We need to instill an understanding that social media algorithms have their own agendas; ones that have nothing to do with positive patient outcomes. As noted by Chamath Palihapitiya, a former vice president of growth for Facebook, social media “wants to psychologically figure out how to manipulate you as fast as possible, and then given you back that dopamine hit.” Knowledge of the potential for bias may abrogate use and perhaps help re-establish our ability to perceive our world more critically.
Quantifying the extent of this influence by computer-based algorithms is near impossible. International news media entities have long been guilty for implanting variable degrees of manipulation, but the usage of internet technology sent this potential for propaganda into hyper-speed.
The dangerous impact of misinformation on medicine is alarming. Never in my career as a physician have I seen healthcare providers, hospitals, the Department of Public Health (DPH), and the Centers for Disease Control and Prevention (CDC) under such vehement and prolonged attack. While I can appreciate a certain degree of apprehension toward vaccines, unproven therapies, and even the Food and Drug Administration (FDA), the degree of anger and hatred is outsized. I have even seen misled ardor among some within the healthcare industry. We have moved far beyond the realm of healthy and logical distrust.
In addition to social media’s manipulative induction of healthcare cynicism, the use of smartphones decreases focus and thus affects patient care. Medical researchers Shelley Ross, PhD & Sarah Forgie, MD said, “Medicine is a vocation of focused attention. To be a good physician, an ability to selectively identify key information is essential. Patients must be listened to and attended to, both for what they are saying and what they are choosing not to say. Generating a differential diagnosis means focusing on what is relevant and discarding what is not.” Patients and families should never witness team members using their personal phone. If a patient was already wary, a healthcare provider distracted by their TikTok feed can deliver a devastating blow to the patient’s confidence in the care they are receiving.
Beyond the bedside, distracted patient interactions affect every part of a healthcare system. From the registration desk to the surgery suite, every healthcare professional is vulnerable to digital distraction. Regardless of department, these interferences ultimately impose a risk on the care for our patients. There has to be strong restrictions on the use of phones while managing patient care. Research on divided attention consistently shows that performance is impaired when there are too many distractions present. For example, errors in medication are significantly associated with interruptions. The severity of the medication error increases as the number of interruptions increases, according to Ross & Forgie. Thus, I am an advocate of hospital-wide implementation of a no personal screen time policy during patient care.
This is not “do as I say, not as I do” advice for everyone else except for medical leadership. We cannot effectively toss edicts out among healthcare team-members and expect improved patient engagement if we as physicians and hospital administrators are seen in work-related scenarios paying more attention to our devices than to the work at hand. We must also regulate our own habits and behavior.
Personally, I began by tracking my screen usage. Knowing is the first step. There are plenty of available apps that lay bare the number of hours we spend staring at a screen. Once I understood how much of my life was spent absorbed by a screen, it became easier to make the effort to address that addition. In auditing my own screen time, I quickly realized why I have neither mastered a second language nor penned my first novel.
Second, I have made it a practice to put away devices when interacting with a client, patient, or colleague. This behavior ensures we are focused and respectful. As I have already discussed, distraction makes us less effective healthcare providers. It also makes us less efficacious professionals and leaders. Just a decade ago, having your cell phone out in a meeting would have been a social faux pas. Now it is routine. This is not simply rude social interaction; it can lead to missing important organizational knowledge or recognizing the complete picture with making a healthcare decision. How many of us have sat in a meeting only to see a majority of participants on their phones and/or computers within minutes? Then, as a small minority of meeting members are actually paying attention, key points are missed, innovative ideas are not promulgated, and everyone’s time is wasted.
A practical caveat and side-note for this proposal is that work-related meetings should be time-limited with intermittent breaks to ensure attention remains focused. For this attention-deficient hyperactive author, I recommend that meetings last no longer than 1 hour, or offer 10 minutes breaks following every hour of focused engagement. Enhancing our focus means that we all make better decisions.
Finally, I recommend setting both scheduled times and time limits for screen usage. How often do we see the new email or text pop up on our phone and feel the need for prompt response. In actuality, those notifications rarely require instant acknowledgement. Even in the modern era, I find that actual emergencies warrant either direct phone calls or alarms. In terms of Stephen Covey’s Seven Habits of Highly Effective People, these types of texting and email distractions frequently fall into the quadrant of waste as non-urgent, non-important tasks. To quell this impulse, schedule times for relaying texts and emails. In fact, utilize technology to schedule screen breaks.
Physicians and hospital administrators have an obligation to recognize not only the opportunities, but the threats imposed by unceasing availability and incessant use of cellphones, tablets, and computers. We must be more conscious of its potential to affect our focus, slowly manipulate our thought processes. The need for computers, phones, and other screens will not abate in the foreseeable future. Still as healthcare leaders, we must remain mindful, and at all times seek out the conceivable ways in which our technological dependence has the potential to compromise patient care.
Dr. Michael D. Brown is a pulmonologist in Moultrie, Georgia. He received his medical degree from Medical College of Georgia and has been in practice between 11-20 years.