Cell phone use in the clinic: “Please hang up now, the doctor is ready to see you!”

MCase scenario

Dr. Courteous (C), a general dermatologist in a busy practice, is running behind on a typical Monday with an overbooked schedule. Ms. Tanning (T), a frequent tanning-bed user, has been waiting 30 minutes to be examined. Ms. T has frequently missed appointments in the past so Dr. C is glad she honored her appointment today. During the examination, Dr. C discovers a suspicious pigmented lesion and informs Ms. T the lesion should be biopsied. After discussing her concerns, Dr. C obtains informed consent and steps out of the room while the nurse prepares for the procedure. When Dr. C returns to perform the biopsy, Ms. T is talking on her cellphone. Ms. T looks up and mouths, “Hold on.” The nurse says to Dr. C: “It’s a work-related call. She said she might have to rush back to her office.”

Several minutes elapse and Ms. T is still talking. With other patients waiting to be seen, what is the best course of action for Dr. C?

• A.Interrupt and insist that Ms. T get off the phone so the biopsy can be performed.
• B.Wait in the examination room until Ms. T is done with her phone call and then perform the biopsy
• C.Perform the procedure while Ms. T is on the phone because consent has already been obtained.
• D.Leave to see the next patient and return to the room afterward, even though Ms. T might leave before the biopsy can be performed.

Discussion

Mobile technology has become ubiquitous in the United States, with 95% of Americans now owning a cell phone and 77% owning a smartphone (Pew Research Center, 2017). Although there has been some research on physician cell phone use in the clinical setting and its potential impact on confidentiality and “distracted doctoring” (Tran et al., 2014), there has been little analysis of how patient cell phone use affects the physician-patient relationship. Just as there is the potential for dermatologists to be distracted from their work due to the presence of a personal cell phone, patients are also at risk for increased distraction in the examination room.

The potential for patient cell phone use to disrupt a clinical encounter may be increased by the problem of long wait times. The average wait for a new patient dermatology appointment is 33 days (Kimball and Resnick, 2008); once in a physician’s office, patients wait an average of 38 minutes before being seen (Bleustein et al., 2014). Predictably, patient satisfaction declines steadily as wait time increases (Bleustein et al., 2014). With cell phone ownership now nearly universal, patients are likely to use their mobile devices while they are waiting and may be occupied on their cell phones when the dermatologist is ready to see them. Some offices post signage that discourages cell phone use, but there has been minimal research examining the effectiveness of no-cell-phone policies. In most cases, patients will take the initiative to end a phone call when the physician walks into the room, but what is the best and most ethical course of action when a patient does not end the call?

The interruption of a clinical encounter by patient cell phone use challenges the dynamic of the physician-patient relationship. Dermatologists being asked to wait for a patient to complete a phone call are likely to feel resentful that their time is being wasted. Conversely, patients may feel justified making this request if they were kept waiting in the waiting room and/or examination room. Responding appropriately to such a scenario requires a consideration of proper etiquette but also—and more importantly—of pertinent ethical principles.

The concept of medical etiquette, which is defined as a set of acceptable, professional behaviors involving patient interactions, has increased in popularity in recent years. So-called physician “good behavior” has been suggested to be more important to patients than good character during clinical encounters (Kahn, 2008). Appropriate behavior such as not grabbing a cell phone out of a patient’s hand or raising one’s voice to a patient is certainly important in maintaining a strong physician-patient relationship. However, this does not diminish the importance of understanding and applying appropriate ethical principles, even in circumstances that may feel routine.

Additionally, professional behavior is most likely to be challenged when a physician is rushed or frustrated (such as by an unreliable patient who will not get off the cellphone), which makes the emphasis on ethical underpinnings all the more important. Despite being a potentially common scenario, the challenge of patients who are preoccupied on their cell phone raises multiple ethical questions, especially when the clinical encounter involves a procedure. The ethical principles of beneficence (i.e., doing what is best for the patient) and nonmaleficence (i.e., avoiding harm) suggest that the physician has an absolute duty to stay and complete the procedure rather than risk a potentially harmful delay in diagnosis.

