Smartphone Use among Anesthesiologists during Work Hours: A Survey-Based Study.

Context: Smartphone use has revolutionized life in all spheres, including the medical field. Smartphones provide immense opportunities but may also lead to negative consequences due to the element of distraction. In the medical profession and more so among anesthesiologists, multitasking has become very common, but the presence of mind is equally important. This study attempts to analyze the smartphone practices and trends among anesthesiologists during work hours in our country. Aims: The study aimed to identify recent trends and practices of smartphone use among anesthesiologists during working hours and its distribution as per designation and institutions. It also intends to determine the purposes of smartphones and their impact on patient care. Settings and Design: Online survey consisting of open-ended multiple-choice questions was conducted and circulated as Google Forms via E-mail and WhatsApp. Subjects and
Methods: This survey was conducted to compare the respondents' views as per designation and workplace distribution. In addition, participants were asked about the current practices in smartphone use at their workplace, purposes of use, time spent on smartphones, and any negative medical consequences faced due to the same. Statistical Analysis Used: One-way ANOVA test was used to compare the means between the groups. Chi-square test/Fisher's exact test was used to compare the proportions.
Results: Two hundred and sixteen (54%) were resident doctors, whereas 184 (46%) were consultants. Most of the respondents were young, with a mean age around 36 years. 31.5% of the residents used smartphones very often during anesthetized patient care compared to 10.3% of the consultants. Purposes of using smartphones were multiple, with phone calls (100%) being the most common followed by WhatsApp messaging (79.2%). 86.1% of the residents, as compared to 61% of the consultants, had anesthesia/intensive care unit-related apps on their smartphones. There was almost an equivocal response to how the smartphone has impacted patient care. 50.9% of the residents and 43% of the consultants felt improved patient care, whereas 38% of the residents and 43.5% of the consultants believed it had worsened.
Conclusion: There was no clear-cut consensus whether smartphone use improved or worsened patient care. On the one hand, there can be distractions leading to adverse medical consequences, while on the other hand, the use of medical apps has been made possible because of the handy and easily accessible smartphones. Thus, the use of smartphones may be carried out with a sense of responsibility by the anesthesiologists during work hours. Copyright:

INTRODUCTION

Smartphones have become an indispensable part of our lives, and their use has increased manifold in recent years. It provides unique benefits in all aspects of life, including the medical field. The landmark year for smartphone evolution was 2007, when the iPhone first came to the market. Smartphones are handy devices with multitasking capabilities[1] and have become an integral part of anesthesiologists' life by facilitating team member communication,[2] knowledge acquisition through the Internet, information transfer, e-learning, and telemedicine and remote monitoring.[3]

Smartphones are frequently used as an alternative to cameras to capture interesting diagnostic images or record procedural videos, which can be used for academic purposes such as learning and demonstration, thus helping in learning, treatment, and communication.[4] Various publications have cited the use of smartphones, but few editorials have mentioned negative consequences due to nonmedical smartphone/laptop use during anesthetized patient care.[56]

There has been no clear-cut answer whether smartphones are distracting or helpful devices during work hours. The level of distraction varies with age and experience, with trainees being more vulnerable because of less experience and less margin for cognitive overload.[5] They commit errors more frequently due to overindulgence at times.[7]

Regularly updated web-based literature is accessed conveniently than referring to hard copies of books or journals.[8] Smartphones perform many functions and provide overwhelming information through apps and calculators in perioperative and critical care settings.[1]

Anesthesiologists can use the apps for multitasking such as maintaining health records, time management, monitoring, consultations, and most importantly, communication. Smartphones provide easy access to study symptoms, diagnosis, medical management of any disease and even drug dosage calculator is promptly available. Apart from providing accessible communication, it also helps to regulate the time, maintain records, and monitor medical education and training, thus becoming an asset to teaching institutes.[910111213] Sharing medical knowledge has become relatively easy via smartphones adding a new dimension to medical practice.[14] It has been emphasized more in COVID-19, where teleplatforms for continuing medical education have become inevitable.[15] Few studies conducted in the past have tried to evaluate the impact of smartphone use on anesthesiologists. We wanted to evaluate multiple aspects of smartphone use among anesthesiologists in present times as the horizon provided by smartphones has expanded due to social media and apps. There is not much-published literature available on the subject that elaborates on current practices' status in our country. Although many studies have been undertaken in health-care workers, we aimed to assess anesthesiologists, so we focused on the domain of anesthesia practice.

