A quiet place: The impact of the word “quiet” on clinical workload

Abstract

Purpose

This study aimed to determine the impact of uttering the word “quiet” on clinical workload during the overnight otolaryngology call shift and understand the factors contributing to resident busyness.

Materials and Methods

A multicenter, single‐blind, randomized‐controlled trial was conducted. A total of 80 overnight call shifts covered by a pool of 10 residents were randomized to the quiet or to the control group. At the start of shift, residents were asked to state aloud, “Today will be a quiet night” (quiet group) or “Today will be a good night” (control group). Clinical workload, as measured by number of consults, was the primary outcome. Secondary measures included number of sign‐out tasks, unplanned inpatient and operating room visits, number of phone calls and hours of sleep, and self‐perceived busyness.

Results

There was no difference in the number of total (P = 0.23), nonurgent (P = 0.18), and urgent (P = 0.18) consults. Tasks at signout, total phone calls, unplanned inpatient visits, and unplanned operating room visits did not differ between the control and quiet groups. While there were more unplanned operating room visits in the quiet group (29, 80.6%) compared to the control group (34, 94.4%), this was not found to be significant (P = 0.07). The majority of residents reported feeling “not busy” during control nights (18, 50.0%) compared to feeling “somewhat busy” during quiet nights (17, 47.2%; P = 0.42).

Conclusion

Contrary to popular belief, there is no clear evidence that uttering the word “quiet” significantly increases clinical workload.

A multicenter, randomized‐controlled trial (n = 10 residents, 80 overnight call shifts) was conducted, with participants randomized into the quiet or control group. There was no significant difference in clinical workload, suggesting that uttering the word “quiet” does not impact busyness.

Key points

• There was no difference in the number of total, nonurgent, and urgent consults, tasks at signout, total phone calls, unplanned inpatient visits, and unplanned operating room visits between the control and quiet groups.

• There is no clear evidence that uttering the word “quiet” significantly increases clinical workload.

INTRODUCTION

Described as beliefs surrounding particular events without scientific or logical reasoning, superstitions continue to persist even with the advent of modern technological advances. Often based on religion, old tales, legends, and personal experience, these beliefs have the potential to influence behavior in a variety of settings. The values that individuals have can directly impact decision‐making and affect responses to certain situations, particularly within healthcare. In patient care, studies have reported superstitions to affect hospital discharge rates, elective orthopedic surgeries, and trauma rates. ¹ , ² , ³ The ability to recognize such beliefs, therefore, is essential to better understand what constitutes motivation for certain behaviors with profound, lasting implications.

Among healthcare providers, one long‐held superstition in the clinical work environment is the word “quiet,” especially in the context of wishing for a “quiet” shift. Along with the lunar cycle and Friday the 13th, using the word “quiet” appears to jinx an otherwise calm workflow, leading to increased admissions, operations, and caseload. This popular superstition has led to avoidance of the word in the United States, as well as the United Kingdom and Japan. ⁴

At academic medical centers, the volume of consults for an otolaryngology service is high, requiring significant time, resources, and attention. ⁵ , ⁶ In addition to inpatient and emergency department (ED) consultations, regular flap checks, airway evaluations, and emergent operative interventions may all be components of an overnight call period. While there are few studies assessing the impact of the word “quiet” in the ED, there is no literature studying this phenomenon in the field of otolaryngology. The objective of this study is to determine the effect of the word “quiet” on clinical workload and resident‐perceived busyness during the overnight otolaryngology call shift at an academic, tertiary care hospital system.

MATERIALS AND METHODS

Study oversight

This protocol was approved by the University of Pennsylvania Institutional Review Board (IRB 843875) and was conducted in accordance with the Declaration of Helsinki and the International Conference on Harmonization Good Clinical Practice guidelines. All participants provided written informed consent before study entry. The principal investigator (K. R.) was responsible for the design of the protocol and oversight of the study. Data safety monitoring was maintained through REDCap, and any downloaded information was password encrypted.

