Decision fatigue among military primary care physicians: a retrospective study

BACKGROUND: Decision fatigue, based on Baumeister's "Strength Model of Self-Control", suggests that the quality of decision-making declines with the accumulation of decisions over time. This phenomenon, previously observed in various professional fields, may impact military physicians who make critical and organizational decisions. We aimed to assess how decision-making changes throughout the workday among military physicians in a clinic setting. METHODS: A retrospective observational analysis was conducted using a database of 2 million medical encounters from the military medical record system between 2015 and 2019. Decision outcomes were tracked for exemptions from specific duties granted, sick leave issued, days of sick leave, emergency department referrals, antibiotic prescriptions for upper respiratory tract infections and spinal X-ray referrals for low back pain - in accordance with appointment time and physician employment type. RESULTS: Findings showed a decrease in specific-duty exemptions granted by physicians until lunchtime, a peak post-lunch and a subsequent decline in the afternoon (p < 0.001). Referrals to the emergency department increased through the morning, dipped post-lunch and rose again by day's end (p < 0.001). Sick leave issuance and the number of days granted both declined as the day progressed, with the steepest decline in the afternoon (p < 0.001). Rates of antibiotic prescription for URTIs and spinal X-ray referrals for LBP did not vary significantly throughout the day. Civilian physicians tended to issue more sick leave, exemptions and referrals than regular duty physicians, though both groups demonstrated similar trends throughout the day. CONCLUSIONS: This study highlights the influence of decision fatigue on clinical decision-making among military physicians, showing a time-based decline in granting sick leave and specific-duty exemptions, with an increase in emergency referrals towards the end of the workday. These might have system-wide implications such as overutilization of healthcare, and increased health expenditure. Recognizing and addressing decision fatigue is important to mitigate its effects.