How many readers are equally mentally sharp at 3 pm as they are at 9 am? I know that I’m not. Late afternoon fatigue affects many physicians. Dr. Jeffrey Linder, professor of medicine at Northwestern University, recently wrote a New York Timescolumn entitled, “Don’t Visit Your Doctor In The Afternoon.” Dr. Linder summarized some recent research demonstrating that primary care physician performance suffered in the late afternoon: According to the study, published in JAMA Network Open, doctors ordered fewer breast and colon cancer screenings for patients later in the day, compared to first thing in the morning. All the patients were due for screening, but ordering rates were highest for patients with appointments around 8 a.m. By the end of the afternoon, the rates were 10 percent to 15 percent lower. The probable reasons? Running late and decision fatigue. In other words, primary care physicians were slipping up and making mistakes in the afternoon that they wouldn’t have made earlier in the morning. In my own field of radiology, other studies have shown that radiologist errors increase later during the workday. For example, Dr. Elizabeth Krupinski found that: [After 8 hours] interpreting bone images with subtle fractures, plain film chest with nodules and CT chest with nodules. In every case, there was a statistically significant drop in diagnostic accuracy of about 4 percent! According to another major study, radiologist errors increased significantly in the final 3 hours of a 12-hour shift: On average, errors occurred a mean (± standard deviation) of 8.97 hours ± 2.28 into the shift (median, 10 hours; interquartile range, 2.0 hours). Significantly more errors occurred late in shifts than early (P < .0001), peaking between 10 and 12 hours. So what can physicians, patients, and government officials do to minimize the chances of fatigue-related medical errors? Physicians can take regular breaks and also strive to work shifts 9 hours (or less) in length. When I’m on duty as a radiologist, I make a point of stepping away from the computer screen every few hours — taking a few minutes to walk around, stretch my legs, and clear my head. I owe the patients whose MRI and CT scans I am interpreting my best efforts. Also, the typical shifts at my workplace are 9 hours or less. Another teleradiology company I'm familiar with structures their work hours such that physician shift lengths are typically 7 hours. Sleeping pathology student. What about patients? They may not be able to directly control how many hours their doctor are working. Dr. Linder suggests: So what can you do when you find yourself with a 4 p.m. checkup? After all, not everyone can get the early-morning appointment. Prepare. Learn about screenings you might be eligible for, work with your doctor to figure out which are right for you. Once screening or follow-up tests are ordered, make the necessary follow-up arrangements right away. Patients can also consider finding a good “direct pay” or “concierge” primary care physician. Such direct pay physicians typically offer a subscription model where patients pay an affordable flat monthly membership fee, outside the usual insurance system. As a result, patients have increased access to their physicians. Physicians can also take more time with each patient — typically 45-60 minutes per appointment, rather than the short 10-15 minutes in many primary care practices. Direct pay physicians thus see fewer patients each day and can concentrate more carefully on each patient’s individual needs. This practice model reduces physician fatigue and burnout, resulting in better care for the patient and improved professional satisfaction for the doctor. Legislators can help by reducing legal and regulatory barriers that prevent patients and physicians from contracting voluntarily in “direct pay” relationships. The Direct Primary Care Coalition has a detailed explanation of the legal issues and proposed model legislation to address this problem. Protecting the right to contract is both good public policy and promotes good medical care. To err is human. But doctors, patients, and lawmakers can all take steps to help reduce medical errors related to human fatigue. As for me, I’m going to have another cup of coffee. Source
