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Editor’s Note: Please see Dr Randall Higashida’s memoriam of Dr Grant Hieshima on the homepage of the JNIS website. Dr Hieshima, who died on August 9, 2019, was a pioneer of neurointerventional surgery and a beloved mentor, friend, and inspiration to all of those fortunate to have known him. The memoriam also includes poignant tributes from many of Dr Hieshima’s colleagues, friends, and students.
A 2011 study published in Proceedings of the National Academy of Sciences found that, over a 10-month period, eight Jewish-Israeli judges made 1112 rulings on crimes of embezzlement, assault, theft, murder, and rape.1 The percentage of favorable rulings dropped from 65% to nearly zero during each session and then abruptly returned to around 65% after a food break. At the surface, these findings challenge the assumption that judges make rulings based solely on laws and facts. Could it be possible that judges trend towards more punitive decisions because they feel hungry?
The delivery of stroke thrombectomy involves many decisions based on incomplete information, including determining symptom onset, therapeutic approach, hospital transfer, necessity of imaging, history of pre-existing dependency, among others. For example, deciding whether to mobilize the team at 02:00 hours for a possible thrombectomy transfer with borderline indications is challenging enough as is.
But with increasing thrombectomy volumes and increasingly liberal indications,2 3 it is not hard to imagine that physician fatigue may threaten rational decision-making, particularly at a time when it is needed most. Fargen and Hirsch found in their survey that half of all neurointerventional respondents were on call every night or every other night and also that most (60%) thrombectomy consultations occurred during non-work hours, and more than half of thrombectomy procedures involved the physician having to commute to the hospital from home.4 How much does our body and brain, oftentimes already sleep deprived, unconsciously favor seeking out a narrative for this 02:00 hours call that justifies a decision that allows us to return to sleep? I would say that, if such a strong influence on decision-making from feeling hungry could be proven among judges, at least the same likely influences neurointerventionalists making challenging thrombectomy decisions in the middle of the night.
Ospel and colleagues recently studied the influence of the time of patient presentation on endovascular therapy decision-making.5 They conducted an online survey of 607 physicians from a variety of specialties from 38 countries, evaluating decision-making based on carefully designed scenarios with different variables. They found that endovascular treatment decisions, even with only level 2B evidence, did not differ between night time and daytime cases. Differences between countries, however, were observed.
The same investigators published another paper based on the same multinational web-based study aiming to evaluate the influence of physician biases on endovascular treatment decision-making by measuring the congruence with guideline recommendations. They found high agreement between responses and class I guideline recommendations.6 However, filling out a hypothetical web-based survey during the day is quite different from the reality of clinical responsibilities in the middle of the night. More importantly, many of these inclinations are not something we care to admit, even on an anonymous survey. It is important to acknowledge that biases and fallibilities persist, perhaps unconsciously, and may not be measurable on a survey.
Besides sleep, obviously many other conflicting interests exist. Among these, trying to optimize enrollment in clinical research studies may introduce biases that can conflict with rational, patient-oriented decision-making. Sometimes patients are enrolled in studies to evaluate a new device for a specific condition without knowing that other time-tested proven options exist.7 Sometimes data needed to meet the inclusion criteria are interpreted to fit a narrative that allows for enrollment.8 Physicians can be designated as proctors if they are among the first physicians in the country to frequently use a certain device. This incentive can promote looser indications during their ‘ramp up’ period to implant a certain number of devices to qualify as a proctor.9
The prestige associated with being a physician or a judge may actually work against rational decision-making that is free of personal bias. Society entrusts certain professions to use their knowledge, reason, and ethics to make the right decision, and implicit to this trust is that we referee ourselves. However, this deference can blind us, as we rather quickly reach firm judgements without the humility of considering other perspectives. Hence, we may easily forget the need to referee ourselves. The outcomes of our patients depend so much on even the small decisions we make. Refereeing ourselves begins with acknowledging our own fallibilities, such as wanting to go back to sleep.
Genuine practiced refereeing occurs when the right decision for the patient is still made despite a significant sacrifice to us. Losing consecutive nights of sleep, I would say, qualifies. Despite incentives to enroll, strictly abiding by each line of the inclusion/exclusion criteria verbatim prior to enrolling a subject in a clinical trial qualifies. Not allowing the appeal of proctoring to affect your treatment decisions also qualifies.
We all know what we should be doing, particularly in hindsight or in an abstract sense such as filling out a survey. Refereeing ourselves even when it is painful is a skill that requires practice. This begins by acknowledging contexts and situations that bring out our worst sides. This is human nature, and this means that, despite our best intentions and efforts, mistakes still sometimes occur. It is during these times that we need to tell ourselves ahead of time that we should be even more deliberate and disciplined and try with great fortitude to referee ourselves.10 Despite how much sacrifice this will take, no one will congratulate, encourage, or recognize you for this. Only you will. Refereeing yourself, like sports referees, should be an invisible yet powerful force that keeps intact the structure and integrity of our profession.
Footnotes
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
Patient consent for publication Not required.