In part 2 of 3 of Turning Off Technology, I'll discuss why (and how) I don't check work-related email evenings or weekends, and how I am still (I think) productive.
First, the why.
Back when I was getting close to burn out, most nights I would either have trouble falling asleep, or I would wake up at 2:00 a.m. worrying about something at work, or both. It wasn't patient care that was causing me this much stress, but rather the admin part of my job.
One night, it struck me that this physician needed to heal herself, and that this needed to start with better sleep. I went back to sleep hygiene 101. I ran through the same questions I ask my patients, and realized that my main problem was that I was getting too much "screen-time" in the hours before bed, and that the content of that (work email) was causing me stress.
I reflected back on a few things I'd learned - or rather, I'd heard but not really learned - about "personal effectiveness" at the Canadian Leadership Institute for Medical Education 2 years before. (More info here - it was life-changing for me.) Now, I was raised by great parents, who were near-hippies, so normally, terms like "personal effectiveness" have me reaching for the airsick bag. However, somewhere in these sessions, a few things resonated, and more things percolated slowly over time. Specifically, I remembered: "Schedule time for email." At the time, I didn't really appreciate this, but somewhere in the blur of 3:00 a.m. wakenings, this bubbled to the top of my brain, and I remembered that they said that there was no law that you had to check your email at all waking hours.
I decided not to check work email in the evenings. I would bring work home if needed, but it was specific tasks (papers to grade, committee reports to read, articles to review, teaching to prep) - things that didn't have cause me that immediate feeling of "I must do something about this right now", or worse "I wish I could do something about this right now but I can't". Because my patient-care communication route is my pager, I didn't need to worry about that part of my job, and, to be perfectly honest, there are very few issues that can't wait 'till the morning in the land of medical education - sorry students, but, unfortunately, your need for an extension on an assignment is not, in fact, a crisis. Nor is there such a thing as a scheduling conflict life and death situation. (I love you all - honest!)
I had a separate personal email account that I used in the evenings to keep in touch with friends and family, or I used this thing called a land-line that some of us still keep up for old time's sake.
My sleep started to improve immediately. I know when I'm drifting back into being too consumed by work when I have my sleep problems, and then I immediately back off on screen time (which is why my blogs won't come out this often usually!) and implement best-practice sleep hygiene practices. Better sleep = better me, so this was good for all.
An important *intended* consequence of this decision to stop checking work email is that I was immediately more engaged with my family. I remember being told by experienced parents that what matters to kids of working parents (or all parents, I would imagine) is that when you are with them, that you are really present. My son has always been happy with caregivers while I'm at work, but he is very much bothered if I'm at home but not able to be with him. Work email was taking my attention away from him and from my husband, and I didn't even realize it. He was 2 at the time, and he couldn't understand why I was at home but not attending to him, in his beautifully developmentally appropriate self-centredness, and he wasn't wrong to be upset.
It may annoy some people that I'm not hooked up 24/7 or something like it, but the literature is starting to back me up:
Stress and smart phones
Efficiency and smart phones (Ignore the "CNN endorsement" please.)
So, I turned that technology off (at specific times). How did I then make this work, well, at work?
And now, the how.
This might seem obvious when you read it, but I'm often asked how I manage this. Here's my how-to guide.
1) Start a personal email account
If you don't have one, get a personal email account. Do not auto-forward your work email here, or vice versa. Trust me, the annoyance of adding another email account is worth the separation of work and the rest of your life. Gently and persistently ask friends and family to only email you there. Gently and persistently, if needed, as work colleagues to not use that email account. (You need to decide if/when work friends use the account. Good ones won't bug you with unnecessary stuff.)
2) Get the work email off your phone
Grab your smart phone and turn off the work email. Yes, you can and should do this. I am simply not capable of ignoring unread email if it's being brought to my attention on my phone - something like how my kid can't help picking up rocks and sticks. However, not seeing the email (or the rock or stick) gets me around the problem.
If you don't know how to do this - I'll take you through it on the iPhone.
Go to settings, and choose "Mail, Contacts, Calendars"
Select work email - here, it's my Exchange account.
(Big moment here. You might need to sit down.) TURN OFF mail, by hitting the nice little button.
You will be rewarded by this screen.
Feel lighter. Feel happier. Feel free!
3) Now what?
I've
been using this approach for almost 3 years now, and it's been very
healthy for me. The main downside is that I arrive to an impressively full
inbox most mornings, since everyone else, it seems, writes work email in
the evenings. I have time scheduled first thing everyday and at the end of the day to deal with quick or urgent matters, and then I have "email time" in my calendar (a topic
for a future post - managing the calendar), several times a week to deal with the rest. I usually check for urgent matters once or twice on
weekends for about 20 minutes, but that's it. I will admit to forwarding work stuff to my personal account not infrequently, but because it's the stuff I choose, it's not stressful for me (e.g. readings for committees).
