Picture of Anthony M DiGiorgio, DO, MHA, FAANS

Anthony M DiGiorgio, DO, MHA, FAANS

Academic Corner

Ah, the pager: often the subject of jokes about healthcare being stuck in the past. NPR’s Planet Money podcast attempted to explain the widespread use of pagers in healthcare and, in typical NPR fashion, completely missed the point.

They discuss a California hospital that tried to replace pagers with a HIPAA-compliant text messaging system, aiming to simplify contact between the ER and consultants. The podcast hosts and ER doctors who implemented the program were shocked when consultants resisted the change. This reduced friction in contacting consultants, which meant consultants became inundated with “curbside” consultations, adding to an already overwhelming deluge of messages.

Low-friction communication isn’t inherently bad. In fact, many consultants openly share their cell phone numbers in the ER and at every nurse’s station in the hospital. In other hospitals, physicians are insulated by layers of residents and/or APPs.

The crux of the issue lies with autonomy.

Corporate America has understood the importance of this for years. Well-run companies maintain hierarchies but encourage autonomy among lower tiers. The upper levels of the hierarchy aren’t bogged down with minutiae because their subordinates have enough autonomy to handle those decisions. Only big-picture issues make it up the chain, fostering dynamic, adaptable systems that encourage creativity.

In contrast, healthcare often structures hierarchies so that every minor detail is escalated up the chain of command, leading to sclerotic and paralyzed decision-making processes. This is what healthcare has become: inundated with mundane inquiries, while significant, big-picture questions (and much quality patient care) go unaddressed.

Various factors contribute to this situation. Top-down controls have stripped nurses of much of their independence. Seemingly minor practices, such as allowing verbal orders or dosing ranges for pain medications, are deemed “dangerous” by certain authorities. ER physicians feel compelled to consult, even in situations where they know the consultant will not intervene, “just to get them on board.” This cult of safetyism has significantly limited many frontline clinicians, often without considering the unintended consequences.

Some hospitals have resisted this erosion of autonomy from the bottom-up. However, there’s still a role for top-down authorities like the Joint Commission or CMS in endorsing autonomy. Practice guidelines from specialty societies could provide protection against medical malpractice, and some areas have successfully experimented with medicolegal “safe harbors” to reduce unnecessary consultations and resource utilization. In these cases, the safe harbors protect clinicians from liability if they adhere to established guidelines for common conditions such as low back pain and minor head trauma.

Granting autonomy to frontline clinicians means there will be misses. A nurse might misinterpret a verbal order. An ER doctor might miss a cauda equina syndrome. However, restricting autonomy doesn’t

necessarily prevent these misses. If every back pain patient receives a neurosurgery consultation, the consultant might still miss the true positive due to alarm fatigue. If every order must be manually entered by a physician into a cumbersome EHR, doctors will spend excessive time on computers, leaving less time for patient care. As Thomas Sowell says, “there are no solutions, only trade-offs.” Many institutions have traded away autonomy for a presumed sense of safety, only to end up with neither.

At one point, the pager was a low-friction means of communication; the doctor could be reached outside the hospital. Now, it acts as a natural barrier, protecting consultants from a barrage of micromanagement questions in environments lacking autonomy.

The pager isn’t the problem. The issue lies with the executive with the mindset that a neurosurgeon must be disturbed in the middle of the night for every colace order or to clear every cervical collar.

That’s the episode NPR should air.