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Turn Off, Tune Out, Drop In

Walker, Graham, MD

doi: 10.1097/01.EEM.0000554294.71276.ce



I made some pretty drastic changes for the new year, and it wasn't easy. I don't know what the future holds, to be honest. I don't know what will happen to me and my relationships. Or my work ethic. Or my ability to concentrate. But I did it because I think I need the change. I turned off notifications on my phone and deleted Facebook.

The latter was pretty easy. Facebook doesn't care about your privacy or mine, but 2018's Facebook scandal after scandal didn't really bother me. I don't care that they could target me as a 38-year-old physician in San Francisco who likes baking, video games, and The Beatles. But it was the last straw when I found out Facebook was giving access to my private messages through Facebook Messenger.

I started thinking about it more, especially while sleeping in my childhood bed over Christmas. I kept coming back to my life before technology was so pervasive. What my relationships were like, how I spent my time, and what I was like. I'm not sure I like today's Graham more than the one 15 years ago, so I decided to at least partially simulate a time warp back to when I controlled my technology, instead of the other way around.

I have frequently found myself in an unhealthy technology vortex, unable to escape. I have Netflix on, which is not the same as actually watching Netflix because I'm only partially paying attention to it. I'm writing a work email on my laptop, which is on my lap, while my two iPhones (personal and work, of course) are on the coffee table. I get a notification on my work phone that I've received three new emails. My personal phone dings that I've got a new email, and four minutes later my laptop, personal phone, and iPad in the other room all chirp that I've received a new text message. I've written two additional sentences in my original email, and rewound Netflix for the third time because I missed that one funny scene on “The Office.”

The scariest part of all? I'm constantly being distracted in the ED during a shift, and I bring just as many distractions home with me.

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Deep v. Shallow Work

Kevin Kelly, the founding editor of WIRED, figured this out years ago, writing in 1997, “The only factor becoming scarce in a world of abundance is human attention.” (WIRED Sept. 1, 1997; Cal Newport, an associate professor of computer science at Georgetown University, understands this as well, and talks about the global fall in our ability to focus in his 2016 book, Deep Work: Rules for Focused Success in a Distracted World.

Deep work, according to Mr. Newport, is the superpower of the 21st century. It refers to “professional activities performed in a state of distraction-free concentration that push your cognitive capabilities to their limit.” Admittedly, we get very little exposure to work free of distraction in the ED, but I know we go into deep work from time to time, and we EPs may be the best at turning on bits of deep work when we need it, like when you see that patient with a weird constellation of signs and symptoms or labs come back very abnormal. I close the door to the doctors' room and focus. I talk to myself and try to concentrate. Some might also refer to this as “Thinking Slow” or “System 2” thinking (from Daniel Kahneman's book Thinking Fast and Slow), but I think we get to that place by getting rid of distractions.

Sadly, I think a lot of our work in the ED is the opposite. It's shallow work, which can be performed while we are distracted. Unfortunately, the more shallow work we perform, the more difficult it is for us to engage in deep work in the future. I wonder if that's the real frustration a lot of us have with seeing a patient who needs a work note or the one with nine months of abdominal pain eating Cheetos. They drain our focus and weaken our ability to concentrate and synergize when we need it most with sick or academically confusing patients or rare disease presentations. If deep work were a muscle, it's atrophied in today's world and probably about to be evolved away.

The good and the bad about writing a print column, of course, is the long lead time. I write these words and submit them to my editor, who cleans up my drivel, and shepherds a final copy through production and printing. It's bothered me for years: I have these great thoughts, and I want to share them now! But having that delay actually allows me to go back, think deeply, and improve my thoughts before they're printed in permanence.

Since this will be coming to you in March, I have a chance to see what the future holds. How many emails will I respond to hours later? How many text messages will I miss for 20 minutes? Most importantly, will anyone, myself included, even notice or care?

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Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (, a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (, and The NNT (, a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter @grahamwalker, and read his past columns at

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