Commentary

Question: Driving home after a demanding 24 hours on call, the sleepy and fatigued first-year medical resident momentarily dozed off at the wheel, ran a stop sign, and struck an oncoming car, injuring its driver. In a lawsuit by the injured victim, which of the following answers is best?

A. The residency program is definitely liable, being in violation of Accreditation Council for Graduate Medical Education rules on consecutive work hours.

B. The resident is solely liable, because he’s the one who owed the duty of due care.

C. The hospital may be a named codefendant, because it knew or should have known that sleep deprivation can impair a person’s driving ability.

D. A and C are correct.

E. Only B and C are correct.

Answer: E. Residency training programs face many potential liabilities, such as those arising from disciplinary actions, employer-employee disputes, sexual harassment, and so on. But one issue deserving attention is auto accidents in overfatigued trainees. The incidence of falling asleep at the wheel is very high – in some surveys, close to 50% – and accidents are more likely to occur in the immediate post-call period.

The two main research papers documenting a relationship between extended work duty and auto accidents are from Laura K. Barger, Ph.D., and Dr. Colin P. West.

In the Barger study, the authors conducted a nationwide Web-based survey of 2,737 interns (N. Engl. J. Med. 2005;352:125-34). They found that an extended work shift (greater than 24 hours) was 2.3 times as likely for a motor vehicle crash, and 5.9 times for a near-miss accident. The researchers calculated that every extended shift in the month increased the crash risk by 9.1% and near-miss risk by 16.2%.

In the West study, the authors performed a prospective, 5-year longitudinal study of a cohort of 340 first-year Mayo Clinic residents in internal medicine (Mayo Clin. Proc. 2012;87:1138-44). In self-generated quarterly filings, 11.3% reported a motor vehicle crash and 43.3% a near-miss accident. Sleepiness (as well as other variables such as depression, burnout, diminished quality of life, and fatigue) significantly increased the odds of a motor vehicle incident in the subsequent 3-month period. Each 1-point increase in fatigue or Epworth Sleepiness Scale score was associated with a 52% and 12% respective increase in a motor vehicle crash.

The Accreditation Council for Graduate Medical Education (ACGME) has formulated rules, which have undergone recent changes, regarding consecutive work-duty hours. Its latest edict in June 2014 can be found on its website and stipulates that “Duty periods of PGY-1 residents must not exceed 16 hours in duration,” and “Duty periods of PGY-2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital.”

Furthermore, programs must encourage residents to use alertness management strategies in the context of patient care responsibilities. Strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 p.m. and 8:00 a.m., was a strong suggestion.

In a 2005 lawsuit naming Chicago’s Rush Presbyterian-St. Luke’s Medical Center as a defendant, an Illinois court faced the issue of whether a hospital owed a duty to a plaintiff injured by an off-duty resident doctor allegedly suffering from sleep deprivation as a result of a hospital’s policy on working hours (Brewster v. Rush Presbyterian-St. Luke’s Medical Center (836 N.E.2d 635 (Il. App. 2005)). The doctor was an intern who had worked 34 hours of a 36-hour work shift, and fell asleep behind the wheel of her car, striking and seriously injuring the driver of an oncoming car.

In its decision, the court noted the plaintiff’s argument that it was reasonably foreseeable and likely that drivers who were sleep deprived would cause traffic accidents resulting in injuries. For public policy reasons, the plaintiff also maintained that such injuries could be prevented if hospitals either changed work schedules of their residents or provided them with additional rest periods.

However, the court held that there was no liability imputed to health care providers for injuries to nonpatient third parties absent the existence of a “special relationship” between the parties.

Thus, training programs or hospitals may or may not be found liable in future such cases or in other jurisdictions – but the new, stricter ACGME rules suggest that they will, at a minimum, be a named defendant.

Note that in some jurisdictions, injured nonpatient third parties have successfully sued doctors for failing to warn their patients that certain medications can adversely affect their driving ability, and for failing to warn about medical conditions, e.g., syncope, that can adversely impact driving.

Court decisions in analogous factual circumstances have sometimes favored the accident victim.

In Robertson v. LeMaster (301 S.E.2d 563 (W. Va. 1983)), the West Virginia Supreme Court of Appeals noted that the defendant’s employer, Norfolk & Western Railway Company, “could have reasonably foreseen that its exhausted employee, who had been required to work 27 hours without rest, would pose a risk of harm to other motorists^.”

In Faverty v. McDonald’s Restaurants of Oregon (892 P.2d 703 (Ore. Ct. App.1995)), an Oregon appeals court held that the defendant corporation (McDonald’s Restaurants of Oregon) knew or should have known that its employee was a hazard to himself and others when he drove home from the workplace after working multiple shifts in a 24-hour period.

On the other hand, in Barclay v. Briscoe (47 A.3d 560 (Md. 2012)), a longshoreman employed by Ports America Baltimore fell asleep at the wheel while traveling home after working a 22-hour shift and caused a head-on collision resulting in catastrophic injuries. Ports America Baltimore contended that it could not be held primarily liable, because it owed no duty to the public to ensure that an employee was fit to drive his personal vehicle home. The trial court agreed, and the Maryland Court of Appeals affirmed.

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].

Question: Driving home after a demanding 24 hours on call, the sleepy and fatigued first-year medical resident momentarily dozed off at the wheel, ran a stop sign, and struck an oncoming car, injuring its driver. In a lawsuit by the injured victim, which of the following answers is best?

A. The residency program is definitely liable, being in violation of Accreditation Council for Graduate Medical Education rules on consecutive work hours.

B. The resident is solely liable, because he’s the one who owed the duty of due care.

C. The hospital may be a named codefendant, because it knew or should have known that sleep deprivation can impair a person’s driving ability.

D. A and C are correct.

E. Only B and C are correct.

Answer: E. Residency training programs face many potential liabilities, such as those arising from disciplinary actions, employer-employee disputes, sexual harassment, and so on. But one issue deserving attention is auto accidents in overfatigued trainees. The incidence of falling asleep at the wheel is very high – in some surveys, close to 50% – and accidents are more likely to occur in the immediate post-call period.

The two main research papers documenting a relationship between extended work duty and auto accidents are from Laura K. Barger, Ph.D., and Dr. Colin P. West.

In the Barger study, the authors conducted a nationwide Web-based survey of 2,737 interns (N. Engl. J. Med. 2005;352:125-34). They found that an extended work shift (greater than 24 hours) was 2.3 times as likely for a motor vehicle crash, and 5.9 times for a near-miss accident. The researchers calculated that every extended shift in the month increased the crash risk by 9.1% and near-miss risk by 16.2%.

In the West study, the authors performed a prospective, 5-year longitudinal study of a cohort of 340 first-year Mayo Clinic residents in internal medicine (Mayo Clin. Proc. 2012;87:1138-44). In self-generated quarterly filings, 11.3% reported a motor vehicle crash and 43.3% a near-miss accident. Sleepiness (as well as other variables such as depression, burnout, diminished quality of life, and fatigue) significantly increased the odds of a motor vehicle incident in the subsequent 3-month period. Each 1-point increase in fatigue or Epworth Sleepiness Scale score was associated with a 52% and 12% respective increase in a motor vehicle crash.

The Accreditation Council for Graduate Medical Education (ACGME) has formulated rules, which have undergone recent changes, regarding consecutive work-duty hours. Its latest edict in June 2014 can be found on its website and stipulates that “Duty periods of PGY-1 residents must not exceed 16 hours in duration,” and “Duty periods of PGY-2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital.”

Furthermore, programs must encourage residents to use alertness management strategies in the context of patient care responsibilities. Strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 p.m. and 8:00 a.m., was a strong suggestion.

In a 2005 lawsuit naming Chicago’s Rush Presbyterian-St. Luke’s Medical Center as a defendant, an Illinois court faced the issue of whether a hospital owed a duty to a plaintiff injured by an off-duty resident doctor allegedly suffering from sleep deprivation as a result of a hospital’s policy on working hours (Brewster v. Rush Presbyterian-St. Luke’s Medical Center (836 N.E.2d 635 (Il. App. 2005)). The doctor was an intern who had worked 34 hours of a 36-hour work shift, and fell asleep behind the wheel of her car, striking and seriously injuring the driver of an oncoming car.

