Decision Fatigue. For Doctors, Too?

This article by John Tierney in the New York Times suggests that humans suffer from decision fatigue, the tendency to make worse decisions as you make a series of hard decisions as the day goes along.  Here are some pertinent excerpts:

No matter how rational and high-minded you try to be, you can’t make decision after decision without paying a biological price. It’s different from ordinary physical fatigue — you’re not consciously aware of being tired — but you’re low on mental energy. The more choices you make throughout the day, the harder each one becomes for your brain, and eventually it looks for shortcuts, usually in either of two very different ways. One shortcut is to become reckless: to act impulsively instead of expending the energy to first think through the consequences. The other shortcut is the ultimate energy saver: do nothing. Instead of agonizing over decisions, avoid any choice. Ducking a decision often creates bigger problems in the long run, but for the moment, it eases the mental strain. You start to resist any change, any potentially risky move. Once you’re mentally depleted, you become reluctant to make trade-offs, which involve a particularly advanced and taxing form of decision making. “Even the wisest people won’t make good choices when they’re not rested and their glucose is low,” Baumeister points out. That’s why the truly wise don’t restructure the company at 4 p.m. They don’t make major commitments during the cocktail hour. And if a decision must be made late in the day, they know not to do it on an empty stomach. “The best decision makers,” Baumeister says, “are the ones who know when not to trust themselves.”

All of this led me to wonder whether there is any evidence that there is a higher rate of medical errors later in the day, after doctors have made dozens of decisions.  So, in tune with the times, I crowd-sourced the question, posing it this way on Twitter and Facebook:  “Query: Has anyone seen studies linking surgical error rate to the time of day?”

Bobby Ghaheri, MD (@DrGhaheri) tweeted, “That’s why I insist on operating in the morning.”

Braden O’Neill (@BradenONeill), an MD student in Calgary, searched the NIH literature and responded:  “There has been some work on time of day and surgical outcomes but it seems more about the cases themselves.”  The article he cites does have some interesting conclusions, but is not supportive of my hypothesis:

After adjustment for patient and procedure characteristics, mortality had a moderately strong association with start time, but only for nonemergency cases starting 9:30 pm to 7:30 am. As for morbidity, after adjustment, operations starting 9:30 am to 1:30 pm and 5:30 pm to 9:30 pm were associated with a weakly elevated risk of morbidity, but those starting 9:30 pm to 7:30 am demonstrated a strong effect on morbidity.. Subgroup analysis showed this effect was largely a result of elevated risk of morbidity in emergency cases from this overnight time period.

David Rosenmann (@DavidRosenman) from Mayo Clinic noted: “A 2011 study suggested increased maternal morbidity when unscheduled cesarean sections took place at night.”  But that may not help, in and of itself, because we don’t know if the doctors handling those cases have been through many during the day, or whether it is a fresh crew.

Over at Facebook, transplant surgery fellow Kristin Raven reported, “The time of day organ transplants occurs is known not have any effect on outcomes.”

A medical colleague who responded to an email supported Kristin’s finding:  Surgery is interestingly less intense than clinic — people are more complicated than bodies. So no consistent findings have emerged except that emergencies/late night cases have poorer outcomes, which is not a surprise.

A few minutes later, he elaborated:  I should correct to say that it depends on the operation — routine feeding tube placement vs Whipple — and the clinic — breaking bad news about a concern vs routine well baby visit. This is the complicated nuance about medical decisions that exists just as the nuance about financial decisions the article talks about matters.

Meanwhile, engineer Roberta Brown noted, “There are some solid safety statistics about the most likely times for accidents. If I remember properly, it’s the half hour after lunch or a break.” But, pathologist Beverly Rogers suggested that I was probably asking about the wrong specialty:

This is a problem for pathologists too, and actually that would be a better measure – surgical error rates could be due to physical fatigue or other factors not related to decisions, whereas pathology or other diagnostic error is clearly related to decision-making (as well as interruptions, and other cognitive errors.)

I am left thinking that Beverly raised the question in a better context than I did.  We would need to look at specialists who need to make several difficult decisions in a row.  For example, here would be the hypothesis to test:  As pathologists look at dozens of tissue samples during the course of the day, making explicit decisions as to whether the cell patterns are evidence of disease, does their percent of positive findings change as a function of time of day and/or the number of cases reviewed? Tierney describes an element of decision fatigue in terms of “crossing the Rubicon.”  He notes:

The experiment showed that crossing the Rubicon is more tiring than anything that happens on either bank — more mentally fatiguing than sitting on the Gaul side contemplating your options or marching on Rome once you’ve crossed. As a result, someone without Caesar’s willpower is liable to stay put.  Part of the resistance against making decisions comes from our fear of giving up options. The word “decide” shares an etymological root with “homicide,” the Latin word “caedere,” meaning “to cut down” or “to kill,” and that loss looms especially large when decision fatigue sets in.

It would indeed be fascinating to know whether, notwithstanding their exceptional training, medical specialists like pathologists display any such patterns of behavior.  And, in the case of pathologists, would “not crossing the Rubicon” lead to more positive findings or fewer? Perhaps this offers a research opportunity for a rising medical star.

Paul Levy is the former President and CEO of Beth Israel Deconess Medical Center in Boston. For the past five years he blogged about his experiences in an online journal, Running a Hospital. He now writes as an advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement at Not Running a Hospital.

2 replies »

  1. Athletes from amateur to professional level all experience muscle fatigue at some point. The people who tend to suffer the most however are surprisingly those who are less active. Many regard professional athletes as much more likely to have complications with muscle fatigue, however in terms of how the muscles use energy those who are less active than professionals are at a distinct disadvantage.It is very important to understand that when you are working out, you are slowly wearing down the muscles and burning all of the energy that is provided to the muscles as well. Because of the energy that the muscles burn not being able to be replaced into the muscle quite as quickly as it is burned this causes muscle fatigue to become a problem. Sports medicine professionals are all well knowledgeable in exactly how to help professional athletes reduce the problems they experience from muscle fatigue. `

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  2. You were headed in the right direction by the end. I would expect the most decision fatigue for physicians who have to make a lot of decisions where symptoms are ambiguous and the correct decision is less clear. Cases where the physician is consciously concerned about making the wrong decision and needs to consciously entertain different possibilities and their possible positive and negative outcomes.

    Work where procedures are routinized would not lead to decision fatigue, though it may lead to other sorts of fatigue (muscle fatigue or sleep deprivation).

    Here is an important consequence of this research: it strongly argues in favor of using evidence-based medicine to form best practice guidelines wherever they can be supported. You need to look at evidence and make a “decision” when following the guideline, but by having acces to clear rules about the order in which you test different diagnoses and engage different treatments, and using the rules with a confidence, there is much less cognitive fatigue.