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SPEAKER_06: For a lot of young doctors starting out their careers, there comes this special moment when you start to feel like a real person of medicine. This rite of passage happens after you've graduated from medical school, when you start working in a hospital, and they hand you this thing. It's almost like a historical artifact. So it's a little black box with a little grey screen in it,
SPEAKER_03: and it emits a sound to alert you that you have a message.
SPEAKER_09: Mary Mercer is an emergency room doctor in California. And yes, she is talking about the pager.
SPEAKER_06: Can you just help me understand what is this sound?
SPEAKER_03: So it's like, something like that. Oh my gosh.
SPEAKER_06: Mary got her first pager when she started her residency training in 2007.
SPEAKER_09: She says the sound of your first pager, it gets seared into your soul. The baa, baa, baa goes off, a number pops up on your pager screen, and you race to find a phone to call that number back. To this day, at a lot of hospitals, pagers are how doctors get summoned when someone needs their help.
SPEAKER_06: Now, there was a time when pagers were everywhere. A lot of business people used to carry pagers. Also, drug dealers. Also, the celebrated rap artist, Sir Mix-a-Lot, came out with a hit song about them in the 80s. How does Mix-a-Lot communicate?
SPEAKER_09: With peepers, baby, peepers. Welcome to Chi Pager.
SPEAKER_06: But the cell phone kind of killed the pager. I mean, what's the point of paging someone when you could just call them, or text them, or email them, or slide into their Insta-DMs? Right. These days, doctors are some of the only people who still use pagers.
SPEAKER_09: I think that's what people joke about, is like, oh, you still have a pager,
SPEAKER_03: so you must be a drug dealer or something. But we take care of people from all parts of society, and I actually have never met a drug dealer who is carrying a pager. So they have all moved on.
SPEAKER_09: Mary was working in the busiest emergency room in San Francisco when she started to wonder, wait, why are we still using pagers? As a profession, why are doctors still putting up with these things? A few years back, she finally got a chance to do something about it.
SPEAKER_06: She was in charge of a project to increase efficiency in the ER, and pagers seemed like one of the most obvious inefficiencies in how doctors were doing their jobs. So Mary got together with one of her colleagues, and they hatched a plan to liberate their hospital from the pager. Hello and welcome to Planet Money. I'm Jeff Guo. And I'm Nick Founzen.
SPEAKER_09: It's easy to think of technology as this endless march of progress, one upgrade after another. But once in a while, you come across this kind of living fossil, some stubborn device that just stuck around long past its expiration date. Like the pager.
SPEAKER_06: The pager is still the backbone of communication at a surprisingly large number of hospitals. When there's an emergency, it is this antiquated piece of technology that lets doctors know they are needed. It doesn't make any sense. Even lots of doctors will tell you this is a ridiculous situation. But when Mary and her colleagues set out to eradicate the pager once and for all, it did not go at all the way they thought it would. Today on the show, why seemingly obsolete technologies
SPEAKER_09: can be so hard to get rid of.
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SPEAKER_06: As an emergency room doctor in San Francisco, Mary Mercer would see all kinds of stuff come through the door, from rashes to car crashes to sea lion attacks. That was real, by the way. People thought maybe they had rabies or something. And when these new patients came in, Mary would often have to call other kinds of doctors, specialists, because ER doctors are not expected to know everything about every kind of medicine. Yeah, this is how the ER works.
SPEAKER_09: Like if the rash were really bad, call in a dermatologist, car crash, trauma surgeon, sea lion attack, zoological infectious disease specialist. Right. And the main way to reach all these other doctors
SPEAKER_06: was by using that thing that, you know, Sir Mix-A-Lot was rapping about in the 80s, the pager. And then they receive a numeric message that just says my phone number.
SPEAKER_03: And so they have no idea what they're being called for. Are they being called to write a Tylenol order? Or are they being called because someone has a half amputated limb? No one knows. So they're then going to call me back at that number and I'll give them the story. Now with some pagers these days, you can also send a short little message,
SPEAKER_09: but you still have the problem of not knowing, did the doctor on the other side even get that page?
SPEAKER_05: It's a one-way communication pathway. We push it out and we hope people receive it. We have no way of knowing. So a classic thing is like, I never got the page, you know? Where were you? Never got the page. This is another ER doc at Mary's Hospital.