In its decision, the court noted the plaintiff’s argument that it was reasonably foreseeable and likely that drivers who were sleep deprived would cause traffic accidents resulting in injuries. For public policy reasons, the plaintiff also maintained that such injuries could be prevented if hospitals either changed work schedules of their residents or provided them with additional rest periods.

However, the court held that there was no liability imputed to health care providers for injuries to nonpatient third parties absent the existence of a “special relationship” between the parties.

Thus, training programs or hospitals may or may not be found liable in future such cases or in other jurisdictions – but the new, stricter ACGME rules suggest that they will, at a minimum, be a named defendant.

Note that in some jurisdictions, injured nonpatient third parties have successfully sued doctors for failing to warn their patients that certain medications can adversely affect their driving ability, and for failing to warn about medical conditions, e.g., syncope, that can adversely impact driving.

Court decisions in analogous factual circumstances have sometimes favored the accident victim.

In Robertson v. LeMaster (301 S.E.2d 563 (W. Va. 1983)), the West Virginia Supreme Court of Appeals noted that the defendant’s employer, Norfolk & Western Railway Company, “could have reasonably foreseen that its exhausted employee, who had been required to work 27 hours without rest, would pose a risk of harm to other motorists^.”

In Faverty v. McDonald’s Restaurants of Oregon (892 P.2d 703 (Ore. Ct. App.1995)), an Oregon appeals court held that the defendant corporation (McDonald’s Restaurants of Oregon) knew or should have known that its employee was a hazard to himself and others when he drove home from the workplace after working multiple shifts in a 24-hour period.

On the other hand, in Barclay v. Briscoe (47 A.3d 560 (Md. 2012)), a longshoreman employed by Ports America Baltimore fell asleep at the wheel while traveling home after working a 22-hour shift and caused a head-on collision resulting in catastrophic injuries. Ports America Baltimore contended that it could not be held primarily liable, because it owed no duty to the public to ensure that an employee was fit to drive his personal vehicle home. The trial court agreed, and the Maryland Court of Appeals affirmed.

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].

Question: Driving home after a demanding 24 hours on call, the sleepy and fatigued first-year medical resident momentarily dozed off at the wheel, ran a stop sign, and struck an oncoming car, injuring its driver. In a lawsuit by the injured victim, which of the following answers is best?

A. The residency program is definitely liable, being in violation of Accreditation Council for Graduate Medical Education rules on consecutive work hours.

B. The resident is solely liable, because he’s the one who owed the duty of due care.

C. The hospital may be a named codefendant, because it knew or should have known that sleep deprivation can impair a person’s driving ability.

D. A and C are correct.

E. Only B and C are correct.

Answer: E. Residency training programs face many potential liabilities, such as those arising from disciplinary actions, employer-employee disputes, sexual harassment, and so on. But one issue deserving attention is auto accidents in overfatigued trainees. The incidence of falling asleep at the wheel is very high – in some surveys, close to 50% – and accidents are more likely to occur in the immediate post-call period.

The two main research papers documenting a relationship between extended work duty and auto accidents are from Laura K. Barger, Ph.D., and Dr. Colin P. West.

In the Barger study, the authors conducted a nationwide Web-based survey of 2,737 interns (N. Engl. J. Med. 2005;352:125-34). They found that an extended work shift (greater than 24 hours) was 2.3 times as likely for a motor vehicle crash, and 5.9 times for a near-miss accident. The researchers calculated that every extended shift in the month increased the crash risk by 9.1% and near-miss risk by 16.2%.

In the West study, the authors performed a prospective, 5-year longitudinal study of a cohort of 340 first-year Mayo Clinic residents in internal medicine (Mayo Clin. Proc. 2012;87:1138-44). In self-generated quarterly filings, 11.3% reported a motor vehicle crash and 43.3% a near-miss accident. Sleepiness (as well as other variables such as depression, burnout, diminished quality of life, and fatigue) significantly increased the odds of a motor vehicle incident in the subsequent 3-month period. Each 1-point increase in fatigue or Epworth Sleepiness Scale score was associated with a 52% and 12% respective increase in a motor vehicle crash.

The Accreditation Council for Graduate Medical Education (ACGME) has formulated rules, which have undergone recent changes, regarding consecutive work-duty hours. Its latest edict in June 2014 can be found on its website and stipulates that “Duty periods of PGY-1 residents must not exceed 16 hours in duration,” and “Duty periods of PGY-2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital.”

Furthermore, programs must encourage residents to use alertness management strategies in the context of patient care responsibilities. Strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 p.m. and 8:00 a.m., was a strong suggestion.

In a 2005 lawsuit naming Chicago’s Rush Presbyterian-St. Luke’s Medical Center as a defendant, an Illinois court faced the issue of whether a hospital owed a duty to a plaintiff injured by an off-duty resident doctor allegedly suffering from sleep deprivation as a result of a hospital’s policy on working hours (Brewster v. Rush Presbyterian-St. Luke’s Medical Center (836 N.E.2d 635 (Il. App. 2005)). The doctor was an intern who had worked 34 hours of a 36-hour work shift, and fell asleep behind the wheel of her car, striking and seriously injuring the driver of an oncoming car.

In its decision, the court noted the plaintiff’s argument that it was reasonably foreseeable and likely that drivers who were sleep deprived would cause traffic accidents resulting in injuries. For public policy reasons, the plaintiff also maintained that such injuries could be prevented if hospitals either changed work schedules of their residents or provided them with additional rest periods.

However, the court held that there was no liability imputed to health care providers for injuries to nonpatient third parties absent the existence of a “special relationship” between the parties.

Thus, training programs or hospitals may or may not be found liable in future such cases or in other jurisdictions – but the new, stricter ACGME rules suggest that they will, at a minimum, be a named defendant.

Note that in some jurisdictions, injured nonpatient third parties have successfully sued doctors for failing to warn their patients that certain medications can adversely affect their driving ability, and for failing to warn about medical conditions, e.g., syncope, that can adversely impact driving.

Court decisions in analogous factual circumstances have sometimes favored the accident victim.

In Robertson v. LeMaster (301 S.E.2d 563 (W. Va. 1983)), the West Virginia Supreme Court of Appeals noted that the defendant’s employer, Norfolk & Western Railway Company, “could have reasonably foreseen that its exhausted employee, who had been required to work 27 hours without rest, would pose a risk of harm to other motorists^.”

In Faverty v. McDonald’s Restaurants of Oregon (892 P.2d 703 (Ore. Ct. App.1995)), an Oregon appeals court held that the defendant corporation (McDonald’s Restaurants of Oregon) knew or should have known that its employee was a hazard to himself and others when he drove home from the workplace after working multiple shifts in a 24-hour period.

On the other hand, in Barclay v. Briscoe (47 A.3d 560 (Md. 2012)), a longshoreman employed by Ports America Baltimore fell asleep at the wheel while traveling home after working a 22-hour shift and caused a head-on collision resulting in catastrophic injuries. Ports America Baltimore contended that it could not be held primarily liable, because it owed no duty to the public to ensure that an employee was fit to drive his personal vehicle home. The trial court agreed, and the Maryland Court of Appeals affirmed.

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].

One of the perks that comes with being a grandparent is that you may get the chance to watch your grandchildren practice, play, and perform in a variety of organized activities. If you are retired and are fortunate enough to live in the same town, the opportunities are limitless and change with the season.

Each event is a kaleidoscope of interpersonal and developmental tableaux. First, of course, you are interested to see how your grandchild is doing. Are her skills improving? How do they compare with her peers’? Is she having fun? But then, what is the goal of the activity? Are the coaches/instructors/organizers doing a good job of reaching that goal?

Last week, I was watching my 8-year-old grandson play the last baseball game of his career (“Grampy, baseball is boring. I’m only playing lacrosse next spring.”) Between innings, I thumbed through the June 2015 Pediatrics. I encountered an article that confirmed my suspicions about some of the organized youth activities I had been watching for the last decade, “Physical Activity in Youth Dance Classes” (Pediatrics 2015;135:1067-73). Using accelerometers, researchers from San Diego State University recorded the activity of more than 250 girls, both children and adolescents, in 21 dance studios, both private and community based.