Subjects

Eligible subjects were postgraduate year (PGY)‐2 and PGY‐3 residents taking night calls in the Department of Otorhinolaryngology at the University of Pennsylvania Health System. Exclusion criteria included refusal to participate.

Study design

A multicenter, single‐blind, randomized‐controlled trial was designed to assess the impact of uttering the word “quiet” on clinical workload during the overnight otolaryngology call (Figure 1). Subjects were randomized to either the control cohort or the quiet cohort before starting the call. Treatment cohort randomization was performed by a separate researcher (K. C.) in a 1:1 ratio format from Excel 2016 (Microsoft Corporation). The primary investigator (K. R.), outcome assessors (B. G.), and adjunct clinical staff were blinded to the cohort assignment. Participants could not be blinded to treatment allocation due to the nature of the intervention. All subjects were responsible for covering a call schedule at five different hospitals in the system: Hospital of the University of Pennsylvania, Children's Hospital of Philadelphia, Pennsylvania Hospital, Penn Presbyterian Medical Center (Level 1 trauma center), and Corporal Michael J. Crescenz Veterans Affairs Medical Center. At 5:00 p.m. or time of signout, subjects in the control group were asked to state aloud, “Today will be a good night,” while subjects in the experimental group were asked to state aloud, “Today will be a quiet night.” Subjects were then asked to continue their call as planned without varying their workflow to the best of their ability. At the end of the overnight call, outcome measures were calculated and recorded in REDCap 10.6.1 (Vanderbilt University), a secure, Health Insurance Portability and Accountability Act‐compliant web application.

Figure 1.

Study design and flow

Sample size

A power analysis was completed before study initiation to address the primary outcome metric. There are few studies addressing the effect of the word “quiet” on clinical workload; among these, only one study investigated the word's impact on busyness during an on‐call night shift in a surgical specialty. ⁷ It is important to note that clinical activity in our health system may be different due to hospital volume/location, patient population, and specialty‐specific disease processes requiring a consult. However, based on this prior study, we expected the pooled standard deviation of night referrals to be approximately 1.96. To achieve a power of 80% with a significance level of 0.05, 31 days were required for each cohort, and accounting for a dropout rate of 15%–20%, a total of 40 days were allocated.

Outcome measures

The primary outcome measure was clinical workload, as measured by the total number of nonurgent and urgent consults. Urgent consults were further divided into the number of bleeding episodes (i.e., hemoptysis, epistaxis) and airway emergencies. Secondary outcome measures included number of tasks at signout, unplanned inpatient visits, unplanned operating room trips, total number of phone calls, and total number of hours of sleep. Subjects were asked to subjectively rate their overall call as “not busy,” “somewhat busy,” “busy,” or “very busy.”

Statistical analysis

Descriptive statistics using RStudio 1.8.6 (RStudio Inc.) were used to assess the effect of uttering the word “quiet” on clinical workload. Differences between the control and quiet groups were assessed using an independent t‐test and χ ² analysis for continuous and categorical variables, respectively. Total hours of sleep were correlated with other outcome measures using Pearson's correlation coefficient. A significant P‐value was defined as less than 0.05.

RESULTS

Study characteristics

The trial was conducted over a period of 80 days from September 6, 2020 to November 24, 2020 including 54 weekdays, 23 weekend days, and 3 holidays (Labor Day, Columbus Day, and Veterans Day). Ten residents (five PGY‐2 and five PGY‐3) from the Otolaryngology Department were involved in the study. Four days from each group were lost to follow‐up and excluded due to unavailable data from that shift. A total of 36 control days and 36 intervention days were included for analysis in the study (Figure 1). No adverse events were encountered during the study period.