During my scheduled email time, I am (usually) focused, efficient, productive, and I can clear 100+ emails in less than an hour.
Some work days, I do have my work email activated on my phone, but since my reception is crummy, this isn't even every day. I do NOT have my work email activated on my phone on vacation. Rarely, I check my email from a "real" computer while on vacation (easier to reply quickly for me as I touch type), but I only do in very exceptional circumstances. I have been known to forget to send a key email before leaving on vacation (ahem) but I draft it on my home email and send it to my assistant who can forward it along without copying me, thus ensuring I don't get sucked into logging in while on vacation, or getting dragged into a thousand replies.
(My next blog post will deal with how I manage the email organization in general and upon my return from vacation, since I get 100 to 200 emails per day at peak times of year.)
Final words
Guess what? Three years in, and I can guarantee you that life goes on. I get work done, and I am sleeping at night. When I'm home, I'm enjoying myself with my family (well, when there are no 5-year-old meltdowns anyway), and when I'm at work, I'm focused, energized, and productive. This, to me, seems like a win-win situation again- don't you think?
And with that... time to exit screen time again.
Next up? Organizing and managing email. I am SOOOOO cool.
This is the first of 3 posts about using technology to (try to) maintain balance - and this is an ode to my pager.
Last week, I misfiled my pager (read: it fell off in
the car and was hiding from me), so I tweeted about this exciting moment
in my life. I got this reply:
This prompted me to reflect a bit about why I (gasp) like my pager. Here it is: ah, yes, the ST800 plus. Sexy.
Reliability:
Pagers are simple creatures -
they are the technological equals, approximately, of a toaster. They are
designed to do one thing well: Let you know that someone needs you at a
certain number. To this end, it provides a few other simple services:
reporting the date and time, and, importantly, vibrating and beeping to
let everyone know that its batteries are dying.
In no small part
due to their basic nature, they work well. My pager has reception in the
bunker of a basement where I work, where my cell phone sadly displays
"No Service". Although I had to upgrade, my pager works in the brand
new Medical Building in which I teach, whereas my cell does not. Because
it carries on like a snack-deprived toddler when its batteries are
dying, I tend to them before they get to the end of their lives, whereas
my cell phone just dies a quiet death at untimely moments.
This
reliability is key because, as an attending physician, the proverbial
buck stops with me. I take my responsibility to patients, nurses, and
housestaff very seriously, and I don't want to be worrying about them
not being able to find me in a timely fashion.
In the reliability wars - pager takes down cell, without question.
Managing my brain:
This
is really quite simple: when I'm woken from sleep, I do better with a few seconds to wake up before I am
expected to be coherent in speaking to another human, never mind being
asked advise on caring for frail older patients. Quite simply, the pager
buys me a precious minute where I can get up, head away from the
sleeping family, and call the floor, during which time, I wake up. It
also works when driving my car - even with hands-free set-up, I don't
trust myself to talk on the phone and drive safely. The pager allows me
to pull over and then call, again, allowing me to focus on the matter
at hand - you know, sick, frail, older adults. Seems to be win-win for
all, don't you think?
Managing my accessibility:
If
we supposed that we could somehow deal with the reliability issues with
my phone (I'm sure there are apps to tell me the battery is dying on my
phone, and one day they may let me out of my bunker), I would have to
confess I would still use my pager.
First, this article highlights a few points:
http://onlinelibrary.wiley.com/doi/10.1002/jhm.2037/abstract
For those without access, here is the CBC take on it:
http://www.cbc.ca/news/health/story/2013/05/28/smartphone-medical-residents.html
It
is my experience that the more obviously present I am, the less likely
it is that housestaff will try to figure out answers themselves - it's
human nature. I would never, ever want to be unavailable to my
housestaff, but I also know how much learners grow and benefit from
working through issues themselves as far as they can (MedEd geek moment here - this is related to Vygotsky's "zone of proximal development").
Somehow, working through the problem is more likely to happen in preparation for paging me.
Don't get me wrong - communication is essential
to good patient care. I ensure my housestaff know exactly when I'll be
present on the floor, and I encourage them to page me if they need me in
interim. It's possible that I would be called at the same rate that I
am paged, but I don't think so.
I'm also very conscious of
interruptions at work. If I used my cell phone for patient-related
matters, I would need to have it on during a difficult conversation with
a patient, only to have to field a call from the phone company. If I am
about to enter a particularly delicate discussion, I sometimes hand my
pager to a reliable person, and ask them to call back on my behalf if I'm paged, and
only interrupt me if it's an emergency. Because the pager is only for
work-related issues, I don't risk handing off my phone only to have
someone answer a wrong number (rare with pagers), or to talk to my
accountant.
