Ha! I have just learned how to easily get my sleeping pills and avoid screenings I don’t want. Thank You!
20
Workload impossible. Why? Not enough doctors. Why? Too difficult to get into medical school. Too expensive an education. Why? Gee, have you seen them buildings. Do you know the monopolistic dictatorship of the AMA. Why? They want medicine to be a very lucrative field. How? Controlling the admissions process. Outcome? Not enough doctors.Result? Workload impossible. Go to step 1.
14
Dr. Lindner recommends that patients consider having a cup of coffee before their medical office visits. But won’t that elevate blood pressure which, added to the ”white coat syndrome” effect, could lead to unwarranted prescriptions of hypertension meds?
4
I liked the reference to the new car sales technique. So true.
1
I am a retired attorney. There is actually quite a bit of decision fatigue in the legal profession. Attorneys are over-worked for the same reasons doctors are-student loans, overhead and paperwork.
I make my medical appointments for the first thing after lunch. It ensures a relatively rested doctor. I generally suggest lawyer appointments for around 10:30 am. The practitioner has had sufficient coffee and hasn't yet begun drinking. And I'm only half joking.
10
So far I’ve only read the first paragraph....you really have time to get a snack and coffee at 3:00 pm? By that time I’m usually way in the weeds and patients are asking “is Dr. Adams coming soon?” No time for snacking.
4
The system is fouled up and primary care doctors work too hard. Do you have a source for that 18 hour a day figure? Because I think you made it up out of whole cloth. Either that or you wrote this in the afternoon. Sorry l, but I flat don't believe you without a citation.
3
Medicine is a science, healthcare is a business, healing is an art.
11
So, the point is that physicians are . . . human?
2
What about nurses who do twelve hour shifts?!!! Among the many things askew with our medical system.
9
Simple solution:
Nationalize healthcare and put us all on salaries....
If the surgical and procedure-based specialties will allow it.
As usual, it's all about money. The medical profession as well as our corporatized system are to blame.
8
Try being an RN at the end of a 12 hour work shift.
500
@Shappy0
As the 12 hour shift thing keeps coming up, I got ask ask if this results in a shorter work week -three days or so a week?
3
@Shappy0
Or a 16 or 24 hour one.
6
Most doctors in primary care work at least that long on a daily basis usually without overtime. When I was working I started at 8 AM and worked until 8PM. My clinic hours were 8:30 to 5:30. The rest of the time including my “lunch hour” was devoted to the EMR reviewing labs, phone calls and emails to patients. If I had a half day and only booked patients in the morning I could sometimes get done by 6 or 6:30. I worked 60 hours a week but got paid for a three and a half day work week. And routinely worked on the computer from home in the evenings and weekends. Unpaid of course.
Nurses work hard too but not necessarily any harder than doctors and they are usually compensated for the hours they put in.
Doctors should learn from nurses and unionize.
72
A well-written and convincing piece.
Eight years ago, in 2011, the Times Magazine published an article by John Tierney on the same subject, using examples other than in medicine:
http://www.nytimes.com/2011/08/21/magazine/do-you-suffer-from-decision-fatigue.html
Worth reading, as well.
1
Further comment from @bruce.
The John Tierney piece* in 2011 suggests a way to combat decisiion fatigue with brain fuel: glucose in your drink or snack. Not artificial sweeteners or more-complex sugars that take longer to break down.
Try it some late afternoon, Dr. Linder, and let us know the effect, even if an uncontrolled and unblinded experiment.
* http://www.nytimes.com/2011/08/21/magazine/do-you-suffer-from-decision-fatigue.html
What about those late Saturday night/weekend emergency room visits...my sister was given the wrong diagnosis/meds on one, had surgery, and never woke up. That was our first thought once the crying stopped and endures today, years later.
3
The solution is to limit OPD care mandatory within the morning of the day. The doctors served in the morning OPD have to take mandatory leave, and therefore, no private consultancy should be allowed. This is possible only when the number of doctors increase to a level that accommodate the daily avarage OPD patients. I don't think to calculate such optimal no. of doctors is not a difficult task.
1
The three things I learned that increased the probability of my making an error were hurry, interruptions, and lack of sleep. Unfortunately, I couldn't change medical training or practice, but I could change my life, so in my early 40s, I moved on. It wasn't easy, but it beat being chronically fatigued, angry, behind schedule. And this was before electronic records.
In my years of practice, doctors always asked me, "Are you busy?" Not once did I hear, "Are you happy?"
3
This is a shout-out to a doctor: My own internist is seldom around anymore and I was transferred to a colleague in the same office.
He is young, he smiles broadly, he sits face-to-face with me and listens, despite my age I feel no "pat on the head" attitude.
He restates my questions to affirm my concerns, made cogent and wise observations about matters which another doctor never seemed to recognize or acknowledge.
He shook my hand when we were done, said "good to meet you."
The results of the tests he ordered were called into me later that day by HIM, not office staff. Perhaps it is his age and he has not yet been around long enough to become jaded. But he is the epitome of what many patients would like to experience.
I like him and trust him very much and I hope he remains the same for the remainder of his career. He is now my doctor. My guess is that he's as busy as any other doctor out there.
18
My daughter left a family medical practice and returned to urgent care. She sees many more patients in the urgent care unit, but at the end of her day she can go home, relax and recharge. The difference is that the facility where she now works employs “scribes,” who enter all the information on the patient’s visit into a standardized online form. The system is not only ideal for the physician but also for the scribe, who is generally a young person preparing for a career in medicine. This week my daughter is attending the graduation of a scribe she had mentored from the medical school she herself had attended.
13
"If doctors were paid based on the quality of care we delivered instead of face-to-face visits..."
And that is an entirely different problem: How do you measure "quality of care"?
All I can see is that that would only add another layer of time-consuming bureaucracy that would further stress out patients and physicians.
Quality of care is measured by word of mouth. Good physicians will have more patients wanting to see them. Not through more bureaucratic CVA.
The article was thought provoking and described some behaviors which are familiar to me. The unfortunate title seems overly dramatic, since I don’t believe the author ever suggested that advice in the body of his essay. This is a frequent, somewhat disingenuous practice that successfully grabs attention, but which is not an honest summation of what is to follow.
I believe that the behaviors described are less the result of fatigue and more likely due to time constraints. An extra 5 minutes per patient on a 25 patient day puts the practitioner over 2 hours behind at the end of the day, which is unacceptable to the patient and physician alike. It is the impetus to avoid this situation that makes the shortcuts described difficult to resist.
This will be getting worse. There is a national physician shortage. I’ve heard that one third of practitioners are over 60 years old. If not already a crisis, we are very close. Half of all patients will have to see their physician in the afternoon and should not be dissuaded from doing so.
We need to solve this on the national stage. Lifting the cap on the number of residency slots for graduating medical students is a necessary first step.
4
It's not just the doctors - their office staff are clearly overworked as well. I recently sought out the best surgeon in the region for a particular problem, got the referral to him, & although my confidence in his skills remains high, my experience since with his practice has been abysmal. Multiple calls with questions have gone un-answered, I've been sent to websites that say, "Your doctor will answer your questions" instead of getting the answers, I've been unsuccessful in finding out what will happen after surgery or how I can best prepare. It's wearing me out & I may cancel altogether. The surgeon may be a star but staff - while I'm sure they are dedicated - has dropped the ball so often that I'm waking up at night worried. BTW, I ALWAYS seek the earliest available appointment.
4
Hey docs, here's an idea. Those of you in private practice need to get a grip on your schedule.
Accept fewer patients, schedule fewer each day.
As someone who feels she was harmed by a doctor - including his inexcusably hostile behavior toward my adult daughter who is also my health advocate - my sympathies for you are nonexistent.
And here's the rub: Our behavior toward this doctor had been nothing short of respectful, cordial and gracious throughout our relationship. Thank goodness, this drove us to a different practice in Boston, where the issues were immediately addressed with professionalism and grace.
Stop right now taking on so much responsibility because here's the deal ... health consumers (what you call "patients") have an expectation that they will not be casualties of your burn out or petulance.
Zero, that's my compassion, because I walk around with the results of behavior by a self-aggrandizing member of your profession.
6
This assumes traditional schedules. With today’s hours your doctor may start 1pm
1
You especially don't want a mid or late afternoon appointment with MY doctor. She is so behind by the time I get there that I've had to wait two hours past my scheduled time. All the office staff and the receptionist are gone and I'm sitting there waiting for the cleaning crew to come around.
They don't have any good magazines, otherwise you better believe I would have stolen them all.
4
If part of the answer involves support staff, I am confused. Doesn’t it stand to reason that support staff would also suffer from late afternoon decision fatigue?
3
The solution is simple but, sadly, impractical for physicians. I own and run a small business --for the last several years, I've made it a habit in early afternoon, to close my office door, turn out the lights, sit in a comfortable chair and take a 20-30 minute nap. I awaken refreshed and can handle complex issues with re-energized focus. Sadly, our medical system doesn't allow that for those who handle life and death issues. Our doctors pay a heavy cost for being so overworked. And so do we.
3
@Woodtrain50
Doctors in private practice DO have the option of taking on only the number of patients who can be ably served. Those in a hospital ER have a different set of issues. Re: private practice... I don't want an overworked doctor killing me or any of those I love.
1
Retired family physician here. If someone canceled on a Friday afternoon the staff would leave their name in so I could have a break. They needed the break too so we all colluded. A very smart pediatrician I know answered the question “ How does meningitis in a child present itself “ with the answer “ Meningitis shows up on Friday afternoon at 4:30 in the middle of flu season.” I drank a lot of mountain dews Friday afternoon.
NZ
1
There are morning people and afternoon or evening people. This means that the level of care or attention will vary during the day based on the diurnal rhythm peculiar to each person. This can be somewhat alleviated by taking a "power" nap. To pretend it away won't solve the problem.
1
If we get the insurance companies out of the equation, we can do two things: pay doctors more to see fewer patients and penalize them for seeing too many.
9
A great article supporting more efforts in AI for primary care.
AI will not get fatigued.
Confronted with the same symptom set, AI will be consistent in diagnosis.
1
What I'm hearing is, bring snacks for your doctor. Homemade treats the doc can't resist, perhaps? Make the first few minutes of your checkup feel like a break — problem solved. Right?
2
@Alex
You are kidding, I hope. Responsibility for conditions lie squarely in the lap of doctors. Too tough a job? Go work in a service station.
1
2/3 of applicants to US medical school are rejected. There are no dummies in medical school in the USA. I had an operation for a hernia during my second year in medical school. Because of this operation, I was 2 months behind schedule for my last 2 years. This two months caused me to lack the same amount of time for the standardized medical exams that normal students have for preparation I passed but not with flying colors that I had hoped. Without those USMLE scores, I could not get a residency. Instead I went to work in the pharmaceutical industry.
Every year 2,000+ extremely competent graduates of medical school are not able to get a residency. Instead, we have tired MDs working too many hours and nurses being used to plug the gap. The US needs more MDs. I would suggest some major changes. 1) The US allow graduate MDs without residencies to do apprenticeships in Primary Care. Successfully completing these apprenticeships should allow these MDs automatic entry into a residency program. 2) Increase the number of spaces for residencies for US medical graduates. Many residency spots go to foreign MDs. In medicine, communication has been shown to be one of the most important elements in patient outcomes. We're losing over 2,000+ every year of excellent MDs for our healthcare system. We need to do much better!
15
Physicians have a tough job. They are humans prone to error just like other professionals but their errors can lead to injury or even death. Medicare for all, a possibility, no matter how you cut it would put a huge dent in physician incomes which are already decreasing. Problems late in the afternoon. Sure, they are fatigued like the rest of us. I think given the developments above you will see fewer docs and more nurse practitioners and physicians assistants in the future, on the whole quite good, but, not as well educated as the docs. The public should have budding concerns about its future medical care here in the states.
7
I hear a lot of blaming of the doctors. For what? Being human?
Multiple comments suggested that doctors should see fewer patients. Ok which of you patients out there will volunteer to see the doctor less often and for a shorter visit? (We won’t see many hands go up.)
Overhead at a doctors private office is typically at least 50%. They don’t even start earning their living until the afternoon!
3
At least his patients have a primary care physician. The one we had in South Carolina went "concierge" so unless you were willing to pay $3500 up front each year plus a fee per visit, he was not interested in caring for you. We moved to the North East and haven't had a "doctor" for two years. At least we have found an excellent PA and assume we would be able to see a regular doctor if necessary. Not many exist in the US anymore. I did see one when we took a European cruise last summer and I got a tick bite in Poland!
3
This is also a sad reminder of the state of our profit driven healthcare system where one of the highest professionals are working for volume of patients rather than quality of care.
3
What about more doctors and fewer profits?
11
You don't have to go very far to find information on Human Factors and fatigue. There are highly regulated industries such as aviation that have had fatigue management systems in place for years. "Fatigue results in slower reactions, reduced ability to process information, memory lapses, absent-mindedness, decreased awareness, lack of attention, underestimation of risk, reduced coordination etc. Fatigue can lead to errors and accidents, ill-health and injury, and reduced productivity." I for one would like to see my doctor when they are at their best. Surprisingly, when I had the need to take an ambulance here in New Zealand, I found out the EMT's - who are the drivers as well - have no fatigue management system in place other than shift patterns - which were in fact often broken due to demand. So great news, your EMT could be very tired and btw as he's speeding through traffic to get you to the hospital, he could really use a break and a cup of coffee! Fatigue is real. Mistakes are real, some with very high consequences. Luckily, the pilot of your commercial airplane has a well-managed system to avoid falling asleep at the wheel!
1
Could we think about another aspect of this problem? Too few doctors trying to grind through too many patients. "Productivity' can be counter-productive if it emphasizes quantity over quality.
