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2.

AFTERNOONS AND

COFFEE SPOONS

The Power of Breaks, the Promise of

Lunch, and the Case for a Modern Siesta

The afternoon knows what the morning never suspected.

—ROBERT FROST

Come with me for a moment into the Hospital of Doom.

At this hospital, patients are three times more likely than at other hospitals to receive a potentially fatal dosage of anesthesia and considerably more likely to die within forty-eight hours of surgery. Gastroenterologists here find fewer polyps during colonoscopies than their more scrupulous colleagues, so cancerous growths go undetected. Internists are 26 percent more likely to prescribe unnecessary antibiotics for viral infections, thereby fueling the rise of drug-resistant superbugs. And throughout the facility, nurses and other caregivers are nearly 10 percent less likely to wash their hands before treating patients, increasing the probability that patients will contract an infection in the hospital they didn’t have when they entered.

If I were a medical malpractice lawyer—and I’m thankful that I’m not—I’d hang out a shingle across the street from such a place. If I were a husband and parent—and I’m thankful that I am—I wouldn’t let any member of my family walk through this hospital’s doors. And if I were advising you on how to navigate your life— which, for better or worse, I’m doing in these pages—I’d offer the following counsel: Stay away.

The Hospital of Doom may not be a real name. But it is a real place. Everything I’ve described is what happens in modern medical centers during the afternoons compared with the mornings. Most hospitals and health care professionals do heroic work. Medical calamities are the exceptions rather than the norm. But afternoons can be a dangerous time to be a patient.

Something happens during the trough, which often emerges about seven hours after waking, that makes it far more perilous than any other time of the day. This chapter will examine why so many of us—from anesthesiologists to schoolchildren to the captain of the Lusitania—blunder in the afternoon. Then we’ll look at some solutions for the problem—in particular, two simple remedies that can keep patients safer, boost students’ test scores, and maybe even make the justice system fairer. Along the way, we’ll learn why lunch (not breakfast) is the most important meal of the day, how to take a perfect nap, and why reviving a thousand-year-old practice may be just what we need today to boost individual productivity and corporate performance.

But first let’s go into an actual hospital, where doom has been forestalled by lime-green laminated cards.

BERMUDA TRIANGLES AND PLASTIC RECTANGLES: THE POWER OF VIGILANCE BREAKS

It’s a cloudy Tuesday afternoon in Ann Arbor, Michigan, and for the first (and probably only) time in my life, I’m wearing hospital greens and scrubbing in for surgery. Beside me is Dr. Kevin Tremper, an anesthesiologist and professor who is chairman of the University of Michigan Medical School’s Department of Anesthesiology.

“Each year, we put 90,000 people to sleep and wake them up,” he tells me. “We paralyze them and start cutting them open.” Tremper oversees 150 physicians and another 150 medical residents who wield these magical powers. In 2010 he changed how they do their jobs.

Flat on the operating room table is a twenty-something man with a smashed jaw badly in need of repair. On a nearby wall is a large-screen television with the names of the five other people in hospital greens—nurses, physicians, a technician—who surround the table. At the top of the screen, in maize letters against a blue background, is the patient’s name. The surgeon, an intense, wiry man in his thirties, is itching to begin. But before anybody does anything, as if this team were playing college basketball at the school’s Crisler Center two miles away, they call a time-out.

Almost imperceptibly, each person takes one step backward. Then, looking at either the big screen or a wallet-size plastic card hanging from their waists, they introduce themselves to one another by first name and proceed through a nine-step “Pre-Induction Verification” checklist that ensures they’ve got the right patient, know his condition and any allergies, understand the medications the anesthesiologist will use, and have any special equipment they might need. When everyone is finished introducing themselves and all the questions are answered—the whole process takes about three minutes—the time-out ends and the young anesthesia resident cracks open supplies from sealed pouches to begin to put the patient, already partly sedated, fully to sleep. It’s not easy. The patient’s jaw is in such dreadful condition, the resident must intubate him through the nose instead of the mouth, which proves vexing. Tremper, who has the long, slender fingers of a pianist, steps in and steers the tube into the nasal cavity and down the patient’s throat. Soon the patient is out, his vital signs are stable, and the surgery can begin.

Then the team steps back from the operating table once again.

Each person reviews the steps on the “Pre-Incision Time Out” card to make sure everyone is prepared. They regain their individual and collective focus. And only then does everyone step back to the operating table and the surgeon begins repairing the jaw.

