Let’s talk about your average workday. Is it a long day? Or is it a half-day that feels like a two-thirds day? Does it start with early morning rounds or taking your daughter to day care … or both? Breakfast? Eaten at home or behind the wheel? Do you have a break at lunchtime? How do you invest that time? Or has someone invested it for you by scheduling a #$@%&*! department meeting?
When does your day end? After the last patient is seen? Or do you stay until your charting is done? Do you make end-of-the-day rounds? Does your office scheduling reasonably approximate the reality of when you would like to leave?
Even more importantly, how does your day end? Are you wasted physically and mentally? Is the last hour and a half a stress packed, clock-watching ordeal because you have to pick up your daughter from day care? And/or be home in time to prepare dinner? Or even just eat? Have you given up on sharing the meal with your family but have promised your son that you will be home to tuck him in and give him a good-night kiss? Did you stop promising to read him a story months ago because you were never there in time?
I suspect that once you have had a cup of coffee, negotiated your commute, and settled into your office routine, the mornings are less taxing than your afternoons. Particularly if your routine includes a drop-dead time commitment when you must leave to do after school pickups and make or join the family for dinner. Do you think the quality of your doctoring is as good in the afternoon as it was in the morning? Be honest! Because I have some data that shouldn’t surprise you.
In a study entitled “Time of day and the decision to prescribe antibiotics ( JAMA Intern. Med. 2014;174:2029-31 ), a group of physicians at Brigham and Women’s Hospital in Boston analyzed the billing and electronic health records of 21,000 clinic visits of adults diagnosed with an acute respiratory illness. The investigators found that the likelihood that a patient would be prescribed antibiotics increased throughout both the morning and afternoon office visit sessions. By the end of each 4-hour session, 5% more patients received antibiotics than at the beginning of the session.
You could argue that, for some, an as-yet-undiscovered quirk of pulmonary bacterial pathogens prompts their victims to schedule appointments later in the day. The authors of the study, however, suggest that the physicians were suffering from “decision fatigue,” a phenomenon that has apparently been described in other professionals, including judges.
But what is decision fatigue? Isn’t it really just a description of one of the things that can happen when we get tired? Everyone with a job is making decisions. “Should I mop behind the toilet or just make a quick swipe where it’s obvious?” Or, “Is it really that important to make sure I have correctly tightened that bolt on that carburetor?”
If you are physically tired or squeezed by commitment to be out of the office at a specific time for another obligation, priority lists can reshuffle as the end of the day approaches. And the quality of care can suffer. Taking the extra time to explain to a patient why antibiotics aren’t appropriate for his or her situation may drop behind the speedier alternative of simply writing a prescription.
I’m sure that this study from a Harvard-affiliated hospital could be repeated using any one of a variety of quality of care measures. It should prompt all of us to rethink how we are structuring our lives. Are you staying up too late watching television or whatever? Has your decision of where to live locked you into a time-gobbling commute? Do you invest your lunch break in a restorative activity, such as a brisk walk outside? Is your office schedule realistic? Have you accepted inflexible commitments at the end of the day that make it impossible for you to spend extra time with a patient when it would probably improve the quality of his care?
Practicing good medicine boils down to making sure that we are in good physical and mental health and have fostered a work environment that fosters good decisions. Fatigue happens, but our patients shouldn’t have to suffer the consequences when it happens to us.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at pdnews@frontlinemedcom.com.