Descriptive details of smartphone use by anesthesia providers during the monitoring of anesthetized patients were studied through this questionnaire-based survey in our country. The study aimed to identify recent trends and practices of smartphone use among anesthesiologists during working hours and its distribution as per designation and institutions. Our study also intends to determine the purposes of smartphones and their impact on patient care.

SUBJECTS AND METHODS

After institutional ethical committee clearance (IEC CODE: 2021-230-IP-EXP-42), we conducted a descriptive questionnaire-based study conducted in a 750-bedded quaternary care teaching hospital during November and December 2021.

Sample size calculation

Based on previous studies the prevalence of the study participants who felt a significant impact of smartphones in operation theater (OT) 3 was 50%, at minimum two-sided confidence interval of 95%and 4 margin of error as 5% estimated sample size was 385. A sample size of 400 was targeted to include in the study. The sample size was estimated using software Power Analysis and Sample Size version 16 (PASS-16, NCSS, LLC, Utah, USA). The first 400 complete responses have been included for the analysis.

Study tool development

A questionnaire containing a series of 17 open-ended multiple-choice questions [Annexure 1] was designed based on the literature search. The questions were designed to evaluate participants' demographic details, purpose, and frequency of usage of smartphones during patient care and participants' opinions regarding their impact on patient care.

The content validity of the questionnaire was performed by six experts (three faculty members and three residents), who rated each question on a Likert scale (score 1–5) based on simplicity, clarity, ambiguity, and relevance. Overall agreement calculated was 87.5% for simplicity (free marginal kappa – 0.82), 82.5% for clarity (free marginal kappa – 0.78), 92.3% for free of ambiguity (free marginal kappa – 0.82), and 90% for relevance (free marginal kappa – 0.81), respectively, indicating good agreement.

Data collection

The questionnaire was created as Google Forms and distributed to the intended study population (certified anesthesia practitioners, consultants, and residents) through electronic mail and social media platforms like WhatsApp all over the country. This online survey was completely anonymous, and participation was voluntary. All the participants were required to fill out an informed consent form before beginning the survey. Completely filled forms were considered for data calculation.

Statistical analysis

Continuous variable is presented as mean ± standard deviation, whereas categorical variables were presented in frequency (%). One-way ANOVA test was used to compare the means between the groups, whereas Chi-square test/Fisher's exact test was used to compare the proportions between the groups. P < 0.05 was considered statistically significant. The Statistical Package for the Social Sciences version 23 (SPSS-23, IBM, Chicago, IL, USA) was used for data analysis

RESULTS

Demographic data

Of the first 400 complete responses, 216 (54%) were resident doctors, whereas 184 (46%) were consultants [Table 1 and Figure 1]. The mean age of the respondents was around 36 years. 52.2% of the respondents were males, and 47.8% were females (P = 0.81), which indicated a homogeneous study group. Most of the residents belonged to government medical colleges (MCs) (65.3%), whereas maximum consultants (33.2%) belonged to the corporate sector.