4
As a physician, for over 35 years I have always feared evenings and weekend emergencies happening to me or my family. It is amazing why doctors - the only ones who can assess the mental condition of an individual have never addressed the same issue in the doctors and made changes! The mortality and morbidity rate will definitely come down if the doctors examine their patients with fresh mind!
9
Much easier to ignore your illness, develop magical thinking, sip healing teas, use over the counter meds, hold immunity group herd parties than reschedule your appointment for Monday morning.
Weekends, afternoons, nights are bad for most healthcare institutions and likely any institution that needs a high intensity of services, mental capacity at unpredictable times.
Patients are humans, doctors are humans, doctors are patients, all are vulnerable at different times. Knowing as you said is half the battle.
3
So the others who are helping the doctors, the aides, nurses, and technicians don't get tired also?
Interesting how the "new fangled" computerized record keeping seems to take longer than the old fashioned "write it down" way did. I watched my doctor transition to the new computer system. It wasn't pretty. Everything took longer and it was easier to put down incorrect information or to lose it. Progress.
1
Part of me thinks that this study is not all that strong. Did they control for the fact that more urgent patients are typically scheduled "first thing" or squeezed into a morning visit, so that it seems as though there is more complex medical decision making the morning but that's actually just confounding by indication?
But I do hear the commenters re the lack of control over one's time. I am a psychiatrist who always thought I would be working 80 hrs a week in academia and dealing with the awful EMR and administrators controlling my time but am a million times happier in private practice working 3 days a week (no insurance accepted but I keep a few pro bono cases always). I would never go back.
3
This seems fairly plausible form experience.
3
When working as an IT Consultant, I noted I could only handle 2 difficult 'problems" each day. By noon my will and mind were gone.
1
A corollary is don't get sick at a teaching hospital in late June/early July when medical internships start.
4
A valuable piece. Refreshingly candid. A role model.
1
"In primary care, doctors run late because the workload is impossible. To do everything we’re supposed to for a typical daily patient load, primary care doctors should spend 11 to 18 hours a day providing preventive and chronic care, never mind addressing new problems. "
Okay, I'll bite, who sets this workload? Isn't it the doctors themselves? If primary care doctors were willing to make less money, couldn't they reduce the work load and so solve the problem of decision fatigue in that way alone?
It strikes me that this article is a vivid illustration that the purpose of current medical care is to make money, not to give patients the best outcome.
5
Your observation would apply in a fee-for-Service system; more $$ for more patients seen. However, the opposite is true in an HMO setting, where the doctors are paid a salary and the system determines how many patients each primary care physician is expected to see.
4
@Kenneth Ranson, half a million dollars in student loans which take 20 years to pay off, that’s why.
2
@Kenneth Ranson
Kenneth, you ask the salient question that was never addressed in this piece. Yes, you are entirely correct. Money, money...
2
Many Urgent Cares across the nation are now providing on-demand primary care/internal medicine managing 30-40 patients/d from 8a-8p. Sometimes the patient load can reach the 50's and extend long into the night. Then the same exhausted provider is expected to wake up the next morning fresh and rested for yet another grueling day of providing care to patient's and their families who are demanding answers and instantaneous solutions to complex medical problems many are uninsured Management only cares about revenue and satisfying unreasonable expectations. That's why I quit and now drive a truck.
4
My perspective as a patient - who for years has had to see a couple of specialists several times a year (and will always have to) - I schedule the 1st appt. after lunch. I'm not a morning person and the doctor should have had some food and a little breathing room. I've never asked a doctor about this strategy. It just seemed optimal for both of us.
7
How about a doctor who has more than 10 hours of nutrition science in pre-med. I requested a doctor (Kaiser Permannte) who has a more holistic view of medicine and less mechanical as found in western medicine. I am in the business of mechanics, I surely do not want a doctor with such a limiting viewpoint, especially in my primary care provider.
I want an expert in health, one who practices what she preaches, not a fat, tired bags under their eyes, overworked individual with her own chronic issues advising me on health, look, if you look chronically (not the sniffles or an occasional bad day) sick, sorry, but I will pass.
Doctors need to understand they are in the business of wellness. If they are not examples of health, they need to get into some other line of business, at the very least take a sabbatical and get well.
Would you hire a CPA who uses turbo tax?, an attorney with a criminal record, a broke financial advisor, No.
Sorry, but we face greater issues than tired doctors , I think many of are medical providers are not just tired, but are suffering themselves, they are struggling with their own health issues and limited to what they can do.
2
I surely hope that you do not experience the lack of empathy from your doctors that you show to them here. The foundation of our mad healthcare "system" is how medicine is financed and the delusion that medicine can work like a consumer market.
As for the deterioration of medical decision-making when a physician is tired or hungry, the realization of 40 years of research into computer aided decision support is finally about to happen. This will make many jobs in medicine less lucrative (eg, pathology, radiology), more structure and surveilled for quality control, but, on average, the quality of decision making will become less dependent on the physiology of the doctor before you, and more dependent on the doctor data scientists shaping the machine learned models and guidelines that will be imposed on practicioners by the technological and legal imperatives of our strange medical economy.
4
@0cella. Sorry to tell you, but life is a terminal condition and entropy always wins in the long run.
1
Ppsss, Dr Linder, just an FYI, nurse practitioners provide the lions share of primary care in the US. You might consider mentioning them, if only in passing, when discussing the trials and challenges of providing primary care in our modern times.
8
@Andrew
Absolutely.
1
Went I joined a small pediatric practice decades ago, the senior partner taught me that medicine is time versus money and the way not to get burned out is to make less money and spend more time with each patient. And make time for yourself and your family. I followed his words of wisdom and never regretted it.
20
When data entry time contributes to fatigue and poor decision making, what does it say about our strategies to collect data supporting pay for quality?
This seems to be the heart of the conundrum. We need more data to run healthcare rationally. Acquiring that data makes healthcare run less efficiently—actually, less well.
2
One more study proving that the 8-hour workday is a mistake for jobs that require us to think...which is to say, any job.
6
Afternoon crankiness is also a problem, me thinks. My primary care doc recently was cold and cranky at a mid-afternoon appointment....to the point I was considering a change of docs before I read this article. Now I know to schedule an early appointment....
3
Given the importance of the job, if a physician can't do as good a job at 4 PM as s/he can at 10 AM, then s/he shouldn't be seeing patients at that time.
Or maybe schedule one less patient per day and take a nap after lunch.
6
That’s nice. Maybe you can explain to me why my psychiatrist at Emory University prescribed daily Ativan for me at 10 am. People are depending on you to make the right decision for their help — be it a colonoscopy, whatever. Sorry you need a cup of coffee at 3 pm — but medical malpractice goes beyond the fact you’re tired and must see too many patients. The health care system is broken, and your patients are the ones paying for it.
3
Decades ago I saw a psychiatrist for anxiety issues. She was a classical psychoanalyst--yeah, I know, I know--so she soon had me on the couch.
One day about a month into our late afternoon meetings she was especially quiet. But since she never said much anyway, I didn't pay it much mind. Until I heard the snoring. I quietly got up and left.
My anxiety dropped precipitously after I realized I'd save about a thousand dollars a month.
17
Don't visit your auto mechanic in the afternoon either.
9
This is why it's called "work".
3
Doc
Everyone wants to see you in the morning.
Can you manage?
4
In our 5 physician independent practice, most of us make time between 11-1:30pm to exercise and have lunch. This helps to fix the afternoon slump. Could not have done it if we have non medical administrators managing out time.
18
Dr. Linder,
When did you write this opinion piece?
Ms. Fields
4
Decision-making short cuts can lead to all kinds of trouble. Going with the "easy" choice is only one option. We have many others that are equally bad ...
http://pjlehrer.blogspot.com/2019/03/which-decision-making-short-cut-is-your.html
1
Or you might consider just skipping the visit altogether. See: New York Times, "Skip Your Annual Physical," by Ezekiel J. Emanuel, January 8, 2015.
1
Don't say "Don't" Jeffrey A. Linder, about seeing one's doctor in the afternoon.
We all have to see our doctor when we can... and when we can get an appointment.
Stupid commentary.
7
Studies have shown that judges are more lenient in their sentencings after lunch. Keep that in mind at your next hearing. Similar science, but better outcomes, doc v judges, postprandial.
1
Too much work? Let's quintuple the number of med schools and let any doctor from any country immigrate and practice here.
6
Another good reason is that your doctor may have had a liquid lunch "to relax" before another grueling afternoon. It happens.
1
"And consider having that cup of coffee before your visit."
Heck, BRING that cup of of coffee. Always more pleasant chatting over a cup of Joe.
3
If you look at the numbers in this article, you will see that the differences, although real, aren't very large.
1
I read an article that doctor's are the worst pilots I do not know if that is in the morning or in the afternoon. I had a cup of coffee in the morning and they told me I had to come back the next day because the coffee would throw the test off. It was only a hundred mile drive. I told the doctor and he said "Your State of Mind affects your driving". So I guess it is true for all of us....
What about reducing the number of appointments a day to be manageable and pay attention to the patients without looking at the clock and interrupting them . It will benefit both doctors and patients . It will reduce your earning , dear doctors , but reduce the number of mistakes and improve your health .
5
The reason doctors see so many patients is that their fees have been dramatically cut over the years. They have to see more patients to pay their dramatically rising overhead. Your plan would work very well if the docs could charge what they are worth.
10
It won’t reduce the $200,000 loan balance that is not infrequent for today’s Young primary physicians. MY tuition many years ago was $2000/year. That’s about 2/3 of a Chevy Impala then or $20-25K today. Now $75,000/ year is not an uncommon tuition number. Also Medicare allowed $750 for a routine benign prostate operation. Today they allow $725 in my region. Malpractice insurance is 3X higher and so are my nurses salaries and other personnel. I’m retiring at the end of the year.
12
Rarely has a cohort with an average salary well north of 200 k whined so much about life as the American MD.
3
I wonder how decision fatigue effects a junior resident during a 27 hour ICU call shift...
12
Residency rules have been changed and a 27 hour shift has been outlawed for many years. I think this concept has been well known for quite some time.
4
My wife in in internal residency right now. Your must be a hospital administrator? You probably believe that colleges have effectively outlawed fraternities from hazing pledges on public universities too.. Try telling your boss when you are 350,000 dollars in medical school debt that you have reached your hourly limit of 70 hours a week. Oh by the way your boss also gives recommendations for fellowships, has contacts at hospitals across the country to place you in after residency, has twenty other residents who don't complain and has the ability to fire you (effectively ending your career) for any reason whatsoever.
9
@DLP
This is untrue. Interns (1st year residents) are allowed to do 24-hour shifts now, and residents from their 2nd year and onwards often stay in the hospital for 30 hours straight. @Omentum's insight above is a good one, but your response is inaccurate.
1
As a family physician with 30 yrs experience I have acquired a few pearls to beat afternoon fatigue. First, schedule 90 mins for lunch...and spend at least half that time napping. Second, treat the patient you see at 4pm on Friday the same as you would the patient at 8 am on Monday (we all learned this in residency). Third, refuse to employ the EMR... it is the bane of compassionate medicine. And lastly...love your job...being a physician is an honor and a responsibility and one that can be done effectively for a very long time, even late in the afternoon!
15
In regards to your comment on not utilizing an EMR, it happens to be the law now that you must utilize it. It’s a mandatory requirement of the ACA.
7
My brother is a primary care physician, and there is no way he is spending 2-3x the time updating the electronic medical records rather than with the patients. When otherwise interesting data such as in this article is mixed with such exaggerations about physicians’ workload, it casts doubt on the reporting and the reporter.
6
All my doctors appointments are around 3 pm. I am most alert then, as my circadian rhythm dictates. I’m about to schedule a slew of appointments with doctors that I also have never seen before. Is it necessary to add this to my list of worries? I’ve been more concerned at going at an optimal time for me; I never considered this as problematic.
5
@Person
I've got the same afternoon / evening alertness you have.
I always schedule my internist in the afternoon, and I can tell the later it gets, the harder it is for her, and thus for me.
Even though she is 'her own boss' as she has told me, she is part of a medical group and it's 15-minute slots for everything unless it's a yearly check-up. She is run ragged by mid-afternoon, it's clear.
Besides my weird circadian rhythm, I'm suspect I'm a little bit 'aspie' ... so 15 min. for anyone else really needs to be 30 min. for me because it takes me longer to settle, focus, get into the situation. No matter ... No quarter or consideration is given that either.
I guess we all do the best we can and muddle through.
Good luck to all!
2
Good luck, and henceforth I will try for an early appointment.
Unfortunate headline and takeaway message. Instead of scaring our patients into not coming to the doctor in the afternoon for fear of substandard care, why don't we direct our focus toward getting more doctors into primary care and making more efficient the current administrative/EMR black-hole where endless time and energy goes? Young doctors are avoiding primary care and going into subspecialties that will help them pay back their endless medical school debt. Until the system incentivizes primary care work, we will be overburdened which can lead to suboptimal care -- and THAT'S the problem, not the time of day.
16
@Sam, MD -- yes, put an end to the measly 10-minute appointment blocks, stop the Everest avalanche of administrative nonsense, get more young doctors to choose primary care so those of us in it already don't see yet another generation of doctors and patients drowning. The problem isn't "the afternoon"!! The problem is that your doctor has no time to think about you because they are shuttled from one person to the next just to stay afloat. There are too few doctors in this line of work, and I worry that this single-payer agenda is only going to make it worse.
7
@Mitchell, this “single payer agenda”??
3
Wherever I look, everyone seems overworked! Maybe if we all worked 40 hour weeks instead of 50 hour ones, we'll finally see wages rising, which seem to be stagnant despite lowest unemployment levels in 50 years.
9
I was highly amused to see this because for years it's been a running joke in my family that I won't make dental appointments in the late afternoon. I have always told my family our (wonderful) dentist might be tired and not do his best work.