(I suppose texting would be similar to paging, but that would imply that nurses could text me - they can't, without phones themselves, and they're stuck in the same bunker I am...)
I may also (ahem) have the same tendency as housestaff
to engage with my phone when I should be attending to meetings, etc.
Not having the thing with me removes the temptation, and I would have to have it with me if I used it for patient matters.
However, even if you don't buy anything that I've noted above, I would still use my pager. Why? Simple. I can TURN IT OFF.
Turning off the pager:
Because
I only use my pager for patient-care matters, when I'm at home or out
with my family (and I'm not on call), I can turn the pager off. The sole
purpose of the pager is for patient care, so if I'm not on call, I can
be with my family without the pager. Some of this is a purely
psychological effect, as, in theory, no one would call me on my cell if I
wasn't on call, but it's a huge relief for me to turn the pager off.
Besides, call schedules and vacation notices are misread all the time,
and the last thing I need is for the floor to call me during my vacation
week about a patient I've not even met.
Again, I don't want readers to think I am not responsible for my patients. In fact, I often offer to be available to residents on call even when I'm not if the patient's case is particularly complex, or for various other reasons.
But for me, I realized that when I am truly not on-call, I need to be truly removed from my medical role. This last point is really the most salient - this is one
part of my quest to maintain balance in my life. This is one of my
examples of turning off work, by turning off technology (more to come).
Final words:
I
understand that my cell-phone angst might not apply to all. Don't get
me wrong - I use my phone a lot when I'm not at work. I do even use it
at work when I need it (assuming I can get reception). I didn't always love my pager. Like most medical
students, any novelty factor quickly wore off when I realized the
terror that could come with that thing going off; and if I hear a pager
go off with the pager tone I used in residency, I'm sure my blood
pressure goes up. It really wasn't until I was juggling so many roles
and that I had to make a conscious choice to prioritize my family when I
was with them that I started to view the pager as my ally and not my
enemy.
Today being July 1, much Twitter chatter has focused around advice
for new residents, and fair enough. However, July 1 often also
represents the beginning of independent practice for any physician lucky
enough to finish residency on June 30th. This transition is a huge one,
and it's where you find out all the things you didn't learn (or weren't
taught, or both) in residency.
When I work with new colleagues,
which is something I enjoy very much, I am often asked how I manage to
juggle all the roles I play (Mom/Spouse, Physician, Educator,
Administrator, and until recently, Student). This request often moves
from the theoretical to the semi-desperate a few months into practice
when everything is overwhelming, and, unlike a rough residency rotation,
there is no end in sight.
The answers to this question are
complex and worthy of much more than a blog post, but there are some
very practical tips I pass on (read: things I learned the hard way). In
honour of July 1, I am posting about one of my favourite topics -
Turning Technology Off. The irony of blogging about this is not lost on
me, but since I can't have coffee with every new attending physician out
there, I offer this blog, and my tips. Grab your salt-shaker and
prepare to take grains, as some of my advice is hard even for me to
take.
Background
Four months after I
started practice, my mother was diagnosed with a rare but terminal
cancer at 58. She died 3 years later. Three months after that, my father
required urgent bypass surgery, and decided to sell the family home and
move closer to us. In the 5 following years, my son was born, and both
my parents-in-law had multiple health crises, and they both died before
my son got to 2.5 years of age.
Just after my father-in-law died, I
realized I could not continue on as I had been doing as I was burning
out. I had come back from a 5 month maternity leave 2 years before (an
eternity by US standards but quite short by Canadian standards) to a
significantly augmented leadership role, and, unexpectedly, we decided
we had to forge ahead and design & launch a new curriculum in
response to accreditation concerns. While I loved my work (I thought), I
was not sleeping well, I was stressed at work and at home, and I was
feeling increased guilt about time and energy spent away from my family.
There
was a great deal of reflection at this point of my life, and while many
of the changes I made were personal, this period was the birth of my
new rules of engagement - and Turning Off Technology was born.
What is Turning Off Technology?
In
my case, it does not mean going off-grid, or even avoiding computers at
home - or really, would I be blogging? It is really about setting
personal boundaries and enforcing them in a technological sense.
It
seems I have a lot to say on this subject, so there will be 3
interrelated posts (hey, I can't help this, I work in geriatrics -
everything is complex and everything is related!) to follow. As they're
done, I'll link to them below. The first is about pagers and why they
are still wonderful and relevant. Yes, I sit around an dream up posts
about ancient technology. I am, in fact, that cool.