I call time-outs like these “vigilance breaks”—brief pauses before high-stakes encounters to review instructions and guard against error. Vigilance breaks have gone a long way in preventing the University of Michigan Medical Center from transmogrifying into the Hospital of Doom during the afternoon trough. Tremper says that in the time since he implemented these breaks, the quality of care has risen, complications have declined, and both doctors and patients are more at ease.

Afternoons are the Bermuda Triangles of our days. Across many domains, the trough represents a danger zone for productivity, ethics, and health. Anesthesia is one example. Researchers at Duke Medical Center reviewed about 90,000 surgeries at the hospital and identified what they called “anesthetic adverse events”—either mistakes anesthesiologists made, harm they caused to patients, or both. The trough was especially treacherous. Adverse events were significantly “more frequent for cases starting during the 3 p.m. and 4 p.m. hours.” The probability of a problem at 9 a.m. was about 1 percent. At 4 p.m., 4.2 percent. In other words, the chance of something going awry while someone is delivering drugs to knock you unconscious was four times greater during the trough than during the peak. On actual harm (not only a slipup but also something that hurts the patient), the probability at 8 a.m. was 0.3 percent—three-tenths of one percent. But at 3 p.m., the probability was 1 percent— one in every one hundred cases, a threefold increase. Afternoon circadian lows, the researchers concluded, impair physician vigilance and “affect human performance of complex tasks such as those required in anesthesia care.”¹

Or consider colonoscopies. I’ve reached the age where prudence calls for submitting to this procedure to detect the presence or possibility of colon cancer. But now that I’ve read the research, I would never accept an appointment that wasn’t before noon. For example, one oft-cited study of more than 1,000 colonoscopies found that endoscopists are less likely to detect polyps—small growths on the colon—as the day progresses. Every hour that passed resulted in a nearly 5 percent reduction in polyp detection. Some of the specific morning versus afternoon differences were stark. For instance, at 11 a.m., doctors found an average of more than 1.1 polyps in every exam. By 2 p.m., though, they were detecting barely half that number even though afternoon patients were no different from the morning ones.²

Look at those numbers and tell me when you’d schedule a colonoscopy.³ What’s more, other research has shown that doctors are significantly less likely even to fully complete a colonoscopy when they perform it in the afternoon.⁴

Basic health care also suffers when its practitioners sail into the day’s Bermuda Triangle. Doctors, for example, are much more likely to prescribe antibiotics, including unnecessary ones, for acute respiratory infections in the afternoons than in the mornings.⁵ As the cumulative effect of dealing with patient after patient saps doctors’ decision-making resolve, it’s far easier just to write the scrip than suss out whether the patient’s symptoms suggest a bacterial infection, for which antibiotics might be appropriate, or a virus, for which they’d have no effect.

We expect important encounters with experienced professionals like physicians to turn on who is the patient and what is the problem. But many outcomes depend even more forcefully on when is the appointment.

What’s going on is a decline in vigilance. In 2015, Hengchen Dai, Katherine Milkman, David Hoffman, and Bradley Staats led a massive study of handwashing at nearly three dozen U.S. hospitals. Using data from sanitizer dispensers equipped with radio frequency identification (RFID) to communicate with RFID chips on employee badges, researchers could monitor who washed their hands and who didn’t. In all, they studied more than 4,000 caregivers (two-thirds of whom were nurses), who over the course of the research had nearly 14 million “hand hygiene opportunities.” The results were not pretty. On average, these employees washed their hands less than half the time when they had an opportunity and a professional obligation to do so. Worse, the caregivers, most of whom began their shifts in the morning, were even less likely to sanitize their hands in the afternoons. This decline from the relative diligence of the mornings to the relative neglect of the afternoon was as great as 38 percent. That is, for every ten times they washed their hands in the morning, they did so only six times in the afternoon.⁶

The consequences are grave. “The decrease in hand hygiene compliance that we detected during a typical work shift would contribute to approximately 7,500 unnecessary infections per year at an annual cost of approximately $150 million across the 34 hospitals included in this study,” the authors write. Spread this rate across annual hospital admissions in the United States, and the cost of the trough is massive: 600,000 unnecessary infections, $12.5 billion in added costs, and up to 35,000 unnecessary deaths.⁷

Afternoons can also be deadly beyond the white walls of a hospital. In the United Kingdom, sleep-related vehicle accidents peak twice during every twenty-four-hour period. One is between 2 a.m. and 6 a.m., the middle of the night. The other is between 2 p.m. and 4 p.m., the middle of the afternoon. Researchers have found the same pattern of traffic accidents in the United States, Israel, Finland, France, and other countries.⁸

One British survey got even more precise when it found that the typical worker reaches the most unproductive moment of the day at 2:55 p.m.⁹ When we enter this region of the day, we often lose our bearings. In chapter 1, I briefly discussed the “morning morality effect,” which found that people were more likely to be dishonest in the afternoon because most of us are “better able to resist opportunities to lie, cheat, steal and engage in other unethical behavior in the morning than in the afternoon.”¹⁰ This phenomenon depended in part on chronotype, with owls displaying a different pattern from larks or third birds. But in that study, evening types proved more ethical between midnight and 1:30 a.m., not during the afternoon. Regardless of our chronotype, the afternoon can impair our professional and ethical judgment.