To further amuse my family, my restrictions also included not going on Mondays (he might be tired and hung over from the weekend), Fridays (he's worn out from the week's work), too early in the morning (he might not yet be completely awake) and finally, not too close to lunch (he might be too hungry to concentrate well).
Maybe someone will do a more extensive study covering these times of day. :)
128
How are your teeth?:-)
13
Dentists as a rule don’t work on Fridays. They figured life out.
7
@Mandeep I go through that same list when making an appointment - not before lunch, not on Monday or Friday, etc. In addition, having cheapie insurance, I'm frequently relegated by staff to appointments on Friday the 13th, gastro-surgery the day before Thanksgiving, etc.
7
Hospitals are being run these days by corporate weenies trying to make more and more and more money. Today everything is about profit. Morality sunk into the toilet long ago in this country.
16
I'm not a doctor, though I play one on TV....
Plenty of people are far better in the afternoons, evenings, or even nights. I've always sucked in the mornings. Going to school for me was a painful. I just can't do mornings. Working afternoons/evenings - though not night - I'm golden.
6
I’m retired orthopedic surgeon. I was the head of the twenty-person medical group. I have supervised physicians and other medical personnel for forty years. This is a well-researched opinion article. Drs. are people. When people get tired, they make mistakes. Guarding against this is important in everything we do from flying an airplane to driving a car. It’s just as important in taking care of patients.
I don’t have a cure for this problem. There isn’t one. When you’re tired you make mistakes. It just makes sense to recognize that and try to control the schedule so that there are many times to take a break. Stimulants such as caffeine help. But keeping a schedule regular and reasonable is the best way to control us.
All of us want to think that our physicians are only interested in them and their health. Obviously, no one can be in the top of their game all day every day.
13
I see a rheumatologist in Boston, and over 13 years, he has been just as on target no matter the time of day my appointments have been. And, he's been in practice a long time. I can understand the stamina issue, but perhaps regular exercise and a good diet keep all things going.
4
I am sorry, but as a registered nurse, I do not think this is necessarily true. How about a provider who worked late or who isn’t a morning person? Their best time might be the afternoon. It’s the general quality of the person, their overall skill, integrity level, and commitment to quality that best determines the positive patient outcome. And their support staff. Some of the best I’ve worked with are the ones woken out of sleep to handle a middle-of-the-night emergency. Some of the worst are morning people except they’re impaired or burnt to a crisp.
Plus, when is the Times going to start using the correct term for the year 2019, “provider” and not just the “doctor,” since you are likely to encounter a nurse practitioner (medicine) or a physician’s assistant (PA) (surgery) these days when you are, “going to the doctors office” or when hospitalized, and both groups are educated and professional.
3
I once had a primary care doctor fall asleep taking my history in a 5pm checkup - I like this article's explanation of decision fatigue better than thinking that I have a boring life (and voice!)
94
@common sense advocate
Funny (and a wee bit scary) story.
8
Hi @Marge Keller - I consoled myself by thinking it's better than if he fell asleep while drawing my blood or giving me anesthesia :) I liked your practical suggestion of scheduling doctor visits in the morning so they are more likely to be on schedule!
4
@common sense advocate
Primary Care docs are so overworked, and at the lowest end of the pay scale for docs. This country has a severe shortage of PCs but doesn't seem to be doing anything to retain burnt out docs or attract anyone to the profession. It's grinding and the work never ends, even days "off" spent at the computer catching up on the endless charting/'paperwork'.
3
In order that people may be happy in their work, these three things are needed: They must be fit for it. They must not do too much of it. And they must have a sense of success in it. John Ruskin
8
Interesting to see just how gullible Times readers are. To be so fully convinced that this article which is only based on how frequently a certain test was ordered ---and published in JAMA of all places...not your go to source for state of the art research papers--can actually prove that all the myriad functions performed by a physician will be predictably impaired just because it is late in the afternoon I find laughable. Well at least they printed this in the Opinion area of the paper and not the science or technology section. Seems like now a days all you need to say is the magic three words " a study shows" and everyone is ready to alter their views. I think I will offer an article to this paper myself entitled "Don't get your medical information from the NY Times Opinion section"
4
@Ledoc254; I find it strange that you call your self gullible!
3
It's hard enough to schedule an appointment with your doctor these days (that's not so far out in the future that it's meaningless unless you have chronic conditions). In some systems (think Kaiser) usually you're referred to a PA or a nurse practitioner (I'm not putting them down - but don't pretend I have an appointment with my PCP if I can't schedule one!) Or now - glory - video appointments. And if it's in person, it usually eats up a half-day of our limited sick time - at best. Now you're telling me I shouldn't go in the afternoon? Why don't we try to fix the problem rather than shift even more responsibility onto the patient? We're already expected to "shop around" for better health care (which is complete bull, as if prices for treatment are available upfront).
This article is a band-aid response - to treat the symptoms rather than the root cause. Can we dig a little deeper? Doctors, nurses, everyone in the medical field is being overbooked because of a largely for-profit health insurance system that is calling the shots on care, *not* the trained medical professionals. And we are the ones suffering.
7
One reason for this .. insurance
2
My goodness, the "boo-hooing" on the part of the doctors in this commentary thread is nauseating. You would think they are the only ones in America working 80 hours a week in lousy conditions. Get a grip, people.
1
when you drop a Big Mac you're preparing, nobody dies and you don't get sued....
6
@drdave39
There are many other jobs that do have life-or-death consequences, and that includes the car mechanic, air traffic controller, cop and firefighter. Just a few examples.
1
Why is the typical patient load so high? If doctors saw fewer patients, they would be less tired, and do a better job. But, as one doctor I know puts it, "The income really takes a hit." So, how much is greed as a major factor in doctor overwork and mistakes?
reimbursement for doctors has been essentially flat for 20 years. over which time, insurance, overhead costs, and school debt has increased dramatically. it's not greed, it's trying to stay even...
6
In primary care physicians are struggling to just break even. The patient loads at that level are necessary just to pay the bills. It isn’t greed, it’s survival.
6
My Dad says that all those years of deciding made him really really good at it. Pre computer he spent a lot of time looking at patients to the point - and he was only half joking - he could "diagnose them the moment they walked in the door". He said it took years to get that good.
So don't despair. Its Hard work. Really hard work. But his walls were covered in images and letters of thanks. h.
78
Here's a thought: Stop whining about how much work you have to do to maintain a "typical daily patient load" and reduce that load to more reasonable levels that will eliminate decision fatigue. Sure, you will make less money by not jamming as many patients as possible into your daily schedule, but think about the patients and the improved quality of care they will receive. You'll make a very good living instead of an excellent one, unless of course you value the economic activity you generate in your practice over the well being of your patients.
4
This sounds like a wonderfully commonsense solution that has been screamed at in numerable administrators for years. Unfortunately, most doctors cannot practice independently and do not have control over the conditions of their practice. This has been taken over by 20 something business managers who have productivity in mind and know nothing whatsoever of medicine.
I am a pulmonary critical care physician who deals largely with lung cancer.I was in an academic medical center for 15 years and finally got sick of People who had none of my training or expertise trying to tell me how to practice. I know practice at a veterans hospital and love it. The elimination of the profit motive allows for sane practice patterns.
21
@smp - If physicians decided to significantly reduce their patient load, they would indeed make less money. As in, no money at all, since they'd be out a job. Could you tell your boss you've unilaterally decided to do a lot less work? No, I didn't think so. Since many doctors are employees now, they couldn't do so either.
13
This article is entertaining but misses many points. The author has time to study this and write letters to the editor. Your comment shows a misunderstanding of the physicians business where 9-5 hours pay everyone but the doctor and the extra work is what they take home. Decision fatigue is interesting because newer grads are and remain much less skilled in decision making because protocols are followed and confidence in synthesis is lower. So the process gets more fatiguing.
Another "Don't Do This" opinion and this one seems to be based on a JAMA study. Dr. Linder, the headline is misleading and I don't know what to think of the study you cite. Fatigue is a real thing but "decision fatigue" sounds like an excuse to use when you have made a diagnostic, judicial or prescribing mistake.
35
@mutabilis
You may be correct...but this op-ed was based on a large general overview involving just under 53,000 patients at 33 clinics. That is quite a large group.
In your defense, the whole premise of "ego depletion" (hence decision fatigue) has been called into question: http://www.slate.com/articles/health_and_science/cover_story/2016/03/ego_depletion_an_influential_theory_in_psychology_may_have_just_been_debunked.html ("Everything Is Crumbling," 6 March 2016).
4
@mutabilis
Is it not anecdotally true that all of us get tired and make mistakes? I guess Doc Savage Man of Bronze would be immune to decision fatigue, but that's about it.
I think what Dr. Linder is saying that anyone can make a mistake of varying magnitudes. Dr. Linder wants to minimize the probability that your doctor will make a mistake.
That's honest; that's progress.
18
I don't go to the doctor in the afternoon, if I can avoid it, because by most doctors I know are running 2 hours late by 3pm.
3
This is a silly editorial. By the arguments laid out, no one should do anything that requires cognition in the afternoon!
I have been a practicing physician for over 20 years. I love seeing patients and caring for them. I despise the increasing administrative tasks including documentation to satisfy payors (with no proof that this provides any meaningful improvement in outcomes for patients), reduced reimbursement that has necessitated seeing more patients in less time, and more and more paperwork that has nothing to do with improved quality of care. Pay physicians fairly for quality work and limit pressures that are forcing them to become part of corporate medicine. Patients and physicians will be healthier and happier and I bet there will be much less "decision fatigue."
4
"The workload is impossible", the author writes. The author is Chief of General Internal Medicine at a prestigious school, Northwestern. Dr Linder, why not intervene to make the workload possible? That's what Chiefs used to do, and are supposed to do. Patients and doctors expect every decision to be prudent. If you can't do that, make it so your colleagues can.
More concerning: Dr Linder himself already commented on the JAMA article in JAMA; there he pointed out 4 limitations to the conclusions, which he doesn't mention here. The article's authors pointed out still more limitations.
The message to me: Don't see a doctor who gets lax at any time, won't take the necessary time but has time for self-promotion, and doesn't tell the facts the same twice.
3
Objectively, this article is a chaff. What’s the scientific relationship between fatigue and antibiotic/opioid/etc prescriptions? It is alluding to a proposition that patients and the preference of appointment time (freedom) are the causes of malpractice, opioid addiction and other medical frauds/bribes by physicians instead of their transgression, cupidity and culpability. For God’s sake.
If the fatigue can be mitigated after a break, shouldn’t the author and perhaps the surfeit number of physicians just take a break. Henceforth they are afresh as new human beings? The article is an oxymoron, isn’t it? The later part contradicts the predicate aforehand. It is a norm that breaks are allowed for physicians who reign in the realm.
It is just another opening for excuses as if in blaming the rape victims.
1
In particular, chronically underslept, overstressed human beings suffer from "decision fatigue," aka "getting tired." Doctors and nurses may believe they can function on less sleep than the rest of us, but 100% of research shows they can't. That's not news, and it applies to judges, police, soldiers, students, artists, waitresses, indeed everybody. "Even" physicians? Yes, even physicians. They are not a special, superior breed of human being. I'm not a doctor, but given the symptoms Dr. Linder describes, I'd advise more sleep in general, and if that doesn't work, maybe a nap in the afternoon. Skip the coffee.
1
No, don't have that coffee just before your doctor appointment. It'll drive your blood pressure up a little bit and --voila--you have hypertension! And another decision for your MD to deal with.
3
This author makes largely unwarranted and unsubstantiated generalizations about late afternoon appointments with physicians. Articles such as these address no healthcare related problems or issues and indeed have the potential to do real harm.
1
Ever think about seeing fewer patients? That might be a good place to start, instead of trying to fit the same square peg into the same round hole day after day.
1
Since there is ample evidence that A.I is not sufficient to peopvide best clinical care, it is incumbent on insurers (including Medicare & VA as well as private insurance) to recognize that redu ced erros saves money so they must abandon the assembly line mentality imposed by clinic & hospital administrators who think they protect the Margin by cranking up volume.
The manufacturing model has been imposed on healthcare delivery because MBAs don't really see the difference between a machine and a relational encounter. Idiotic.
Seeing fewer patients for longer can do a lot to reduce mental fatigue at 4pm.
2
dr linder seems to believe that everyone is at their best first thing in the morning - this is simply untrue.
78
@linh And your evidence to back up your assertion is ???
@JP
The evidence is those of us who are not morning people. I am not ready to function until I get up and have some coffee. I am retired so that might not be until about 11. Worked construction during the summer year s ago. Had to be there at 7 am. It was brutal.
8
@JKile same thing here. Breakfast at 11 a.m.
2
My husband often sees one of his doctors in the doctor's last time slot of the day. It's done on purpose because of my husband's baffling condition. This way, the doctor spends the necessary amount of time with my husband but no other patients are inconvenienced. It's not uncommon for his front office staff to have already left by the time we do. (And for those who think that my husband might not be well served by this doctor since he hasn't figured out what's going on with my husband, my husband is definitely a 'zebra' and not a 'horse' and my husband has been seen by several accomplished medical centers and they haven't figured him out either.)
2
For decades now, residents and medical students and fellows have had controlled call hours. They simply are not allowed to work those long hours they did historically. Getting enough rest is mandatory.
Then they graduate, and are shocked at the long hours needed to fulfill productivity obligations.
So attending physicians are utterly exhausted and burned out.
So then you go to the airport, and lo and behold, your flight crew cannot take off because getting enough rest is mandatory.
hmmmmmm
It is time to mandate enough rest for people who work in health care.
