Teaching and evaluating multitasking ability in emergency medicine residents - what is the best practice?

Multitasking is an essential skill to develop during Emergency Medicine (EM) residency. Residents who struggle to cope in a multitasking environment risk fatigue, stress, and burnout. Improper management of interruption has been causally linked with medical errors. Formal teaching and evaluation of multitasking is often lacking in EM residency programs. This article reviewed the literature on multitasking in EM to identify best practices for teaching and evaluating multitasking amongst EM residents. With the advancement in understanding of what multitasking is, deliberate attempts should be made to teach residents pitfalls and coping strategies. This can be taught through a formal curriculum, role modeling by faculty, and simulation training. The best way to evaluate multitasking ability in residents is by direct observation. The EM Milestone Project provides a framework by which multitasking can be evaluated. EM residents should be deployed in work environments commiserate with their multitasking ability and their progress should be graduated after identified deficiencies are remediated.

Evolutionary constraints or opportunities?

Natural selection is traditionally viewed as a leading factor of evolution, whereas variation is assumed to be random and non-directional. Any order in variation is attributed to epigenetic or developmental constraints that can hinder the action of natural selection. In contrast I consider the positive role of epigenetic mechanisms in evolution because they provide organisms with opportunities for rapid adaptive change. Because the term "constraint" has negative connotations, I use the term "regulated variation" to emphasize the adaptive nature of phenotypic variation, which helps populations and species to survive and evolve in changing environments. The capacity to produce regulated variation is a phenotypic property, which is not described in the genome. Instead, the genome acts as a switchboard, where mostly random mutations switch "on" or "off" preexisting functional capacities of organism components. Thus, there are two channels of heredity: informational (genomic) and structure-functional (phenotypic). Functional capacities of organisms most likely emerged in a chain of modifications and combinations of more simple ancestral functions. The role of DNA has been to keep records of these changes (without describing the result) so that they can be reproduced in the following generations. Evolutionary opportunities include adjustments of individual functions, multitasking, connection between various components of an organism, and interaction between organisms. The adaptive nature of regulated variation can be explained by the differential success of lineages in macro-evolution. Lineages with more advantageous patterns of regulated variation are likely to produce more species and secure more resources (i.e., long-term lineage selection).

Nurses' perceptions of multitasking in the emergency department: effective, fun and unproblematic (at least for me) – a qualitative study

INTRODUCTION

The aim was to understand how multitasking is experienced by registered nurses and how it relates to their everyday practice in the emergency department.

METHOD

Interviews with open-ended questions were conducted with registered nurses (n = 9) working in one of two included emergency departments in Sweden. Data were analyzed using Schilling's structured model for qualitative content analysis.

RESULTS

Three core concepts related to multitasking emerged from the interviews: 'multitasking - an attractive prerequisite for ED care'; 'multitasking implies efficiency' and 'multitasking is not stressful'. From these core concepts an additional theme emerged: '… and does not cause errors – at least for me', related to patient safety.

DISCUSSION

This study shows how the patient load and the unreflected multitasking that follows relate to nurses' perceived efficiency and job satisfaction. It also shows that the relationship between multitasking and errors is perceived to be mediated by whom the actor is, and his or her level of experience. Findings from this study add value to the discourse on multitasking and the emergency department context, as few studies go beyond examining the quantitative aspect of interruptions and multitasking and how it is experienced by the staff in their everyday practice.

Evolutionary constraints or opportunities?

Natural selection is traditionally viewed as a leading factor of evolution, whereas variation is assumed to be random and non-directional. Any order in variation is attributed to epigenetic or developmental constraints that can hinder the action of natural selection. In contrast I consider the positive role of epigenetic mechanisms in evolution because they provide organisms with opportunities for rapid adaptive change. Because the term "constraint" has negative connotations, I use the term "regulated variation" to emphasize the adaptive nature of phenotypic variation, which helps populations and species to survive and evolve in changing environments. The capacity to produce regulated variation is a phenotypic property, which is not described in the genome. Instead, the genome acts as a switchboard, where mostly random mutations switch "on" or "off" preexisting functional capacities of organism components. Thus, there are two channels of heredity: informational (genomic) and structure-functional (phenotypic). Functional capacities of organisms most likely emerged in a chain of modifications and combinations of more simple ancestral functions. The role of DNA has been to keep records of these changes (without describing the result) so that they can be reproduced in the following generations. Evolutionary opportunities include adjustments of individual functions, multitasking, connection between various components of an organism, and interaction between organisms. The adaptive nature of regulated variation can be explained by the differential success of lineages in macro-evolution. Lineages with more advantageous patterns of regulated variation are likely to produce more species and secure more resources (i.e., long-term lineage selection).