SPEAKER_09: His name is Christopher Peabody. Everyone calls me Toph, Chris Toph. My parents did that to me.
SPEAKER_05: Toph says the pagers weren't just a bad system for the ER docs.
SPEAKER_09: They were also a bad system for the doctors in dermatology, trauma surgery, zoological internal medicine, the people receiving all those pages from the ER. This was especially true for the junior doctors in those other departments,
SPEAKER_06: the residents. As part of their training, they had to spend a lot of time on pager duty. When they showed up to work, a lot of times they wouldn't just get handed one pager, they'd get handed a whole pile of pagers, one for each team they were covering for. You get these residents that literally are wearing like a Rambo-looking ammunition thing
SPEAKER_05: of the multiple pagers, and so when one of them goes off, you see this frantic searching of the Rambo belt, pulling the pagers off to try to silence the one that's beeping so much. This whole system was a mess.
SPEAKER_09: And it probably wasn't great for the patients either. At the time, the hospital was really concerned about how long it took for the patients in the yard to get treated and sent on their way. Mary and Toph thought this slow, inefficient paging system was part of the problem. The solution for all of this seemed obvious.
SPEAKER_05: We all use text messaging or WhatsApp on a daily basis in every other aspect of our lives. And there were companies that were starting to offer these apps
SPEAKER_06: that let doctors send encrypted text messages on their phones with read receipts that would completely protect patient data. Basically, WhatsApp for doctors. Now, it's not like Mary and Toph hadn't heard all the arguments
SPEAKER_09: about why hospitals have hung on to pagers for so long.
SPEAKER_05: They're like the cockroaches of communication, right? You can throw them in the toilet, you can drop them. And they run on a AA battery, okay? Like forever. And they're cheap.
SPEAKER_09: Also, pagers are more reliable, they have fewer dead spots. They run on entirely different networks than cell phones. If there's a big emergency and everyone tries to use their phones all at once, pager networks are less likely to be completely overwhelmed.
SPEAKER_06: But Mary and Toph were like, these benefits just do not outweigh the massive advantages of being able to, you know, text another doctor and have them text you back.
SPEAKER_09: And to prove it, they decided to run a pilot program. They convinced a company that made one of those texting apps for doctors to let them try it out. They wouldn't get rid of the pagers, not right away. But they let a few teams in the ER, in orthopedics and in neurology, use their pagers alongside this new app so that they could see for themselves just how much better their jobs would be with this new technology. Their plan wasn't just to win over the doctors.
SPEAKER_06: They were also going to prove to the powers that be at the hospital that phasing out the pager would make things better for patients, cut down on the amount of time they spent waiting around in the emergency room. Mary and Toph spent six months getting buy-in from different people at their hospitals,
SPEAKER_09: doing a risk assessment, collecting all the right signatures. Finally, the day arrived, when they were ready to unveil the new app. So we basically had a launch party of like a demo and isn't this amazing
SPEAKER_05: and why don't we all download it together? The experiment had officially begun, and the doctors in the emergency department,
SPEAKER_06: at least, they all seemed pretty jazzed. I mean, it was like almost euphoric.
SPEAKER_05: Like we were like, oh, we're not going to have to wait for pagers. We could actually send secured messages. This was a no-brainer. Now, there were some growing pains.
SPEAKER_09: Doctors spend their entire careers developing this Pavlovian response to their pagers. Their pagers go off and they snap to attention. Mary says this new app didn't necessarily generate the same response.
SPEAKER_06: One night she was trying to use the new system to text another doctor, never heard back.
SPEAKER_03: So they were trying to get some shut-eye, and so I think their phone settings had not been allowed enough chirp.
SPEAKER_06: To wake them up, Mary had to, you know, page them. Wah wah wah wah. That worked.
SPEAKER_02: And so that was my first clue that, okay, there are definitely some bugs in this system,
SPEAKER_03: not necessarily in the technology itself, but just bugs in the mistake-proofing the process.
SPEAKER_09: But pretty soon as the ER doctors and the doctors they were texting in other departments got used to the new app, it really started to prove itself. One of the real game changers was the doctors could now send photos back and forth. Toff remembers treating a patient who came in with a really bad broken leg.
SPEAKER_06: Like the bone was literally sticking out of the skin. So I took a secure photo and texted to an orthopedic surgeon and just put the room the patient was in.