The good news is that vigilance breaks can loosen the trough’s grip on our behavior. As the doctors at the University of Michigan demonstrate, inserting regular mandatory vigilance breaks into tasks helps us regain the focus needed to proceed with challenging work that must be done in the afternoon. Imagine if Captain Turner, who hadn’t slept the night before his fateful decisions, had taken a brief vigilance break with other crew members to review how fast the Lusitania needed to travel and how best to calculate the ship’s position in order to avoid U-boats.

This simple intervention is backed by heartening evidence. For instance, the largest health care system in the United States is the Veterans Health Administration, which operates about 170 hospitals across the country. In response to the persistence of medical errors (many of which occurred in afternoons), a team of physicians at the VA implemented a comprehensive training system across the hospitals (on which Michigan modeled its own efforts) that was built around the concept of more intentional and more frequent breaks, and featured such tools as “laminated checklist cards, whiteboards, paper forms, and wall mounted posters.” One year after the training began, the surgical mortality rate (how often people died during or shortly after surgery) dropped 18 percent.¹¹

Still, for most people, work doesn’t involve paralyzing others and cutting them open—or other life-on-the-line responsibilities such as flying a twenty-seven-ton jet or guiding troops into battle. For the rest of us, another type of break offers a simple way to steer around the dangers of the trough. Call them “restorative breaks.” And to understand them, let’s leave the American Midwest and head to Scandinavia and the Middle East.

FROM THE SCHOOLHOUSE TO THE COURTHOUSE: THE POWER OF RESTORATIVE BREAKS

In chapter 1 we learned about some curious results on Denmark’s national standardized exams. Danish schoolchildren who take the tests in the afternoon score significantly worse than those who take the exams earlier in the day. To a school principal or education policy maker, the response seems obvious: Whatever it takes, move all the tests to the morning. However, the researchers also discovered another remedy, one with applications beyond schools and tests, that is remarkably easy to explain and implement.

When the Danish students had a twenty- to thirty-minute break “to eat, play, and chat” before a test, their scores did not decline. In fact, they increased. As the researchers note, “A break causes an improvement that is larger than the hourly deterioration.”¹² That is, scores go down after noon. But scores go up by a higher amount after breaks.

Taking a test in the afternoon without a break produces scores that are equivalent to spending less time in school each year and having parents with lower incomes and less education. But taking the same test after a twenty- to thirty-minute break leads to scores that are equivalent to students spending three additional weeks in the classroom and having somewhat wealthier and better-educated parents. And the benefits were the greatest for the lowest-performing students.

Unfortunately, Danish schools, like many around the world, offer only two breaks each day. Worse, legions of school systems are cutting back on recess and other restorative pauses for students in the name of rigor and—get ready for the irony—higher test scores. But as Harvard’s Francesca Gino, one of the study’s authors, puts it, “If there were a break after every hour, test scores would actually improve over the course of the day.”¹³

Many younger students underperform during the trough, which risks both providing teachers with an inaccurate sense of their progress and prompting administrators to attribute to what and how students are learning something that is really an issue of when they’re taking a test. “We believe these results to have two important policy implications,” say the researchers who studied the Danish experience. “[F]irst, cognitive fatigue should be taken into consideration when deciding on the length of the school day and the frequency and duration of breaks. Our results show that longer school days can be justified, if they include an appropriate number of breaks. Second, school accountability systems should control for the influence of external factors on test scores . . . a more straightforward approach would be to plan tests as closely after breaks as possible.”¹⁴

Perhaps it makes sense that a cup of apple juice and a few minutes to run around works wonders for eight-year-olds solving arithmetic problems. But restorative breaks have a similar power for adults with weightier responsibilities.

In Israel, two judicial boards process about 40 percent of the country’s parole requests. At their helm are individual judges whose job is to hear prisoners’ cases one after another and make decisions about their fate. Should this prisoner be released because she’s served enough time on her sentence and shown sufficient signs of rehabilitation? Should that one, already granted parole, now be permitted to move about without his tracking device?