They discovered that the young dancers were, on average, engaged in moderate to vigorous activity 17.2 minutes (plus or minus 8.9 minutes), which amounted to about 36% of the usual class session. Only 8% of the children and 6% of the adolescents met the Centers for Disease Control and Prevention 30-minute guideline for after-school physical activity during dance.

I’ve watched a fair share of dance classes, and these findings come as no surprise. Typically, there is a lot of sitting around cross-legged in a circle, “listening” to “instruction.” There is even more lining up and waiting, and, then of course, adjusting the line, and an abundance of relining up, followed by a 6-second burst of activity. There is considerable poking and/or hugging fellow line mates, that I suspect wouldn’t have budged an accelerometer.

Unfortunately, this degree of inactivity is not unique to little girls’ dance classes. I have observed the same phenomenon during soccer, baseball, lacrosse, and swim classes – in which the ratio of inactivity to activity often exceeds 4:1. Although it may be slightly more prevalent when the instructors are parent/volunteers, professional physical educators also are guilty of injecting too little physical activity into the activities they are managing. Remember gym class. How much time was spent having your attendance taken, being instructed on how to do the activity, and then standing in line waiting your turn?

There are simple solutions, but they require thinking outside the box. Why have two lines of participants? Wouldn’t six lines mean three times as many children would be active at one time? For example, it has taken a while for soccer and hockey programs to catch on, but now both have games on smaller surfaces with less than the usual number of team members, in hopes that more children will be involved and active. Most great coaches have a knack for creating drills that keep the maximum number of participants active, foster the necessary skills, and at the same time are fun for the participants. The bottom line is that most children, particularly the younger ones, learn by imitating, not by being lectured to. They learn even more quickly if they have older children from which to model their behavior.

You could ask, “What’s the big deal?” Am I just venting the frustrations of an efficiency-obsessed former athlete? Does every minute of a child’s organized activity need to be packed with physical activity? No, not if children were allowed more opportunities for free play at other times during the day. No, not if parents were more diligent in restricting screen time. But if parents are going to count on dance classes and organized sports as physically active time for their children, they need to look more carefully at how that time is being used. An hour of dance class or soccer practice may be better than an hour in front of the tube, but it may fall far short of what the child needs.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”

One of the perks that comes with being a grandparent is that you may get the chance to watch your grandchildren practice, play, and perform in a variety of organized activities. If you are retired and are fortunate enough to live in the same town, the opportunities are limitless and change with the season.

Each event is a kaleidoscope of interpersonal and developmental tableaux. First, of course, you are interested to see how your grandchild is doing. Are her skills improving? How do they compare with her peers’? Is she having fun? But then, what is the goal of the activity? Are the coaches/instructors/organizers doing a good job of reaching that goal?

Last week, I was watching my 8-year-old grandson play the last baseball game of his career (“Grampy, baseball is boring. I’m only playing lacrosse next spring.”) Between innings, I thumbed through the June 2015 Pediatrics. I encountered an article that confirmed my suspicions about some of the organized youth activities I had been watching for the last decade, “Physical Activity in Youth Dance Classes” (Pediatrics 2015;135:1067-73). Using accelerometers, researchers from San Diego State University recorded the activity of more than 250 girls, both children and adolescents, in 21 dance studios, both private and community based.

They discovered that the young dancers were, on average, engaged in moderate to vigorous activity 17.2 minutes (plus or minus 8.9 minutes), which amounted to about 36% of the usual class session. Only 8% of the children and 6% of the adolescents met the Centers for Disease Control and Prevention 30-minute guideline for after-school physical activity during dance.

I’ve watched a fair share of dance classes, and these findings come as no surprise. Typically, there is a lot of sitting around cross-legged in a circle, “listening” to “instruction.” There is even more lining up and waiting, and, then of course, adjusting the line, and an abundance of relining up, followed by a 6-second burst of activity. There is considerable poking and/or hugging fellow line mates, that I suspect wouldn’t have budged an accelerometer.

Unfortunately, this degree of inactivity is not unique to little girls’ dance classes. I have observed the same phenomenon during soccer, baseball, lacrosse, and swim classes – in which the ratio of inactivity to activity often exceeds 4:1. Although it may be slightly more prevalent when the instructors are parent/volunteers, professional physical educators also are guilty of injecting too little physical activity into the activities they are managing. Remember gym class. How much time was spent having your attendance taken, being instructed on how to do the activity, and then standing in line waiting your turn?

There are simple solutions, but they require thinking outside the box. Why have two lines of participants? Wouldn’t six lines mean three times as many children would be active at one time? For example, it has taken a while for soccer and hockey programs to catch on, but now both have games on smaller surfaces with less than the usual number of team members, in hopes that more children will be involved and active. Most great coaches have a knack for creating drills that keep the maximum number of participants active, foster the necessary skills, and at the same time are fun for the participants. The bottom line is that most children, particularly the younger ones, learn by imitating, not by being lectured to. They learn even more quickly if they have older children from which to model their behavior.

You could ask, “What’s the big deal?” Am I just venting the frustrations of an efficiency-obsessed former athlete? Does every minute of a child’s organized activity need to be packed with physical activity? No, not if children were allowed more opportunities for free play at other times during the day. No, not if parents were more diligent in restricting screen time. But if parents are going to count on dance classes and organized sports as physically active time for their children, they need to look more carefully at how that time is being used. An hour of dance class or soccer practice may be better than an hour in front of the tube, but it may fall far short of what the child needs.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”

One of the perks that comes with being a grandparent is that you may get the chance to watch your grandchildren practice, play, and perform in a variety of organized activities. If you are retired and are fortunate enough to live in the same town, the opportunities are limitless and change with the season.

Each event is a kaleidoscope of interpersonal and developmental tableaux. First, of course, you are interested to see how your grandchild is doing. Are her skills improving? How do they compare with her peers’? Is she having fun? But then, what is the goal of the activity? Are the coaches/instructors/organizers doing a good job of reaching that goal?

Last week, I was watching my 8-year-old grandson play the last baseball game of his career (“Grampy, baseball is boring. I’m only playing lacrosse next spring.”) Between innings, I thumbed through the June 2015 Pediatrics. I encountered an article that confirmed my suspicions about some of the organized youth activities I had been watching for the last decade, “Physical Activity in Youth Dance Classes” (Pediatrics 2015;135:1067-73). Using accelerometers, researchers from San Diego State University recorded the activity of more than 250 girls, both children and adolescents, in 21 dance studios, both private and community based.

They discovered that the young dancers were, on average, engaged in moderate to vigorous activity 17.2 minutes (plus or minus 8.9 minutes), which amounted to about 36% of the usual class session. Only 8% of the children and 6% of the adolescents met the Centers for Disease Control and Prevention 30-minute guideline for after-school physical activity during dance.

I’ve watched a fair share of dance classes, and these findings come as no surprise. Typically, there is a lot of sitting around cross-legged in a circle, “listening” to “instruction.” There is even more lining up and waiting, and, then of course, adjusting the line, and an abundance of relining up, followed by a 6-second burst of activity. There is considerable poking and/or hugging fellow line mates, that I suspect wouldn’t have budged an accelerometer.

Unfortunately, this degree of inactivity is not unique to little girls’ dance classes. I have observed the same phenomenon during soccer, baseball, lacrosse, and swim classes – in which the ratio of inactivity to activity often exceeds 4:1. Although it may be slightly more prevalent when the instructors are parent/volunteers, professional physical educators also are guilty of injecting too little physical activity into the activities they are managing. Remember gym class. How much time was spent having your attendance taken, being instructed on how to do the activity, and then standing in line waiting your turn?

There are simple solutions, but they require thinking outside the box. Why have two lines of participants? Wouldn’t six lines mean three times as many children would be active at one time? For example, it has taken a while for soccer and hockey programs to catch on, but now both have games on smaller surfaces with less than the usual number of team members, in hopes that more children will be involved and active. Most great coaches have a knack for creating drills that keep the maximum number of participants active, foster the necessary skills, and at the same time are fun for the participants. The bottom line is that most children, particularly the younger ones, learn by imitating, not by being lectured to. They learn even more quickly if they have older children from which to model their behavior.