Table 1

Distribution of responses as per residents and consultants (n=400)

Variables	Total (n=400), n (%)	Residents (n=216, 54%), n (%)	Consultant (n=184, 46%), n (%)	P
Age (years)	36.20±9.96	29.03±3.01	44.61±8.58	<0.001
Sex
Male	209 (52.3)	114 (52.8)	95 (51.6)	0.819
Female	191 (47.8)	102 (47.2)	89 (48.4)
Type of institutions
Government	169 (42.3)	141 (65.3)	28 (15.2)	<0.001
Private	57 (14.3)	34 (15.7)	23 (12.5)
Research	77 (19.3)	32 (14.8)	45 (24.5)
Corporate	69 (17.3)	8 (3.7)	61 (33.2)
Freelancer	28 (7)	1 (0.5)	27 (14.7)
Restriction using smartphone in operation theater
Yes	77 (19.3)	63 (29.2)	14 (7.6)	<0.001
No	285 (71.4)	142 (66)	143 (77.7)
Partly	38 (9.5)	11 (5.1)	27 (14.7)
Do you think smartphones should be restricted in operation theater
Yes	88 (22)	26 (12.1)	62 (33.6)	<0.001
How often do you use a smartphone during anesthetized patient care
Very often	87 (21.8)	68 (31.5)	19 (10.3)	<0.001
Often	141 (35.3)	88 (40.7)	53 (28.8)
Some times	121 (30.3)	47 (21.8)	74 (40.2)
Never	51 (12.8)	13 (6)	38 (20.7)
How often do you use smartphones during critical stages of anesthesia
Very often	5 (1.3)	4 (1.9)	1 (0.5)	0.392
Often	43 (10.8)	27 (12.5)	16 (8.7)
Some times	187 (46.8)	98 (45.4)	89 (48.4)
Never	165 (41.3)	87 (40.3)	78 (42.4)
Purposes of using smartphone during anesthetized patient care
One	84 (21)	25 (11.6)	59 (32.1)	<0.001
Multiple	316 (79)	191 (88.4)	125 (67.9)
Have you ever felt distracted or negative medical consequences due to smartphone use
Never	157 (39.3)	97 (44.9)	60 (32.6)	<0.001
Once	86 (21.5)	60 (27.8)	26 (14.1)
2-5	107 (26.8)	44 (20.4)	63 (34.2)
>5	50 (12.5)	15 (6.9)	35 (19)
Have your colleagues’ felt distracted or negative medical consequences due to smartphone use
Never	112 (28.1)	57 (26.4)	55 (30.1)	0.862
Once	82 (20.6)	46 (21.3)	36 (19.7)
2-5	129 (32.3)	72 (33.3)	57 (31.1)
>5	76 (19)	41 (19)	35 (19.1)
Do you feel smartphone result in distraction during anesthetized patient care
Yes	144 (36)	68 (31.5)	76 (41.3)	0.001
No	101 (25.2)	71 (32.9)	30 (16.3)
Sometimes	155 (38.7)	77 (35.6)	78 (42.4)
How much time do you spend on the smartphone during duty hours
<25%	260 (65)	149 (69)	111 (60.3)	<0.001
25%–50%	56 (14)	37 (17.1)	19 (10.3)
>50%	30 (7.5)	13 (6)	17 (9.2)
Cannot say	54 (13.5)	17 (7.9)	37 (20.1)
Do you feel irritable if juniors/staff use smartphones during work hours
Yes	300 (75)	157 (72.7)	143 (77.7)	0.247
Have you ever been warned by colleagues, seniors, surgical team for using smartphone during patient care
No	195 (48.8)	61 (28.2)	134 (72.8)	<0.001
Once	66 (16.5)	45 (20.8)	21 (11.4)
Some times	106 (26.5)	83 (38.4)	23 (12.5)
Very often	33 (8.3)	27 (12.5)	6 (3.3)
Is there any anesthesia/ICU-related applications on your smartphone
Yes	297 (74.6)	186 (86.1)	111 (61)	<0.001
How do you feel smartphone use has impacted patient care
Improved	189 (47.3)	110 (50.9)	79 (43)	0.274
Worsened	162 (40.5)	82 (38)	80 (43.5)
Cannot say	49 (12.2)	24 (11.1)	25 (13.5)

Age presented in mean±SD, compared by independent samples t-test. Categorical variables presented in frequency (%) compared by Chi-square test/Fisher’s exact test used. P<0.05 significant. SD=Standard deviation, ICU=Intensive care unit

Figure 1

Distribution of the study participants as per their working hospital/institutes and designation

Smartphone use data [Table 1]

During the OT time, significant restriction (fully or partly) was noted for residents as compared to consultants (39.2% vs. 7.6%, P < 0.001).

