Special Report

Emergency physicians can undoubtedly list tons of causes of decision fatigue in their daily practice, but one at the top of roll may be the very computer technology designed to reduce it. Take it from James Feldman, MD, who was stymied trying to view imaging studies after a long day in the emergency department. He had forgotten a particular password for a particular application. Frustration mounted as he unsuccessfully tried to log in. Now he chalks it all up to a case of “too many passwords and systems” required for information retrieval. And, since then, he's never without a cheatsheet of all of them. Dr. Feldman, the vice chair of research in emergency medicine at Boston Medical Center, labels the incident an end-of-shift irritant, but psychology experts blame situations like it for a whole lot more. Pile on multiple events of such unwanted aggravation, and what do you get? A diminished capacity for decision-making, they say. The concept of “decision fatigue” is far from new, as any medical resident can attest. But now studies are documenting more precisely how clinical focus can be lost over short periods of time. Ten years after Indiana University's Carey Chisholm, MD, and like-minded colleagues in emergency medicine began looking at how often emergency physicians suffer from work interruptions, more empiric research is showing these disruptions can interfere with judgment, or, in the parlance of experimental psychologists, trigger impairment in executive function. It turns out that the part of the brain that concentrates on problem-solving doesn't work like the flip of a switch, no matter how much multitasking practice it gets in a place like the ED. Turning attention suddenly to a new task in favor of another can compromise the one at hand, and attending to a new demand saps time and energy. There are individual differences in energy depletion, of course, and some people — among them emergency physicians as a group — seem to toggle back and forth better than others. Good planning helps mitigate the cognitive resource loss that comes from frequent disruption of minute-to-minute goals as well. (J Pers Soc Psychol 2011;101[4]:667.) But as Dr. Chisholm and co-investigators found, emergency physicians seem to have more interruptions than their primary care counterparts, who arguably are the closest professional match to them. (Ann Emerg Med 2001;38[2]:146.) In fact, emergency physicians appear to be a group at risk for decision fatigue. This topic has gained new prominence, thanks in part to the New York Times, which has revisited decision fatigue over the past few years. One of the Times' articles highlighted, among other findings, the fact that some parole boards have a higher probability of saying yes to applicants in the morning than at the end of the day. (NY Times Magazine, Aug. 17, 2011; http://nyti.ms/qpAHLe.) This skewing in positive responsiveness has been reported anecdotally by employees whose requests for raises are timed to occur after the boss's first cup of coffee and by anyone with a last name beginning with S who has ever had a teacher grade essays alphabetically by surname. Time pressure, sleep deprivation, encroaching fatigue, and stress can all cast a deleterious shadow on decision-making. When these factors occur concurrently — take, for example, a sleep-deprived resident in a crowded ED who has been under physical exertion for hours — decision fatigue is bound to occur. It can be mitigated if the resident is well-rested and the ED has effective measures to diminish patient flow, but such steps only go so far. Exhaustion makes errors more likely by the end of a grueling shift, as does personal duress, which, unlike tiredness, cannot be easily spotted. “You don't know what is going on in that person's life usually,” observed Pat Croskerry, MD, PhD, a professor of emergency medicine at Dalhousie University in Halifax. Dr. Croskerry, who has termed such factors “hidden elements,” has shown how these psychological stressors can exert a powerful influence on thinking, proving a barrier to cautious evaluation. (J R Coll Physicians Edinb 2011;41[2]:155.) Some controversy swirls around exactly how this happens, which has given rise to investigations of different decision models. (Psychol Rev 2013;120[1]:1.) But experts generally agree that the concept of “dual process cognition” — intuitive and analytical — has helped to distinguish how most decisions are made. In fact, there is so much more clarity in decision-making by understanding this two-pronged cognitive process “that I think it is a fair comment to say that there is a renaissance going on,” Dr. Croskerry said. Simply put, these two processes can be generally thought of as relying on intuition, which is believed to be formed by experience and heritable hard-wiring, or by analytical reasoning, which is exemplified by the scientific method, he said. Intuitive decisions “can be surprisingly quick and accurate, but — and this is a critical ‘but’ — intuition is only accurate in domains where it has been carefully trained,” Dr. Croskerry said. “Training intuition requires a predictable environment where you get lots of repetition and quick feedback on your choices.” That's the way acquiring intuition is described by Chip Heath, a Stanford professor, and his brother, Dan Heath, a senior fellow at Duke, in their best-selling book Decisive. Most people use intuitive and analytical reasoning, but many have a dominant style, depending far less on one than the other. Accordingly, artists and poets would be expected to score higher on the intuitive scale while scientists would show more analytical thinking. Gender differences crop up, too. Women seem to be more intuition-influenced than men, but that appears to be because they absorb experiences in a way that may tap into memory more automatically. It is important to keep in mind that both ways of processing are important, Dr. Croskerry cautioned. “It is circumstance-dependent,” he stressed. If a patient is suffering severe trauma, “you might want rapid intuitive thinking,” he said, adding that “in contrast, when presented with a vague headache, a slower, more analytical approach would be better.” So, do emergency physicians have a distinct, decision-making style because incoming emergency physicians are pretty evenly split between men and women? The answer appears to be yes, said Dr. Croskerry. A survey of 434 emergency physicians showed that they favor analytical decision-making, but even among this group, women had higher intuition scores than their male colleagues. (Emerg Med J 2012;29[10]:811.) Time constraints