SPEAKER_05: No other information, and I got a response immediately that said, be right there. Oh wow. Okay, so at that moment I was like, this thing's genius. We're definitely going to be implementing this technology system-wide. And Mary had the same experience.
SPEAKER_09: A patient came in with a seriously broken ankle, and instead of having to page someone and wait for them to call back and then describe to them exactly how the ankle was broken, Mary just texted over a photo. The orthopedic resident saw exactly what the problem was and came right down to take care of it.
SPEAKER_03: Everyone was high-fiving after that. Really? Yes. The emergency resident and I high-fived, the patient high-fived, the orthopedic resident high-fived. You high-fived the patient? Yes. Oh, they were thrilled.
SPEAKER_06: Everyone was thrilled. Mary, the patient, even the orthopedic resident who came down for the consult. Thanks to the app, they were able to get this patient looked at and out the door in under an hour. This was the dream scenario. Increasing efficiency, reducing patient wait times. But a few weeks into the pilot program, Mary and Toph realized not everyone was high-fiving about the new system.
SPEAKER_09: One night, Toph was working in the ER. He had just texted one of the neurology residents, one of the young doctors on call.
SPEAKER_06: The resident walked into the ER wearing that, you know, Rambo belt of five or six pagers across their chest. And I turned to them and I said, isn't this new system awesome? Like, to just get this, you could get rid of all of those pagers you have.
SPEAKER_05: And they turned to me and said, it's awful. And I was like, what? And he was like, it's awful. Here was this incredibly well-educated doctor who'd spent like all day working with state-of-the-art brain imaging technologies.
SPEAKER_09: And he couldn't see that texting was obviously better than paging. Toph could not believe it. Why do you hate the new platform? It's great. We have like bi-directional communication stuff. It's redundant.
SPEAKER_05: Like, just page me and then I'll call you. And it was like, why would I want to do that? Like, there's all these problems with like with with doing that. And I remember like, you know, three in the morning, just looking at this person like they had two heads. Like, why can't you see like how awesome this is? And and you know what? They had a pervasive opinion of opinion that was actually in the majority for especially the consulting residents.
SPEAKER_06: Yeah, a lot of the consulting doctors, the ones on the receiving end of all those texts and pages from the E.R., they were starting to grumble about the app. And as weeks turned into months, their complaints got louder and louder, so loud that Mary and Toph worried that the whole project was in jeopardy. Now, we're just going to pause their story here for a second, because what Mary and Toph were facing was not unique to them.
SPEAKER_09: They were not the first crusaders who had tried and tried to vanquish some outdated technology, only to run into surprisingly strong resistance. Yeah, there are banks that still rely on floppy disks and fax machines.
SPEAKER_06: The reports earlier this year that the State Department still has computers running Windows XP, an operating system from two decades ago. You know, there's kind of a laundry list. Pagers are not alone in outdated technologies that are sustained in otherwise sophisticated organizations.
SPEAKER_04: That's Michaela Kerasie. She's a professor of management at Harvard who studies organizations, especially how they adopt new technologies and why sometimes they don't.
SPEAKER_06: Michaela says part of the answer is that technology is not just about the tools themselves. Technology changes how people work, and it changes how people work together, how they interact, how they collaborate.
SPEAKER_09: In other words, choices about technology are tangled up in a whole complicated, you know, social system. There's a mnemonic that I use with my students to break it down a bit, because I don't think it's—if you just say the social system, you're kind of like, well, yeah, there's a social system. I get it. It's complicated. But what about it?
SPEAKER_04: And so the mnemonic that I use with my students is RHIP. Risk, Habit, Identity, Power. R-H-I-P. It's pronounced rip. The H is silent. Now, we should say Michaela actually knows TOF. They went to school together.
SPEAKER_09: A few years ago, he told her about their struggles to get rid of pagers at their hospital, and Michaela thought the story was so interesting that she wrote an entire case study about it. Teaches it to her students every year. She says you can see how these four rip factors were playing out in Marion TOF's story. Yeah, like, take risk, right? Every new technology comes with some risk. In this case, the concerns about how cell phones didn't have enough battery life to get through a shift, or how pagers had fewer dead zones, or how they worked better during big emergencies when everyone overloaded the cell phone network.