You could ask, “What’s the big deal?” Am I just venting the frustrations of an efficiency-obsessed former athlete? Does every minute of a child’s organized activity need to be packed with physical activity? No, not if children were allowed more opportunities for free play at other times during the day. No, not if parents were more diligent in restricting screen time. But if parents are going to count on dance classes and organized sports as physically active time for their children, they need to look more carefully at how that time is being used. An hour of dance class or soccer practice may be better than an hour in front of the tube, but it may fall far short of what the child needs.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”

Recently, there have been several news stories about physicians committing suicide. This is across all levels of the profession, including medical students, residents, and attendings.

Historically, doctors have had a higher rate of suicide than most professions. I’m not sure if that number has crept up recently, or if events are garnering more attention than before. They’re certainly mentioned prominently on various medical blogs.

Why do you see this in medicine? There are probably a number of factors that overlap:

• A high pressure job, where mistakes aren’t allowed (which isn’t humanly possible).

• A culture of litigation, where even minor mistakes are taken to court.

• Declining financial reimbursement, making it harder to support a practice and family, especially when you’re already six figures in debt coming out of medical school.

• Pressure to work longer hours and see far more patients than is possible, which increases the potential for mistakes. This further reduces the amount of family and recreational time available to balance ourselves.

• An increase in “empowered patients” demanding unnecessary tests and treatments because it said so on the Internet.

• A general lack of respect for the profession, to where we’re now “providers” who are vilified for political reasons by insurance companies, consumer groups, and both major parties.

• The need for us not to admit or seek treatment for human vulnerabilities. Our own health (mental and physical) is neglected because we can’t take time off to address it and a fear that doing so may result in us having our licenses penalized.

Any of the above makes life unpleasant, but when you combine them … it can be a perfect storm that tips a person over the edge.

In medicine, seeking help is often seen as a weakness, and even the most rational person under difficult circumstances can snap. None of the physicians who’ve ended their lives started out saying that was how they wanted their medical career to wind up. But when stressors pile up, it may appear to them to be the only way out. In that frame of mind, you think doing something so drastic is better for everyone around you. It isn’t true, but at that point you don’t believe it.

A physician’s suicide, even outside of its effects on their family, is a loss. A physician is a community resource, leaving behind relationships with patients in various stages of work-ups and treatments. There’s always another doctor, but it’s not easy, or immediate, to find someone who’s a good fit for the area.

I don’t know if this is a peculiarly American phenomenon or if my colleagues in Canada, Europe, and elsewhere face similar challenges. If the suicide rate elsewhere is lower, what can we learn from them to make things better here? If it’s the same, what can we do collectively to find an answer? Every country needs doctors and can’t afford to lose them.

Is there an easy solution? Probably not. Too many factors to fix. But it’s a serious problem and needs attention.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Recently, there have been several news stories about physicians committing suicide. This is across all levels of the profession, including medical students, residents, and attendings.

Historically, doctors have had a higher rate of suicide than most professions. I’m not sure if that number has crept up recently, or if events are garnering more attention than before. They’re certainly mentioned prominently on various medical blogs.

Why do you see this in medicine? There are probably a number of factors that overlap:

• A high pressure job, where mistakes aren’t allowed (which isn’t humanly possible).

• A culture of litigation, where even minor mistakes are taken to court.

• Declining financial reimbursement, making it harder to support a practice and family, especially when you’re already six figures in debt coming out of medical school.

• Pressure to work longer hours and see far more patients than is possible, which increases the potential for mistakes. This further reduces the amount of family and recreational time available to balance ourselves.

• An increase in “empowered patients” demanding unnecessary tests and treatments because it said so on the Internet.

• A general lack of respect for the profession, to where we’re now “providers” who are vilified for political reasons by insurance companies, consumer groups, and both major parties.

• The need for us not to admit or seek treatment for human vulnerabilities. Our own health (mental and physical) is neglected because we can’t take time off to address it and a fear that doing so may result in us having our licenses penalized.

Any of the above makes life unpleasant, but when you combine them … it can be a perfect storm that tips a person over the edge.

In medicine, seeking help is often seen as a weakness, and even the most rational person under difficult circumstances can snap. None of the physicians who’ve ended their lives started out saying that was how they wanted their medical career to wind up. But when stressors pile up, it may appear to them to be the only way out. In that frame of mind, you think doing something so drastic is better for everyone around you. It isn’t true, but at that point you don’t believe it.

A physician’s suicide, even outside of its effects on their family, is a loss. A physician is a community resource, leaving behind relationships with patients in various stages of work-ups and treatments. There’s always another doctor, but it’s not easy, or immediate, to find someone who’s a good fit for the area.

I don’t know if this is a peculiarly American phenomenon or if my colleagues in Canada, Europe, and elsewhere face similar challenges. If the suicide rate elsewhere is lower, what can we learn from them to make things better here? If it’s the same, what can we do collectively to find an answer? Every country needs doctors and can’t afford to lose them.

Is there an easy solution? Probably not. Too many factors to fix. But it’s a serious problem and needs attention.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Recently, there have been several news stories about physicians committing suicide. This is across all levels of the profession, including medical students, residents, and attendings.

Historically, doctors have had a higher rate of suicide than most professions. I’m not sure if that number has crept up recently, or if events are garnering more attention than before. They’re certainly mentioned prominently on various medical blogs.

Why do you see this in medicine? There are probably a number of factors that overlap:

• A high pressure job, where mistakes aren’t allowed (which isn’t humanly possible).

• A culture of litigation, where even minor mistakes are taken to court.

• Declining financial reimbursement, making it harder to support a practice and family, especially when you’re already six figures in debt coming out of medical school.

• Pressure to work longer hours and see far more patients than is possible, which increases the potential for mistakes. This further reduces the amount of family and recreational time available to balance ourselves.

• An increase in “empowered patients” demanding unnecessary tests and treatments because it said so on the Internet.

• A general lack of respect for the profession, to where we’re now “providers” who are vilified for political reasons by insurance companies, consumer groups, and both major parties.

• The need for us not to admit or seek treatment for human vulnerabilities. Our own health (mental and physical) is neglected because we can’t take time off to address it and a fear that doing so may result in us having our licenses penalized.

Any of the above makes life unpleasant, but when you combine them … it can be a perfect storm that tips a person over the edge.

In medicine, seeking help is often seen as a weakness, and even the most rational person under difficult circumstances can snap. None of the physicians who’ve ended their lives started out saying that was how they wanted their medical career to wind up. But when stressors pile up, it may appear to them to be the only way out. In that frame of mind, you think doing something so drastic is better for everyone around you. It isn’t true, but at that point you don’t believe it.

A physician’s suicide, even outside of its effects on their family, is a loss. A physician is a community resource, leaving behind relationships with patients in various stages of work-ups and treatments. There’s always another doctor, but it’s not easy, or immediate, to find someone who’s a good fit for the area.

I don’t know if this is a peculiarly American phenomenon or if my colleagues in Canada, Europe, and elsewhere face similar challenges. If the suicide rate elsewhere is lower, what can we learn from them to make things better here? If it’s the same, what can we do collectively to find an answer? Every country needs doctors and can’t afford to lose them.

Is there an easy solution? Probably not. Too many factors to fix. But it’s a serious problem and needs attention.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The recent endorsements by the FDA’s Endocrinologic and Metabolic Drugs Advisory Committee of the new genetically manufactured, subcutaneously administered cholesterol-lowering agents alirocumab (Sanofi-Regeneron) and evolocumab (Pfizer) have sent a jolt through the world of cholesterol therapy. Proposed for the treatment of patients with high-risk cardiovascular disease and homozygous familial hypercholesterolemia (HoFH), the decisions suggest that the committee has developed a severe case of scientific amnesia.

A case can be made for the approval for the very-high-risk and untreatable patients with HoFH, but the decision to treat millions of Americans based on the paucity of clinical data available would be disturbing, if not irresponsible.

It is clear that these proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors provide a powerful therapy for reducing LDL cholesterol, with a reported decrease of about 60% after only 12 or 52 weeks of treatment. Based on four small studies lasting 10-12 weeks and without any clinical outcome data, the committee recommended approving evolocumab for lifetime therapy without anything to support its clinical effectiveness or safety.