There was a significant difference of opinion among consultants (33.6%) who advocated smartphone use restriction in OT as compared to residents (12%) (P < 0.05). 31.5% of the residents used smartphones very often during anesthetized patient care compared to 10.3% of the consultants. Among residents, 6% claimed not using smartphones, while 20.7% of the consultants never used smartphones during anesthetized patient care (P < 0.001). Purposes of using smartphones were multiple, with phone calls (100%) being the most common followed by WhatsApp messaging (79.2%). Smartphone use for other purposes such as the Internet and social media was less followed by playing games which was least common (4.75%) [Figure 2]. During critical stages of anesthesia, very few residents and consultants (1.9% and 0.5%, respectively) used it very often; 40.3% of the residents and 42.4% of the consultants claimed not using smartphones during critical stages of anesthesia (P = 0.39).

Figure 2

Purposes of smartphone use during work hours

Among residents, 44.9% never faced any negative medical consequences, while 6.9% faced it more than five times. Among consultants, 32.6% never faced any negative medical consequence, while 19% faced it more than five times (P < 0.001).

31.5% of the residents felt that smartphone results in distraction compared to 41.3% of the consultants (P < 0.001). Consultants spent significantly more time than residents, with 9.2% of the consultants spending more than 50% of their working hours on smartphones compared to 6% of the residents doing the same (P < 0.001). Residents received more warnings from seniors, colleagues, or surgical teams than consultants (12.5% vs. 3.3%, P < 0.001).

86.1% of the residents, as compared to 61% of the consultants, had anesthesia/intensive care unit (ICU)-related apps on their smartphones. There was almost an equivocal response to how the smartphone has impacted patient care. Out of 400 respondents, 47.3% felt that smartphone use has improved patient care, while 40.5% felt it has worsened the same [Figure 3]. 50.9% of the residents and 43% of the consultants felt improvement in patient care, whereas 38% of the residents and 43.5% of the consultants believed it had worsened. 11.1% among residents and 13.5% of the consultants were inconclusive in this regard.

Figure 3

Impact of smartphone use during work hours on patient care

We compared and tabulated the responses based on the type of institute in Table 2.

Table 2

Distribution as per type of institute (n=400)

Variables	Medical college (n=226, 56.5%), n (%)	Super specialty institute (n=77, 19.3%), n (%)	Corporate and freelancer (n=97, 24.3%), n (%)	P
Is there any restriction for smartphone usage in the operating theater at your institution
Yes	71 (31.4)	20 (26)	24 (24.7)	0.400
Do you think that smartphone usage should be restricted in operation theaters
Yes	49 (23.2)	20 (28.6)	29 (32.6)	0.222
How often do you use your smartphone during anesthetized patient care
Very often + often	207 (91.6)	68 (88.3)	74 (76.3)	0.001
What purposes do you use your smartphone during anesthetized patient care
Multiple	184 (81.4)	60 (77.9)	72 (74.2)	0.336
Use your smartphone at critical stages of anesthesia like induction and emergence
Very often + often	130 (57.5)	51 (66.2)	54 (55.7)	0.317
You experienced any distraction or negative medical consequence during anesthetized patient care due to smartphone
More than once	128 (56.6)	51 (66.2)	64 (66)	0.158
Colleagues/seniors experienced any distraction or negative medical consequence during anesthetized patient care due to smartphone
Yes, more than once	163 (72.1)	57 (74)	68 (70.1)	0.847
Feel that smartphone results in distraction or negative medical consequence during anesthetized patient care
Yes	163 (72.1)	57 (74)	79 (81.4)	0.207
Time spent on smartphone during duty hours
>4 h	17 (8.2)	7 (11.7)	6 (7.7)	0.657
Feel irritable if you find your juniors/staff using smartphone during work hours
Yes	168 (74.3)	54 (70.1)	78 (80.4)	0.280
Have you ever been warned for smartphone usage during patient care
Yes	134 (59.3)	47 (61)	24 (24.7)	<0.001
Any anesthesia/ICU-related apps on your smartphone
Yes	177 (78.3)	61 (79.2)	60 (61.9)	0.005
Feel smartphone use has improved patient care
Yes	109 (48.2)	31 (40.3)	49 (50.5)	0.366

