Do you make different clinical decisions late in the day when you are more fatigued? Jeffrey A. Linder is a professor and chief of the division of general internal medicine and geriatrics at the Feinberg School of Medicine at Northwestern. Through a recent NY Times article, he would like you to know that there is such a thing as Decision Fatigue, and physicians are not immune.
Decision fatigue is the progressive erosion of self-control as we make more and more choices. Decision fatigue is why car dealerships offer you expensive, unnecessary options at the end of a series of choices and why the supermarket has all that candy right at the checkout counter.
Linder cites a study published in JAMA Network Open, where doctors ordered fewer breast and colon cancer screenings for patients later in the day, compared to first thing in the morning. All the patients were due for screening, but ordering rates were highest for patients with appointments around 8 a.m. By the end of the afternoon, the rates were 10 percent to 15 percent lower. The probable reasons? Running late and decision fatigue. In his own study, Linder and his fellow researchers and found doctors prescribed fewer unnecessary antibiotic prescriptions for respiratory infections first thing in the morning, but that unnecessary prescriptions gradually increased over the day. We found the exact same doctor, caring for the exact same patient, had a 26 percent higher chance of writing an antibiotic prescription at 4 p.m. compared to 8 a.m. What can be done about Decision Fatigue? As always, there is a mix of operational, big picture solutions, and short term personal ideas. Payment based on quality of care vs. face to face visits; improving the efficiency of the EMR; and reasonable case loads could make a significant difference. In the meantime, becoming more aware of your own fatigue and taking short breaks can also help. Pausing long enough to know how you are doing is good for you and your patients. Questions for Reflection and Conversation: How aware are you of your own fatigue? What strategies do you have for those times you are tired and still have multiple patients ahead of you?
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