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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 64, NO. 24, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jacc.2014.11.001
FELLOWS-IN-TRAINING & EARLY CAREER PAGE
Text Messaging Versus Paging
New Technology for the Next Generation
Jarrod D. Frizzell, MD, Bina Ahmed, MD
O
f all the labels applied to my generation,
all experienced the uncomfortable silence after
the “millennials,” there is 1 for which we
paging a consultant or the attending on call and have
are fully deserving: we are the “digital gen-
worried whether they received the page. Perhaps
eration.” Born roughly between 1980 and 2000, we
more frustrating is the endless ringing of the phone
are the first to grow up with computers and video
number to which we are urgently paged. With today’s
games in our homes. Surveys have shown that millen-
smartphones, we are notified immediately if our
nials may have difficulty fathoming a world without
messages are unable to be sent (e.g., poor reception),
computers or cell phones (with owner rates of 97%
and in many cases, we can also see that a recipient
and 94%, respectively) (1). Similarly, the penetration
has read the message.
of texting has rocketed upward, now to the point
where
advertising
campaigns
must
warn
Although data are limited, 1 survey of general
users
surgery residents and faculty demonstrated the fre-
against the dangers of texting during inappropriate
quency and importance of text messaging as a typical
times (e.g., while driving).
component of patient-related care (PRC) duties (2).
Millennials are the first generation to be a part of
Among both residents and attending physicians, PRC
the pervasive use of multimedia messaging services
was the most common reason for texting while at
as a transformative technology among health care
work, with a plurality supporting text as the preferred
providers. Nonetheless, it appears this change among
method for communicating “routine” PRC. A majority
providers has apparently gone largely unnoticed in
of all respondents were either “comfortable” or “very
the literature. Perhaps this is because of the “obvi-
comfortable” texting about PRC. As one may predict,
ousness” of its use. When mentioning my interest in
texting is more prevalent among residents than fac-
this topic among my peers, the general reaction was a
ulty. Granted, there is likely selection bias in such a
blank stare, followed by: “Of course, we text.” Older
study, and many of us have anecdotal evidence of an
attending physicians, particularly those proudly hol-
upward generational trend in text message usage.
stering a “flip phone” on their belt clip, evinced even
more consternation on the topic.
The advantages of text messaging over traditional
paging are evident across multiple clinical experi-
The benefits of instant 2-way communication like
ences. When on call, I am often awakened by a text.
texting in improving patient care are obvious in ways
Before viewing the contents, the sound of receiving a
both large and small. Texting is simple and straight-
text message compared with the jarring alert of a
forward, with immediate results. In 1 sense, it is an
pager harkens a more pleasant experience. A text
extension of hallway conversations among clinicians
implies that it is someone I know personally enough
that are often more fruitful than the more common
to give them my number. Sometimes, it is along the
method of communicating through patient medical
lines of “Hey, could you give me a call? There’s a
charts. “It’s a digital extension of the corridor,”
patient I’m worried about and I’d like to talk it over.”
a colleague stated. In a similar vein, texting also
Frequently it is a photo of an electrocardiogram, with
expedites communication and relieves other short-
a short question like “VT? HD [hemodynamically]
comings of 1-way communication systems. We have
stable.” Knowing the question and having the opportunity to preview such information beforehand
improves direct communication prior to returning the
From the Division of Cardiology, University of New Mexico, Albuquerque,
phone call. Another example came while admitting a
New Mexico.
young woman for syncope while she was driving. As
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Frizzell and Ahmed
JACC VOL. 64, NO. 24, 2014
DECEMBER 23, 2014:2703–5
Fellows-in-Training & Early Career Page
is often the case with motor vehicle accidents, the
made solely via text messaging. The traditional
history can be somewhat confusing. Whether the loss
“curbside
of consciousness preceded or succeeded the crash
which left no trace. With “digital curbside” over text
makes all the difference. Telemetry overnight sealed
messaging, there is a digital footprint of a recommen-
the diagnosis of long QT syndrome leading to tor-
dation made without an actual evaluation of a
sades de pointes, and texting an image to our offsite
patient by the consultant. The legal ramifications of
electrophysiologist of the telemetry showing R-on-T
such advice remain unclear and mandate cautious
causing torsades greatly enhanced the efficiency of
widespread use of “digital consults.” Last, contempo-
additional care, workup, and treatment.
rary culture continues to march toward digitizing
consult”
was
verbal
communication,
However, despite the positive applications of text
the art of conversation and communication. Taking an
messaging, it must be said that a conversation over
actual history, being in a room with the patient,
text regarding a patient should not replace the need
and conveying important details about a particular
to fully evaluate a patient when that is what is
case to other consultants in person remain crucial
required. As with any new technology, there are still
to good medicine and optimal patient care. Overuse
many issues left to be resolved before encouraging
of digital communication may come at the cost
unfettered adoption. Chief among these are privacy
of these foundations of modern health care and,
and security concerns. Despite the prevalence of text
therefore, must be considered before wider adoption.
messaging in PRC in the above-mentioned survey,
A common joke is that only doctors and drug
only a small minority of respondents agreed with the
dealers carry pagers anymore. In fact, pagers and
statement “texting is secure.” In the era of enhance-
physicians are so synonymous that 1 was included
ments to the Health Insurance Portability and
in my toddler’s toy doctor kit—sounds and all
Accountability Act (HIPAA) as well as frequent head-
—along with an electronic stethoscope. Much like
lines about secure data breaches, maintaining the
the resistant old man in “Monty Python and the
privacy of patient data must be paramount. The fear
Holy Grail” (6), the use of a pager is not quite dead
of HIPAA violations, in particular, has driven some
yet, despite insistence to the contrary in the
much-needed conversations (3,4). Secure messaging
nonmedical
systems have been developed for use in health care,
march toward easier communication continues un-
world.