Dr. Robert J. Smith, who chaired the advisory committee meeting, faced with approving the drug or delaying a decision until a randomized clinical trial can be completed said, “I am unwilling to subject patients to the wait.” A publication of the American College of Cardiology suggested that these two monoclonal antibody drugs could replace generic statins in 70 million Americans at an estimated cost of $7,000-$12,000 a year. Talk about breaking the bank.

Only recently, we decided that the appropriate statin therapy for cholesterol control should use the dosing from the original clinical trials rather than chasing LDL levels to the lowest level possible. We now have a class of drugs that clearly can lower the cholesterol to a level never seen before, and we are about to discard that therapeutic advice.

We have experience in chasing blood levels with uncertain outcomes. Reducing blood sugar to a very low hemoglobin A_1c level led to adverse clinical events and increased mortality in type 2 diabetes. Raising HDL with the cholesterol ester transfer protein (CETP) inhibitor torcetrapib in a study of 15,000 patients in an outcome trial carried out over a number of years led to increased blood pressure and mortality by 58%, which was associated with a 25% decrease in LDL cholesterol and a 72% increase in HDL, both effects presumed to be remarkably beneficial (N. Engl. J. Med. 2007;357:2109-22).

It is quite possible that these new agents can further decrease coronary vascular mortality. A healthy controversy has raged for some time in regard to the “LDL hypothesis,” compared with therapy based upon the clinical trial outcome. The recent IMPROVE-IT report (N. Engl. J. Med. 2015;372:2387-97) provides some data to support the LDL hypothesis. In that study, the addition of 10 mg of ezetimibe to 40 mg of simvastatin in 18,144 patients followed for up to 6 years resulted in a 2% decrease in mortality associated with a 15.8-mg decrease in serum LDL.

Would it not be prudent to have similar data with the new drug on the street? If it is as potent as it appears to be, a trial of much shorter duration might demonstrate its potency and safety before it is offered to 70 million Americans. The FDA has been reluctant to use surrogate endpoints for approving drugs, but its position has not always been consistent. For some time the FDA has, on occasion, approved drugs that can lower cholesterol with limited outcome data as it did with ezetimibe. However, the decision in regard to the PCSK9 inhibitors will have a much larger impact on care than an add-on drug like ezetimibe. Let’s hope that the FDA shows better judgment than its advisory committee.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

The recent endorsements by the FDA’s Endocrinologic and Metabolic Drugs Advisory Committee of the new genetically manufactured, subcutaneously administered cholesterol-lowering agents alirocumab (Sanofi-Regeneron) and evolocumab (Pfizer) have sent a jolt through the world of cholesterol therapy. Proposed for the treatment of patients with high-risk cardiovascular disease and homozygous familial hypercholesterolemia (HoFH), the decisions suggest that the committee has developed a severe case of scientific amnesia.

A case can be made for the approval for the very-high-risk and untreatable patients with HoFH, but the decision to treat millions of Americans based on the paucity of clinical data available would be disturbing, if not irresponsible.

It is clear that these proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors provide a powerful therapy for reducing LDL cholesterol, with a reported decrease of about 60% after only 12 or 52 weeks of treatment. Based on four small studies lasting 10-12 weeks and without any clinical outcome data, the committee recommended approving evolocumab for lifetime therapy without anything to support its clinical effectiveness or safety.

Dr. Robert J. Smith, who chaired the advisory committee meeting, faced with approving the drug or delaying a decision until a randomized clinical trial can be completed said, “I am unwilling to subject patients to the wait.” A publication of the American College of Cardiology suggested that these two monoclonal antibody drugs could replace generic statins in 70 million Americans at an estimated cost of $7,000-$12,000 a year. Talk about breaking the bank.

Only recently, we decided that the appropriate statin therapy for cholesterol control should use the dosing from the original clinical trials rather than chasing LDL levels to the lowest level possible. We now have a class of drugs that clearly can lower the cholesterol to a level never seen before, and we are about to discard that therapeutic advice.

We have experience in chasing blood levels with uncertain outcomes. Reducing blood sugar to a very low hemoglobin A_1c level led to adverse clinical events and increased mortality in type 2 diabetes. Raising HDL with the cholesterol ester transfer protein (CETP) inhibitor torcetrapib in a study of 15,000 patients in an outcome trial carried out over a number of years led to increased blood pressure and mortality by 58%, which was associated with a 25% decrease in LDL cholesterol and a 72% increase in HDL, both effects presumed to be remarkably beneficial (N. Engl. J. Med. 2007;357:2109-22).

It is quite possible that these new agents can further decrease coronary vascular mortality. A healthy controversy has raged for some time in regard to the “LDL hypothesis,” compared with therapy based upon the clinical trial outcome. The recent IMPROVE-IT report (N. Engl. J. Med. 2015;372:2387-97) provides some data to support the LDL hypothesis. In that study, the addition of 10 mg of ezetimibe to 40 mg of simvastatin in 18,144 patients followed for up to 6 years resulted in a 2% decrease in mortality associated with a 15.8-mg decrease in serum LDL.

Would it not be prudent to have similar data with the new drug on the street? If it is as potent as it appears to be, a trial of much shorter duration might demonstrate its potency and safety before it is offered to 70 million Americans. The FDA has been reluctant to use surrogate endpoints for approving drugs, but its position has not always been consistent. For some time the FDA has, on occasion, approved drugs that can lower cholesterol with limited outcome data as it did with ezetimibe. However, the decision in regard to the PCSK9 inhibitors will have a much larger impact on care than an add-on drug like ezetimibe. Let’s hope that the FDA shows better judgment than its advisory committee.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

The recent endorsements by the FDA’s Endocrinologic and Metabolic Drugs Advisory Committee of the new genetically manufactured, subcutaneously administered cholesterol-lowering agents alirocumab (Sanofi-Regeneron) and evolocumab (Pfizer) have sent a jolt through the world of cholesterol therapy. Proposed for the treatment of patients with high-risk cardiovascular disease and homozygous familial hypercholesterolemia (HoFH), the decisions suggest that the committee has developed a severe case of scientific amnesia.

A case can be made for the approval for the very-high-risk and untreatable patients with HoFH, but the decision to treat millions of Americans based on the paucity of clinical data available would be disturbing, if not irresponsible.

It is clear that these proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors provide a powerful therapy for reducing LDL cholesterol, with a reported decrease of about 60% after only 12 or 52 weeks of treatment. Based on four small studies lasting 10-12 weeks and without any clinical outcome data, the committee recommended approving evolocumab for lifetime therapy without anything to support its clinical effectiveness or safety.

Dr. Robert J. Smith, who chaired the advisory committee meeting, faced with approving the drug or delaying a decision until a randomized clinical trial can be completed said, “I am unwilling to subject patients to the wait.” A publication of the American College of Cardiology suggested that these two monoclonal antibody drugs could replace generic statins in 70 million Americans at an estimated cost of $7,000-$12,000 a year. Talk about breaking the bank.

Only recently, we decided that the appropriate statin therapy for cholesterol control should use the dosing from the original clinical trials rather than chasing LDL levels to the lowest level possible. We now have a class of drugs that clearly can lower the cholesterol to a level never seen before, and we are about to discard that therapeutic advice.

We have experience in chasing blood levels with uncertain outcomes. Reducing blood sugar to a very low hemoglobin A_1c level led to adverse clinical events and increased mortality in type 2 diabetes. Raising HDL with the cholesterol ester transfer protein (CETP) inhibitor torcetrapib in a study of 15,000 patients in an outcome trial carried out over a number of years led to increased blood pressure and mortality by 58%, which was associated with a 25% decrease in LDL cholesterol and a 72% increase in HDL, both effects presumed to be remarkably beneficial (N. Engl. J. Med. 2007;357:2109-22).

It is quite possible that these new agents can further decrease coronary vascular mortality. A healthy controversy has raged for some time in regard to the “LDL hypothesis,” compared with therapy based upon the clinical trial outcome. The recent IMPROVE-IT report (N. Engl. J. Med. 2015;372:2387-97) provides some data to support the LDL hypothesis. In that study, the addition of 10 mg of ezetimibe to 40 mg of simvastatin in 18,144 patients followed for up to 6 years resulted in a 2% decrease in mortality associated with a 15.8-mg decrease in serum LDL.