4
@Subspecialty physician
GME rules recently (as in the last few years) enforced an 80-hour workweek for residents and fellows, an average of 1 day of per week, and limited overnight call for 1st year interns and residents. These rules did not apply to me as a medical student (I'm 5 years out of med school), where I regularly took 30 hour calls on surgery rotations. The GME rules have not existed for decades....I think that for the most part, newly graduated docs are well aware of the hours we are facing, and many of us make career choices based on what schedules we are willing to accept.
I agree that doctors do not get enough protected rest, but I don't have any good solutions to the problem.
1
This article, coming from an employee-professor of medicine, where med students and residents do nearly all his work for him.
As an ex-med-student and ex-resident, and as a current private practice physician, I could not trust this man’s analysis any less.
Try working in the real world for a few years, and then tell me about fatigue.
9
I didn't need an "expert" to tell me this. For years, all my doc appointments begin at 7a.m. for labs, no later than 9 a.m. for the doc. Just plain makes sense.
A general observation: for the most part, the working world revolves around the proposition that human beings should be awake and raring to go at daybreak, and ready to go to sleep at 9 p.m.
Last I read, approximately 30% of people function best in the afternoons and evening and, if left to their natural body rhythms, would stay up to the wee hours and sleep 'til late morning. About 40% are "day people," and the rest are some combination of the two.
Maybe, whenever possible, we should just be more flexible about allowing each individual to determine when he or she is at peak efficiency.
4
We ‘regress’ with fatigue, hunger, the pain of holding patient’s distressful states, and time. This is very obvious with little children, late in the day, which is I think part of every parents experience. Adults are the same. We are all human. Medical practitioners are often expected to function in an idealized, almost superhuman way. Colluding with this expectation is very dangerous, as is chasing more money to pay for the house, the school fees, keeping up with the Jones’s etc. Emotional maturity, strong ethical standards, and a capacity to look after one’s basic needs for rest, love, relationships, especially family are critical. I firmly believe doctors should not drink alcohol during the working week, the effects of which are obvious.
You need to hire a better office manager if you are incapable of allocating your time efficiently Dr. Linder.
I supervised a staff of 6 and 2 nternal Medicine doctorswhen I was an office manager to help them achieve a certain monetary income for 1 year so they could be bought out by a clinic.
From 7am to 9am the doctors had no appointments They were expected to use those two hours to their best advantage. I didn't care what they did as long as they held to schedule the rest of the day.
From 9-11am they had two 15 minute appointments each hour with a call-in sick patient. The rest were appointments scheduled as follow-ups to previous exams. Believe me the entire staff was running to keep up with the doctors charting, diagnostic orders, etc. From noon until 2pm the doctors were doing whatever they wanted but if they had a patient in hospital they were expected to stop in and say hello, look over the chart, talk to the nurses, and note something into the patients chart. If no patients were in the hospitals then I really didn't care what they did. The nurses gave vitamin and hormone shots, and I worked with the billing clerk and receptionist. At 2 pm they began seeing follow-up patients again. At 4 pm it was once again call-in sick patients. The office closed at 5:30pm. I took and gave a report to them, they left at 6pm and I stayed to assist a podiatrist or a sports therapy doctor until 8pm, depending on the day.
You need a better office manager.
1
Allow nurses with advanced degrees and pharmacists see patients with relatively minor ailments. Most patients who see family physicians could be helped as much by nurse practitioners or clinicians.
My father came down with gout and I took him to the GP, who diagnosed it as an infection and prescribed Cephalexin—a common antibiotic—for seven days. When it did not respond after three days, I took him to emergency at the local hospital. I chose early Sunday morning, knowing that the hospital would be less busy. After a two-hour wait, the attending physician diagnosed the condition correctly and put him on a five-day regimen of intravenous Cephalexin, along with Prednisone (anti-inflammatory), Pantoprazole Magnesium (Stomach), and Tylenol 3/Codeine (Painkiller). I do not know if the emergency room physician had just come on duty, but his diagnosis and treatment were very thorough, which included referrals to an Infectious Diseases specialist and a Rheumatologist.
The GP subsequently prescribed Colchicine once a day and suggested he avoid fish. The rheumatologist took him off the Colchicine, but she indicated that if the gout flared up he should take Colchicine twice a day. None of the other physicians suggested diet had anything to do with my father’s gout, but the emergency room doctor indicated a correlation with gender and age. These differing opinions were a little troubling.
Prevention is the best medicine. Physicians can actually make you worse—at any time of the day.
1
I thought the article was great and the situations described accord well with my experience. However, the final sentence has got to go. Do NOT drink a cup of coffee before a doctor visit. Your vital signs will not be normal. I've been told this by multiple doctors.
2
Like with many things, technology has exacerbated the problem. Healthcare outcomes were better 40 years ago, and the cost of care was less than half.
Seeing a doctor these days is seeing a doctor type things onto an iPad.
Whatever happened to basic healthcare?
3
What happened was increased government and insurance company meddling in how a doctor and patient interact in their relationship. Before every visit we now have gave to check the state-run prescription database to determine whether the patient is taking a controlled substance; we have to apply to the insurance company receive prior authorization for the visit, to determine whether your employer’s out of state insurance company will even cover your visit, shop for you to get the best deal we can on any effective drugs you may require, and then apply again to your insurance company for another prior authorization for that medication. Oddly they will pay us to do procedures but not to counsel you on the best diet, or develop an exercise program. That’s why you get referred to someone else. Then there are two hours of mandatory electronic charting for each hour we spend with you. Obamacare may have brought you an insurance card but it did not provide the average policy holder with quality time with a doctor. In fact many are simply throwing up their hands and quitting after years of increasing frustration and cost. It did provide a lot of financial and legal support of Silicon Valley’s computerized nonsense that we are required by law and/or insurance company mandate to use. Oh and that medication your insurance company approved may, when you get to the pharmacy be so unaffordable because of all the middlemen getting in the way we have to start over again with the Rx.
14
@Junior
Health outcomes were better 40 years ago? Citations, please.
1
@Junior
Untrammelled capitalism is what happened.
Maybe the doctors had reached their quotas for prescribing unnecessary tests by mid-afternoon.
3
Great advice, but I suffer decision fatigue in the morning! My mental fog lifts around 10 am and I do my best thinking between 11 am and 11 pm.
My reason for booking early morning doc appointments is that they haven't yet had time to slide behind schedule.
5
Academic physicians like the author see far fewer patients than physicians in private practice. If the author is so stressed out and operates so inefficiently, then maybe this is a personal problem with him and his experience should not be generalized.
8
So, the later in the day you see your doctor, the better your chance of getting a clean bill of health!
2
This common sense article also militates for the patient being prepared for the visit. Accurate, concise communications could lessen the burden on all participants.
3
@R. Anderson
That is hard to do, depending on the vulture of the patient. Plus, there are studies that show that many physicians do all the talking . . . they may talk over the patient or turn away when the patient starts to speak ( maybe to work on those EMRS)-- closing off communication.
Perhaps some form of regulated capitalism has its place in society, but it has no business being a work model for health services, emergency and care. Some of us are night owls, by the way, and we are better and more competent from about 2pm to 10pm. Working 9-5 M-F (now 8-6 M-F and some Sat) is some sociopathic white male anachronism. Humans don’t seem to be able to break free of capitalistic rule.
3
In my experience as a patient, doctors these days pretty much diagnose the disorder, then present a set of options for the patient to choose from. The doctors don't seem to decide much, so no decision fatigue, right?
5
The paternalistic medical practice went out with Marcus Welby MD. We try to present options to engage in shared decision-making when’d discussing treatment options.
4
I always take afternoon appointments to see my doctors. Last time I saw my primary she kept yawning the entire time I was in her office. I told her, your patient prescribes a good nights sleep.
4
Thanks for writing this piece. I am a dermatologist and pathologist. Decision fatigue is real and, at least in my experience doesn't relate to just feeling tired in the afternoon. When I function as a pathologist, there are only so many diagnoses that I can make in a work day. I wouldn't describe it as an "erosion of self-control" as much as a blunting of the mental acuity which needs to be present to make very important decisions about a patient's health. Knowing that, I limit the amount of case sign out I will perform in a day, no matter what the clock says.
I sense cynicism in some of the replies. I believe that I represent most physicians in writing that the awesome responsibility we feel in caring for patients is ever-present in our minds and hearts. Avoiding decision fatigue is important, for that reason alone.
12
And if you are female (and especially over 65), go to females only! Males resent management as a team approach. The females tend to have less of the Doctor God Complex going on like the male ones do - especially the former military ones!
Know who you are going to and always ask questions. If they resent or do not listen to the questions, change doctors!
6
I used to believe that, until I met a few doctors who didn’t believe me, treated my symptoms as a psychomatic or mon-existent, simply because they couldn’t figure out what was going on, despite some obvious clues. They too suffered from the God complex.
Now I try to see whoever comes highly recommended and who shows that he or she is actively listening and believes me, and attempting to search for an answer
3
@ml
I had fibromyalgia for years before a female doctor referred me to a male who not only knew what it was, but knew how to treat it without all the antidepressants which I had refused to take ( and did not have to go on other meds because of the permanent side effects. Since she moved away, every single male I have seen since could care less and take offense if you question about anything. I live in a rural area and have to travel 2 hours to see a half-way decent doctor. In rural areas we have the ones who have had to move, have drug problems (which peer review protects), cannot make it in other areas or hd to move for various reasons(their backgrounds are all vague and imporssible to find), are nearing retirement, retired military - in other words, rural America has become the dumping ground for doctors. American healthcare is for the rich or those who still have insurance via work.
Shocked but not surprised at surgeon’s wife who writes “ after 35 years in the game” to refer to her husband’s years of practice. I have been to doctors at 11:00 am, 1:30 p.m. and 5:00 p.m. I have been a victim of demonstrable malpractice, doctor error, including misdiagnosis and subscribing the wrong meds. In addition the doctors have been rude and dismissive at all hours of the day. There is no good time to go to a doctor. If you stay home you die. If you go they may kill you.
3
@old lady cook
So don't go.
2
if you want something from somebody the best time to ask is right when they get back from lunch.
1
Do some doctors still break for lunch? Won’t work in my practice. Way too much to do—can’t allow time for respite mid-day.
7
Dr. Linder: Of course no one should visit the doctor in the afternoon. Isn't "pm" short for professional malpractice?
1
Anyone who reads this article and then schedules any appointment or any other important activity for the afternoon must be suffering from decision fatigue. Hmmm, I wonder if I should take that 4:00 pm flight?
3
Give me a break. If you cannot be counted on to be able to use your brain after lunch maybe you should schedule less patients after noon. That you cram as many patients onto your schedule as possible chasing a dollar is on you.
I irked on aircraft in the middle of a live airliner trip for many years, troubleshooting was my primary job, trying to figure out what was causing the fault on very complex systems. I couldn’t throw a antibiotic prescription at it and hoped the 250 on board survived. I was also subject to condescending know nothing pilots and a dispatch department that only cared that the airplane was airborne, never mind the jet blast and a ramp that was often 110 degrees.
If you cant handle the heat in your air conditioned office get out of the kitchen. Maybe you shouldn’t have married that gold digger wife that always wants more stuff.
2
There are optimal times to visit all healthcare providers. My cat's "doctor" told me that Friday afternoons are a bad time to visit the vet. That's when all the bad cases who have waited until the last minute to come in - come in. But I believe that doctors - both human and animal - are trained professionals and do the best they can the majority of the time.
6
I disagree. I have on occasion visited my doctor late in the afternoon and found him much more relaxed and willing to talk. Since my biggest complaint about doctors is that they never have time to listen, these late-afternoon appointments have become my favorites. I can talk to him about problems he just doesn't have time to listen to early in the day. He may be tired, but he's also more open to listening, and more open to long-term solutions.
The past five years my CBC and other hematological values have been flagged by the lab but my doctor always shrugged it off as nothing. I have now developed polyneuropathy due to severe anemia, and I am outraged because I feel this diagnosis is uncalled for and could have been prevented. I always voiced my concern but I was dismissed, he did not order further testing such as Ferritin, which is now a 6. I saw my doctor in the afternoon.
2
Its a great idea! but we would need twice the number of physicians; so that there can be coverage for the morning half and afternoon half OR better yet; we could all just see patients for part of the day; therefore, doubling the time it takes for a person to see a physician.
GREAT IDEA!!
This essay assumes that the doctor you see at 8AM is competent. I moved to an area (Tucson AZ) where finding a competent doctor at any time of day is close to impossible. The last time I changed PCP's, it was because the doctor walked out of the room when I still had a few questions to ask (which went unanswered) and he completely forgot to order a mammogram. And that was an 11AM appt. I wish time of day was a primary factor; unfortunately, bad doctors are bad starting with their first patient til they go home.
5
Thank you for your column, Dr. Linder.
I wonder why it took so long to reform the schedules of medical residents at hospitals?
This business of keeping young physicians on duty for 24 to 48 hours seems patently ridiculous. I can only see that it conferred marginal learning, and a lot of negligence.
I wonder what the etiology of medical resident training was in previous decades? WW ll? A patriarchal structure of the medical establishment? Older doctors wanting to lord power over younger ones and patients?
Thank goodness the perception of doctors is coming back down to earth.
2
As a physician I disagree very strongly with your criticism of longer resident work hours. Contrary to your assertions, it teaches professionalism, prioritization of the patient over the self, and allows for experiential learning and observation of the development of full disease processes. It eliminates multiple handoffs of patients which have been shown to Generate errors in patient care.
Rather than adopt some trendy tagline, I strongly suggest you educate yourself about the issues before condemning system to give us the greatest medical system in the world with little more than politically correct cliches.