Consults

The average number of total consults was 2.83 on control days compared to 3.54 on intervention days (mean difference [MD] = 0.71, 95% confidence interval [CI] = −0.45, 1.87), P = 0.23, Figure 2. The number of total consults ranged from 0 to 14, with the maximum number of total consults occurring on a Sunday. There was no difference in the number of nonurgent consults when comparing controls (2.62 ± 1.67) with the intervention group (3.29 ± 2.28), MD = 0.67, 95% CI = −0.31, 1.65, P = 0.18. There was also no difference in the number of urgent consults between the control group (0.35 ± 0.69) and the intervention group (0.58 ± 0.67), MD = 0.23, 95% CI = −0.31, 1.65, P = 0.18. The number of bleeds and airway emergencies did not differ between the two groups (MD = 0.09, 95% CI = −0.44, 0.62, P = 0.72; MD = 0.04, 95% CI = −0.54, 0.62, P = 0.88), respectively.

Figure 2.

Average number of consults per group

Clinical workload

In both groups, the majority of residents had 1–5 tasks at signout, 0–5 total phone calls, 1–3 unplanned inpatient visits, and no unplanned operating room visits (Table 1). Tasks at signout, total phone calls, unplanned inpatient visits, and unplanned operating room visits did not differ between the control and quiet groups. There were less unplanned operating room visits in the control group (34, 94.4%) compared to the quiet group (29, 80.6%), although this was not found to be significant (P = 0.07). In the control group, the majority of residents reported feeling “not busy” (18, 50.0%), while in the quiet group, more residents reported feeling “somewhat busy” (17, 47.2%). The mean number of hours slept was 3.17 h on control days compared to 3.14 h on intervention days (−0.03[−0.87, 0.93), P = 0.95]. Hours of sleep were found to be negatively correlated with the total number of consults (r = −0.48, P < 0.001), nonurgent consults (r = −0.38, P < 0.001), and urgent consults (r = −0.16, P = 0.22).

Table 1.

Workload during the study period

Measure	Control	Quiet	P value
Tasks at signout
0	10 (27.8%)	6 (16.7%)	0.22
1–5	24 (66.7%)	22 (61.1%)
6–10	2 (5.6%)	6 (16.7%)
10+	0 (0%)	2 (5.6%)
Total phone calls
0–5	17 (47.2%)	18 (50%)	0.87
6–10	9 (25%)	7 (19.4%)
11–15	5 (13.9%)	7 (19.4%)
15+	5 (13.9%)	4 (11.1%)
Unplanned inpatient visits
0	9 (25%)	10 (27.8%)	0.76
1–3	22 (61.1%)	22 (61.1%)
4–6	5 (13.9%)	3 (8.3%)
6+	0 (0%)	1 (2.8%)
Unplanned OR trips
Yes	2 (5.6%)	7 (19.4%)	0.07
No	34 (94.4%)	29 (80.6%)
Overall busyness
Not busy	18 (50%)	12 (33.3%)	0.42
Somewhat busy	11 (30.6%)	17 (47.2%)
Busy	4 (11.1%)	5 (13.9%)
Very busy	3 (8.3%)	2 (5.6%)

Abbreviation: OR, operating room.

DISCUSSION

The findings of this study suggest no clear evidence that uttering the word “quiet” increases clinical workload during the overnight otolaryngology call shift across multiple hospitals. The word “quiet” further demonstrates no significant impact on subjective, self‐reported perception of busyness among residents. While this study is certainly tongue in cheek, it can reassure healthcare providers that avoidance of the word may not be necessary.

Among the few studies investigating the impact of the word “quiet” on clinical workload, the results are widely variable. The majority of these trials conclude that the word “quiet” has a negligible effect on increasing clinical busyness, a finding that is confirmed by our study. One such example is a noninferiority trial that was conducted over a total of 61 days, which found no evidence of a difference in workload measured by phone calls, clinically significant results, and validated results by a microbiology team over a 24‐h period. ⁸ Other similar findings have been reported in a variety of other emergent settings, notably in a pediatric ED and a veterinary emergency service. ⁹ , ¹⁰ Although one trial in the ED of a tertiary care hospital in Japan reported increased hospital transfers in the intervention group, this difference was noted to be clinically small (+0.5 patients), with no resident‐reported increase in busyness or difficulty of shift. ⁴

