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Doctors and decision fatigue (nytimes.com)
123 points by hhs 7 days ago | hide | past | web | favorite | 57 comments

The author uses the Israeli parole board study as an example supporting his case, but doesn't mention that the study failed to account for other factors that might affect parole decisions.

When other researchers took a closer look, it turned out that in each session, prisoners without attorneys (who are less likely to be granted parole) were scheduled last, just before the breaks. After accounting for this and several smaller factors, the original conclusion could no longer be supported. [1]

[1] https://www.pnas.org/content/108/42/E833.full

I'm about halfway through "When, The Scientific Secrets of Perfect Timing" and it references many studies and topics relating to, obviously, timing. Many hospitals have implemented mandatory break schedules to combat this. An interesting read so far, recommended if you enjoy the linked article from the HN post.


And direct from the author some insights from the book:

'Afternoons are the Bermuda Triangles of our days. Across many domains, the trough represents a danger zone for productivity, ethics, and health. Anesthesia is one example. Researchers at Duke Medical Center reviewed about 90,000 surgeries at the hospital and identified what they called “anesthetic adverse events”— either mistakes anesthesiologists made, harm they caused to patients, or both. Adverse events were significantly “more frequent for cases starting during the 3 p.m. and 4 p.m. hours.” The probability of a problem at 9 a.m. was about 1 percent. At 4 p.m., 4.2 percent. In other words, the chance of something going awry was four times greater during the trough than during the peak. On actual harm (not only a slip up but also something that hurts the patient), the probability at 8 a.m. was 0.3 percent — three-tenths of one percent. But at 3 p.m., the probability was 1 percent — one in every one hundred cases, a threefold increase. Afternoon circadian lows, the researchers concluded, impair physician vigilance and “affect human performance of complex tasks such as those required in anesthesia care.”'


The next step though would be individuation of results. Are these consistent, or is there some minority that has the opposite results?

Quite interesting links here!

Ps: I, on the other hand, am really more productive and attentive to details after lunch and specially after 2pm. Mornings for me are just good for physical activities..

Good call, "When..." is an excellent book. In a related vein, "Algorithms to Live By" is useful and interesting.

Ego Depletion, which is related, failed to replicate in a pre-registered, 23-lab, 2141-participant replication study. [1]

[1] https://journals.sagepub.com/doi/10.1177/1745691616652873

Almost nothing is psychology replicates apart from g.

The criticisms he makes against IQ are pretty easy to argue against. 1. So it looks like any correlation against IQ is strongest at IQ's < 100. This is a fine conclusion and shows an important result- as your IQ increases, your life outcomes are more dependent on other personality factors and choices. He knocks this as a "no correlation existing" for high IQ's, even when you can see the damn correlation on his scatterplots (even after he blacks out large portions of them).

2. For income vs. IQ, there will be high variance. This is obvious.

3. He intentionally omits R-values for many of his plots to hide their predictive power. Even smaller R-values, given a large sample size and good p-test, show the power of a correlation.

I wouldn’t use Taleb if you want to be taken seriously in the area of psychology.

What's the difference ego depletion and decision fatigue?

I was just listening to the audiobook “Thinking Fast & Slow” a few hours ago which references this study and specifically notes that the researchers couldn’t find any other factors and that the order of the prisoners review was random. Weird discrepancy.

It would be great if he would publish an amended second edition - unless he already has.

On that page he wrote:

> I am still attached to every study that I cited, and have not unbelieved them, to use Daniel Gilbert’s phrase. I would be happy to see each of them replicated in a large sample. The lesson I have learned, however, is that authors who review a field should be wary of using memorable results of underpowered studies as evidence for their claims.

So it sounds like stands by the claims in the book. If that's the case, then I'm not sure what would be in a second edition.

I liked "Thinking Fast and Slow", but would recommend "Hare Brain, Tortoise Mind" above it in this space, as better bang for the buck (wrt time investment / value derived).

Also had to think about that. Maybe similar factors could apply to doctors?

For example patients with more severe illness could be more eager to see the doctor asap, and therefore be more likely to take the morning appointments, skipping work?

Patients will probably also worry about doctors getting tired, and try to schedule accordingly. I know I do worry about that kind of thing.

No doubt doctors also do get tired, but perhaps, like the judges, they also arrange their schedules accordingly?

If you want the attention of a crowd, speak at 10am.

Any earlier, the night people won't be well-rested.

11am, the morning people become hungry for lunch and impatient.

After lunch, anyone who overate will be sleepy.

By the time everyone's digested their lunch, the older morning people are fading for the day.

10-11am is the golden hour.

This is surprisingly poorly understood by everyone from consultants and sales people to speaking coaches.

It doesn't matter what you say or how you say it (within reason) if you're battling against your audience's metabolism the whole time.

My favorite is half-day or all-day meetings where they always plan out 10 minutes for a break every hour and it just slips and slips. You end up being lucky if you can get 10 minutes of an "official" break in a 4 hour window.

I've taken to just getting up and walking away for my 10 minutes. I have to piss. I need a coffee, or some water, or just the opportunity to go and breath some other stale air in some other corner of the office (I work full-time remote, so it's generally my own stale air, but the point remains). How is this lost on so many people? It strikes me as being so basic and so obvious and I feel like I invariably end up looking like an asshole because I can't sit in a chair and listen to people fill a volume of space with their words for 2 hours straight.

> people fill a volume of space with their words for 2 hours straight.

And those are the run of the mill self-lovers. Real pros like Fidel Castro and others of the ilk could go solo for up to 7 hours.

(The other day heard from someone who attended one of those speeches. Not a happy memory, for some reason.)

My colleague recently recommended the book "Why We Sleep" by Matthew Walker. While I was expecting it to tout the benefits of good sleep, I was surprised at the evidence around the inverse: not getting a full night's sleep is alarmingly bad for you.

The evidence suggests that this extends far beyond cognitive and psychological health impacts. For example, the author notes that there is a 24% increase in heart attacks the day after we lose an hour of sleep during daylight savings. This is just the tip of the iceberg, in my opinion.

Given these mental and physical risks, it is insane that we allow physicians to routinely work shifts that endanger themselves and lead to measurable drops in their performance.

I'm currently reading this book at the moment. The part of it that discusses the disastrous effect of the removal of the biphasic "siesta" sleeping in Spain, versus those that maintain it, had a distinct impact on me. I honestly think that we culturally need to return to this. I work on a team of engineers and you can see people flag around this time, yet they'll grab a cup of coffee and struggle through. It makes you wonder how many errors are solely due to this sleep deprivation that is now all so common.

I highly recommend people read it. I've gone from getting into bed about 11 and waking up around 6, to getting into bed at 9 and waking up before my alarm clock even goes off, and having a 20 minute nap at lunch. The difference in my mood and energy levels, and most amazingly memory, has been stark. I miss out on an hour of reading or games, but I feel like I actually have more time because I'm alert - not in that state of flux where I'm gormlessly staring at my book or computer with nothing actually happening in my head. You won't realise how sleep deprived you are until you're not, and I would never have changed my perspective if I wasn't given the statistics that he presents in this book.

All these go to bed early stories sound great until I remember that the majority of my social life happens from 9PM-1AM

An unfortunate reality but at least that means sleep deprivation only needs to happen 1-3 times a week, not every night like I got used to. The difference between 7 hours sleep a night to 8 hours during the midweek days has made the biggest impact on my life. The book discusses that the difference between 7 hours and 8 hours has almost as much an effect on you as that of 5 hours and 7 hours. The last moments before you wake up seem to be the part when the electrical "waves" that happen during REM sleep are at their strongest, but sadly it's that REM cycle particular that almost everyone misses. I'm a night owl forced into a day time job (if given the option I'd happily stay up till 2am), so I struggle with getting to sleep early - but now I've learnt how important it really is I'm much more motivated to force myself to do it.

>For example, the author notes that there is a 24% increase in heart attacks the day after we lose an hour of sleep during daylight savings.

How did the author directly attribute those stats to the "lost" hour of sleep? Even apart of the fact that people don't necessarily lose an hour of sleep, there could be many other reasons. It sounds like a case of conflating causality with correlation.

I am reasonably confident that the author is aware of the distinction between correlation and causation.

If you're interested or skeptical, I would highly recommend this book. It's from the "Sleep Loss and the Cardiovascular System" section of Chapter 8. He includes chapter endnotes discussing sources.

I believe we need to do away with “the Kaiser’s trick hour” and restore a truly reliable, truly American sense of time

There's talk of doing away with it in Europe: https://www.theguardian.com/uk-news/2019/mar/26/when-do-the-...

The Kaiser? I always thought it was Adenauer...

I've long advised my family and friends: "always take the 1st appointment or flight of the day. Never book the end of the day's schedule" for doctors visits and airline flights. Chaos, delay, and error compound themselves throughout the day and then get reset to baseline overnight.

That, or after a break or meal is the best to meet the judge.

"They found that the likelihood of a favourable ruling peaked at the beginning of the day, steadily declining over time from a probability of about 65% to nearly zero, before spiking back up to about 65% after a break for a meal or snack."


I read this as I dread waking up to board a flight at 5:20am leaving Austin.

Maybe doctors should work less?

Hospitalization with acute myocardial infarction during Transcatheter Cardiovascular Therapeutics meeting dates was associated with lower 30‐day mortality, predominantly among patients with non–ST‐segment–elevation myocardial infarction who were medically managed.


For some reason, society has this observational attitude about these practices. It’s not clear to me at all while medical institutions think doctors and nurses need to work excessive amounts of hours in a row with no rest.

I guess real doctors can be more precise than me here.

However, at where I live only doctors working with trauma/ER work long hours. From what I understand, that’s mostly to work around the overhead of context switch and patient hand over. For my friend, a lot of stress came from the responsibility, which might not be well distributed across specializations (hence the insurance premiums, etc).

It just doesn’t seem to me that having a doctor who has been awake for 22 hours straight is preferable to handing the patient over to a doctor who has slept within the last day.

I wonder how doctors would feel about reducing their hours/pay by a third. To be honest, I'd prefer that.

I'm one that likes(liked) to schedule doctors appointments in the afternoon. My experience has been a bit negative. I've had doctors that rush because they are running late, inattentive because they are tired, cancel because they have other appointments, doctors that seem to want to discuss their previous cases, and they have plainly told me that they can only give me a few minutes because they have other things to do. I suspect that even the ones that are attentive are thinking about other things than my situation.

It turns out that doctors are people too. So I completely agree an AM appointment is your best bet if you want to get the best service from the doctor.

From the reference JAMA study: As the clinic day progresses, clinicians may fall behind schedule and experience decision fatigue

I wish the paper tried to differentiate which of these two it was. My guess is that it would have more to do with falling behind schedule than decision fatigue. When you are already behind schedule, you at least subconsciously try to do stuff that minimizes your time. Having a long talk about required screening or arguing about antibiotics may not feel very worthwhile to you when you have 6 patients that have been waiting an hour for you.

I always try to get the first appointment of the day. The thing that annoys me to no end is that doctors are already running late by that time. Sometimes I think there's a basic lack of respect for their patient's time.

Imagine having the purest ideals of helping people when entering medical profession, only to end up burned out, going through motions, knowingly but hopelessly harming your own patients, leading you to substance abuse to cope with that as the system is set up to drive you to the brink of collapse. I am wondering what kind of sociopaths designed medical profession guidelines, maximizing unintended damage, depriving doctors of any quality off-time for their own recovery.

For those who need to take a driving test, it's always best to try schedule it for the earliest morning time slot. The examiners typically don't want to start off their day by being a prick and fail someone.

I think we need a push up toward a simpler and slightly denser monitoring culture across the whole board. Just enough so everybody can keep the rate but decrease the errors.


... What exactly do you have against the NY Times? I'm from Germany, don't have any ties, and generally enjoy their articles (thus upvote them). Not everything you disagree with is a conspiracy.

NYtimes is probably the most reputable news source on earth. I incredibly doubt there's a significant number of NYTimes employees here.

It may be amongst them, but do not discount other organizations with a similar pedigree merely because they're not American. Financial Times, The Economist, and so on.

At any rate, this article is an opinion piece along with plenty of other NYTimes articles posted to Hacker News. When judging an opinion piece the the pedigree and reputability of the newspaper matters much less.

That is true but HN is overwhelming an American readership, which is obvious to non-Americans or anyone who lives outside of the US timezones.

Which isn't too surprising, all things considered, it just is what it is.

But given all too human "familiarity bias", it also isn't surprising that an American readership submits & upvotes primarily American sources.

Tangential, but I would be very interested in a census of HN. Does anyone know if this has been done?

Except for that time they weren't! https://en.wikipedia.org/wiki/Jayson_Blair

You're probably getting downvoted for sounding paranoid. Is it really that difficult to believe that professionally written articles published in one of the most reputable newspapers can appeal to the HN crowd?

What are these NY Times articles competing against on HN anyways? More JS libraries that reinvent the wheel? Rants against big tech companies? TechCrunch rehashes of press releases? If you want to see other publications represented, you're welcome to submit them yourself. (And I would welcome more non-paywalled, non-newspaper things on HN as well.)

HN has pretty sophisticated countermeasures against that sort of thing, both technical and human.

Where would one be able to find out what these countermeasures are? Unless you're involved with the operation of HN, how would you know?

dang has mentioned the behind-the-scenes workings of HN a few times over the years, although finding them in amongst all of the other comments might be a bit of a slog: https://news.ycombinator.com/threads?id=dang

There is a surprising amount of manual intervention going on when it comes to what appears on the front page, for example. This was discussed a few days ago IIRC but I can't find the relevant comments now.

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