'Decision Fatigue' looms large among doctors

M3 India Newsdesk Nov 25, 2018

It is common to tire out when a large part of your day involves making crucial decisions that can affect the lives of people, and no one better than doctors understand this. This is probaby why doctors too are no strangers to Decision Fatigue.

Hypothesize this scenario: A patient visits a doctor with flu-like symptoms, may be indicative of viral infection. The doctor prescribes an antibiotic and sends the patient home.

Despite suspecting a viral infection, the doctor prescribes the antibiotic, just to avoid deciding tests to confirm the diagnosis and devising a treatment protocol thereafter. This scenario is very common in clinics and hospitals but is rarely acknowledged.

A study published in JAMA analysed doctors who had a huge caseload of patients (more than 40) with acute respiratory infection and classified them into two groups- ‘antibiotics sometimes indicated’ or ‘antibiotics never indicated’. Researchers scored probability of antibiotic prescription by physicians as per consultation hours, number of consultations per day, and patient confounders.

The study found that antibiotic prescription was significantly higher in the later hours of the day and in most cases were not necessary for the patient. The results were consistent to prove the hypothesis of Decision Fatigue being prevalent amongst doctors.

Decision Fatigue is a condition that occurs among professionals whose jobs involve a lot of decision-making. It is rampant in any profession and clinicians are no exception to it.We have had examples of influential political leaders and successful businessmen who choose to wear the same "grey" or "black" dress every single day to avoid decision overload.  However, this issue assumes a greater significance in the context of clinicians involved in patient care.

Decision Fatigue: Too many decisions to be made

Decision fatigue is the progressive lack of quality of decisions made by an individual. It involves ego depletion, where the willpower to make good decisions comes from a limited source of mental energy that enables self-control. An old study (1987) by Parker JB defines fatigue as; "The inability or unwillingness to continue effective performance and is caused by excessive workload, stress, sleep loss, and circadian disruption."

Apart from the relentless pressure of a doctor's job, in this day doctors often find themselves facing tasks which they are not trained to do.Administrative duties, record keeping, documentation to avoid legal hassles and so many more. Clinical evidence backs the fact that tired mind more often opts for the choice that it perceives as less risky.

Fatigue is often under-reported within the medical community.Probably because the visible signs are vague or because fatigue involves dimensions such as emotions, tolerability etc.

Interestingly, a blood-alcohol equivalent measure was used by Dawson and Ried, as early as 1997,  for easy understanding and quantifying the impairment caused by fatigue. They studied 40 subjects and compared the effect of fatigue with that of alcohol. What they found was that after 24 hours of sustained wakefulness, cognitive psychomotor performance decreased to a level equivalent to that at a blood alcohol concentration of 0.10%. This study was published in Nature by the title "Fatigue, alcohol and performance impairment."

Decision fatigue in medicine

Sound-decision making is the keystone of medical care. Evaluating symptoms, ordering diagnostic tests, selecting treatments, and managing complexity — and uncertainty — is crucial to the patient's well-being and is necessary to gain their trust. A doctor must be in a good mental state to make all decisions that are in the best interest of the patient. But, as the day goes on, prescription of antibiotics by doctors becomes more likely in the second half than the first half, even when they are not indicated.

The scenario in India

As the population of the country is increasing, the number of doctors is becoming inadequate.

According to WHO, the doctor-patient ratio of a country must be 1:1000, whereas in India it is 0.62:1000. This ratio denotes that one doctor in the country serves approximately 1,668 people, a heavy case load. More patients directly affect the number of minutes a doctor spends to diagnose the patient. Therefore, in a very short span of time, a doctor will have to decide treatments and write down prescriptions.

More so, in a country like India, the common man is accustomed to the use of antibiotics for almost any infection, and most people also use it as prophylaxis for suspected infections. Increase use of antibiotics and the subsequent multi—drug resistance makes it more important for general practitioners to be more patient and take out the time to talk to their patients during consultations. Sadly, very often, by the end of the day, doctors are too tired and reach a state of saturation where they don’t have enough energy to spend on convincing patients that they don’t need unnecessary drugs and instead choose the easier way of prescribing antibiotics.

You can handle what impacts decision fatigue

Studies have indicated that a lot of environmental factors contribute to decision fatigue. Noise, more often than not, acts as a distractor and negatively impacts information processing and short-term memory, interferes with effective verbal communication, and masks task related cues and so does ambient temperature. Overheated, dry rooms cause performance deterioration, and extremely cold temperatures cause distraction and reduce manual dexterity. A temperature range of 17°C to 18°C (62.6°F to 64.4°F) with a moderate humidity (50%) is recommended for best work.[Ramsey JD et al.Journal of Safety Research.1983].

Personal habits of medical professionals also should be aligned to combat decision fatigue.Cooper JB, in his paper, highlights the fact about the effects of caffeine and alcohol use.It is imperative to keep in in mind that though small doses of caffeine can have a positive effect on performance at the same time it may increase tremor and anxiety. And, alcohol in small amounts (20 to 35 mg/dL) too, significantly impairs performance, as do the effects of a hangover.[J Clin Anesth. 1989;1(3):228-31.1989]

A CME by  Ramsay MAE. [Physician fatigue. Proceedings (Baylor University Medical Center). 2000;13(2):148-150.] handled this topic prudently and laid down following general guidelines for doctors to avoid decision overload from affecting their performance. It was proposed that, whenever possible, doctors should avoid any surgery between 2 AM and 5 AM and when this is not possible, they should automate as much of the task as possible and design a clear protocol so that mistakes are reduced and errors are limited to those of omission only.

Ramsay MAE also suggests that after 24 hours of continuous work, it would seem prudent to have a mandatory rest break of at least 5 hours.

He highlighted that it is about time that the medical community addresses this issue before the legal community decides the guidelines for them.


Original article was published on April 12, 2018.

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