7
Actually the answer to all this is to avoid visiting the doctor as much as possible. Other than emergency care, the medical system is basically about the selling of drugs, which are all toxic. Any substance ingested is toxic if it is synthetic, ergo the adverse effects warnings in every pharma ad. Doctors, no matter how smart are trained in pharmacology and know essentially nothing about natural foods, herbs and medicines, which are the basis of the majority of drugs that are synthesized by pharma. These drugs, duly prescribed and taken, kill over 100,000 patients per year (per a year 2000 article in JAMA authored by Barbara Starfield). And lo and behold when they prescribe the wrong drug, you go back to them, pay another copay and then pay for a different drug. That is, you the patient, pay for their mistakes. Outsourcing your health to a paid hack of the pharmaceutical company is a bad choice. You must become more responsible for your health.
5
The problems described here make a strong case for patients to prepare for office visits by informing themselves as much as possible about their medical problem and treatment options. The informed patient can make better choices when the doctor suggests various options, and become a more active partner in medical contacts.
2
@William
I always told patients - and have taught young doctors for decades - that the best patient a doctor can have is one who understands their disease as much as a lay person can.
Such a well informed patient becomes an even more valued partner in the relationship, and makes therapy much easier for all.
3
@Bob I will make sure only to get diseases that I've researched ahead of time.
Seriously, you are of course correct that it helps the clinician if the patient knows a lot. But typically a patient is scared or worried or in pain. And you surely know the story about the patient who, after a long explanation by the doctor, replied, "Thanks, Doc. But I don't remember anything you said after you said 'cancer'."
3
Thank you for letting us know that research shows doctors prescribe more opiods late in the day. That's usually when my back starts hurting.
1
O my, now the poor receptionists at doctors' office across the country will be besieged with people wanting to change appointments to the morning.
Ugh
5
The corollary to this is never go to the ER in July. That is when the freshly minted interns start and have no idea what they are doing.
Office medicine is ripe to largely be done by AI anyway. We will all be talking to some robot with an Alexa-like soothing voice, with its infinite database and instant record keeping. No two hours of book-keeping for every one hour of patient face-time for a robot. The AI behind the robot will know immediately of diseases circulating in your community and efficacy of different treatments. It makes sense for medicine to go this way, although I think it will be unfortunate.
1
@Scott Werden
Your corollary is based on the false premise that interns in July are less supervised. The reality is, EVERYONE is paying as much attention as possible in July, both interns (because they have so much to learn, and are terrified of making a mistake) and their senior staff who supervise them (who know interns have lots to learn, and also know THEY are responsible should the intern make a mistake). July is a great time to go to the hospital. A few months in, when confidence rises but skills don't necessarily keep pace...that's when I would keep my guard up.
3
Of course one should avoid visiting the doctor in the afternoon. What do you think "pm" stands for? Professional malpractice.
/s
1
My doctor starts seeing patients at 8:00 AM
His last appointment of the day is at 3:00 PM
He spends the hour from 3:00 - 4:00 PM attending to paperwork and answering phone messages - as he did with me when I left a recent message asking if he thought I needed a measles booster -
He also devotes an hour in the evening - around 7:00 PM - to call patients with important test results.
I've been with my doctor since 2005 and have always received outstanding care -- he's always alert, attentive and thorough --
Lucky me...
6
And he’s still working at 7 and not seeing the patients that get I’ll late in the day. You are lucky.
I really do not understand why nurses must work 12 HOUR shifts. They are amazing. Primary doc are wimps.
5
@Marie Walsh
Belittling physicians only contributes to burnout of physicians.
Nurses work 12 hour shifts _3 days_ a week. Often they also have the choice of 4 10 hours shifts a week or 5 8 hour shifts. Notice the word shift, nurses aren't forced for free to catch up on charting or call patients with results after their shift is over either. If they work more, it's paid overtime.
Resident doctors work 36 hours in a row and 80 hours a week only because there's limits. Before those limits were implemented they'd routinely worked even more. Would you consider everyone else who doesn't work these inhumane hours a wimp? Stop pitting members of the health care team against each other. If anything you need to ask the hours insurance and hospital CEOs are working .
35
You are so right. We do the insurance company and the hospital bidding for them and not the patient or doc or nurse.
2
@Marie Walsh
The same problem likely affects nurses at the end of a long shift.
1
This is such a generalization. My husband is a surgeon and, no, he does not operate at 7 pm. After 35 years in the game, he only accepts 8 am OR time. His office hours are in the afternoon, along with minor surgeries so that the complex ones can be done in the morning. All of us, as professionals, should understand how to pace ourselves for optimal performance. Working for a hospital or HMO, with production demands, impedes performance significantly whereas, in private practice, a patient will not accept a doctor who speaks more to the machine than to the individual.
72
@legal-lioness
That’s because your husband is 35 years into the game. Those of us who are young and take call are operating at 7 am, and 7pm, and 2am, and whenever the scenario requires it. OR time only at 8am? We should all be so lucky!
28
@legallioness If your husband in on staff at a hospital, he likely takes call, including call for the ER. I doubt that he comes to evaluate a patient in the ER and tells the patient "I know that you have a surgical emergency but it is now 8PM and it's just going to have to wait till 8AM because I don't operate in the evenings."
7
My sister is an anesthesiologist. She works 5:30am up to 8:00pm. This is not a personal choice. The hospital demands it. You work or your fired. Also don’t forget those overnight calls every week. The overwork and fatigue is a real issue. It hurts doctors and patients. We as a society need to be managing this better.
16
I was a solo private practice non cosmetic dermatologist for over 40 years, and my patients were seen and treated only by me. I started at 8:45 and worked until 5:00. It was a great source of pride to me that I was virtually always on time.
Several devices I used for four decades that other doctors could use:
1. I adored being an MD and loved seeing patients in my office - and this was reflected in the tenor of the practice. I was continually energized by seeing patients (and that is not an exaggeration).
2. Probably most important: I made sure that the schedule was MY servant, and not the other way around. I was not going to work myself into hysteria - or worse.
3. I had 15 minute blocks built into my schedule at hourly intervals in which there were no patients: that way I could catch up if I got behind (which rarely happened), and it gave me "breathing room" to finish charts, schmooze with the staff, and nosh a little. This allowed me to always adhere to my schedule. Patients knew they would be seen on time.
4. I carefully designed my office setup and procedures so that I could accomplish what I needed to do (ranging from exams to surgery) as efficiently and effectively as possible.
5. I declared 1.5 hours for lunch for everyone (and often partook of a snooze, since I had an apartment upstairs from my office!). This longish break allowed all of us to recharge.
Because of the above I never got the droopies in the afternoon.
334
I wish nurses had the same kind of control over their work-life.
46
@JenB
In my office the nurses were consulted about scheduling and procedures.
A happy nurse is a marvelous asset: an unhappy one is quite the reverse.
47
Great that you got to manage your schedule to your liking! However, most physicians and physician assistants (like me) have very little say in how much work we have to do. I have worked at my current job for eleven years and we never have a scheduled lunch or dinner break. Maybe you could make a few calls for me.
62
Maybe think about what happens when your elective surgery is scheduled for 7pm and the whole staff, surgeon and anesthesiologist has already been working nonstop for 12 hours
4
How about - insurance-permitting &/or budget-allowing - going to clinics or clinic networks where they have well-vetted doctors who work overlapping shifts (i.e. 6am to 2pm team, 9am to 5pm team, 12nn to 8pm team)?
That way, the chances of being seen by an understandably fatigued doctor may be lessened, and the doctors still get to work full 8-hour shifts to help pay off their school loans &/or catch up w/ their own growing expenses (ex. raising families of their own).
Also, depending on the symptoms/ailments involved, perhaps some consults may be done via telemedicine - rather than taking on the stress & drama of driving roundtrip during breaks or after work hours, just for an in person consult w/ a hungry/fatigued doctor.
Not all doctors who work long hours are greedy for money earned from insurers, private fees etc.
In fact, many doctors do genuinely want to save the longevity & quality of their patients' lives, leveraging their own growing professional experience - even if it just is so happens that he or she might be the only doctor in town (common in rural or economically depressed, out of the way areas).
We need to be pragmatic & creative w/ the evolving technologies we have to make the most of modern doctor-patient interactions.
2
Interesting that the conclusion is for patients to be wiser consumers.
Why is it forbidden to say--stop triple booking. Hire more physicians for the practice? If the system is sick, why is the patinet being tol to "learn about screening, etc?"
8
You miss the point. There are many reasons to be more informed, and it’s under your control.
And do not go to a teaching hospital in June. That's when all the new medical school graduates start their internships. You'll know they are new if they are wearing crisp new white coats.
2
@mark
Actually, July.
1
@mark LOL, chose when you have your heart attack or car accident.
1
I’m not a morning person. I make my appts in the afternoon. There must be MDs who are night people. Let them start work at 1 p.m. Voilà! No more fatigue.
6
Let’s cut to the chase! Maintain good health! From garbage generics to Doctor’s fatigue, (and most of them get in the field today, for the MONEY!) the patient is doomed! The horror stories of our time!!!
2
I don’t think you know many doctors.
I do and none of them (in primary care, anyway) went into it “for the money”.
If some did they must be sorely disappointed
3
"We spend one to two hours updating the electronic health record for every hour we spend with patients."
A professor of medicine has just admitted that electronic medical records actually harm patients. The contrary stream of propaganda that claims those records will vastly improve patient care are basically lies.
Before I went on Medicare (in other words, when I had to purchase insurance), I told my physician that as long as he was typing into that machine I would answer his questions with the same care I would answer questions from the police. If a statement or diagnosis went in there in an improper way, it could have affected my insurability.
Meanwhile, the professor admits that telling my physician important personal things is a waste of my time, because he lacks the time to troubleshoot anything. Incidentally, I already knew this from personal observation.
Electronic medical records are a scam by the government and Wall Street to vacuum up your personal data (anonymized...haha) and use it to make money. The pharmacy industry makes more than 3 billion dollars a year on that anonymized information. Industry wide it's probably tens of billions.
Whenever I sign one of those HIPAA notices, I always tell the person who gave it to me, "I know exactly what HIPAA means--it means that everyone has a right to my medical records, except for me." Data fusion firms like Axion take all that "anonymized data" and combine it with other data to "de-anonymize" into a dossier.
4
The only thing wrong as that private docs have been saying it for years and don’t have time to argue unless you have a computer company willing to listen.
Go in June but early and don’t handle fireworks on July 4.
When you say, "even physicians," how do you mean, exactly?
I thought the era of doctor deification was over, but I guess I was wrong.
I hate to break this to you all, but physicians are regular people who had all of the right supports in place such that allowed them to keep handing in their homework in school for longer periods than many. They are also people who are excessively concerned with status (and thus are more insecure than the average person)--as all anonymous surveys of first year medical students consistently show.
This is not to knock the wonderful work many docs do. But so do many people in many walks of life do wonderful work. (And, let's not forget that the real superheroes of medicine are the nurses.)
For heaven's sake, don't feed into this pipeline of insecure people going in to medical school in order to find status and validation by writing nonsense about "even" physicians getting tired.
4
@EB
I'm so glad you have described me as "insecure" and "excessively concerned with status". Such judgement! I went into medicine to help people. And guess what, I make less than $70K a year, now 5 years out of med school, with advanced training necessary to diagnose the kinds of cancer that I do. I drive a basic car that is 7 years old only because the car I had from 1996 was totaled when I started residency. But yeah, I am obsessed with status! You sure do know me!
3
@Dr. ES it’s called “delayed gratification.” And cars aren’t the only way to signify status. Indeed, your old car is part of your badge right now, isn’t it.
1
Quite true.
Another reason that it is a bad idea to staff primary care and urgent care clinics as well as emergency departments based on 12 hour shifts.
My clinic closes at 8 PM and patients arriving at 10 minutes before closing have no clue they may be shortchanged.
At least the for-profit company that operates the clinic makes as much on the last patient as the first.
2
The root cause is greed. More patient visits yields higher income for the health care service provider. All the other explanations are simple excuses.
2
Good thing I was the first and only patient of the day, signing my life away to my surgeon at 2:30AM and getting emergency spine surgery to save my life 90 minutes later at 4AM SUNDAY morning Thanksgiving season when my surgeon and his assistants were wide awake. I'm still around, so I guess the surgical team was awake enough and any partying Saturday evening did not affect their performance much.
5
Thankfully!!!
So why do residents and/or interns get put into positions where they work 36 hour shifts (even 12 hour shifts are probably not ideal in some environments)? It seems that the old guard feels like "this is how we learned, so these young doctors in training need to go through the same thing." Rather than setting more realistic expectations.
My father interned at Kaiser in San Fran in the late 1950s and used to talk about how he and others felt like zombies late in their 24 to 36 hour shifts - how does that serve any patients well? Sleep deprived doctors (and nurses) have to make critical decisions, but their cognitive abilities are impaired.
I generally try to have appointments as early in the day as possible for many reasons, but when the physician is 45 to 60 minutes behind schedule on a regular basis, afternoons become very late.
12
@nvguy
Well, they don't anymore. There are work hour restrictions for trainees that protect them from those old fashioned 36 hour shifts (which I stumbled through many years ago). But there are no restrictions for physicians once they complete their training, which is what people are speaking of here.
1
Airline pilots and crews are only allowed to fly for a certain number of hours, and have built in rest periods. There are also procedures in place to make certain a pilot doesn't immediately get back in the cockpit after a particularly challenging/difficult flight. That we work doctors beyond their natural limits from the time they enter school makes little sense.
46
@H.L. True, it would be lovely if the ER doctor or surgeon had a co-pilot or autopilot option.
It's not possible for everyone to visit the doctor at the start of their shift. We need to reorganize the way people work and give serious consideration to the fact that attention is a very scarce resource. If that means doctors work less, we need to be prepared to pay more for their limited time.
15
It’s about time afternoon decision issues are being recognized as a problem. Expecting people, regardless of profession, to function at the same levels of effectiveness and efficiency throughout their daily work is not realistic.