Categorical variables presented in frequency (%) were compared by the Chi-square test/Fisher’s exact test. P<0.05 significant. ICU=Intensive care unit

Smartphone use data [Table 2]

56.5% of the respondents were from MCs, 19.3% belonged to research institutes (RI), whereas the corporate sector and freelancers (CF) comprised the remaining 24.3%. In MC, 31.4% had restrictions in using smartphones in OT, whereas 26% of the RI respondents and 24.7% among CF had restrictions using smartphones during OT hours which was insignificant P = 0.4. 72.1% from MC, 57% from RI, and 79% of the CF respondents felt that smartphones were distracting and had negative medical consequences (P = 0.20). 8.2% of the MC, 11.7% of the RI, and 7.7% of the CF respondents spent >50% on smartphones during work hours (P = 0.65). 74.3%, 70.1%, and 80.4% of the respondents belonging to MC, RI, and CF, respectively, felt irritable to find juniors and staff using smartphones (P = 0.28). Anesthesiologists in MC and RI received significantly more warning 59.3% and 61%, respectively, as compared to CF (24.7%) (P < 0.001). 78.3% of the MC, 79.2% of the RI, and 61.9% of the CF groups had ICU/anesthesia-related apps on their phones (P = 0.005). 48.2% of the MC, 40.3% of the RI, and 50.5% of the CF groups felt improved patient care (P = 0.36).

DISCUSSION

To the best of our knowledge, it is the first survey of its kind in junior and senior anesthesia providers in our country, which adds valuable insight into both the beneficial and harmful effects of smartphone usage during work hours. It also throws light on the potential for smartphones in educational technology. Our survey has also compared residents and consultants among anesthesiologists in various workplaces.

Smartphones in medical practice can be a double-edged sword. As quoted by Cory Doctorow, “This is why I loved technology: If you used it right, it could give you power and privacy.” On the other hand, a handy, readily available, and user-friendly smartphone can be of great help for patient care and intraoperative safety.[16] It provides immediate access to unlimited medical information, thus improving decision-making and reducing medical errors.[1718]

It gives the fastest means of communication among inhospital medical staff[1920] and improves telemedicine facilities.[2122] Nevertheless, it can also lead to medical errors due to distraction. Regardless of the intended use, the findings from this study and a few previous studies have demonstrated that smartphones can lead to distraction and impaired performance in the clinical area.[2324] Therefore, we intend to discuss all aspects of smartphone use during work hours through this study.

In this study, most of the residents belonged to government MCs (65.3%), whereas consultants were from all sectors with maximum representation from corporate (33.2%). All respondents had smartphones, and few (especially in the residents' group) had restrictions on using smartphones during working hours. As expected, more consultants (33.6%) than the residents (12.1%) felt that smartphone usage should be restricted during work hours. As younger and more adept at using smartphones, residents used them more frequently than consultants during anesthetized patient care. The majority of the respondents (41.3%) in both the groups refrained completely to use their smartphones during critical stages of anesthesia, while 46.8% used it rarely. All the respondents, irrespective of designation or workplace, were using smartphones for making phone calls, followed by 79.25% for WhatsApp messaging. Maximum use for making calls is in concordance to a study by Pinar et al.,[24] who showed similar results (phone calls – 65.4% and messaging – 46.4%). In our study, almost 53% of the respondents used smartphones for medical apps, and 47% used medical smartphones for social media use, similar to a previous study by Pinar et al. where 52.6% had at least one anesthesia-related medical application on their smartphones.[24] Dasari et al. conducted a questionnaire-based study in 2010 involving 918 subjects, indicating that 80% of the users' smartphones had medical applications, 60% of which were anesthesia applications higher than our study.[25] In another study by Payne et al., nearly 80% of the junior doctors and medical students were found to have at least one medical application on their smartphones.[26] The decline in rates of app use as compared to previous studies, which were conducted almost a decade ago, could be because social media was not so popular then.

