The Hidden Cost of Excellence: When Working at Your Peak Becomes Too Much
Joshua Tamayo-Sarver, MD, PhD, FACEP, FAMIA
In our rush to maximize efficiency through AI and innovative workflows, we may be creating unsustainable cognitive demands on professionals. My experience with a seemingly perfect emergency department workflow model revealed a surprising truth: working exclusively at the top of your license — focusing solely on your highest-value skills — can be profoundly draining in ways we hadn’t anticipated. As healthcare and other industries increasingly leverage AI to elevate work, we must consider the unexpected mental toll of cognitive concentration without natural breaks and design systems that balance peak performance with human limitations.
When Efficiency Meets Reality in the Emergency Department
Years ago, before scribes became commonplace and AI assistance was still theoretical, I participated in a workflow experiment that, on paper, represented the pinnacle of emergency department efficiency. The model was elegantly simple: each physician would partner with four physician assistants in a tag-team approach that maximized everyone’s credentials.
The process worked like clockwork. I would enter a room with Physician Assistant A, evaluate the patient, develop a diagnosis and treatment plan, and communicate it clearly to everyone. Then, while PA-A managed that case’s follow-through — ordering tests, documenting findings, coordinating with specialists — I would immediately move to the next patient with Physician Assistant B. Throughout each patient’s journey, the PA handled all the “lower-level” tasks: responding to lab abnormalities, following up on imaging studies, speaking with consultants, and completing all documentation requirements. I would then immediately go into the next room with Physician Assistant C and so on.
From an efficiency standpoint, the results were remarkable. I could see significantly more patients per hour than in traditional workflows. The quality indicators looked excellent. Patients received attentive care and thorough follow-up. The PAs exercised independence while having physician backup when needed. On paper, it was a triumph of workflow design, with everyone operating at the top of their respective licenses. There was just one problem we hadn’t anticipated.
It was absolutely exhausting.
The Unexpected Mental Marathon
At first this model felt like a revelation — the physician was freed from documentation burdens and administrative tasks to focus purely on clinical decision-making. But by the end, there was a bone-deep fatigue unlike anything else.
It took a lot of discussion and reflection to understand what was happening. Making only high-stakes decisions for hours without interruption — walking into a room with an undifferentiated patient and leaving with a concrete plan — it was constant, intense cognitive labor without natural breaks.
Those “lower-level” tasks I’d been so eager to delegate — documenting in the EHR, following up on lab results, making phone calls — had actually served as built-in cognitive rest periods. While checking boxes for quality metrics isn’t intellectually stimulating, it requires minimal mental energy. These tasks provided natural breathers between the intense decision-making moments that define emergency medicine.
Research confirms this experience. Studies on cognitive workload demonstrate that sustained attention on complex decision-making tasks leads to mental fatigue and performance degradation over time. The brain’s executive function capabilities — the very skills needed for medical decision-making — deplete with continuous use, much like how a muscle tires with extended exertion.
AI’s Promise and Peril for Knowledge Workers
Fast forward to today, where AI tools promise to eliminate the mundane aspects of our work across industries. ChatGPT drafts our emails, automated documentation tools capture our patient encounters, and predictive analytics pre-process information before it reaches us. These advances sound universally positive — who wouldn’t want to eliminate busywork?
Yet our experience in the emergency department offers a cautionary tale. As AI increasingly handles routine tasks, knowledge workers across industries may find themselves in a continuous state of high-cognitive demand without natural breaks. Physicians making back-to-back clinical decisions, attorneys analyzing complex case strategies without documentation downtime, engineers solving difficult problems without administrative interludes — all may experience unprecedented mental exhaustion.
The neuroscience explains why this happens. Task-switching, despite being often maligned as inefficient, provides cognitive variability that can prevent neural fatigue in specific brain regions. Additionally, research on attention restoration theory suggests that engaging in less demanding cognitive tasks allows for recovery of directed attention resources.
Designing Sustainable Excellence
So how do we harness AI and workflow innovation without burning out our brightest minds? The answer isn’t abandoning efficiency or rejecting AI assistance but rather designing systems that account for the cognitive rhythm humans require.
Here’s what organizations should consider:
Create intentional cognitive downtime. Schedule brief periods for lower-intensity tasks between high-stakes decisions. Don’t eliminate all routine work — repurpose it as recovery time.
Implement “cognitive pacing” in workflow design. Alternate between complex and routine tasks rather than batching all complex work together. Research shows that strategic task ordering can maintain higher performance throughout the day.
Develop AI tools that complement rather than eliminate. Design systems that handle portions of complex tasks while keeping humans meaningfully engaged, rather than relegating humans to only the most difficult decisions.
Train for cognitive endurance. Like physical athletes, knowledge workers can build mental stamina through targeted practice. Implement progressive training that gradually increases sustained cognitive load while teaching recovery techniques.
Measure the right outcomes. Beyond efficiency metrics, evaluate sustainable performance. A workflow that delivers impressive results for one week but leads to burnout by month’s end isn’t truly efficient.
Recognize individual differences. Some professionals have greater capacity for sustained cognitive work than others. Personalized workflow design allows for these variations rather than enforcing one-size-fits-all approaches.
When I think back to our emergency department experiment, I realize we were measuring the wrong things. We counted patients seen per hour and tracked quality metrics, but ignored the cognitive sustainability of the model. Not surprisingly, despite impressive initial results, physician satisfaction plummeted and the program was eventually modified.
The Future Workforce Requires Cognitive Design
As we design the AI-augmented workplaces of tomorrow, cognitive workload management must become as fundamental as ergonomic desk design became in the physical workplace. The organizations that thrive won’t be those that push their knowledge workers to operate continuously at peak cognitive capacity, but those that design workflows accounting for human cognitive rhythms.
For clinicians, this might mean integrating moments of reflection between patient encounters. For software engineers, it could involve alternating between complex system architecture tasks and more straightforward coding. For executives, perhaps scheduling decision-making meetings with buffers for processing and integration.
Cognitive work design represents a frontier of workplace innovation that will define sustainable excellence in the AI era. The most valuable resource in our AI-augmented future won’t be technology — it will be sustained human judgment. Let’s build systems that preserve and enhance that capability rather than depleting it in the name of efficiency.
Dr. Joshua Tamayo-Sarver, MD, PhD, FACEP, FAMIA, develops and deploys technology solutions in the healthcare ecosystem as a clinician, business leader, software engineer, statistician, and social justice researcher. As the Vice President of Innovation at Inflect Health and Vituity, his unique formula of skills has helped develop over 35 solutions and scale multiple new healthcare products, including the first AI occult sepsis tool with FDA breakthrough designation. Dr. Tamayo-Sarver oversees corporate venture, internal incubation, and advisory services for AI-driven healthcare solutions, blending consumerism and clinical quality to fit the delicate balance of patient desire, user experience and quality medical care. A Harvard graduate, he holds degrees in biochemistry, epidemiology, and biostatistics, as well as a medical degree from Case Western Reserve University. He is a Mentor in the Emergence Program at Stanford University.
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