Two to 4:00 PM in many Mediterranean and South American countries was a time for lunch and a nap. Stores and many offices closed and neighborhoods were silent. Children needed to play quietly if they wanted to avoid being “shushed” by nearby adults.
I personally said or made many regrettable things if I made the mistake of attending a meeting in the mid afternoon.
Restructuring the hours of the work day might result in improving productivity and reducing mistakes and stress.
5
@Glenn Eisen I like the idea of your campaign. I even have the tagline: "Americans say Yesta Siesta!"
1
This issue has been covered and researched for many years in psychology. And different cultures around the world have their own ways to address this issue. One Cornell psychologist had recommended a long time ago for folks to have a 15 minute nap, no more than that as you might hit REM. In Taiwan, it's not uncommon for lunch breaks to be longer at some companies, where office workers might bring pillows to nap quickly at their desks. In Japan, you might see some office workers sip a small amount of coffee before shutting their eyes. And obviously there a siesta culture in Spain.
2
Also worth noting that blood pressure peaks in the afternoon, so if that’s a concern, go in the morning.
1
I used to get an appointment about 3 weeks away at the time they gave me, now my GHI dropped my OBGyn and I have been without a PCP for 5 years...
But gosh, I'll be sure and book an AM appointment!
What a divided country we live in.
2
Have doctors do medical care that requires decision making. Let support staff and nurses do everything else.
2
@Louise, nurses also experience late-in-the-shift decline in energy and focus. Nurses frequently do not get the breaks they need to maintain full energy and alertness. Medication errors, which can be deadly, may result. It's not just the MDs that suffer from insufficient nutrition (lunches skipped or cut short) and fatigue (rare breaks). I am a nurse and I speak from experience (mine and coworkers).
8
Part of the answer to this problem is: Allow physicians to spend more time with each patient. That means paying them more fo each visit so they don’t feel they have to see 25 patients daily to earn a decent income.
A retired Family Medicine from a small city in rural Minnesota
25
That’s what I’ve tried to do and I’m bombarded with all the statistics I have to pronto prove I’m doin a “good” job to people who have no idea what that looks like. I’d rather ask my patients.
Thank you for your post. I would totally agree and congrats on your retirement.
2
My doc is great. She doesn't try to persuade me to do anything without my own personal research, and she can always rationally-defend her recommendations.
I listen to her always, but am persuaded by her statements maybe 50% of the time. That works well for her and for me.
I like her and respect her, but definitely don't do knee-jerk compliance with her recommendations/
4
And always have surgery early in the day and early in the week.
Early in the day means the surgeon and OR staffs' aren't fatigued and feet aren't hurting yet.
Early in the week means you minimize the weekend days in the hospital when the second-stringers are on duty.
16
@Johnny Stark
Honestly? It gives people less of a chance to mess up by eating etc and if they aren't there in the AM they won't be there. Afternoon is usually in house.
It controls for human nature, but on the part of the patient.
@Johnny Stark - The second stringers on the weekends? You don't seem to know how hospitals work. Everyone has to take their turn covering weekends.
4
We all take turns working on the weekend. It’s called “on call”.
2
Reason number 874 to rely on software running algorithms in health care. Physicians are making diagnostic and therapeutic decisions based on a series of "if this, then that" calculations that they run on their head. This kind of work is best left to software with algorithms that have been created by teams of physicians and testing specialists. A Nurse Practitioner or Physician's Assistant equipped with the right software could provide better, cheaper care than a primary care physician 9 times out of 10.
The dystopian future that you are describing will lead to frustration, over-testing, misdiagnosis, and medical error. I wish medical decisions were the way you are describing--it would all be alot simpler, but the art of medicine is very real. To your point though, routine preventive care and maintenance of chronic diseases (not diagnosis, mind you) could certainly be protocolized and farmed out to a lesser trained workforce.
6
You clearly do not know who in medicine even makes a diagnosis. But I'll be happy to leave your family's medical care to web md.
All those professionals, as well as paramedics, make a diagnosis. The quality and accuracy depends largely on experiences and empathy, two things you won't find in an algorithm.
5
@Robert
They already are, and thus care by RN's and PA's.
The misdiagnoses and wrong therapies I encountered as an MD were numerous and appalling.
1
All of my doctors have some pretty cheesy hours. My neuro shows up once a week for half a day. My choices for an appt are 10, 10:30 or 11. Mind you, once he walks in he thinks nothing of spending an hour with me and seems to ignore the rest of the world.
My internal medicine clinic is only open a couple of days a week and again, I can't get anything other than 10, 10:30 or 11.
My real concern is the number of surgeons and ER nurses that talk to me about how regularly they pull 16 hour shifts.
People below are talking about Mexican siestas. And when I spent a year in Central America it made sense because the summer afternoons there can be pretty difficult to deal with. But here in Seattle? Most of the year I can't tell if its 8 a.m., noon, or 3.pm because it all looks and feels the same.
3
Primary care physicians are in short supply. They are generally paid on a fee for service basis which creates an incentive to see as many patients as possible for as little time as possible.
I had a physician who was fed up with rushing his clients day after day. So he dropped all insurance and set a reasonable fee schedule for all. That set him free to give extra time to those who needed it.
I now prepare for my sessions and get extra time as needed, generally without paying extra. I get a relaxed doctor who feels good about what he is doing, generally for $95 per session. I don’t visit him often so the fee is eminently affordable.
Since he dropped insurance, both my doctor and I are much happier. I know this won’t work for everybody. But it seems to work for all his clients, who give him uniformly excellent reviews.
12
@michjas
Appalling that you refer to yourself as a client - you are supposed to be a patient. After all, there are subtle and not so subtle differences between them, and you should learn them.
You want to be the former.
As an aside, not accepting insurance can only work in an affluent and educated area that happens to have a real abundance of physicians. It will not work in any area which does not fulfill that.
6
The incentive to see as Many patients as you can is real particularly if you think in the short term like hospitals and insurance companies do. If you are trying to build a practice treat patients with your whole effort and there is nothing magical about that. You can still schedule a call or another visit to limit the delays.
The incentives are what you make them. The incentives that insurance companies provide are so off target. One has to be realistic but you will burn out if you take on insurance company cause as your own. Remember THEY don’t care and neither do the algorithms they created. The only people who care see you face to face.
@michjas
Patients, not clients. Lawyers have clients, doctors have patients.
2
This makes me wonder about the decisions of other professionals -- say, immigration court judges who have both morning and afternoon sessions.
People's well-being is at stake not just in doctors' offices.
10
Even a "morning" appointment frequently turns into an afternoon appointment since physicians are chronically late.
Their standard excuses of "emergencies" wear thin when one discovers otherwise.
Respecting the patient involves decent customer service.
3
@Jeff Caspari - They are chronically late because they cannot do what they need to do in the 15 minutes allotted. Each patient visit makes them more behind.
3
@PM What excuse do you make for physicians that are chronically late for their first appointments?? Also, if they need more than 15 minutes per patient they should adjust their schedules.
What about having a group practice where each doctor covers no more than 4 hours at a time with a 2 hour break in between. And take into account doctors who are naturally 'larks' and 'owls'...? And what about having the admin who comes in and takes your vitals stick around and type in the stuff the doctor suggests so you have face time with the doctor and not while they are talking to you while they are bent over a laptop?---
105
@Franklin
Great ideas, except in the current system this is untenable and unfundable. No doctor is employable in 4 hour shifts, we aren't worth employing unless we work long hours...That's why we work 12-14-16-18 hours at a time. Not to mention at least in the departments I have worked in, we are chronically understaffed by administrative folks, so much of this burden becomes ours as well.
21
@Frankin
As an “owl,” I would be happy to have more services, including doctors take this into account. “Owls” serving “owls” — a brilliant idea.
15
@Franklin
Because if you're not seeing patients during those 2 hours, you're not making money.
9
And definitely don't go into labour overnight, because you are almost certainly not going to be as well treated as if you checked into the hospital at 9AM!
1
@kate
Kate do you think you can choose when to go into labor?
Already feeling sleepy reading this piece while awaiting arrival of office patients apparently running late!! Might take a nap before their arrival to improve my decision making.
2
Great, going to see my doctor tomorrow, after 3 to go over annual exam.
@Sherry Moser steiker
With all due respect, since this is an annual exam, I would reschedule for the first available AM appointment.
Bring the doctor some homemade cookies or brownies. Sometimes a simple and thoughtful gesture sticks with the attending physician.
Just a thought. The very best of luck with the appointment!!!
2
Hope everyone follows this advice. Then I can get to see my doctor in the afternoon without having to wait an eternity.
6
Not so sure about afternoon visits, but do know it's best to avoid Friday medical procedures for lack of competent follow-up attention over the weekend (at least here in socialist Canada, which is generally better than iits deological critics would have it).
1
Latin American countries and some countries in Europe break for “siesta time” from 12p to 2p. Everyone goes home, eats lunch or at least takes a break then the work day resumes! There’s wisdom in that!
5
So, patients should avoid needing care at bad times? This article discusses an important issue but doesn't really give a solution, as many commenters are showing. I guess the system needs to change--maybe fewer patients per day, shorter nursing shifts? Again, finances will prevent this. And again, it's the American system of financing health care that will be a cause. Is anyone remotely ready to change that? If not, then these articles are not productive.
4
I realize that updating the electronic health record is a small part of this large problem, but when I visit my urologist, he reads the file, then listens to me and offers his diagnosis and other comments, and at the end of the session, he dictates the account of our session, to be transcribed into the personal record later, by someone else. Aside from the work load relief for the physician, it has the benefit of my hearing the account, so that I can correct information. I’m curious about why other physicians don’t do this; I’ve never encountered it among all the physicians I have visited.
47
@Ockham9, it's a reasonable idea but I'm guessing it's because they then have to pay for a medical transcriptionist.
4
@Ockham9 25 years ago, when I was a med student, my neurology mentor had a similar way of doing things. He would dictate his note directly in front of the patient. However, there are several reasons he could do this. For one, he was in private practice and controlled his own schedule. Primary care docs who are forced to see a certain number of patients every hour don't have this option and if they took time to dictate, all appointments would be set back even further. For another, he only had to focus on one organ system and not the other ones so much. He also did not have to handle social issues the same way primary care docs do. A third reason is documentation requirements back then are different than what is required now.
One of my ideas -- which would of course require addressing issues of liability, privacy, etc. -- is whether visits should just be recorded (either video or audio). That way, the documentation is happening DURING a visit and takes up no extra time. It would also be more accurate.
1
The Mexicans have been way ahead of us on this nearly universal human frailty: daily siesta between 1pm and 4 pm. It’s also customary in other Central American and Southern European countries. While traditionally motivated by the afternoon heat in those countries, it does address afternoon mental fatigue, which certainly has a circadian component to it.
7
They also do this in France. I always see my Dr. here in France, avoiding fritzed out doctors as much as possible in the US. Dr. here sometimes returns from lunch around 3 pm.
1
@JHM definitely not 1 - 4...more like 12 - 2...been there done that
@JHM
This will never work in a fee for service workplace . Close the OR from 1-4 pm?
I make appointments for the earliest time of day that a physician begins, for an early morning appointment for surgery on Mondays through Thursdays and never on Fridays or weekends, and early-to-mid morning for labs. Insurance companies have so highly regulated doctors' schedules that 15 minute appointments and many patients per day have been the norm for well over 15 years. Patients have to come with a list of discussion points, and if these exceed the 15 minute limit, another appointment needs to be made. Turnover of the medical profession, due in part to burnout and insurance company pressure, has made it difficult to maintain a long-term doctor-patient relationship. I have also found more doctors who are not well informed of a patient's history because of these pressures; this can be a rather serious matter with dire consequences.
3
"Learn about screenings you might be eligible for,"
This study is far from my experience, as my doctor's computer seems to have an alert for all screenings that are due and overdue.
In fact, that is my main complaint about my visits: Given how compressed the doctors' schedules are, there is little time for serious discussion of what might be causing new symptoms during the visit. The only result seems to be referrals to screenings.
3
...Or on a Friday before the pubs close. Sounds like a joke, but it left me in abdominal pain for 20 years when doctors refused to believe I had ruptured my appendix, and allowed an intern to do exploratory surgery that was far above his pay grade.
3
I can't relate to that, but can attest to the difficulty in getting medical attention on a weekend or a holiday when the primary care physicians offices are closed. The burden is on the patient then, and many opt to push their medical condition that doesn't seem right on a Saturday off until a Monday visit. Can be risky.
5
As a patient, I have never been too concerned about decision fatigue; no, for me it's the fact that I can wait up to an hour because the cumulative effect of everything taking longer than scheduled.
5
I learned a long time ago to be first in line for medical examination, surgery and treatment.
By nature and nurture I am a morning person. And I do not do well by midafternoon.
1
Sure, we docs get tired. Want an antibiotic for your virus? Make a 4:45 pm Friday appt and we'll met around 5:30. I will be well-cooked, the meat falling off the bone. I still probably won't give it to you, but your chances are better.
More interesting in this opinion piece is the author stating that the workload is impossible. It is, of course, but the mainstream media seem to soft-pedal this. It's nice to see someone come right out and say it.
Why can't you see your doctor when you want?
Because there is a shortage because the workload is impossible.
Why can't your elderly parents find a doc when you move them to your town? Because there is a shortage because the workload is impossible.
Same answer to each of the following:
Why can't I get my medicines refilled on time?
Why won't the doctor look at me during the visit?
Why does the doctor sigh and frown when I bring up an extra problem?
Why do the doctors all keep retiring or moving?
Why do I have to see a nurse practitioner or physician assistant instead of my doctor?
Why do they refer me to a specialist for every little thing?
I wish I could say it will get better, but it will get worse. The businessmen are in the driver's seat and they have all the heart and consideration of, well, businessmen. The number of Medicare patients will increase by 50% or so in the next decade. Strap yourselves in for rough times in the clinic.