Would it not be prudent to have similar data with the new drug on the street? If it is as potent as it appears to be, a trial of much shorter duration might demonstrate its potency and safety before it is offered to 70 million Americans. The FDA has been reluctant to use surrogate endpoints for approving drugs, but its position has not always been consistent. For some time the FDA has, on occasion, approved drugs that can lower cholesterol with limited outcome data as it did with ezetimibe. However, the decision in regard to the PCSK9 inhibitors will have a much larger impact on care than an add-on drug like ezetimibe. Let’s hope that the FDA shows better judgment than its advisory committee.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

A study published in JAMA Internal Medicine in December 2014 looked at decision fatigue in primary care providers. The researchers focused on antibiotic prescriptions for acute respiratory infections (including those for which antibiotics are never indicated) over a 16-month period covering 21,867 visits to 204 clinicians. They compared the rate of antibiotic prescription at the first, second, third, and fourth hour of clinic, with the premise being that over a period of repeated decision making the quality of the decisions declines (JAMA Intern. Med. 2014;174:2029-31).

If, like me, you think you have unrealistic expectations about physicians being unimpeachable, you might be disappointed to learn that antibiotic prescriptions were significantly higher for the third and fourth hour of clinic. It seems that as the clinic session wore on, physicians opted for the “safer,” “easier” option.

Another paper involving similarly weighty consequences was published in 2011 in Proceedings of the National Academy of Sciences (and cited as one of only six references in the JAMA paper). The researchers looked at parole decisions made by judges in four Israeli prisons. Data from 1,112 judicial rulings involving eight judges showed that “the percentage of favorable rulings drops gradually from ~65% to nearly zero within each decision session and returns abruptly to ~65% after a break” (Proc. Natl. Acad. Sci. U.S.A. 2011;108:6889-92). (Breaks lasted about 30 minutes and involved a meal.) That’s a pretty dramatic rate of change. It is sobering to think of lives being hugely affected by such seemingly irrelevant details. Talk about fate being fickle.

Decision fatigue suggests that when we make repeated decisions over a brief period of time there is an erosion of self-control and we are more likely to choose the “affectively pleasing” option. It has been written about in psychology journals for the past 2 decades, but for practical and ethical reasons, most studies on the subject involve minor decisions, such as what to choose at the grocery store or which items to add to one’s wedding registry. The concept has become quite popular in the fields of behavioral economic and advertising. It is the reason groceries display candy at the cash register.

Decision fatigue is part of a larger theory on our executive functions, proposed by Dr. Roy Baumeister, professor of social psychology at the University of Florida. His central idea is that self-control, volitional acts, responsibility, and self-regulatory efforts “draw upon a common resource and deplete it.” He calls it ego depletion. In one simple but powerful experiment, researchers conducted a study where students were asked to commit either two digits or seven digits to memory. When offered a choice of fruit salad or chocolate cake as compensation for participation in the study, those who had to remember seven digits were far more likely to choose the chocolate cake – certainly the more “affectively pleasing” option. So ego depletion is to blame for my constant kitchen-grazing behavior at the end of a trying clinic day. Apart from affecting my waistline, I’m sure it affects me in ways that I am unaware of, ways that may have an impact not just on patients but on society, too.

The JAMA Internal Medicine article seems to be the first of its kind in the medical literature. To me, it is hugely important because it reminds us of two major truths: that there are often bigger things at stake, and that doctors, being mere mortals, are not exempt from human frailty.

Dr. Chan practices rheumatology in Pawtucket, R.I.

A study published in JAMA Internal Medicine in December 2014 looked at decision fatigue in primary care providers. The researchers focused on antibiotic prescriptions for acute respiratory infections (including those for which antibiotics are never indicated) over a 16-month period covering 21,867 visits to 204 clinicians. They compared the rate of antibiotic prescription at the first, second, third, and fourth hour of clinic, with the premise being that over a period of repeated decision making the quality of the decisions declines (JAMA Intern. Med. 2014;174:2029-31).

If, like me, you think you have unrealistic expectations about physicians being unimpeachable, you might be disappointed to learn that antibiotic prescriptions were significantly higher for the third and fourth hour of clinic. It seems that as the clinic session wore on, physicians opted for the “safer,” “easier” option.

Another paper involving similarly weighty consequences was published in 2011 in Proceedings of the National Academy of Sciences (and cited as one of only six references in the JAMA paper). The researchers looked at parole decisions made by judges in four Israeli prisons. Data from 1,112 judicial rulings involving eight judges showed that “the percentage of favorable rulings drops gradually from ~65% to nearly zero within each decision session and returns abruptly to ~65% after a break” (Proc. Natl. Acad. Sci. U.S.A. 2011;108:6889-92). (Breaks lasted about 30 minutes and involved a meal.) That’s a pretty dramatic rate of change. It is sobering to think of lives being hugely affected by such seemingly irrelevant details. Talk about fate being fickle.

Decision fatigue suggests that when we make repeated decisions over a brief period of time there is an erosion of self-control and we are more likely to choose the “affectively pleasing” option. It has been written about in psychology journals for the past 2 decades, but for practical and ethical reasons, most studies on the subject involve minor decisions, such as what to choose at the grocery store or which items to add to one’s wedding registry. The concept has become quite popular in the fields of behavioral economic and advertising. It is the reason groceries display candy at the cash register.

Decision fatigue is part of a larger theory on our executive functions, proposed by Dr. Roy Baumeister, professor of social psychology at the University of Florida. His central idea is that self-control, volitional acts, responsibility, and self-regulatory efforts “draw upon a common resource and deplete it.” He calls it ego depletion. In one simple but powerful experiment, researchers conducted a study where students were asked to commit either two digits or seven digits to memory. When offered a choice of fruit salad or chocolate cake as compensation for participation in the study, those who had to remember seven digits were far more likely to choose the chocolate cake – certainly the more “affectively pleasing” option. So ego depletion is to blame for my constant kitchen-grazing behavior at the end of a trying clinic day. Apart from affecting my waistline, I’m sure it affects me in ways that I am unaware of, ways that may have an impact not just on patients but on society, too.

The JAMA Internal Medicine article seems to be the first of its kind in the medical literature. To me, it is hugely important because it reminds us of two major truths: that there are often bigger things at stake, and that doctors, being mere mortals, are not exempt from human frailty.

Dr. Chan practices rheumatology in Pawtucket, R.I.

A study published in JAMA Internal Medicine in December 2014 looked at decision fatigue in primary care providers. The researchers focused on antibiotic prescriptions for acute respiratory infections (including those for which antibiotics are never indicated) over a 16-month period covering 21,867 visits to 204 clinicians. They compared the rate of antibiotic prescription at the first, second, third, and fourth hour of clinic, with the premise being that over a period of repeated decision making the quality of the decisions declines (JAMA Intern. Med. 2014;174:2029-31).

If, like me, you think you have unrealistic expectations about physicians being unimpeachable, you might be disappointed to learn that antibiotic prescriptions were significantly higher for the third and fourth hour of clinic. It seems that as the clinic session wore on, physicians opted for the “safer,” “easier” option.

Another paper involving similarly weighty consequences was published in 2011 in Proceedings of the National Academy of Sciences (and cited as one of only six references in the JAMA paper). The researchers looked at parole decisions made by judges in four Israeli prisons. Data from 1,112 judicial rulings involving eight judges showed that “the percentage of favorable rulings drops gradually from ~65% to nearly zero within each decision session and returns abruptly to ~65% after a break” (Proc. Natl. Acad. Sci. U.S.A. 2011;108:6889-92). (Breaks lasted about 30 minutes and involved a meal.) That’s a pretty dramatic rate of change. It is sobering to think of lives being hugely affected by such seemingly irrelevant details. Talk about fate being fickle.

Decision fatigue suggests that when we make repeated decisions over a brief period of time there is an erosion of self-control and we are more likely to choose the “affectively pleasing” option. It has been written about in psychology journals for the past 2 decades, but for practical and ethical reasons, most studies on the subject involve minor decisions, such as what to choose at the grocery store or which items to add to one’s wedding registry. The concept has become quite popular in the fields of behavioral economic and advertising. It is the reason groceries display candy at the cash register.