Nonetheless,
the
inexorable
with at least 1 usage trial reporting success (5).
abated. It appears that my generation will be lead-
Although promising, these systems have yet to reach
ing the way in cautiously turning the page, by
the tipping point required by adoption of communi-
turning the pagers off.
cation modalities to become mainstream. For now,
deidentification of any PRC communicated via text
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
messaging is what many should rely upon as a
Jarrod D. Frizzell, Cardiovascular Disease, Division of
minimum.
Cardiology, Department of Internal Medicine, 1 Uni-
Another aspect to bear in mind is the yet unconsidered medico-legal implications of recommendations
versity of New Mexico, MSC10-550, Albuquerque,
New Mexico 87131. E-mail: jfrizzell@salud.unm.edu.
REFERENCES
1. Junco R, Mastrodicasa J. Connecting to the Net.
program: prevalence, purpose, and patient care.
5. Przybylo JA, Wang A, Loftus P, Evans KH, Chu I,
generation: What Higher Education Professionals
Need to Know About Today’s Students. Washington, DC: National Association of Student Personnel
Administrators, 2007.
J Surg Educ 2013;70:826–34.
Shieh L. Smarter hospital communication: secure
smartphone text messaging improves provider
satisfaction and perception of efficacy, workflow.
J Hosp Med 2014;9:573–8.
2. Shah DR, Galante JM, Bold RJ, Canter RJ,
Martinez SR. Text messaging among residents and
faculty in a university general surgery residency
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3. Norfolk ER, Glazier J, Hamilton E, Maddux FW.
Electronic communication and text messaging
among nephrology providers. Am J Kidney Dis
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4. Blustein AE, Gulick SL. To text or not to text?
J Am Coll Radiol 2012;9:434–6.
6. Gilliam T, Jones T, directors. Monty Python and
the Holy Grail [DVD]. United Kingdom: EMI Films,
1975.
Frizzell and Ahmed
JACC VOL. 64, NO. 24, 2014
DECEMBER 23, 2014:2703–5
Fellows-in-Training & Early Career Page
RESPONSE: Time for the Pager to
Enter Retirement
Steven R. Steinhubl, MD, Eric J. Topol, MD
Scripps Translational Science Institute, 3344 North Torrey Pines Court, Suite 300, La Jolla, California 92037.
E-mail: steinhub@scripps.edu.
The practice of medicine is steeped in tradition. The
structures, can be weak and inconsistent. Phones lose
use of pagers is 1 of them. In fact, 1 of the first paging
power much more rapidly than a pager will. A busy night
systems ever developed was in 1950 for New York City
on call can both increase power drain and decrease
physicians, representing 1 of the first commercial uses of
charging opportunities. Most importantly, pagers offer
the newly invented transistor (1). More recently, we
greater security and less risk to privacy than do personal
recall receiving our first pagers as advanced medical
phones. For example, you cannot accidently send a page
students and admiring them with near reverence as
to a friend from college when awakened in the middle of
another talisman, similar to our white coat and stetho-
the night with a patient-related question. Nonetheless, all
scope, on our journey to becoming physicians.
of these issues have existing solutions, and as Drs. Frizzell
A lot has changed in health care in the 65 years since
and Ahmed aptly point out, the use of smartphones is so
the introduction of pagers. Yet, pagers have remained
ubiquitous, and the advantages to both patients and
the cornerstone of all interprofessional communications
providers are so numerous, the time has come to break
in the medical field—routine, critical, or otherwise. This
from tradition and start implementing the solutions
is despite a clear need for improved methods of com-
necessary to enable improved communications.
munications. For example, the Joint Commission has
Just as the white coat has been shown to be a refuge
identified communication failures to be 1 of the most
for bacteria and infection risk for our patients (4), and
common causes for sentinel events (2). In addition,
the availability of pocket ultrasounds is transforming
another study found that nurses spend up to 7% of their
stethoscopes into little more than nonstylish neckwear
already overstretched workday on tracking down phy-
(5), it is time for the pager to enter retirement along with
sicians (3).
these other vestigial hallmarks of an anachronistic doc-
Of course, the staying power of the pager goes beyond
just tradition. Cell signals, especially within hospital
tor look and for our profession to break from tradition to
do what is best for our patients.
REFERENCES
1. Ennis C. Pocket radio pages doctors night or
day. Pop Sci 1951:104–5.
2. The Joint Commission. Sentinel Event Data Root
Causes by Event Type 2004–2013. Available at:
http://www.jointcommission.org/assets/1/18/Root_
Causes_by_Event_Type_2004-2Q2013.pdf. Accessed
October 31, 2014.
3. Hendrich A, Chow M, Skierczynski BA, Lu Z.
A 36-hospital time and motion study: how do
medical-surgical nurses spend their time? Perm J
2008;12:25–34.
4. Banu A, Anand M, Nagi N. White coats as a
vehicle for bacterial dissemination. J Clin Diagnostic Res 2012;6:1381–4.
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5. Khan HA, Wineinger NE, Uddin PQ, Mehta HS,
Rubenson DS, Topol EJ. Can hospital rounds with
pocket ultrasound by cardiologists reduce standard echocardiography? Am J Med 2014;127:669.
e1–7.
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