SPEAKER_06: These concerns were not nothing. Or think about the H. It's silent, but it's a very important one. This one is habits.
SPEAKER_04: This one's obvious, right? If you're used to using a pager, you know how to use it. You have your routines for using it. Learning how to use a new device is just a pain. Yeah, the doctors at Marion TOF's hospital were being asked to change some long-standing habits. And that comes at a cost.
SPEAKER_06: Then there's I for identity. That's about how new technology can change how you feel about your job. Michaela says if you're a doctor, a pager can feel like a symbol of your doctorness in a way that a phone can't. Patients see it the same way. You pull out your pager in front of a patient, they know you're doing doctor work. Pull out your phone, they think, I don't know, maybe you're texting your friends, sliding into someone's Insta-DM's. So, those are the first three RIP factors. Risk, Habit, Identity. And Michaela says, sure, they all had a part to play in what happened next.
SPEAKER_09: But the thing that really stood out to her was the fourth factor. P. Power. Because one of the most dangerous, most disruptive things that a new technology can do is change who in an organization has power. And who doesn't.
SPEAKER_06: That is after the break.
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SPEAKER_06: People who are more senior, people who are more junior, people who have power over others, people who barely have power over their own work.
SPEAKER_09: Among the doctors at Marion Toff's hospital, it was the residents who had the least power. They were the most junior doctors on their teams. And in specialties like orthopedics and neurology, one of their duties was to be on call to respond to all those messages and photos and everything else that the ER doctors could now send instead of paging. When you are on call, if there's a busy night, then you're not really sleeping.
SPEAKER_06: That's Abhinav Jangala. He was an orthopedics resident during Marion Toff's pilot program. He was one of the ones wearing that, you know, Rambo belt with a bunch of different pagers. There's a whole team that's on call, but the junior most person is usually the one that's in-house, you know, being the first line of defense.
SPEAKER_07: Abhinav had started out pretty optimistic about this new texting app.
SPEAKER_06: This is a way that hopefully we can have faster and more efficient communication with the emergency department that can be more thorough.
SPEAKER_07: Pretty quickly, Abhinav noticed that this app that was supposed to be making communication between doctors easier, maybe it was actually making communication too easy.
SPEAKER_09: It's like somebody hurts their, you know, their nail gets ripped off in some sort of a woodworking accident or something.
SPEAKER_07: You go into the emergency room, the provider there is like, okay, I'm comfortable sewing up the nail bed and sending this patient home. But, oh, I can just text orthopedics real quick. Hey, it's not a consult. I just wanted to ask, like, what do you think of this? And so now you've lowered the thresholds at the point where you're so available, your work is increasing, but is it changing the care of the patient?
SPEAKER_06: Abhinav would be in the middle of surgery and his phone would ping with these random FYIs and updates and minor questions, stuff that he would have never gotten paged about. Or he'd get trapped on long group texts about patients he wasn't even treating. Let's say you're getting, normally you would get 10 to 20 consults. Now you're getting 25 to 30 texts overnight and only out of the 30 people, maybe 20 of them you actually needed to know about.
SPEAKER_07: All those texts gave Abhinav a newfound appreciation for his pager. His pager could only receive short messages. It forced his colleagues to be succinct, to think before they reached out to him.
SPEAKER_09: I started to see the pager as a way where it puts the person receiving the page in control of the communication.
SPEAKER_07:
SPEAKER_06: This is where the power comes in, the P in Michaela's four RIP factors. In any organization, being able to control how other people communicate with you, that is a potent form of power. You know, being able to turn off your email or put up a do not disturb sign or take a few days to get back to someone. And for junior doctors like Abhinav, who were kind of at the beck and call of all the other doctors at the hospital, the pager was one of the few things that gave them just a little bit of control, a little bit of power over their own jobs. It was this little barrier that stopped people from contacting them all the time. And when they did get paged, they were the ones who had to decide when they were going to call someone back. The texting system had taken that away. Now, ER doctors could send Abhinav a lot more messages, see if he had read their messages, basically demand a lot more of his time and attention. It all started to feel a little oppressive.
