I was reading an email late on a Friday afternoon when I felt my jaw tighten.

The tone was wrong. The implication was clear. I drafted a response that said exactly what I thought needed to be said, shut my laptop and went home.

The next morning I read the original email again.

I had misread it entirely.

The tone I was certain I detected wasn’t there. The implication I’d built a response around didn’t exist! What I sent the night before was a reaction to something that hadn’t happened.

I wish that had only happened once.

DECISION FATIGUE DOESN'T ALWAYS FEEL LIKE FATIGUE

It feels like clarity. Like you've finally cut through the noise and you know exactly what needs to happen. Like competence, not compromise.

That's the trap.

Decision fatigue doesn't feel like fatigue. It can feel like certainty. The drive to close out a decision– to just answer the email, finalize the call, sign off on the thing already– can be indistinguishable from decisive leadership in the moment.

The research is clear: cognitive performance degrades measurably across a day of sustained decision-making. The neural resources required for careful judgment are finite, and they deplete with use. The quality drops before you feel it dropping.

Conventional guidance treats decision fatigue as acute– something that resolves with breaks and adequate sleep. That’s not wrong. It’s just incomplete. Healthcare leaders operate in an environment that generates hundreds of cognitive inputs daily– staffing, strategy, safety events, the 47th email– without the structural protections that industries like aviation built once the research became impossible to ignore.

The volume isn’t episodic. It is the operating condition.

And for many healthcare leaders, the one mechanism designed to reset it overnight is the first thing compressed when demand is high: SLEEP.

Sleep-deprived leaders tend to keep using solutions that aren't working because the cognitive architecture required to see better options is exactly what fatigue degrades first. Sleep, specifically slow-wave deep sleep, is when the brain clears the metabolic waste of a full day of sustained cognitive load (glymphatic flush). Without that window, the cleanup doesn't happen. The brain starts the next day carrying what it couldn't clear from the last.

The capability looks intact from the outside.
The quality of output quietly isn't.

. . .

WHAT AVIATION HAS FIGURED OUT THAT MEDICINE HASN'T

In 2012, the FAA published a final rule setting flight and duty time limits based on scientific evidence regarding pilot fatigue. Commercial pilots in the United States are legally prohibited from flying beyond defined hour thresholds – not because airlines are generous, but because the research on fatigue-impaired judgment in high-stakes roles is so conclusive it became federal law.

The parallel isn't subtle. Healthcare leaders make consequential decisions – about people, patient care, resources, strategy, and risk– across days that routinely extend beyond what the research considers safe for optimal judgment. Aviation built structural protections around this. Healthcare leadership mostly hasn’t. The assumption, implicit and rarely examined, is that clinical training or executive experience confers some sort of immunity to what is fundamentally a biological limit.

It doesn’t.

THE SIGNAL TOO MANY LEADERS MISS

A single misread email is noise. Everyone has a bad day.

Frequency is the signal.

When it starts happening regularly; when the responses you send at the end of the day look different in the morning; when your patience at home is shorter than it should be; when you notice yourself pushing to just close decisions rather than consider them– that is a pattern. And a pattern is data.

The closure drive is a dangerous symptom precisely because it mimics competence. The urge to finalize, to resolve, to move on– that feels like decisiveness.

In hour 2 of your day, it probably is.
In hour 10, it’s your depleted system choosing the fastest available exit from cognitive load.

The decision gets made.
The quality of the decision is a separate question.

This is also why the threshold question from the last issue– how do you know when a rubber ball has been on the ground long enough to start changing– is so difficult to answer from inside a stretched season.

You cannot fully audit the system with the system that is compromised.

FOR YOU, THIS WEEK

Think back over the last two weeks. The decisions you revisited. The emails you rewrote. The moments where your reaction in the evening looked different in the morning.

How many were there?

One is noise.
A pattern is data.

If the pattern is there, the Leadership Capacity Snapshot shows you the biomarkers accumulating underneath it– the ones that appear in your lab work before they appear in your decisions. If you haven’t accessed it yet, you can do that here.

The next time you feel the urge to just close something out, pause long enough to ask whether you’re deciding or depleting.

References:

FAA 14 CFR Part 117Federal Register original final rule :https://www.federalregister.gov/documents/2012/01/04/2011-33078/flightcrew-member-duty-and-rest-requirements Current regulation (eCFR):https://www.ecfr.gov/current/title-14/chapter-I/subchapter-G/part-117

Williamson A, Feyer AM. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication. Occupational and Environmental Medicine. 2000;57(10):649–655.

Lockley SW et al. Effect of reducing interns’ weekly work hours on sleep and attentional failures. New England Journal of Medicine.2004;351(18):1829–1837.
Maier M., et al. Systematic review of the effects of decision fatigue in healthcare professionals on medical decision-making. Health Psychology Review. 2025.

Xie L et al. Sleep drives metabolite clearance from the adult brain. Science. 2013;342(6156):373-377.