266
@vbering Maybe less stereotyping by doctors would help? (less hatred of the old)
Personally, physicians assistants have been great for me! I was always told doctors didn't like them so that reduced their numbers.
6
@vbering--you've summed it up perfectly. Now get back to work!! I'm just waiting for my patient to get out of the bathroom. I''m two patients behind.
20
Yes, the workload is impossible. After a couple decades of Consistently great than 70 hour work weeks I needed to give up and leave medicine. The intensity was killing me. I tried numerous ways of decreasing the load. As noted in the article, for every clinic hour with a patient I had, about, another hour of work. Of course, this time answering the never ending, usually urgent, email questions, was unpaid. Though that was not the issue. The issue was 13 hour days being a “good” day, and at least another 8 hours of intense, detailed, always trying to be perfect, work on the weekends. As a result my patients lost a doctor (whose online reviews were ‘excellent ‘).
32
I've never had a dr walk into an exam room and say, hi, I'm feeling a bit tired right now so let's take things slow and make sure we tick all the boxes and get you what you need today without making any avoidable errors. And I don't expect that to happen.
I suspect there's a lot of pretending going on behind the invulnerability of the white coat. The trick is to try and remember that when one is standing in front of you speaking so authoritatively.
In my experience most times you don't get a lot of choice over when to see your dr anyway, especially if you want to be seen soon.
11
I worry most about pharmacists working at any given time of the day at those large chain drug stores.
All those pills, all those orders, all those calls and walk-in questions. And then there's the never ending complaints about the prohibitive costs of medication.
They are doctors filling the role of never ending pill dispensary.
4
@Marge Keller
No worries. Pharmacists tend to be some of the most educated, brilliant people you'll ever encounter.
It is their job to find mistakes that our medical system allows, such as improper dosing, or potential reactions you might be prescribed from different MDs.
Usually you see pharmacy techs filling those bags, but patients with long med lists or potentially dangerous drugs are reviewed by the pharmacist.
Although the best pharmacists I've ever encountered are the hospital in-house.
They just tend to be a very on point group. Mainly because earning that degree is ridiculously difficult.
I think you're seeing the staff at the local pharmacy, and yes they worry me too, but that's just filling the bag.
As the article casually mentions, the “3 o’clock fade” is not limited to just physicians. Reading through some of the comments, others like me that are in different occupations experience the same thing. We could all benefit with a break in our routine, even for just 10 minutes at a time.
12
Since this well known late afternoon slump affects "everyone" why is this article solely focused on Doctors? What about the rest of us who are working to save lives, employ large teams and put dinner on table for workers across the world? People in "elite" professions aren't the only ones that matter.
10
@Bizarro
This article is focused on doctors because a doctor authored it based on her and others' research about doctors. If you would like your profession mentioned, please perform the research and publish your findings.
11
As much as we physicians complain about them, this is one area where electronic medical records truly help us. A very commonly used EMR has a built-in feature that reminds physicians about the routine tests, screenings, and vaccines that are due for the patient whose chart is open. I have been "saved" by this feature on more than one occasion.
5
I have patient fatigue always being bounced around from Medical specialist to labs then to another specialist.
Recently my internist here in NYC would not look into my ears as during a general health care exam but sent me to an ENT, I so remember being in good hands in the 1950's when our family Dr did it all...other then surgery..also back then we never had defensive testing to rule out any chance mal-practice litigation.
16
@Carlyle T. What I find particularly dismaying about this is that once the referral is made, the follow up is often absent. In a sense, the PCP is saying, "that's not my problem." There was a time that the job description involved coordinating care rather than handing it off. I realize it is not so black and white, but I hear from dozens of patients that is their exact experience. Whether the origin is business demands or not, something's got to give if people are to receive good care.
6
@Stewart
Add to this sweet sour pudding where one specialist the patient chooses is at a different hospital then where the "primary" Physician practices ,not communicating with each other.
I have this repeating issue with my wife treated for a brain disease at a good neurological clinic at one hospital and also a surgical patient at another Orthopedic hospital for her advanced Osteoporosis
issues.
Do hospitals compete for patients in our large city where we have many choices of care?
1
It is estimated that up to 25% of health care providers suffer from some form of substance abuse. Several years ago I worked with a very busy state program that offered treatment and a chance for them to retain their licenses.
The reason almost all of them give ;
' I was trying to deal with the stress".
Go figure......
I
2
@WIndhill
Where do you get 25 percent
As medicine is consolidated into large health care organizations medical providers have less and less autonomy. Clinic starts and ends when the managers say it does so we can't just decide now we need a break. A senior physician in my clinic once described lunch as "theoretical." Docs ( and NPs and PAs ) often work through any scheduled breaks to address an unanticipated problem or spend more time with an anxious patient or type. Those shiny electronic records are completed by docs up at all hours typing furiously instead of giving calm consideration to your issue or even sleeping. I don't doubt the phenomenon Dr. Linder describes is real but when these 18 hour days are the usual state of affairs, everyone is chronically tired no matter how much coffee they drink. Please cherish the providers who have managed to carve out humane schedules for themselves and their patients and still stay in business. And be open to creative changes in how care is provided to address these issues as research identifies where we might improve care or decrease errors.
26
The sad truth is no matter what profession or career we choose, a young adult or an older one, even our kids when they come home from school, 3 PM is a down-time. I suppose there is a good reason why so many Latin countries have siestas of sorts between lunch and that fateful hour above. However, doctors need to transcend this built-in, human fact of life. There are some people we can not coddle, and that means doctors and nurses. I say this as a retired hospital nurse. For the day shift, it was non-stop from 7 to 3. For the swing it was the same from 3 or 4 to 11 or 12AM. And those were in the days of 8 hour shifts. Now nurses often work a 12 hour one. What I am saying is that when it comes to the medical profession we must find a way to be super-human. Our oath is to cure and treat, no matter the time of day. Primary doctors, drink more coffee or eat a little dark chocolate. I can not tell you enough how much of that See's candy I hurriedly ate when a patient offered me some of hers or his. And I never became diabetic or gained weight!
5
Same with going to the dentist in the afternoon for a cleaning, I noticed that mine rushes to get it done in the afternoon, but takes his time when I visit in the morning.
4
How do surgeons do in the late afternoons? Do they take naps or breaks before, say, a 3pm surgery? The first surgery of the day is usually 8am.
3
@Vmerri I had surgery about 5 yrs ago and my dr's first surgery of the day turned out to be longer and more complex than expected, delaying mine. When she came by to see me in between her procedures, my husband and I told her to please take her time, get some lunch, get rested before beginning mine (which also turned out to be longer and more complex than expected!) Last thing I wanted was a tired hungry cranky dr operating on me.
4
@Vmerri
Susi, nudging your surgeon to take a break was a good move. Many people would be afraid to say that to a surgeon, probably because they feel safer with the myth that surgeons are superhuman, and infallible.
@Vmerri
Sometimes. It depends on the surgery. That 8 AM surgery started for the staff at 530 AM. Sometimes you are simply in the afternoon staff with emergency on-call sleeping somewhere. Depends how many rooms there are and how they are scheduled, hospitals are different. You may actually be in the next 'shift' In which case, first of the day.
A late afternoon clinic appointment is not optimal, but a late afternoon clinic appointment on a Friday if you are chronically ill with a complex medical history or presenting with a confounding new array of symptoms is best avoided. As a physician, I can tell you that staff morale and energy dwindles at twice the rate once the clock hits 1pm on a Friday afternoon.
14
Decision fatigue also occurs with registered nurses. Today most hospitals are staffed in 12 hour shifts. If a patient is going to hemorrhage, stroke or experience a cardiac emergency, they should avoid the hours of 4 to 7, AM and PM. At that point a nurse has already been on duty for 9+ hours and is getting fatigued, both physically and mentally. Mistakes are statistically more likely to happen overnight, where the alteration in circadian rhythm affects the body's ability to remain alert.
4
It also pays to avoid emergency rooms or treatment at night and if one is going to need emergency surgery, not in the middle of the night or holidays.
Of course one cannot always plan one's emergencies.
2
In our current system the best advice ought to be "take excellent care of yourself in order to avoid the doctor".
23
What about taking advantage of the messaging service with your medical team? Mine allows me to send my doc a message and he replies within 24 hours ... I ask about Rx, blood work, worries or concerns and he responds forthwith.
I always schedule late afternoon appts.
That would suggest that most physicians are early birds rather than night owls, because night owls feel notoriously bad in the morning, but after 5-6 hours of being awake, their energy level is going up remarkably, to attain their best moments of concentration by the late afternoon and night. Or that's at least my own subjective experience.
Objectively, however, this op-ed is leaving out information that is crucial to get to the whole picture.
Why is it that doctors prescribe more unnecessary antibiotics in the afternoon than in the morning, according to Dr. Linder? Because:
"As the day went on, doctors’ fears of disappointed, dissatisfied, angry or confrontational patients may have loomed larger and larger. The will to confront those fears may have dwindled and more patients left the clinic with unnecessary antibiotics."
From a neurological point of view, this is exactly what studies discovered and describe as "empathy fatigue". The mirror neurons in our brains make us copy-paste the emotional state in which a patient finds himself, so when they feel angry, we literally start feeling angry ourselves.
To be able to deal with this patient-caused anger in a professional/rational way, we need to be able to quickly activate our self-compassion networks, so that compassion and not anger is the emotion with which we respond to that patient.
You can only activate already existing brain networks, though. And how many doctors get self-compassion training? Almost none...
2
Don't visit them in the morning because they're still sleepy and fatigued from actually being sleepy. Great article.
2
On a similar note, I always grab the first dentist appointment of the day!
2
I don't visit my doctor in the afternoon for the simple fact that by then s/he is already running 90 minutes behind.
58
@Chris
I spent 15 years working in a private practice. 90% of the time a patients waits is due to greed. The Doctor overbooks and rushes to get more patients in. 15 years ago reimbursement for billing was about 78-80%...now it's about 38-40%. When I complained there wasn't enough time for me to appropriately assist him with evaluating a patient, I was terminated.
5
All shortcomings are true, as described. Technology must come to the rescue, especially for preventive medicine and routine check-ups. But for new patients, with complicated issues, aside from timely coffee (hand-trembling being the higher limits) to simulate being awake enough to make it patient-worthy, it may not be enough. Any 'recs' for physicians up all night, so to tackle a new day's schedule...with a smile? In the old days, self-abuse for long hours of work, was taken for granted, at times demanding an escape from the constant unrelieved chronic stress (in the form of drugs, alcohol, etc). This seems to be abating, and I would like to offer a toast to that, as it benefits all involved. Now, if we could get rid of the paperwork...
1
Same for hairdressers!
65
@Dinesh Shah
Yes an restaurant chefs standing over a hot stove for hours or a lawyer who has to watch an innocent client be found guilty by a jury who just wants to go home....this remark is senseless
2
@Dinesh Shah
That might explain why my hair color is a different shade of blue towards the end of the day . . . and here I thought it was just my eye sight going bad.
5
I am a physician and can state to attribute all those things to fatigue is wrong.
the willingness to prescribe more unneeded drugs later in the day and spend less time explaining tests and preventive care is more likely due to physicians wanting to get to the end of seeing patients for the day which may have already been extended by unscheduled patients coming in for care.
Of course, docs could ease this by seeing less patients per day but as we pay by how many patients docs can see, there is little incentive to do this.
by the way, it's still amazing for me to see things like mammograms and prostate cancer tests labelled as "preventive care." They detect cancer, not prevent it. Prevention of cancer involves things such as stopping smoking and better diet, both of which most docs only give lip service to. Colonoscopy is different because by detecting and removing polyps that can become cancerous it can actually prevent cancer from developing.
28
@Steve Preventive screenings are essential as not all causes of disease origination is based on smoking and eating better diet. Sadly, only a small fraction of our patients get preventive screenings leading to catastrophic outcomes due to missed early diagnosis.
4
@Steve - They are secondary prevention. Trying to prevent the disease from becoming problematic even though it exists. And screening tests are imperfect, by the way. They *may* detect cancer, but they may not. And they may return a false positive.
5
How about doctors work 5 days a work instead of cramming all their patients into 2 or 3 days? How about doctors not restricting the number of new doctors entering the market place?
4
@Sabrina Restricting new doctors is an old concept, mainly myth, but when there were few doctors with specialties, it may have been a factor.
Now, with our interview committee, we are begging for QUALIFIED candidates to show up for an interview, and when a sharp cookie shows up, fall all over trying to get their consideration.
No, Sabrina, there is no restricting for most kinds of docs for over 20 years.
8
@Sabrina I'm glad I don't live in NY if that is the norm there. I live in Minnesota, and I can assure you those situations are rare, if at all. Sometimes a doc can't see you on the day you want, is because he is making rounds at a hospital to check on his patients there. And its pure baloney that doctors restrict the number of new physicians entering the market. That is more likely to be caused by the high cost of getting a medical degree.
9
@Sabrina
Seeing as how I and every other doctor I work with, works 6-7 days a week and 75-90 hours a week, I'm not sure what you are talking about.
6
Here in France my GP only consults from 1:00 PM until 7:00 (or until his waiting room is empty, more like 9:00 PM). So I guess his fade period is around... 6:00 PM when most people are getting off work and coming to see him. I generally show up before his door shuts at 7:00 PM so I'm sure to see him when he's ready to leave. Don't really have a choice. He doesn't take appointments so you can wait anywhere from 1 -4 hours.
2
Thanks for sharing this with honesty. I've read that glucose levels may dip around the time decision making becomes harder. Lunch came and went. Perhaps an apple with the coffee??
2
@kathyb Maybe a bit of protein as well as coffee/fruit?