Although most of the respondents (71.4%) believed that smartphones should not be restricted in OTs, at the same time, they felt irritable (75%) to see their staff or juniors using smartphones during work hours, thus emphasizing that it is considered to be a distraction device by the majority. Mobile phones are considered distractions for the operating team, anesthesiologists as well as other OT staff.[4] In the study conducted by Pinar et al., 87.3% of the participants stated that they had never experienced any negative medical consequences due to smartphone use.[24] However, 41% had witnessed or heard about their colleagues in such a situation at least once. Our study differed by having 40% of the respondents who never experienced any distraction or negative medical consequences due to smartphone use, but 70% of their colleagues had experienced it at some point of time in their practice. This discrepancy could be due to the individual's nonrealization of misconduct or the vagueness of question many will not be able to classify the incident as a negative medical consequence.

Nevertheless, the fact that smartphones cause distraction is accepted in many studies including ours. Cho and Lee[27] reported that smartphone usage during anesthesia leads to distractions in patient care (24.7%), similar to the study by Singh and Owusu who reported smartphone as a cause of distractions as reported by 23.6% of their study participants.[23]

Smartphone use leads to increased reaction time, reduced focus, and lowered behavioral performance during cognitive tasks, especially driving.[28]

In 2009, Slagle and Weinger defined intraoperative anesthesia care as “hours of boredom punctuated by moments of terror,” very similar to aviation.[29] These catastrophic instances require swift reaction times, which may get affected by smartphone use.

Since the definition of work hours is different as per the designation and workplace, we asked the respondents the percentage of duty hour time spent on their smartphones. Previous studies by Singh and Owusu and Cho and Lee showed that younger anesthesiologists (≤41 years) use smartphones more (78.5%) than senior anesthesiologists (≥41 years) (21.5%).[2327] In our study, the difference in the smartphone usage rates was significant, but it has come down, indicating that even the consultants were using smartphones frequently. Furthermore, most of our respondents were on the younger side, thus justifying more use even though they fall in consultant category. Most of the respondents (65%) spent <25% of their duty hours on smartphones, while almost 8% of them spent >50% of their duty time. Few could not quantify the time spent. More than 50% received warning at least once, which was seen more in the residents' group and MCs. Hence, this implies that trainees are more at risk of getting distracted and committing mistakes, thus being warned more frequently. Furthermore, MCs have a teacher–student relationship; thus, the residents are under continuous scrutiny by their seniors. This percentage has increased compared to the study by Pinar et al.,[24] where 81% had never been warned even once. The reason could be the increasing trend and time spent on smartphones in recent years because of the advent of social media. None of the groups vehemently supported or defied its use, and the response to whether it has improved or worsened patient care was equivocal. Few respondents opined that they could not say for the same. The comparisons based on types of institutes of the respondents showed insignificant differences in P values for most of the questions, which implied that anesthesiologists shared common perspectives and experiences regarding smartphone use during work hours irrespective of their workplace.

Limitations

Our study population comprised mainly younger respondents, so it could not represent all anesthesia doctors' populations. In addition, the sample size was not very large, so a larger sample size including all age groups is required.

CONCLUSION

This study demonstrated the recent trends and practices related to smartphone use. The time spent on smartphones during work hours has increased from the past, probably because of medical apps and social media usage, which has become popular in recent years. Our study emphasizes the fact that smartphones should be used judiciously so that the benefits outweigh the risks involved in patient care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.