Links - I'll keep adding them as I finish the posts:
Ode to my pager
About 5 years ago, while I was in the final stages of my M.Ed course work, I took a measurement course at Queen's University with the awesome Dr. Don Klinger. The course was divided roughly into two themes - reliability and validity. My inner math geek had a grand time mucking about with spreadsheets and SPSS (no, there is nothing wrong with that) in the reliability portion. However, it was when we got to validity that I had one of those "a-ha!" moments that keep perpetual students in school.
While in class, as Don was challenging us to remember that a test is not "valid", but rather, the interpretation of the test can be valid or not, I almost felt a lightbulb go off in my head. (I probably stopped paying attention at this point, but we'll just skip over that fact for now.)
This, exactly, I realized, is how I was taught to practice medicine. Over the years, as I failed (miserably) to convey this idea to others, I finally arrived at the hemoglobin metaphor to explain what I mean.
What does hemoglobin have to do with assessment results?
Here is the scenario. If I approach a physician and said to them: "Hey, Dr. X, I have a patient whose hemoglobin is 90. Should I give her a blood transfusion?", no competent physician would give me a yes or no answer without knowing a lot more about the patient. Or, to put it more simply, as a recent victim of this discussion said: "What's the story?" Physicians would want to know who the patient was, where the patient was, what their symptoms are, why the test was done, what medical conditions does the patient have, and a myriad of other questions. Most would engage me in a long discussion about the patient, discussing the pros and cons of transfusions, and would explore other options. Many would question if I was sure the hemoglobin was "valid" - i.e. did that measurement represent what was going on with the patient's blood at the time the test was done, or could there have been a measurement error? They likely would not want to make a reasonably high-stakes decision based only on one measurement.
If you are reading this and you do not deal with hemoglobin values regularly, you might have already gleaned that this is not a straightforward question with this particular lab value. Specifically, a hemoglobin of 90 is perfectly in the gray zone. If someone had much higher value (say, 140), then no one would ever consider transfusing (OK, rarely ever), and if it was much lower (like 40), most people would advise strongly considering transfusing the patient, barring extenuating circumstances. However, it's not clear when the answer would change from "it depends" to yes or no. Likely, if you asked 20 clinicians, you would get 10-20 different answers.
The other issue that is important in this scenario is that giving a patient a blood transfusion is a reasonably high stakes intervention. If the intervention was much lower stakes, with little potential for harm, the answers would be quite different. Many would say: "Well, there would be little harm (note I didn't say 'no harm') in doing X or Y, so you might as well try it", but no one would say that (I hope) with respect to a transfusion.
OK, so can we get to test scores already?
Yes we can. What hit me is that the exact same clinicians who would provide a very thoughtful analysis of the scenario above were often taught to blindly accept test scores as 100% "valid". Student 'a' gets 60.1% on a test and thus, they pass. Student 'b' gets 59.9% on a test, and thus, they fail. Yes, most of the time in our institution anyway, the test items are analyzed to ensure that we delete problem questions, but again, there is a certain leap of faith that is involved when going from item analysis score being acceptable to "it's a good question so we'll keep it in".
In undergraduate medical education, where I work, these pass/fail decisions are high stakes for our students, as a failed exam at best means they have to write a supplemental exam, or at worst, they fail a course and may have to repeat a portion of the curriculum - a not insignificant set back by anyone's standards.
These decisions are also, of course, high stakes for everyone else, as no one (faculty, administration, or the general public) wants medical students to move on if they are not ready to do so. (The discussion about decisions about whether students are going to be able to 'succeed' in medicine is not part of the hemoglobin metaphor, thankfully, though it is an important discussion beyond the scope of this post.)
The other parallel is around the "what is the magic number?" question. At what point is a score too low? We are currently grappling with the 60% issue, which is what currently exists in the student assessment policy at our school. If a test is well-constructed, and, if the teaching/learning opportunities were aligned with the test, then many people would argue that "only" knowing 60% of, say, anatomy, might not be sufficient to move on. If we are moving towards criterion-referenced testing (which we're trying to do), where we are focusing on "need to know" vs. "nice to know" then the 60% pass mark may well be too low.
There are a lot of "ifs" in the above paragraph. To my mind, this simply highlights the need to ask the exact same question: "What is the story?" What are the possible outcomes of the decision, and what factors led to the test score?
So, now what?
Here is where I admit that the Hemoglobin metaphor doesn't actually answer the question about how to interpret a test score. It simply highlights the some of the thinking processes that are required in order to interpret a score. Oversimplified, this might boil down to "treat the patient, not the number".
I hope, simply, that this metaphor might help us to have the hard discussions - is 60% enough? If it's not, what is? How are we going to determine that? Are our tests constructed to answer these high stakes questions?
I'll feel I've succeeded if I've left you with more questions than you had before you read this blog.