SPEAKER_09: But as the weeks went on, Abhinav noticed a kind of guerrilla resistance beginning to form among some of his fellow residents. Some of them started quietly ignoring the app, leaving the emergency room on read. If the ER doctors wanted their attention, they would have to go back to calling their pagers. Is that right or wrong? I'm not sure. But if you are getting message over and over and over again and you don't agree with the communication being increased, then one way of filtering that is to just not use that program.
SPEAKER_07: The new technology only gave power to the ER doctors if the residents they were texting were willing to use it.
SPEAKER_06: At the end of the pilot program, when the three months were up, Mary and Toph got back all the data. And they were surprised to learn that their project had failed. Their big goal, you know, to use this efficient new communications technology to get their patients treated faster in the emergency room. None of that happened. We weren't able to show that it delivered a clear value to patients. It didn't reduce the length of time for patients that were receiving consultations.
SPEAKER_03: There was no statistically significant change in how long patients were spending in the ER.
SPEAKER_06: Now, it could be that the pagers were a good enough way to communicate already, that there wasn't much room for the app to make an improvement. But when Mary and Toph looked at the statistics, they saw something else. A lot of people hadn't even been using the app.
SPEAKER_09: Yeah, they could see in the data the extent of the whole guerrilla resistance thing that Abhinav had been talking about, and how much that had forced the ER docs to go back to old fashioned paging. By the end of the pilot program, traffic on the app had gone down 50 percent.
SPEAKER_06: I remember feeling like, what did we do wrong? You know, like, how could this not have gone well? How could this project have failed? Like, this is clearly something that is needed. So why wasn't it adopted in the way we thought? And maybe it was how we rolled it out.
SPEAKER_05: Look, everybody who works in medicine understands that paging is an outdated way for doctors to communicate. Everybody knows that pagers are not the future.
SPEAKER_09: That eventually in 10, 15, 20 years, hospitals are going to be using more modern forms of communication, like texting. And Mary and Toph really believed that if they could just put this better technology in the hands of their colleagues, they would all embrace it. But they did not. Mary and I would have these great conversations of like, we're going to snowball this thing into killing the pager. And we're just going to have a great ceremony where we're dumping pagers like into the ocean or something, and we're rolling over them with a car or whatever. But we never got there. Right?
SPEAKER_06: For Mary and Toph, the moral of the story is, no matter how great a technology might be, how you implement that technology matters. Because even the shiniest new technology comes with some drawbacks. It might introduce new risks, or disrupt old habits, or call people's identities into question, or maybe change the power dynamic in an organization. Now, any of these drawbacks can be overcome. So long as you do a good enough job of rolling out the new technology, do what you can to foresee the drawbacks and figure out ways to address them ahead of time.
SPEAKER_09: For Mary and Toph, one of the biggest unforeseen drawbacks was this paradox of increased communication. But sometimes having more communication doesn't improve communication. That it can just make people feel more powerless.
SPEAKER_06: That's why it wasn't enough to just replace the pager. They also needed to replace the whole culture that had grown up around the pager. Decades and decades of unwritten rules about how and when you're supposed to page someone. Rules that nobody at their hospital had worked out for this new texting app. And it's not like this was an impossible task. Other hospitals have done it. Other hospitals have replaced the pager with an app. Just not Mary and Toph's hospital. Not yet at least.
SPEAKER_09: I'm going to go into shift this weekend and someone's going to hand me the trauma pager to put on my belt just like I did prior to the project.
SPEAKER_05: Toph's pager will go off. Waa, waa, waa. Number will show up on his tiny little screen and he'll rush off to the next emergency.
SPEAKER_06: The 90s just hit different. The clothes, the pagers, the ads even. There was a time when people were actually walking around being like wazzup. Will things ever be the same again? As if. Because the 90s were the golden age of advertising. That's the 411 on the next Planet Money.
SPEAKER_09: This episode was produced by Sam Yellow Horse Kessler. It was edited by Keith Romer and fact checked by Sierra Juarez. It was engineered by Robert Rodriguez with help from Maggie Luthar. Alex Goldmark is Planet Money's executive producer.
SPEAKER_06: A special thanks to Dr. Theodore Miklau, the chief of orthopedic surgery at SF General, told us a lot of his pager stories. And to Dr. Maria Raven, the chief of emergency medicine at UCSF, who doesn't use a pager anymore.
SPEAKER_09: I'm Jeff Guo. And I'm Nick Fountain. This is NPR. Thank you for listening.
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