Decision fatigue is part of a larger theory on our executive functions, proposed by Dr. Roy Baumeister, professor of social psychology at the University of Florida. His central idea is that self-control, volitional acts, responsibility, and self-regulatory efforts “draw upon a common resource and deplete it.” He calls it ego depletion. In one simple but powerful experiment, researchers conducted a study where students were asked to commit either two digits or seven digits to memory. When offered a choice of fruit salad or chocolate cake as compensation for participation in the study, those who had to remember seven digits were far more likely to choose the chocolate cake – certainly the more “affectively pleasing” option. So ego depletion is to blame for my constant kitchen-grazing behavior at the end of a trying clinic day. Apart from affecting my waistline, I’m sure it affects me in ways that I am unaware of, ways that may have an impact not just on patients but on society, too.

The JAMA Internal Medicine article seems to be the first of its kind in the medical literature. To me, it is hugely important because it reminds us of two major truths: that there are often bigger things at stake, and that doctors, being mere mortals, are not exempt from human frailty.

Dr. Chan practices rheumatology in Pawtucket, R.I.

Despite all its glamour and opportunities to write columns like this one, primary care does not attract as many clinicians as it needs to provide for the aging population. Some have proposed that this is because when learners rotate with us, they witness frustration with preauthorizations and physician-patient relationships poisoned by opioid addiction – not the intangible spiritual fulfillment of long-term relationships with people who share their lives with us.

In addition, many primary care providers have other competing interests that take them away from practice. This trend will likely increase as practitioners work beyond the age of 65 years but at reduced hours. These demands naturally decrease patient access and can theoretically lead to dissatisfaction, which is potentially devastating if we are reimbursed based upon satisfaction scores.

So, do reduced hours frustrate patients?

Laura Panattoni, Ph.D., and her colleagues at the Palo Alto Medical Foundation Research Institute, Mountain View, Calif., evaluated the relationship between physicians’ clinical time, continuity of care, access to care, and patient satisfaction with the physician (J. Gen. Intern. Med. 2015;30:327-33). The study was a cross-section survey of physicians in family and internal medicine and their patients.

The investigators found that greater office time was directly associated with increased continuity and access but with lower patient satisfaction scores. Restated, reduced clinical hours were associated with improved patient satisfaction.

These findings are interesting and important at many levels. First, they suggest that clinicians who choose less than a full-time clinical obligation can keep their patients happy. Second, we can hypothesize that what is lost in continuity and access is made up for in effective communication delivered by clinicians who are happy themselves. Third, practice redesign should not require full-time commitment to deliver on the satisfaction side of the equation. The world is clamoring for alternative care models where electronic “touches” alleviate the pressure for “patients in rooms.” Studies have shown that up to 93% of patients would select a physician who allows them to communicate with them electronically. About 450,000 patients will see a doctor through the Internet this year. UnitedHealth Group started covering telemedicine and plans to expand this to 20 million customers next year.

I personally spend one-third of my time seeing patients in rooms, but I am electronically and telephonically accessible to them every day at all times. Maybe this helps keep my patients happy, despite me not being in the office every day.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified, practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow Dr. Ebbert on Twitter @jonebbert.

Despite all its glamour and opportunities to write columns like this one, primary care does not attract as many clinicians as it needs to provide for the aging population. Some have proposed that this is because when learners rotate with us, they witness frustration with preauthorizations and physician-patient relationships poisoned by opioid addiction – not the intangible spiritual fulfillment of long-term relationships with people who share their lives with us.

In addition, many primary care providers have other competing interests that take them away from practice. This trend will likely increase as practitioners work beyond the age of 65 years but at reduced hours. These demands naturally decrease patient access and can theoretically lead to dissatisfaction, which is potentially devastating if we are reimbursed based upon satisfaction scores.

So, do reduced hours frustrate patients?

Laura Panattoni, Ph.D., and her colleagues at the Palo Alto Medical Foundation Research Institute, Mountain View, Calif., evaluated the relationship between physicians’ clinical time, continuity of care, access to care, and patient satisfaction with the physician (J. Gen. Intern. Med. 2015;30:327-33). The study was a cross-section survey of physicians in family and internal medicine and their patients.

The investigators found that greater office time was directly associated with increased continuity and access but with lower patient satisfaction scores. Restated, reduced clinical hours were associated with improved patient satisfaction.

These findings are interesting and important at many levels. First, they suggest that clinicians who choose less than a full-time clinical obligation can keep their patients happy. Second, we can hypothesize that what is lost in continuity and access is made up for in effective communication delivered by clinicians who are happy themselves. Third, practice redesign should not require full-time commitment to deliver on the satisfaction side of the equation. The world is clamoring for alternative care models where electronic “touches” alleviate the pressure for “patients in rooms.” Studies have shown that up to 93% of patients would select a physician who allows them to communicate with them electronically. About 450,000 patients will see a doctor through the Internet this year. UnitedHealth Group started covering telemedicine and plans to expand this to 20 million customers next year.

I personally spend one-third of my time seeing patients in rooms, but I am electronically and telephonically accessible to them every day at all times. Maybe this helps keep my patients happy, despite me not being in the office every day.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified, practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow Dr. Ebbert on Twitter @jonebbert.

Despite all its glamour and opportunities to write columns like this one, primary care does not attract as many clinicians as it needs to provide for the aging population. Some have proposed that this is because when learners rotate with us, they witness frustration with preauthorizations and physician-patient relationships poisoned by opioid addiction – not the intangible spiritual fulfillment of long-term relationships with people who share their lives with us.

In addition, many primary care providers have other competing interests that take them away from practice. This trend will likely increase as practitioners work beyond the age of 65 years but at reduced hours. These demands naturally decrease patient access and can theoretically lead to dissatisfaction, which is potentially devastating if we are reimbursed based upon satisfaction scores.

So, do reduced hours frustrate patients?

Laura Panattoni, Ph.D., and her colleagues at the Palo Alto Medical Foundation Research Institute, Mountain View, Calif., evaluated the relationship between physicians’ clinical time, continuity of care, access to care, and patient satisfaction with the physician (J. Gen. Intern. Med. 2015;30:327-33). The study was a cross-section survey of physicians in family and internal medicine and their patients.

The investigators found that greater office time was directly associated with increased continuity and access but with lower patient satisfaction scores. Restated, reduced clinical hours were associated with improved patient satisfaction.

These findings are interesting and important at many levels. First, they suggest that clinicians who choose less than a full-time clinical obligation can keep their patients happy. Second, we can hypothesize that what is lost in continuity and access is made up for in effective communication delivered by clinicians who are happy themselves. Third, practice redesign should not require full-time commitment to deliver on the satisfaction side of the equation. The world is clamoring for alternative care models where electronic “touches” alleviate the pressure for “patients in rooms.” Studies have shown that up to 93% of patients would select a physician who allows them to communicate with them electronically. About 450,000 patients will see a doctor through the Internet this year. UnitedHealth Group started covering telemedicine and plans to expand this to 20 million customers next year.

I personally spend one-third of my time seeing patients in rooms, but I am electronically and telephonically accessible to them every day at all times. Maybe this helps keep my patients happy, despite me not being in the office every day.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified, practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow Dr. Ebbert on Twitter @jonebbert.

For those of us who appreciate the value of science and accept its limitations, it is sometimes difficult to understand how parents can choose to not immunize their children against serious and life-threatening diseases. To some extent, the explanation may be that immunizations simply have become victims of their own success.

How many adults have a relative, friend, or neighbor whose child has died as the result of bacterial meningitis or epiglottitis? They might have had a friend whose month-long cough was eventually diagnosed as whooping cough, but how many parents know of an infant who succumbed to pertussis? If you were trained in the last decade, you may not have had first-hand experience with most of the diseases for which we now have immunizations.

Reading a recent review of a new biography of Jonas Salk triggered a stream of memories of what it was like when polio descended on the landscape of North America – unchecked by an effective immunization. Moving through communities, choosing victims seemingly at random, it was every parent’s nightmare.

