Monday, August 22, 2011

Do Surgeons Suffer From "Decision Fatigue"?

What is “decision fatigue”? An article in yesterday’s NY Times Magazine describes “decision fatigue” as what happens when people are forced to make numerous decisions in short time periods. Israeli parole boards apparently grant parole to prison inmates much more frequently earlier in the day vs. later. It has something to do with overwhelming their ability to make choices, causing them to eventually opt to do nothing. Many social psychologists have experimented with this phenomenon and found it also affects willpower negatively. Repletion of glucose helps reverse the problem.

This prompted Paul Levy (@Paulflevy), who is an “Advocate for patient-driven care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement,” to tweet, “Good article in Times: [NY times link] Query: Has anyone seen studies linking surgical error rate to the time of day?”

The answer is, “Yes.” But if the question had been, “Anyone seen any good studies linking surgical error rate to time of day?” the answer would have been, “No.”

Many studies on the purported effect of time of day on surgical outcomes have been published. The results are inconclusive. Some say there is no effect. Some say there is an effect on morbidity; i.e., surgery at night results in more complications and longer hospital lengths of stay. Some say there is an increase in early, but not long-term, mortality. In one study of critically ill non-surgical patients, those admitted at night actually fared better than those admitted in the daytime.

The studies are all retrospective, and there are many confounding variables. With or without emergency operations, it is not clear that time of day is an important cause of adverse outcomes. The impact of the number and complexity of surgeon decisions has not been addressed in any study.

I discussed surgeon fatigue and complications in high-risk surgery in a previous blog. (There is no difference in mortality rates by time of day of the procedure.) Besides fatigue, a very controversial subject, other potential confounders include system issues (number of physician staff, level of supervision, nurse experience and numbers, ancillary service availability, consultant availability), patient co-morbidities and whether a case is truly elective or urgent (not a raging emergency, but not a case that can wait until the next day).

In most instances, a surgeon does not have to make numerous complicated decisions in a short time. It is unlikely that decision fatigue plays an important role in the incidence of errors.

Here’s something that a lot of people do not understand. A bad outcome is not necessarily someone’s fault. There are times when, despite everyone’s best efforts, a patient suffers complications or even death.

References available upon request.

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