Rushing, distraction, and anger.

William Osler cited Marcus Aurelius when he advocated aequanimitas—imperturbable equanimity in the face of conflict and suffering—as the pinnacle of medical professionalism (1). This advice is perhaps more important today than it was a century ago. In this issue of The American Journal of Medicine, we are reminded of the physical costs of distraction, anger, and rushing, or, as Sir Osler might have stated, of perturbability. Fisman et al. (2) report that in their study of health care workers who suffered sharps-related injuries, the injuries were often attributable to these risk factors. This is not a minor problem. The Centers for Disease Control and Prevention estimates that more than 380,000 such injuries occur in U.S. hospitals each year, with each injury initiating a costly cascade of events that tax the physical and emotional resources of health care systems and workers (3). Who though would disagree with the finding that rushing, anger, and distractedness are associated with needlestick injuries? These same risk factors are associated with car accidents, forgetting important social events, and wearing mismatched socks. They are associated with almost any mishap. Why then did the editors of the Journal decide to publish the article? I would argue that it is because we often fail in our efforts to solve problems until we are confronted by their true cost. Unfortunately, we need these important reminders. When I was a medical student about to perform my first lumbar puncture, my resident instructor took me aside and said: “First things first. You are responsible for making sure that you are comfortable while doing this procedure. Fix the chair, fix the table, arrange the patient, arrange your tools, then focus. No patient with a fourinch needle in their back wants you preoccupied with the minor ache in your own back!” This is advice that I have often repeated, usually with a smile of appreciation for the young physician who had taught me. Indeed, many of our preparations, certainly our rituals, have the important benefit of providing focus and clearing distraction. Ask any surgeon. It is a key to their success. Human nature being what it is, we often fail to maintain equanimity, particularly in this age of ‘multitasking.’ Multitasking is part of the problem. As Volpp and Grande point out in their superb review of system flaws that foster error as seen from a medical resident’s perspective, distraction has not been adequately addressed in our health care training programs (4). They offer practical suggestions that can make a difference. Each of us can envision methods for reducing fatigue or distraction (and certainly anger) if we focus on the problem. And that is the point. We need to pay attention to root causes of error and strive to reduce them. This certainly was the conclusion of the Institute of Medicine’s landmark report on medical errors (5), and the heartening news is that health care systems are responding. Osler’s message is that each of us must do the same. If we do not, the costs associated with failing to address anger, fatigue, and distraction in the workplace are surely much more distracting in the long run.