Judges aspire to be rational, deliberative, and wise, to mete out justice based on the facts and the law. But judges are also human beings subject to the same daily rhythms as the rest of us. Their black robes don’t shelter them from the trough. In 2011 three social scientists (two Israelis and one American) used data from these two parole boards to examine judicial decision-making. They found that, in general, judges were more likely to issue a favorable ruling— granting the prisoner parole or allowing him to remove an ankle monitor—in the morning than in the afternoon. (The study controlled for the type of prisoner, the severity of the offense, and other factors.) But the pattern of decision-making was more complicated, and more intriguing, than a simple a.m./p.m. divide.

The following chart shows what happened. Early in the day, judges ruled in favor of prisoners about 65 percent of the time. But as the morning wore on, that rate declined. And by late morning, their favorable rulings dropped to nearly zero. So a prisoner slotted for a 9 a.m. hearing was likely to get parole while one slotted for 11:45 a.m. had essentially no chance at all—regardless of the facts of the case. Put another way, since the default decision on boards is typically not to grant parole, judges deviated from the status quo during some hours and reinforced it during others.

But look what happens after the judges take a break. Immediately after that first break, for lunch, they become more forgiving— more willing to deviate from the default—only to sink into a more hard-line attitude after a few hours. But, as happened with the Danish schoolchildren, look what occurs when those judges then get a second break—a midafternoon restorative pause to drink some juice or play on the judicial jungle gym. They return to the same rate of favorable decisions they displayed first thing in the morning.

Ponder the consequences: If you happen to appear before a parole board just before a break rather than just after one, you’ll likely spend a few more years in jail—not because of the facts of the case but because of the time of day. The researchers say they cannot identify precisely what’s driving this phenomenon. It could be that eating restored judges’ glucose levels and replenished their mental reserves. It could be that a little time away from the bench lifted their mood. It could be that the judges were tired and that rest reduced their fatigue. (Another study of U.S. federal courts found that on the Mondays after the switch to Daylight Saving Time, when people on average lose roughly forty minutes of sleep, judges rendered prison sentences that were about 5 percent longer than the ones they handed down on typical Mondays.¹⁵)

Whatever the explanation, a factor that should have been extraneous to judicial decision-making and irrelevant to justice itself—whether and when a judge took a break—was critical in deciding whether someone would go free or remain behind bars. And the wider phenomenon—that breaks can often mitigate the trough—likely applies “in other important sequential decisions or judgments, such as legislative decisions . . . financial decisions, and university admissions decisions.”¹⁶

So if the trough is the poison and restorative breaks are the antidote, what should those breaks look like? There’s no single answer, but science offers five guiding principles.

1. Something beats nothing.

One problem with afternoons is that if we stick with a task too long, we lose sight of the goal we’re trying to achieve, a process known as “habituation.” Short breaks from a task can prevent habituation, help us maintain focus, and reactivate our commitment to a goal.¹⁷ And frequent short breaks are more effective than occasional ones.¹⁸ DeskTime, a company that makes productivity-tracking software, says that “what the most productive 10% of our users have in common is their ability to take effective breaks.” Specifically, after analyzing its own data, DeskTime claims to have discovered a golden ratio of work and rest. High performers, its research concludes, work for fifty-two minutes and then break for seventeen minutes. DeskTime never published the data in a peer-reviewed journal, so your mileage may vary. But the evidence is overwhelming that short breaks are effective—and deliver considerable bang for their limited buck. Even “micro-breaks” can be helpful.¹⁹

2. Moving beats stationary

Sitting, we’ve been told, is the new smoking—a clear and present danger to our health. But it also leaves us more susceptible to the dangers of the trough, which is why simply standing up and walking around for five minutes every hour during the workday can be potent. One study showed that hourly five-minute walking breaks boosted energy levels, sharpened focus, and “improved mood throughout the day and reduced feelings of fatigue in the late afternoon.” These “microbursts of activity,” as the researchers call them, were also more effective than a single thirty-minute walking break—so much so that the researchers suggest that organizations “introduce physically active breaks during the workday routine.”²⁰ Regular short walking breaks in the workplace also increase motivation and concentration and enhance creativity.²¹

3. Social beats solo

Time alone can be replenishing, especially for us introverts. But much of the research on restorative breaks points toward the greater power of being with others, particularly when we’re free to choose with whom we spend the time. In high-stress occupations like nursing, social and collective rest breaks not only minimize physical strain and cut down on medical errors, they also reduce turnover; nurses who take these sorts of breaks are more likely to stay at their jobs.²² Likewise, research in South Korean workplaces shows that social breaks—talking with coworkers about something other than work—are more effective at reducing stress and improving mood than either cognitive breaks (answering e-mail) or nutrition breaks (getting a snack).²³