Interestingly, there is one study, to our knowledge, that reported contrary findings to ours. This study by Lamb et al. ⁷ was conducted across multiple orthopedic departments in the United Kingdom, and reported a significant increase in night referrals leading to admission in the quiet arm. Differences in the number of admissions were attributed to potential supernatural reasons, although the authors commented that the true mechanism required further investigation. Between our two studies, it is interesting to observe a difference in the night call workload between two surgical fields. Potential explanations include variations in study design and inherent differences in the patient population, location, and hospital systems. Although designed with validated treatment allocation and randomization procedures, results were not reported with adherence to CONSORT guidelines. Control shifts where the word “quiet” was accidentally uttered were excluded and therefore not subject to an intention‐to‐treat analysis. In contrast, in our study, a power analysis and adherence to CONSORT guidelines were performed to limit potential sources of bias.

Although this study is certainly humorous and demonstrates no clear evidence supporting the superstition, it is important to consider its implications on provider well‐being. Words have been shown to directly impact perception of busyness and difficulty. In one pediatric program, residents labeled as “black clouds” slept less and perceived a higher workload despite no difference in admission rates. ¹¹ A trial where house staff were told “You will have a great call day!” reported fewer hospital admissions, more sleep, and lower subjective level of difficulty. ¹² On the contrary, there was no significant difference in the subjective level of busyness in our study, although more control shifts were “not busy” compared to intervention shifts. With the stress of working in the hospital, particularly during the coronavirus‐19 pandemic, providers may seek to identify and limit any external factors that could potentially increase workload. Thus, it may still be wise and considerate to avoid saying the word “quiet” around colleagues who are superstitious despite no clear evidence supporting its impact. Among those who hold the word with less regard, use of “quiet” should not be limited and may even be encouraged to genuinely wish others to have a quiet shift.

There are a few limitations to this study. First, a single‐blind study design may introduce additional sources of bias, including performance bias. However, a double‐blind study design would not have been appropriate or practical to assess the intervention as the “quiet” superstition requires the individual to hear the word aloud. Second, our data were dependent on the reliable recording by the participants, who frequently recorded the information after a long night call shift. To help ensure accurate recall and encourage participation, reminders were given after the immediate end of a shift. Finally, while the participants ideally spoke their intervention aloud at the start of the shift, other staff and patients could have inadvertently used the word “quiet” or similar phrases throughout the shift. Despite these limitations, this study is adequately powered to demonstrate no clear evidence of an increase in clinical workload when using the word “quiet.” Future investigations should be broadened to assess impact on additional metrics of provider wellness, self‐reported busyness, and perceived difficulty of shift.

CONCLUSIONS

There is no clear evidence that uttering the word “quiet” increases clinical workload and self‐reported busyness during the overnight otolaryngology call shift. In the midst of a busy clinical shift, providers can be reassured that use of the word “quiet” should not be avoided and can be used to wish colleagues well.

AUTHOR CONTRIBUTIONS

Beatrice C. Go and Kevin Chorath were involved in study conception and design, acquisition, analysis, and interpretation of data, drafting and revising work, and final approval, and agree to be accountable for the work. Amy Schettino, Vincent Anagnos, Ivy Maina, Laura Henry, Lukas Dumberger, Neel Sangal, Vasiliki Triantafillou, Solomon Husain, Chad Sudoko, and Evan Cretney were involved in the acquisition, analysis, and interpretation of data, critical revisal of work, and final approval, and agree to be accountable for the work. Karthik Rajasekaran was involved in study conception and design, analysis and interpretation of data, drafting and revising work, and final approval, and agrees to be accountable for the work.

CONFLICTS OF INTEREST

The authors declare no conflicts of interest.

ETHICS STATEMENT

This protocol was approved by the University of Pennsylvania institutional review board (IRB 843875) and was conducted in accordance with the Declaration of Helsinki and the International Conference on Harmonization Good Clinical Practice guidelines.

Go BC, Chorath K, Schettino A, et al. A quiet place: the impact of the word “quiet” on clinical workload. World J Otorhinolaryngol Head Neck Surg. 2023;9:91‐96. 10.1002/wjo2.53

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author, Karthik Rajasekaran, upon reasonable request.