can override both. “There is the tendency to jump to the obvious conclusion,” Dr. Croskerry said. “In the past, this may even have been seen as a sign of sharp clinical acumen.” Transfers of information in emergency medicine, such as shift changes that involve patient handoffs, can do the same. A possible solution: electronic tools. (Int J Med Inform 2007;76[11-12]:801.) One aim of such etools is to remove the positive bias that can occur when decision fatigue sets in. Positive bias is the capacity, often unconscious, to view a decision confidently. It serves an essential, adaptive function, said Benjamin Djulbegovic, MD, PhD, a distinguished professor of medicine and oncology at the University of South Florida and Moffitt Cancer Center. Dr. Djulbegovic, who has studied the effects of positive bias, stressed that “without it, you cannot move forward.” But over-confidence can also cloud judgment. “We found that investigators, when they design their studies, are overly optimistic in what they hope will be the effects of treatment they can detect,” he said, but they're right only 17 percent of the time. “This means that 83% of the time the findings will be contrary to the researchers' expectations.” The risk of optimism, metaphorically speaking, is that someone needs to cross a river and “sees a bridge when there isn't one,” Dr. Djulbegovic said. On the other hand, too much skepticism can lead to visualizing worst-case scenarios, seeing a bridge ahead and pondering “if there are structural problems that might threaten the stability of it.” Critical thinking as a result is now seen as something that should be taught and assessed in medicine. (See sidebar.) One other partial solution: teamwork in reaching a decision, which offers two fatigue-fighting strategies: cross-monitoring of conclusions and mental stimulation. Yet modern technology often serves to separate people, such as nurses and doctors who frequently are at different terminals with reduced opportunities for interaction. Electronic systems, with prompts for diagnosis and warnings for risk, were designed to help guide decision-making. But the electronic health record has proven, at least in some places, to be cumbersome, requiring access of separate systems or sites to check patient history, lab results, or imaging studies, Dr. Feldman pointed out. Add to that the fact that EHRs seem geared to coding and billing, not just patient care. In fact, the EHR can be so attention-consuming that, at times, it becomes “dis-association by technology,” said Dr. Feldman, who also is a professor of emergency medicine at Boston Medical Center. Under the best of circumstances, just using a computer can take attention away from the patient and put it into a computer screen, he said. “There has to be a better way.” Dr. Feldman said physicians need to do a better job with EHRs to overcome the limitations of paper records and leverage the data in electronic form to improve health care,” said William Hersh, MD, a professor and the chair of medical informatics and clinical epidemiology at Oregon Health & Science University in Portland. Just listening to patient descriptions may be the best spot-on advice for avoiding the mistakes that can arise from decision fatigue. Swedish researchers looking at malpractice claims arising from missed diagnoses in their tele-health program, where nurses who advised patients by phone found it was “a failure to listen” that largely was the cause. Most of the patients described their symptoms in a way that pointed to a diagnostic condition. And patients tended to call back to report exacerbation of the clinical signs or to reiterate their concern, which provided another possibility for making the diagnosis. The study, which sought to find out what went wrong in such cases and why determined that early conclusions about these patients should have been re-evaluated and the need for care reconsidered. (J Telemed Telecare 2012;18[7]:379.) Click and Connect! Access the links in EMN by reading this issue on our website or in our iPad app, both available onwww.EM-News.com. Teaching Critical Thinking Some medical schools are now building critical-thinking evaluation into their admissions process. But can it be taught? Results so far show critical thinking skills can be improved individually by 10-20 percent, said Pat Croskerry, MD, PhD, a professor of emergency medicine at Dalhousie University in Halifax, Nova Scotia. A program at his university to do just that has been implemented, with milestones to measure progress at each of three levels. “There was a group of us who wanted that, and then we were fortunate to get a dean who liked the idea,” Dr. Croskerry explained. Level one calls for understanding how emotion influences thinking and for helping students develop an awareness of the importance in weighing evidence and the need to exercise skepticism in reaching conclusions. Level two helps students form bias-detecting habits — self-checks to ensure critical thinking is occurring, including the ability to perceive potentially prejudicial interferences, such as ego-seeking behavior in themselves and others. Level three expects students to learn to use critical thinking routinely to examine all kinds of information and to demonstrate humility and integrity, among other traits consistent with open-mindedness, in making determinations. The need for this sort of education has not escaped notice at U.S. medical schools either. Two years ago, pediatrician Sean Palfrey, MD, a clinical professor of pediatrics and public health at Boston University School of Medicine, asserted in a call-to-action speech to the Massachusetts Medical Society: “When students and residents first come onto a new service, their supervisors focus on teaching them the new technologies — the lab ordering systems, the note and discharge summary documentation, the way to order consults and retrieve lab results and x-rays. Much more emphasis is placed on those tasks than on the thinking processes they will need to use to evaluate and treat the new types of patients on that particular service.” More recently, this same concern was echoed at the American Medical Association's Physician Consortium for Performance Improvement this past spring, noted James Feldman, MD, a professor of emergency medicine and the vice chair of research in emergency medicine at Boston Medical Center. Support is growing for changes that would put more emphasis on thinking skills and human interaction, he added. Without such changes, “what can happen is asynchronous care,” he said. — Anne Scheck

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