4. Outside beats inside

Nature breaks may replenish us the most.²⁴ Being close to trees, plants, rivers, and streams is a powerful mental restorative, one whose potency most of us don’t appreciate.²⁵ For example, people who take short walks outdoors return with better moods and greater replenishment than people who walk indoors. What’s more, while people predicted they’d be happier being outside, they underestimated how much happier.²⁶ Taking a few minutes to be in nature is better than spending those minutes in a building. Looking out a window into nature is a better micro-break than looking at a wall or your cubicle. Even taking a break indoors amid plants is better than doing so in a green-free zone.

5. Fully detached beats semidetached

By now, it’s well known that 99 percent of us cannot multitask. Yet, when we take a break, we often try to combine it with another cognitively demanding activity—perhaps checking our text messages or talking to a colleague about a work issue. That’s a mistake. In the same South Korean study mentioned earlier, relaxation breaks (stretching or daydreaming) eased stress and boosted mood in a way that multitasking breaks did not.²⁷ Tech-free breaks also “increase vigor and reduce emotional exhaustion.”²⁸ Or, as other researchers put it, “Psychological detachment from work, in addition to physical detachment, is crucial, as continuing to think about job demands during breaks may result in strain.”²⁹

So if you’re looking for the Platonic ideal of a restorative break, the perfect combination of scarf, hat, and gloves to insulate yourself from the cold breath of the afternoon, consider a short walk outside with a friend during which you discuss something other than work.

Vigilance breaks and restorative breaks offer us a chance to recharge and replenish, whether we’re performing surgery or proofreading advertising copy. But two other respites are also worth considering. Both were once sturdy features of professional and personal life only to be dismissed more recently as soft, frivolous, and antithetical to the head-down, laptop-up, inbox-zero ethos of the twenty-first century. Now both are poised for a comeback.

THE MOST IMPORTANT MEAL OF THE DAY

After you woke up this morning, some time before you began a day of filing reports, making deliveries, or chasing children, you probably ate breakfast. You might not have settled in for a full, proper meal, but I’ll bet you broke the nighttime fast with something—a piece of toast maybe or a little yogurt, perhaps washed down with coffee or tea. Breakfast fortifies our bodies and fuels our brains. It’s also a guardrail for our metabolism; eating breakfast restrains us from gorging the rest of the day, which keeps our weight down and our cholesterol in check. These truths are so self-evident, these benefits so manifest, that the principle has become a nutritional catechism. Say it with me: Breakfast is the most important meal of the day.

As a devout breakfast eater, I endorse this principle. But as someone paid to muck around in scientific journals, I’ve grown skeptical. Most of the research showing the salvation of a morning meal and the sin of missing it are observational studies rather than randomized controlled experiments. Researchers follow people around, watching what they do, but they don’t compare them to a control group.³⁰ That means their findings show correlation (people who eat breakfast might well be healthy) but not necessarily causation (maybe people who are already healthy are just more likely to eat breakfast). When scholars have applied more rigorous scientific methods, breakfast’s benefits have been much more difficult to detect.

“A recommendation to eat or skip breakfast . . . contrary to widely espoused views . . . had no discernable effect on weight loss,” says one.³¹ “The belief (in breakfast) . . . exceeds the strength of scientific evidence,” says another.³² Layer in the fact that several studies showing the virtues of breakfast were funded by industry groups and the skepticism deepens.

Should we all eat breakfast? The conventional view is a flaky and delicious yes. But as a leading British nutritionist and statistician says, “[T]he current state of scientific evidence means that, unfortunately, the simple answer is: I don’t know.”³³

So eat breakfast if you’d like. Or skip it if you’d prefer. But if you’re concerned about the perils of the afternoon, start taking more seriously the often-maligned and easily dismissed meal called lunch. (“Lunch is for wimps,” 1980s cinematic supervillain Gordon Gekko famously declared.) By one estimation, 62 percent of American office workers wolf down lunch in the same spot where they work all day. These dismal scenes—smartphone in one hand, soggy sandwich in the other, despair wafting from the cubicle—even have a name: the sad desk lunch. And that name has given rise to a small online movement in which people post photographs of their oh-so-pathetic midday meals.³⁴ But it’s time we paid more attention to lunch, because social scientists are discovering that it’s far more important to our performance than we realize.