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Can Decision Fatigue Lead To Medical Errors?

Do you suffer from decision fatigue when you are sick or anxious or overwhelmed by bad health news?  Does your doctor make less well-reasoned decisions about the 10th patient she sees before lunch?  How about the surgeon during his second operation of the day?  How about the radiologist reading the last mammogram in a daily batch of 60?

A provocative article by John Tierney in Sunday’s NYTimes Magazine adds a new layer of complexity to the body of knowledge collecting around decision-making processes.  Considerable news reporting has focused on how cognitive biases influence our judgment and how many of us experience the abundance of choices available to us as a burden rather than a privilege.  This article adds to that understanding: Our decision-making abilities appear to be powerfully affected by the demands of repeated decision making as they interact with depleted blood glucose levels. That fatigue mounts over a day of making decisions and as blood glucose levels fall between meals. In response, we tend to either make increasingly impulsive decisions without considering the consequences or to make no decisions at all. Tierney describes a study analyzing 1,100 parole decisions by judges over the course of a year:  “Prisoners who appeared early in the morning received parole about 70 percent of the time, while those who appeared late in the day were paroled less than 10 percent of the time.”

The effects reported in the article were found in normal, healthy people.  What do these findings mean for us when we are ill?

I can say with great certainty that when I am sick – whether from a bad cold or from the effects of chemotherapy or recovering from surgery in the hospital – my normally good judgment is, ummm, “shot” – this would be a kind word to describe some of the questionable decisions I have made about simple things like eating, rest, socializing, exercise and medication-taking.  Similarly, my ability to make good decisions repeatedly falters under the strain of having to make the series of significant and often complicated choices about surgery, doctors, hospitals and drugs following a serious diagnosis.  I know I am not alone in either of these experiences.

This is another good argument for having a well-rested, well-fed, healthy companion attached to our hip when we are ill, no?  I wish there were a way to make sure all of us had someone who could serve as that auxiliary back-up decision-helper…

There is no reason to believe that clinicians are exempt from decision-making fatigue over the course of their stressful work days, although Paul Levy found little research on the topic.  I wonder whether and how clinicians and health care institutions would address evidence that casts doubt on the quality of professionals’ decisions that take place in an eight-hour day, regardless of those professionals’ training and technical excellence. The effects Tierney reported are not trivial.  While much of the research he cites is based on studies about whether to buy a green or red T-shirt, for example, those prisoners seeking parole had considerably more at stake.

If the glacial timeframe it took to restrict medical resident duty hours – in the face of robust evidence (not including the research Tierney reports) that their long hours contributed to medical errors – is any example, it is a good bet that in the near term, at least, we will need to depend on individual clinicians to exercise good judgment about taking breaks and maintaining their glucose levels.  Can you see the little notes on their name tags: “Ask me if I have washed my hands and drunk Gatorade in the last hour?”

Of course, for institutional policy makers, this concern is dwarfed by the health care cost crisis, the growing number of people who have no real access to health care, current reorganization of funding streams and a professional workforce that feels overburdened by new requirements.

As patients, however, our eyes are first and foremost on our own health and the health of those we love.  Sometimes we need more time to understand the risks and benefits of the treatments available to us and the decisions we have to make: We need permission from our clinicians to take it.  But try as we might, we can’t always snag the first appointment of the day for our baby’s fever, hold out for the first surgical slot for that heart bypass operation, or predict when our dad is going to fall and crack his head in the bathroom.

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*

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