This is Scott Selinger and welcome to another fantastic jabbering edition of - ABC’s for ECP’s, the podcast on behalf of the Northern California’s chapter of the American College of Physicians Council of Early Career Physicians.
To those most loyal of followers, you’ll notice it’s been a number of months since there’s been any movement with this podcast due to a combination of work, extracurriculars, and a new baby, but I am making an early new years resolution to more regularly get these up, up and away. Let’s put a pin in the idea of new years resolutions too because I want to come back to that.
There was a recent research letter in JAMA that set off a few ideas downstream for me. The letter was dubbed “Time of Day and the Decision to Prescribe Antibiotics.” Now just reading that title, my reaction and that of most people I’ve talked to about this was “well of course antibiotic prescribing goes up as the day wears on.”
To summarize a little bit, the study looked at outpatient encounters for a number of upper respiratory infections through coding review, some of which are cases where antibiotics are sometimes indicated (i.e. sinusitis, otitis, strep pharyngitis) and others where they are never indicated (i.e. acute bronchitis, non-strep pharyngitis) in patients with NO comorbidities or other indications to receive antibiotics. There were a number of more subtle findings but the answer did end up looking like yes, the amount of antibiotics prescribed, whether for conditions indicated or not, did increase as both the morning and afternoon clinic shifts wore on.
This sounds like an expected result, but why? The study talked about the idea of decision fatigue, meaning the more decisions you have to make, the more you start looking for the easiest solutions. Think about when you get a survey to fill out - do you spend as much time and thoughtfulness on the first answer as you do the tenth? For most of us, no, we don’t. And the translation for this is the otherwise healthy, mildly sick patient coming in asking for a z-pack for their cold. If it’s 9am and you just finished your coffee, you have a lot more energy in you to talk with them about the lack of efficacy and risk of side effects than you do when it’s 5:30, you’re worrying about traffic on the ride home, you have some loose ends to follow up on from the rest of the day, and you’re just physically and mentally tired. And those are the people more likely to get inappropriate antibiotics.
This letter pointed to an idea from The Psychology Bulletin comparing the mind’s self-regulation and self-control to a muscle - the more you use it, the more fatigued it gets. This idea that you have a set amount of self-control to use throughout the day is certainly something to think about. When you’re running a marathon, you make sure to take in some water at set intervals and sometimes slow down and walk so you can make it to the finish line. But most of us don’t necessarily get to have those breaks when we need them - usually that’s the busiest part of our day.
And I don’t think this is necessarily something limited to the outpatient world. Admissions also seem to go up as the day wears on in most places along with more decisions to make about workup and treatment (addendum: I was just guessing at this at first but it was hard to find data to back this - a VA study showed about 51% of patients visiting between 5 pm and 1 am were admitted, but also said this was contrary to national findings. The only real data I could find from the CDC (see below) showed an uptick in the afternoons but pretty steady admissions from about 10 am to 10 pm). At the end of a shift, are you more likely to order a CT scan than at the start of the day? What about admitting someone who could potentially be sent home? What about dealing with calls from the wards?
Looping back around to New Years resolutions, is this the same reason why most people fall off their wagon as the days and months drag on? Do we just get tired of making the decisions we know we should? This might be a reason why things like meal planning for weight loss are always recommended - it focuses most of the decision making at the beginning of the week so that when you get to Thursday night, you know you’re having brown rice and salmon with broccoli and not a Double-Double with fries from In-N-Out on the drive home.
So how is all this helpful in our daily practice? With all the focus on mindfulness - mindful meditation, mindful eating, etc. - I think it’s a reminder of an area to focus on for mindful practice with the idea of going into your day knowing you’re going to be tired and trying to factor in a mental break towards the end of your shift, be it something like an actual snack break or a short meditative session (for fun tips about how to do this, check out the earlier podcast in the series, “Just Breathe”). And maybe a way to help us stick to our new years resolutions as well and help our patients with theirs too.
As always, I’d love to hear your feedback on this, so if you have any burning questions or comments, you can post them on the blog at canocecp.blogspot.com, our podcast page on itunes, our facebook page or email them to firstname.lastname@example.org. And if you have time, be sure to head on over and check out our brand new official page for the Northern California Chapter of the ACP Council of Early Career Physicians so you can find out more about the events going on in the chapter.
Stay safe and have a happy 2015!