Hospitalists have to face countless decisions throughout the day, a burden that can be overwhelming and lead to a reduced quality of decisions, especially when they have too many patients.

Decision fatigue happens when a physician’s ability to make decisions is impaired because they have to make too many of them. Humans have a finite cognitive reserve for making decisions, after which the quality of those decisions can be influenced. A recent study published in the Journal of Hospital Medicine found that hospitalists with more than 13 patients at a time may experience decision fatigue.

Why Hospitalists Are Vulnerable to Decision Fatigue

Both the nature of the decisions and the number of them make hospitalists more vulnerable to decision fatigue, said study author Areeba Kara, MD, a hospitalist and interim division chief of General Internal Medicine and Geriatrics at Indiana University School of Medicine in Indianapolis.

“Hospitalists take care of patients who are acutely ill and require a number of complex decisions around their care,” said Kara.

The level of acuity can also take a big toll because every decision that a hospitalist is asked to make during the day can be life or death, said Christina Adams, MD, an obstetrics (OB)-gynecologist and OB hospitalist in St. Augustine, Florida.

“When I was in private practice, I made a million decisions a day for patients I was seeing in the office, but most of those decisions weren’t potentially life threatening,” said Adams.

Not to mention, that in the case of an OB hospitalist like Adams, it’s really decision-making for two patients at the same time, balancing the interests of each one of your decisions with both mother and child.

For example, if a physician has a patient in labor and their fetal heart rate tracing — which shows the fetal heart rate alongside uterine contractions — isn’t where it needs to be, doctors can work to correct it, but at some point they have to decide whether the mother requires delivery via caesarian section instead of vaginally.

While there are risks associated with cesarean section, you also has to concern yourself with risks to the baby. These are all important decisions and too many of them at once can take a toll.

“You’re taking care of two patients at the same time on a day that most parents hope and expect will go perfectly,” said Adams.

How Decision Fatigue Affects a Hospitalist

Research has shown that as the day goes on and physicians become more fatigued they may also become more conservative, not less, in their decision-making. This means they may order tests that aren’t necessary or those that might not yield better outcomes for their patients.

What’s more, a study published recently in Scientific Reports, found that for intensive care physicians, “participants described decisions made in this depleted state as more impulsive, less deliberate, and more driven by gut feeling.”

For the Journal of Hospital Medicine study, researchers looked at what happened at the beginning of a hospitalist’s shift on day-one vs what happened on the seventh day of their shift because most hospitalists abide by a 7-day-on/7-day-off shift schedule. The study found that the number of patients that a hospitalist had affected their decision-making abilities.

“We found that it wasn’t the progression of days that mattered, it was patient load,” said Kara.

Jensa Morris, MD, a hospitalist and associate clinical professor at the Yale School of Medicine, New Haven, Connecticut, said we still don’t have enough data to show that decision fatigue affects decisions among hospitalists, though she thinks anecdotally that it does. It’s something that definitely needs to be further studied. But she does agree the patient load has a huge impact.

“With too many patients you just don’t have time to be meticulous and as a hospitalist, that’s the key to success,” said Morris.

How to Reduce Decision Fatigue Among Hospitalists

The findings suggest that keeping patient load to 13 per hospitalist is a key factor in reducing decision fatigue. Additionally, doing rounds in the morning with your most complex patients can help to preserve time in the day and help you serve these patients before any sort of fatigue has set in, said Kara.

Hospitalists are interrupted every 8 minutes by Epic, secure chat, or some other means of inbox interruption. These digital interruptions, which often amount to questions for the hospitalist, are also a place where both digital and decision fatigue can be reduced.

“The volume of interruptions distracts from focused work and not only is it taking your attention, it often consists of a decision that has to be made,” said Morris.

She added that once you get distracted, you have to refocus on your work, which takes extra time and can take a toll on the analytical thought process. In the end, it can affect a hospitalist’s ability to decide what is the best care plan for each patient.

Morris said that she never makes medical decisions over text, no matter how many secure texts she receives. She always insists on talking to patients and other physicians who are caring for the patient. She happily puts together a group call or video chat to make these complex decisions, which can be done swiftly, rather than enduring hours of interruptions via a secure text message conversation.

Adams said that having protocols in place to protect hospitalists from constant interruptions can also go a long way in keeping decisions that do not require the physician from making it to them in the first place. She said that learning to set boundaries around interruptions is also a great place to start. If it’s an emergency, they’re probably not going to secure text you through Epic, they’re going to call you.

Physicians can also kindly encourage staff to use their best judgment before interrupting a doctor who is sitting at a computer. For example, asking that physician if it’s a good time rather than just jumping in when a physician is working on another question. The same is true when it comes to secure text message questions, they might not always need to be answered immediately.

“Not every nonurgent question you get on the EMR [electronic medical record] text message platform has to be addressed right away while you’re involved in analyzing more complex questions for another patient’s care,” said Adams.

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