However, a busy dermatologist cannot be expected to wait indefinitely for a patient to finish a phone call. In striving to provide equitable care and in keeping with the ethical principle of justice, the dermatologist’s duty to other waiting patients must also be considered. A dermatologist who waits for a patient to finish an important phone call may be doing what is best for one patient but could potentially be harming the many patients who are then asked to wait longer.

The egalitarian approach, which strives to treat all individuals equally, would argue that the dermatologist must leave the room and attend to other patients. However, this approach does not take disease severity into account. A utilitarian approach, which aims to provide the most good to the most people, might argue that the dermatologist has a greater responsibility to the current patient than to others who are waiting because the current patient has a potentially serious diagnosis. When ethical principles are in conflict, physicians must rely on their clinical judgement to decide whether causing subsequent patients to wait is more or less harmful than delaying important care for the patient at hand.

Analysis of case scenario

In the current scenario, Ms. T had to wait more than 30 minutes before being seen. While being prepped for her procedure, she has gotten involved in a work-related phone call. Because the phone call was important, she asked Dr. C to wait for her to finish. The phone call does not end quickly, which creates a difficult logistical and ethical situation for Dr. C, who is frustrated and has other patients waiting.

Option A, in which Dr. C insists that Ms. T gets off the phone immediately, is both disrespectful and damaging to the physician-patient relationship. Maintaining trust and good rapport with a high-risk patient such as Ms. T is important, so option A is not an ideal choice. Option B, waiting indefinitely for Ms. T to finish her phone call, could be argued from an ethical perspective of beneficence because it is undoubtedly in the best interest of the patient to perform the biopsy. Furthermore, the principle of nonmaleficence might dictate also that the dermatologist stay and wait to avoid a delayed diagnosis if Ms. T leaves before her biopsy can be performed. However, in a real-world clinical setting, waiting indefinitely is both impractical and unfair to other patients. Blind duty to the patient at hand without regard for others who are waiting violates the ethical principle of justice and an egalitarian approach.

Performing the biopsy while Ms. T is on the phone (option C) may be tempting, especially because the procedure has already been discussed and informed consent has been obtained. In some situations, the use of a cell phone may be a helpful distraction for fearful patients, but this assumption cannot be made simply because a patient has failed to end a phone call with the dermatologist in the room. This is especially true in our scenario because Ms. T asked Dr. C to hold on. Moving forward with the biopsy while Ms. T is on the phone violates her autonomy and denies her the opportunity to communicate with Dr. C or ask questions during the biopsy. It could also prevent Ms. T from revoking the previously obtained informed consent.

Although there is no perfect solution, the best course of action is closest to option D, despite the risk that if Dr. C goes to see her next patient Ms. T might leave before the biopsy is performed. In this situation, the egalitarian approach and ethical principle of justice conflict with the principles of beneficence (performing a necessary biopsy) and nonmaleficence (avoiding harm caused by a missed or delayed diagnosis). With multiple ethical principles in conflict, a utilitarian approach can help determine the best course of action. Dr. C should inform Ms. T that she must go see her other waiting patients and that she will return to perform the biopsy as soon as possible. The nurse (or another staff member) should be asked to inform Dr. C when Ms. T is ready for the biopsy, but ultimately the decision is up to Dr. C’s clinical judgment when the other patients can be left to complete Ms. T’s procedure. There is no guarantee that Ms. T will not leave the office prior to the biopsy, but this course of action represents a solution that is both ethically acceptable (minimizing potential harm to as many of Dr. C’s patients as possible) and practical in a clinical setting.

Bottom line

Cell phone use by both physicians and patients is a reality of today’s clinical practice. Long wait times may encourage patients to use their cell phones in waiting areas and examination rooms and is often a helpful distraction. When cell phone use by a patient interrupts a clinical visit, the challenge goes beyond questions of proper etiquette. The physician must act ethically in balancing duty to the patient at hand with duty to other waiting patients. When multiple ethical principles are in conflict, physicians should use their clinical judgment and a utilitarian approach to determine a course of action that both serves the best interest of the patient and minimizes harm to others who are waiting.