I have been invited to comment on the appropriateness of the anesthesiologist reading while tending to an anesthetized patient, an issue raised recently in this Newsletter. (1) First off, I would like to emphasize that there are no scientific data on the impact of reading on anesthesia provider vigilance or task performance. Thus, all further discussion must be either -1 personal opinion or 2 reasoned hypotheses based on data from related endeavors/venues. I hope to present an argument based on the latter approach.
Most of the time during the administration of an anesthetic, there are many patient-care tasks to perform and the diligent anesthesia provider will prioritize and undertake these tasks appropriately. Under this circumstance, if reading occurs, it will only be during ‘idle time’ when no other tasks (other than general patient monitoring) are required. In the study by Drui and colleagues (2) the anesthesiologist was ‘idle’ during 40% of routine cases. This idle time is essential because it acts as a reserve (e.g., spare capacity) to be called into play during critical events when additional cognitive and physical resources must be rapidly deployed to optimize patient care.
Recent studies suggest that more experienced providers will perform tasks more efficiently, report lower workload, and have more spare capacity at a given level of task performance.(3) I would assert that most anesthesia providers read during these idle periods to prevent boredom. Boredom is a problem of information underload, insufficient work challenge, and under-stimulation. (4) Boredom appears to be a major problem in many complex real-life tasks. For example, boredom may be a contributing factor to human error in locomotive driving and in prolonged routine flight in high-performance and commercial aircraft. Low workload may result in a low arousal state which can lead to impaired performance. (5) In laboratory experiments, increased effort in the presence of boredom is necessary to suppress distracting stimuli and a generalized feeling of fatigue. (6) Adding tasks to a monotonous job may decrease boredom and dividing attention among several tasks (time-sharing) may, in some circumstances, actually improve monitoring performance (7,8)
Observation of private anesthesia practitioners has revealed that, during times of low workload, many add an additional task to their routine. These secondary tasks include clinically-relevant functions such as rechecking the composition or organization of the anesthesia workspace. Alternatively, it is common to observe anesthesiologists reading, listening to music, attending to personal hygiene, or conversing with their intraoperative colleagues about matters unrelated to patient care.
Few studies have defined the actual incidence of boredom or of reading in the operating room. A few years ago, I asked 105 anesthesia providers at the University of California, San Diego, to complete a questionnaire on human factors in anesthesia practice. This questionnaire included questions on the occurrence of boredom and the frequency of reading in the OR. Fifty-seven anesthesia faculty, residents, and CRNAs returned the questionnaire (54% response rate). The respondents were bored only infrequently while administering anesthesia although almost 90% admitted to occasional episodes of ‘extreme’ boredom. To relieve their boredom while in the operating room, 29% of the respondents read. When asked specifically ‘how often do you read while administering anesthesia,’ 19% of the respondents stated that they ‘frequently’ read, 46% said they ‘sometimes’ read, and 33% ‘rarely’ read. Only one respondent .never’ reads in the OR. Forty-nine percent of the respondents felt that reading detracted from anesthesia vigilance while 21 % believed that reading enhanced vigilance and 30% were ambivalent. I believe that these results are representative of many anesthesia departments throughout the United States. Thus, during anesthetic cases that are long and impose minimal physical and intellectual demands, the addition of non-patient care tasks such as reading appears to be quite common. To the extent that the addition of these secondary tasks prevent boredom, they could improve vigilance by maintaining arousal.
The choice of reading material may make a difference. In our questionnaire, the vast majority of respondents almost always read anesthesia-related materials. However, these individuals were from an academic institution and I suspect that non-medical reading material is more common in community hospital operating rooms. Nevertheless, I would postulate that mentally absorbing or engrossing reading materials (e.g., fictional novels) would be more likely to impair vigilance. It should be noted that there are potentially significant adverse medicolegal implications of reading in the OR if an acute critical event is not detected or managed appropriately.
Laboratory studies suggest that there is a discrete time-sharing ability which can be separated from other vigilance skills (9,10) but may be able to be trained. However, anesthesia providers are not given any formal training in time-sharing techniques although ‘resource allocation’ and ‘divided attention’ skills are probably learned on an informal basis. There is probably tremendous individual variability in the impact of reading on anesthesia vigilance. For some anesthesia providers, intraoperative vigilance could be enhanced by reading during low workload periods, while in others, their ability to detect acute events may be impaired.
No Clear Recommendation
At this time, in the absence of controlled studies on the effect of reading in the operating room on anesthesia vigilance and task performance, no definitive or generalizable recommendations can be made. The decision must remain a personal one based on recognition of one’s capabilities and limitations. From a broader perspective, the anesthesia task including associated equipment must be optimized to minimize boredom and yet not be so continuously busy as to be stressful. This will yield the highest consistent levels of vigilance and optimal performance for all anesthesiologists.
Dr. Weinger is Associate Professor of Anesthesiology, University of California, San Diego, and Staff Physician, San Diego VA Medical Center.
1. Bostek CC: Is it OK to read during OR cases? APSF Newsletter 9:45,1995.
2. Drui AB, Behm RJ, Martin WE: Predesign investigation of the anesthesia operational environment. Anesth Analg 52:5W591,1973.
3. Weinger MB, Herndon OW, Paulus MP, Gaba D, Zornow MH, Dallen LD: Objective task analysis and workload assessment of anesthesia providers. Anesthesiology SO: 77-92,1994.
4. Weinger MB, Englund CE: Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment. Anesthesiology 73:995-1021,1990.
5. Boadle 1: Vigilance and simulated night driving. Ergonomics 19: 217-225,1976.
6. Davies DR, Shakleton VJ, Parasuraman R: Monotony and boredom, Stress and fatigue in human performance. Edited by Hockey GRJ. Chichester, England, John Wiley and Sons, 1983, PP. 1-32.
7. Gould JD, Schaffer A: The effects of divided attention on visual monitoring of multi-channel displays. Hum Factors 9:191-202,1967.
8. Haskell BE, Reid GB: The subjective perception of workload in low-time private pilots: a preliminary study. Aviat Space Environ Med 58:1230-1232,1987.
9. Jennings AE, Chiles WD: An investigation of timesharing ability as a factor in complex performance. Hum Factors 19: 535-547, 1977.
10. Siering GD, Stone LW: In search of a time-sharing ability in zero-input tracking analyzer scores. Aviat Space Environ Med 57:1194-1197,1986