I grew up in a small town in New York State, so small that its inhabitants refer to it as a “village.” Everyone in Pleasantville knew at least one family that had been touched by polio. I don’t recall being aware of anyone in my family’s extended network of acquaintances who had died of the disease, but I suspect there may have been some fatalities that my parents avoided discussing in my presence. But I knew it was a disease with a significant mortality rate, and I knew of children and adults who had luckily survived several weeks or months in an iron lung. One of my parents’ closest friends walked with a limp as a result of polio.

There was rumor in town that all five members in one family had contracted polio and incredibly survived. Their cat had allegedly died of the disease. Our community was said to be particularly vulnerable because we had a public pool. This gift from the federal government’s Works Progress Administration provided a multi-lane superhighway for the virus to spread from child to child.

Even as a young child, I could sense that a blanket of fear hung over our little village during the summer when the disease was at its most prevalent. Now, as a parent, I am surprised how well my own parents disguised the fears that they and their peers must have harbored. My sister and I were still allowed to go swimming at the pool on the hottest days, but we knew that there were other families who stayed away.

When a vaccine trial began at our school, there was no question that we would participate. In fact, I don’t recall bringing home any permission slips to be signed. Nor do I remember hearing of any families who had opted out. We always wondered whether we had received the real vaccine or the placebo. But when the trials were over and the real vaccine was available, what parent in his or her right mind would even consider depriving his or her child from protection against this scourge that had taken up residence among us? I’m sure that Dr. Blum, my pediatrician, never needed to spend more than 30 seconds trying to convince my parents or any other parents, for that matter, of the need to vaccinate against polio.

My childhood ended before the development of the vaccines against the other common viral illnesses, and as a result I contracted and survived measles, mumps, rubella, and varicella. Of course, there must have been a few children who died of the diseases that had left me unscathed, but the number of fatalities was so small that I’m sure my parents would have wondered why we would need vaccines for these “usual diseases of childhood.”

But polio was different, and while it pales in comparison to Ebola, polio and its successful eradication created a generation of parents with a respect for science and the value of immunization. However, that generation has passed, and with it the stories they could have told the parents of today. Unfortunately, vaccine refusers seem to be immune to education and deaf to the lessons history can teach. I suspect that they would have foolishly ignored my parents’ stories about polio as just so much when-I-was-your-age mumbling.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected].

For those of us who appreciate the value of science and accept its limitations, it is sometimes difficult to understand how parents can choose to not immunize their children against serious and life-threatening diseases. To some extent, the explanation may be that immunizations simply have become victims of their own success.

How many adults have a relative, friend, or neighbor whose child has died as the result of bacterial meningitis or epiglottitis? They might have had a friend whose month-long cough was eventually diagnosed as whooping cough, but how many parents know of an infant who succumbed to pertussis? If you were trained in the last decade, you may not have had first-hand experience with most of the diseases for which we now have immunizations.

Reading a recent review of a new biography of Jonas Salk triggered a stream of memories of what it was like when polio descended on the landscape of North America – unchecked by an effective immunization. Moving through communities, choosing victims seemingly at random, it was every parent’s nightmare.

I grew up in a small town in New York State, so small that its inhabitants refer to it as a “village.” Everyone in Pleasantville knew at least one family that had been touched by polio. I don’t recall being aware of anyone in my family’s extended network of acquaintances who had died of the disease, but I suspect there may have been some fatalities that my parents avoided discussing in my presence. But I knew it was a disease with a significant mortality rate, and I knew of children and adults who had luckily survived several weeks or months in an iron lung. One of my parents’ closest friends walked with a limp as a result of polio.

There was rumor in town that all five members in one family had contracted polio and incredibly survived. Their cat had allegedly died of the disease. Our community was said to be particularly vulnerable because we had a public pool. This gift from the federal government’s Works Progress Administration provided a multi-lane superhighway for the virus to spread from child to child.

Even as a young child, I could sense that a blanket of fear hung over our little village during the summer when the disease was at its most prevalent. Now, as a parent, I am surprised how well my own parents disguised the fears that they and their peers must have harbored. My sister and I were still allowed to go swimming at the pool on the hottest days, but we knew that there were other families who stayed away.

When a vaccine trial began at our school, there was no question that we would participate. In fact, I don’t recall bringing home any permission slips to be signed. Nor do I remember hearing of any families who had opted out. We always wondered whether we had received the real vaccine or the placebo. But when the trials were over and the real vaccine was available, what parent in his or her right mind would even consider depriving his or her child from protection against this scourge that had taken up residence among us? I’m sure that Dr. Blum, my pediatrician, never needed to spend more than 30 seconds trying to convince my parents or any other parents, for that matter, of the need to vaccinate against polio.

My childhood ended before the development of the vaccines against the other common viral illnesses, and as a result I contracted and survived measles, mumps, rubella, and varicella. Of course, there must have been a few children who died of the diseases that had left me unscathed, but the number of fatalities was so small that I’m sure my parents would have wondered why we would need vaccines for these “usual diseases of childhood.”

But polio was different, and while it pales in comparison to Ebola, polio and its successful eradication created a generation of parents with a respect for science and the value of immunization. However, that generation has passed, and with it the stories they could have told the parents of today. Unfortunately, vaccine refusers seem to be immune to education and deaf to the lessons history can teach. I suspect that they would have foolishly ignored my parents’ stories about polio as just so much when-I-was-your-age mumbling.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected].

For those of us who appreciate the value of science and accept its limitations, it is sometimes difficult to understand how parents can choose to not immunize their children against serious and life-threatening diseases. To some extent, the explanation may be that immunizations simply have become victims of their own success.

How many adults have a relative, friend, or neighbor whose child has died as the result of bacterial meningitis or epiglottitis? They might have had a friend whose month-long cough was eventually diagnosed as whooping cough, but how many parents know of an infant who succumbed to pertussis? If you were trained in the last decade, you may not have had first-hand experience with most of the diseases for which we now have immunizations.

Reading a recent review of a new biography of Jonas Salk triggered a stream of memories of what it was like when polio descended on the landscape of North America – unchecked by an effective immunization. Moving through communities, choosing victims seemingly at random, it was every parent’s nightmare.

I grew up in a small town in New York State, so small that its inhabitants refer to it as a “village.” Everyone in Pleasantville knew at least one family that had been touched by polio. I don’t recall being aware of anyone in my family’s extended network of acquaintances who had died of the disease, but I suspect there may have been some fatalities that my parents avoided discussing in my presence. But I knew it was a disease with a significant mortality rate, and I knew of children and adults who had luckily survived several weeks or months in an iron lung. One of my parents’ closest friends walked with a limp as a result of polio.

There was rumor in town that all five members in one family had contracted polio and incredibly survived. Their cat had allegedly died of the disease. Our community was said to be particularly vulnerable because we had a public pool. This gift from the federal government’s Works Progress Administration provided a multi-lane superhighway for the virus to spread from child to child.

Even as a young child, I could sense that a blanket of fear hung over our little village during the summer when the disease was at its most prevalent. Now, as a parent, I am surprised how well my own parents disguised the fears that they and their peers must have harbored. My sister and I were still allowed to go swimming at the pool on the hottest days, but we knew that there were other families who stayed away.

When a vaccine trial began at our school, there was no question that we would participate. In fact, I don’t recall bringing home any permission slips to be signed. Nor do I remember hearing of any families who had opted out. We always wondered whether we had received the real vaccine or the placebo. But when the trials were over and the real vaccine was available, what parent in his or her right mind would even consider depriving his or her child from protection against this scourge that had taken up residence among us? I’m sure that Dr. Blum, my pediatrician, never needed to spend more than 30 seconds trying to convince my parents or any other parents, for that matter, of the need to vaccinate against polio.

My childhood ended before the development of the vaccines against the other common viral illnesses, and as a result I contracted and survived measles, mumps, rubella, and varicella. Of course, there must have been a few children who died of the diseases that had left me unscathed, but the number of fatalities was so small that I’m sure my parents would have wondered why we would need vaccines for these “usual diseases of childhood.”

But polio was different, and while it pales in comparison to Ebola, polio and its successful eradication created a generation of parents with a respect for science and the value of immunization. However, that generation has passed, and with it the stories they could have told the parents of today. Unfortunately, vaccine refusers seem to be immune to education and deaf to the lessons history can teach. I suspect that they would have foolishly ignored my parents’ stories about polio as just so much when-I-was-your-age mumbling.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected].