Five Ways to Conquer Cognitive Fatigue and Meaningless Use


Are you letting meaningless details squander your mental currency in rheumatology practice? The author points out how to recapture energy stolen by mere paperwork that should be used on your real job: Patient care.

Think about the last time you really pushed your muscles to the point of anaerobic lactic acid build-up (some of have to think back longer than others). Muscle fatigue hurts, doesn’t it?

Now, think about times you have said, “My brain just hurts to think about this!” Mental effort is work, too. We call it “brainpower” because the brain needs glucose and expends effort in order to think. There is only so much mental “currency” we can spend in a normal day, and every single decision, from what shoes to wear through what way to get to work and which test to order on a patient, all require a nickel here and a dime there of mental energy.

Medical practice currently uses up our mental currency at a remarkable rate. Consider what you must think about during the clinic day: collecting clinical data via the traditional H&P, entering data and checking meaningful use boxes in an EMR, keeping up with what Part D formulary allows which biologic modifier medication, etc. with redundancy.

It takes 14 clicks to send a single prescription from my EMR – let’s call that 14 cents of mental effort. Like cable TV bills, the costs add up.

We also face an avalanche of clinical data. Arthur Kavanagh MD summed it up recently: “…due to the government requirements of the EMR, most of the notes are useless.   Have you seen an ER note lately? Typically 20 pages long…with 19 pages of formulaic detritus.”

Our cognition is literally being nickeled and dimed all day. Every time you do something related to health care delivery, like clicking a meaningful-use box or taking the extra steps needed to send a prescription, you have that much less mental energy to use thinking about your patients' health care.

Cognitive fatigue leads to decision fatigue, and decision fatigue leads to suboptimal care.

Consider the most inappropriately prescribed class of all medicines: antibiotics. Providers know the guidelines, but studies now shed insight on why we don’t follow them, and it has to do with cognitive fatigue. More antibiotic errors in an emergency department occur on the weekends, and more deviations from prescribing guidelines happen in clinic later during the day – both times when providers are fatigued. Radiologists have more reading errors when their eyes get tired.

Mere information overload can also deplete our mental currency: EMR pop-ups can lead to distracting errors during patient care, and journal editors suffer from information overload in selecting articles to publish.

Even taking a lunch break seems to matter. A study showed that judicial decisions were often different before and after the judge’s lunch break!

It makes sense for us to use our mental energy where we need to spend it most: taking care of patients. How can we deal with the nickel-and-dime costs that healthcare delivery places on our cognitive currency? I’ve been thinking hard about this, and I have some ideas:

1. If you have a say in selecting your EMR, take the care required choose one that follows your practice workflow efficiently. Don’t let start-up cost be your sole focus. Spend the time mecessary to analyze how much the EMR forces you to follow its rules. Find out whether the software can be modified to meet your particular needs. The day-to-day high costs in time and mental energy of a poorly functioning EMR can make a low-cost, sweet-deal system into a real lemon after only a few months.

2. If you can, delegate non-essential decisions to support staff. We deal with the myriad formulary differences of various insurance plans by having a trained medical assistant whose job it is to stay current with formulary changes, or to contact the pharmacy representative for assistance.

3. As much as possible, avoid interruptions during a patient visit. There will always be true emergencies, but have protocols for dealing with potential interruptions that every member of the staff understands. We schedule specific breaks during clinic so we can catch up on “urgent” issues without interrupting patient visits.

4. Have a quick sugar fix when you know your energy is waning; Not a huge lunch that will blow your diet and ruin your youthful figure, but just a quick snack.

5. Identify your best “recharging” mechanism and take advantage of it. A psychiatrist I know takes a 20-minute walk at lunch while listening to music. He jokes that it gives him the power he needs to deal with his “crazy” afternoon clinic!

A busy medical practice may still leave you feeling exhausted at the end of a day, but you can feel better about that fatigue if you know that your mental energy was not wasted on trivial matters.

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