1
I try to schedule an appointment for the first of the morning or first after lunch. Hate having to wait 2 hrs. for a 5 minute visit. Then there was the specialist who was called away for a surgery, appointment cancelled and another long wait for the next available date.
5
This is a very honest and accurate article, and I share the experience of being a harried primary care doctor.. Here is where the EMR can help, by automatically scheduling and reminding us what's needed. Which is a very short step to replacing the MD altogether, and simply have YOU check the little boxes on the computer screen, instead of me...
Your choice is simple: replace us with machines or accept that we are human beings too.. imperfect, potentially distracted, or simply exhausted.
17
The study focused on ordering of breast and colon cancer screening tests based on times (AM vs PM) of visits.
Most health/screening and physical exams are made in the morning. Most afternoon visits are for problems NOT physicals or screening. Doctors frequently order screening tests during physicals, NOT problem visits.
With all due respect, Dr. Linder, and the authors of the study; maybe your conclusions and assumptions are little off.
4
@MM Your generalizations aren't accurate. I see patients in mornings and afternoons and preventive care visits are definitely mixed into both sessions for myself, and most primary care doctors I know. Moreover, we often order preventive tests that are due during sick visits if we have the time to discuss with the patient, so they don't have to come back necessarily just for that.
6
@cornellpcp
Agree. I see sick and well visits any time of day.
4
The real solution to his problem is to simply pay physicians by the hour rather than by the patient. This would allow physicians to spend as much time as needed with each patient, and would create an incentive for the government and insurers to reduce pointless busywork. It works for almost every other type of professional service, so why should medicine be so different?
1
@roger I get you, and by-hour makes sense, but the challenge is not paying the physician, but reimbursing the HMO/Hospital/outpatient facility, from the insurer. I am no fan of insurance as it is, and favor single-payer all day long, but I realize insurers need to differentiate based on service delivered. I don’t think an hourly time card that doesn’t distinguish between services delivered would cut it on the reimbursement end. I’d be happy if somebody found a way however!
2
@Roger
Insurance agencies. If people knew or understood what a role that played in their actual care we would have complete universal coverage by next year or riots in the streets.
When you see comments from other countries on this board, now you understand.
Gee, how about not having primary care physicians overloaded with patients? How about not having to pay back $300K in loans? How about making less money? I know, all silly questions.
138
@CarolSon: How about making insurance non-profit?
How about tort reform in order to lower the cost of malpractice insurance?
And when a person has spent eight-plus years getting the education needed to practice medicine, shouldn't there be a commensurate reward in terms of salary? Instead, their staff is burdened with colossal amounts of paperwork and phone calls, also cutting into their earnings.
80
@Miriam
Many people spend 8 or more years qualifying for degrees in their fields, without ever expecting to get a physician's salary.
I agree that it is a difficult job, but I always hear this so-many-years in school moan, as though PhDs in math, history or other fields don't go to school for protracted periods to learn their stuff.
Becoming an expert in your field takes a long time, if you are truly an expert.
30
@CarolSon
I like your other points, except about making less money? I am nearing 40 and finally finishing my training, and get paid $67K a year. I have lost a decade or more of of earning potential. I have minimal savings and no retirement. I can't afford kids and put that off too. But yet I should be punished for taking on this level of training, for the benefits of my patients and for advancing scientific research in the fight against cancer, for a pay cut?
Nope.
33
I would be interested in a study of Donald Trump's tweets to see if the ones he texts in the afternoon are more inane than the tweets he texts during other parts of the day.
97
@Jay Orchard you are a more generous person than I, assuming that his tweets at any hour of the day are anything better than abysmal.
31
@Jay Orchard
Clearly, his 'excellent' checkup was done in the late PM.
12
@Jay Orchard
That presumes he was actually working during other parts of the day!
6
Private pilots usually have a "pilot's" lounge with large, well upholstered reclining chairs that provide a silent, comfortable environment for "recharging."
Place an "appointment" in the daily schedule for a specific time for a short nap or at least a rest.
Coffee, when you awake, will provide a better mental condition for decision making.
A foolish decision in flying can cost lives, rather than an inaccurate diagnosis from a doctor which will probably not kill anyone.
3
@Chris Anderson
I see you know your air industry!
And Nothing about medicine. Improper diagnosis is the easiest way to kill someone.
1
I find that when I read opinion pieces later in the day I have much less patience for them and submit comments that are much more critical than comments I submit on pieces that I read earlier in the day. After reading this piece, I'll make sure to have some coffee before shooting off my mouth.
35
@Jay Orchard
Too late!
3
@April Kane
I just knew that was coming April. I'm just glad I heard it from you and not from some stranger.
LOL
5
“Fatigue” on the part of most physicians these days seems far far less of a problem than the issues of ‘I don’ really care about you personally very much’ and ‘how many procedures can I possibly squeeze in today’
12
@Blusyohsmoosyoh To be fair, it may not be that the doctor "doesn't care" or is trying to "squeeze in" visits and procedures. Scheduling is often decreed by the hospital or medical group (e.g., Partners healthcare), forcing the doctor to limit a patient visit to 15-20 minutes. And that in turn makes visits often seem rushed, leading to a feeling of "the doctor doesn't care."
20
@Art MacPherson Except that the goal really is profit over all. Certainly physicians benefit from higher salaries, nurses too. This competes with care. Is anyone going to take a step for change?
1
Decision fatigue! I remember cobbling up this expression maybe ten years ago for one of my staff when explaining why I didn't want to decide whether it was OK for her to take a particular day off. My job consisted of reviewing my staff's legal memoranda and deciding whether to forward their recommendations to the company or offer differing ones of my own. Cumulatively this could be mentally draining. I didn't want to be burdened with any unnecessary decisions.
Like Dr. Linder I also experienced an afternoon slump. I attributed it to my system digesting lunch but maybe I fingered the wrong culprit. My focus usually revived in the early evening after 5 p.m.. I do wonder, though, whether the doctor's higher rate of ordering tests for patients seen at the beginning of the day was the result of excessive vigilance. I suspect his decisions were better by 9:30 or 10:00 in the morning.
Here's another thing I would say to my staff: people are not machines.
10
So, how does this work? We all refuse to see our doctors in the afternoon, so we all end up with 7.5 minute morning appointments instead of 15 minute appointments? Good plan.
1
I'm a teacher. Going in the afternoon is the only time I can go, or I have to either take a whole day or half day depending on the appointment time.
9
As a radiologist in practice for 21 years I know that the cases read at the end of a 24 hour long weekend shift (12 hours a day) are more prone to error than those on Saturday morning.
Humans are not machines.
It is definitely helpful to be aware of this fact and always keep it in the back of one's mind when making decisions toward the end of a shift.
36
@TheMikey - Which is why the shifts need to be shorter.
1
I think the author's personal experience is limited in application. Otherwise, how will I be certain that my my afternoon court hearings are going to be fair? How will I know my commute home at 5 will be safe? The answer is not to encourage everyone to push to be first in line, it is to pace yourself. Wearing yourself out too early in the day is not the fault of the clock.
8
A few years ago I asked my then PCP, a veteran doc, what he thought of the 'new and improved' computerized digital medical records systems and he responded with a short, sharp profanity.
35
@Cody McCall
I can't imagine that a centralized digital medical records system is "bad" for either patients or doctors.
Isn't it better to have every doctor who treats a patient knowing the patient's full medical history and prescribed medications to avoid double dosing or dangerous drug interactions?
10
@JM If there actually was such a thing as a "centralized" digital medical record, it would be great.
Unfortunately, medical record systems do not talk to each other. So, as a primary care doctor, I can not access the records of any other doctors that my patient has seen unless the patient signs a release and the other doctor faxes (yes! faxes!) the records to me.
16
@Marni Nicholas, @Cody McCall
Also, EMRs are not necessarily accurate. My EMR states that I have hepatitis C, although I don't. I don't know how this error got in there. My suspicion is that someone must have checked the wrong box by mistake. It is nearly impossible to get changed, and I often have to pull up my negative test result with a new provider to show them that I don't have hep C.
9
The relentless appointment schedule, often at 15 minute intervals, barely gives a “provider” the chance to cover necessary ground, let alone new concerns. Medicine used to be a calling, now it is a job, with high burnout. We all ( patients and caregivers) suffer as a result. This is sold as an economic necessity- more patients, more dollars. But where does that money go? Not necessarily to the providers. A highly complex problem. For the moment, get those early appointments, get on the surgical schedule early in the day, and hope for the best, for physicians and patients alike.
63
I love and trust my doctor. He's been a family friend for many decades. The quality and quantity of time he spends with me or my husband is no less than any of his myriad of patients. He cares deeply about everyone of his patients.
That being said, his appointment times tend to run long even before the first scheduled appointment in the morning. Knowing this pattern up front, I never make an appointment after 10 a.m. because I want to be home for the wonderful dinner my husband prepares at 7 p.m.
It's not a matter of our fantastic doctor being tired and fatigued in the afternoon, but rather, I don't want to be rude and disrespectful towards my husband by arriving late for his beautifully prepared meal.
5
@Marge Keller
One time my father was waiting about 2 hrs after his appointment and struck up a conversation with the lady next to him. When he was finally called, he told the secretary, "Tell him to wait, we're having a conversation."
The waiting room cheered.
2
@elle
Fantastic story! Sounds like the caliber of folks in the waiting room of our doctor. Thanks so much for sharing.
2
Having just spent the morning grading exams, I now feel sorry for the students whose exams I will grade this afternoon.
157
@Chris Rasmussen: Well, they might be better off. More attentive grading picks up more problems and, maybe, a lower grade. Grading while tired causes the professor to ride on through and, maybe, not bother with more 'minor' problems.
10
@Chris Rasmussen
I was grading while driving once. I was considering whether it was unsafe. I look over at the car next to me and the other driver was doing the same thing. (We were at a red light)
5
Is there any work activity that it is "safe" to engage in later in the afternoon? If not, then maybe there should be a siesta between 2-4 pm with the work day extended accordingly (as is the case in some other countries).
69
@Jay Orchard the siesta would not be 2 - 4 but in most of those countries (I lived in one for 8 years) from 12 - 2 and the work end extends to 6 PM...it works! we humans do best with 4 hour periods of focus...and sleep. ever wonder why the 8 hours sleep is considered the norm? 2 4-hour periods...
6
@Jay Orchard You're not wrong...A number of studies demonstrated that people without a time schedule and working on natural rhythms eventually revert to a bimodal sleep schedule of 8ish hours at night and a short nap in the afternoon. Afternoon sluggishness is not the result of laziness, but rather, is the result of biology.
2
I have a better plan...I always ask for the first appointment of the day, any day (I am retired). Being first means no waiting plus getting an alert doctor.
8
@Marilyn Roofner
It doesn’t guarantee no waiting. I always try to get first or very early appointments, but still have to wait, just not quite as long usually. Plus I think once the nurse or ast puts you in a room, the clock starts ticking and they consider themselves on schedule, even if it’s still half an hour before you see a doctor or PA.
Imagine what we could have done with the productivity gains that resulted from computers and the Internet if we had a socialist, rather than capitalist economy. We would right now be working a 4 hour day, and a 20 hour week. There would be no decision fatigue in the afternoons if your shift started at Noon.
52
@Walter Bruckner
The author/doctor spends twice as much tome updating the electronic record.
So while agree that the increased productivity of the last 75 years has not led to fewer hours under capitalism, the greatest myth of our time is that computers have led to increased productivity. By creating tools that can do everything, ie word process, make videos, share infinite info, computers have actually undone to economic benefits of specialization. Most workers now have to do everything.
When economists start studying the productivity benefits of computers they will also realize how much of our time these devices demand simply to maintain and keep up with the latest tech.
Computers have not helped productivity.
6
@Morth I think the point is not technology, but the approach capitalism uses with it.
I think: billionaires who created a platform for easier taxi service, no money for good medical care. That's American capitalism.
11
@Walter Bruckner - Yes and there would be sunshine and rainbows every day and everyone would be given a free puppy.
4
I am 64, and practicing full time law for the past 39 years. The 3-5PM time slot is difficult and, yes, fatiguing. At 3 from hereon, I will pause and take a 15-minute coffee break--no phones, no clients, no reading. I will report back in 30 days.
70
@Bruce Egert I am two years younger and just retired from primary care. I would take a few minutes to step out the back door for an "oxygen break", kind of like a smoke break without the nicotine. It helped but not as much as actually taking more than a "lunch minute".
19
@Bruce Egert
Just curious if you're in court whether you can convince a judge to break for you at 3?
3
@Bruce Egert as an IT pro I find that a 20-30 power nap is even better than the cup of coffee, even if it is just kick back in a comfortable chair but better if you get your feet up and of course in either position close your eyes. set an alarm because the body that is tired will actually fall into deep sleep if you go past the max 30 minutes...when you awaken have a few nuts or other protein snack and you should be great until maybe 6PM!!!
6
Wow. Have you not heard of night owls? My peak working hours were from 2-4pm to 10pm, when I was able to set my own schedule. When I was in an 8am-5pm schedule, the quality and quanity of my work was not nearly as good.
75
@Gem YES!
2
missing the point. it's not time of day, it's decision fatigue from time on the clock.
Aren't there any doctors who work better during second shift type hours? Sure would be nice for the working population if there were regular doctors offices that had hours from 2PM-10PM, or something similar. This might also cut down on emergency room visits.
176
@H Silk Many physicians have families who follow a more conventional work and school schedule: they want to be home with their families in the evenings.
9
@H Silk. This would seem to be an economic question: How much more do you need to offer someone to work a later shift than the traditional 8-5? Alternatively, how many doctors do we need to make a glut in the 8-5 so we can pay them less? This is also relevant to the “crisis “ in rural health care.
5
@marklee; Nurses work in this manner, at least in hospitals. Their needs for family time and their schedules are no less important than for physicians.
53