Performance on a computerized shopping task significantly predicts real world functioning in persons diagnosed with bipolar disorder

Persons diagnosed with bipolar disorder often suffer from cognitive impairments. However, little is known concerning how these cognitive deficits impact their real world functioning. We developed a computerized real-life activity task, where participants are required to shop for a list of grocery store items. Twenty one individuals diagnosed with bipolar disorder and 21 matched healthy controls were administered the computerized shopping task. Moreover, the patient group was assessed with a battery of cognitive tests and clinical scales. Performance on the shopping task significantly differentiated patients and healthy controls for two variables: Total time to complete the shopping task and Mean time spent to consult the shopping list. Moreover, in the patient group, performance on these variables from the shopping task correlated significantly with cognitive functioning (i.e. processing speed, verbal episodic memory, planning, cognitive flexibility, and inhibition) and with clinical variables including duration of illness and real world functioning. Finally, variables from the shopping task were found to significantly explain 41% of real world functioning of patients diagnosed with bipolar disorder. These findings suggest that the shopping task provides a good indication of real world functioning and cognitive functioning of persons diagnosed with bipolar disorder.

Avoiding the problem state bottleneck by strategic use of the environment

We investigated whether environmental support can be used to circumvent the problem state bottleneck in human multitasking. Previously, it was shown that people can only maintain a single chunk of information in their problem state resource, the central part of working memory. Consequently, when the problem state resource was required by multiple tasks concurrently, performance decreased. This phenomenon was termed the problem state bottleneck. To investigate whether the environment can be used to circumvent this bottleneck, we conducted an experiment with two main conditions. In the No-Support condition we replicated an earlier experiment that indicated the existence of the problem state bottleneck. In the Support condition we presented external cues, reducing the load on the problem state resource. To support the results of the experiment we present a computational cognitive model. The experiment and model indicated that the problem state bottleneck can be avoided by using external cues. However, subjects only used external cues when this led to faster behavior. These results were interpreted in the light of the Soft Constraints Hypothesis, which states that humans always follow the fastest strategy possible, as opposed to the most accurate strategy.

Domestic outsourcing and multitasking: How much do they really contribute?

The bulk of responsibility for domestic work and childcare in heterosexual couples falls on women. But the means they find to cope with this load, and how these means relate to the factors underpinning the division of labor are not often studied. Two much-cited ways of reducing overall work time are purchasing domestic assistance (outsourcing) and the multitasking of domestic/caring tasks. Using UK 2000/2001 time-use data (N=4196 couples), we find domestic outsourcing is related to having dependent children and to partners' resources, but has little impact on the total domestic/caring workload of either partner. Nor can outsourcing account for the reduction in women's unpaid labor with increasing economic resources. Wives spend more time multitasking than husbands, but their proportion of multitasked domestic time is similar, and is not affected by resources or dependent children. Domestic multitasking seems to be more related to opportunity (time at home) than to time pressure.

The functional neuroanatomy of multitasking: combining dual tasking with a short term memory task

Insight into the neural architecture of multitasking is crucial when investigating the pathophysiology of multitasking deficits in clinical populations. Presently, little is known about how the brain combines dual-tasking with a concurrent short-term memory task, despite the relevance of this mental operation in daily life and the frequency of complaints related to this process, in disease. In this study we aimed to examine how the brain responds when a memory task is added to dual-tasking. Thirty-three right-handed healthy volunteers (20 females, mean age 39.9 ± 5.8) were examined with functional brain imaging (fMRI). The paradigm consisted of two cross-modal single tasks (a visual and auditory temporal same-different task with short delay), a dual-task combining both single tasks simultaneously and a multi-task condition, combining the dual-task with an additional short-term memory task (temporal same-different visual task with long delay). Dual-tasking compared to both individual visual and auditory single tasks activated a predominantly right-sided fronto-parietal network and the cerebellum. When adding the additional short-term memory task, a larger and more bilateral frontoparietal network was recruited. We found enhanced activity during multitasking in components of the network that were already involved in dual-tasking, suggesting increased working memory demands, as well as recruitment of multitask-specific components including areas that are likely to be involved in online holding of visual stimuli in short-term memory such as occipito-temporal cortex. These results confirm concurrent neural processing of a visual short-term memory task during dual-tasking and provide evidence for an effective fMRI multitasking paradigm.