Have you ever felt that you are not making the same decisions at the end of your shift compared to the beginning?
Do you feel mentally drained at the end of the shift and feel that you “can’t make one more decision”?
Have you ever prescribed an antibiotic to a febrile child when you really felt it was a viral process?
You are not alone.
Decision fatigue centers around making deteriorating quality choices after a long session of decision making. Sounds familiar? As physicians, this is an all too common scenario. Compound the fact that our choices carry a heavy burden as we are possibly making life-altering choices for our patients on every shift.
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Decision Fatigue is All Around Us
The researchers at Cornell University estimated that we make approximately 35,000 conscious decisions each day. Approximately 27 choices each day on just food.
While decision fatigue is prevalent in medicine, it is also seen across multiple industries. It is especially exploited in marketing and sales. As an example, have you ever wondered why sweet sugary snacks are placed in the check-out aisle of your local grocery store? Or, think back to when you bought your last vehicle. After spending time at the dealer, it has been shown that buyers will more likely purchase add-ons toward the end of negotiations (i.e., rustproofing) rather than the beginning.
Decision Fatigue and Time of Day
To highlight what we intuitively know, a 2011 study reviewed the parole rulings of 8 judges over a ten-month period compared to the time of day. The reviewers, amazingly, found the likelihood of a favorable ruling is greater at the beginning of the day or immediately after a food break compared to later in the sequence of cases (see figure below).
Proportion of rulings in favor of the prisoners by ordinal position. Circled points indicate the first decision in each of the three decision sessions; tick marks on x axis denote every third case; dotted line denotes food break. Because unequal session lengths resulted in a low number of cases for some of the later ordinal positions, the graph is based on the first 95% of the data from each session.
Also, a 2014 article in JAMA Internal Medicine found a similar trend of decision fatigue related to antibiotic prescribing practices and the time of day. The authors reviewed over 21,000 patients presenting with symptoms of acute respiratory illnesses across 204 providers in 23 different practices. The authors found that the provider is more likely to prescribe an antibiotic as the day progressed.
Tips to Reduce Decision Fatigue
1. Make Fewer Decisions
It seems simple to say but hard in practice. I am not suggesting making fewer decisions at work related to your patient’s health, but I am recommending making fewer decisions on things that don’t matter.
Plan (and Simplify) Your Wardrobe
First, simplify your work clothes. For me, as an emergency physician, it’s straightforward–scrub bottoms and a T-shirt. In fact, some of the highest performers take this to the next level. As an example, President Barack Obama only wears grey or blue suits. In a 2012 Vanity Fair article, he mentions:
“You see I wear only gray or blue suits’ [Obama] said. ‘I’m trying to pare down decisions. I don’t want to make decisions about what I’m eating or wearing. Because I have too many other decisions to make.’ He mentioned research that shows the simple act of making decisions degrades one’s ability to make further decisions.”
Plan your Meals Ahead of Time
I have recently written about Mealime. It’s a straightforward meal planning app that can provide you quick and easy meals for the whole week. Each meal can be completed within 30 minutes, and Mealime also creates a grocery list for you. You can just print and take it to the grocery store with you. Better yet, head over to Instacart and have the groceries delivered right to your door.
Very importantly, have healthy snacks in your white coat or office desk. Don’t complicate this. Some of my favorites include:
- Rx Bars
- Dried fruit
- Dark Chocolate
- Beef Jerky
Steer clear from the vending machines. The sugary options are a) unhealthy and b) will provide you a “crash” far worse than before you ate it.
Make your most important decisions first
There is truth in the common phrase “sleep on it.” Your cognitive function is greatest in the first 1-3 hours of the day. According to a recent study, most change their decision-making throughout the day. In the morning, we are more methodical, meticulous, and creative. As the day goes on, we may make riskier decisions. Use the morning to focus on the most critical tasks first and move on with your day.
2. Have a Process for Making Decisions
For me, I was able to gain control when I recognized that not every small thing is an emergency. I began using the Eisenhower Matrix.
The Eisenhower Matrix, popularized by Steven Covey in his book The Seven Habits of Highly Effective People, created a decision matrix to identify what’s important and what not; what’s urgent and what’s not.
A guiding principle for President Eisenhower is “what is important is seldom urgent and was is urgent is seldom important.”
The Difference Between Urgent and Important
Urgent is a task that needs immediate attention. For example, a crashing patient, a seizing baby, or a myocardial infarction. This task puts us in a reactive mode. In this setting, we are laser-focused and hurried. This task needs intense concentration because the consequences of not dealing with them are immediate.
Important is a task where the outcome achieves our personal or professional goals. This task looks toward our long-term ambitions. The important tasks are performed calmly, intentionally, and thoughtfully.
In the Eisenhower Matrix, there are four quadrants labeled as:
- Quadrant 1: Important and Urgent
- Quadrant 2: Important but Not Urgent
- Quadrant 3: Not Important but Urgent
- Quadrant 4: Not Important and Not Urgent
3. Remove Technology Distractions
How many times do you reach into your pocket to check your phone–be it a text ping or a “quick look” at social media? This decision drains your mental energy. It shifts your focus and causes you to have to make more unnecessary and trivial decisions.
Minimize your phone icons to set you up for success.
- Categorize your apps and place them in a folder. Then move them to your second page on your phone rather than your home page
- Disable sound notifications. It will prevent the urge to look at the phone every time you hear a ping. In cases of emergencies, make sure the people closest to you have your office or department work number
- Turn off “Mail” from your account setting. Make a habit of checking your email twice a day, in front of the computer. That’s it–no more “putting out fires” countless times throughout your day.
- Delete social media apps from your phone. Not only is it a productivity drain, but it also saps your mental energy, which can be used for far better things.
4. Master the Power of Checklists
I am a BIG fan of checklists (ask my wife!). The most extraordinary power of a checklist is that it replaces decisions with routines. The book The Checklist Manifesto written by Atul Gawande, MD, MPH, a New York Times bestseller, has been in my home library ever since it came out. He opines that we fail at a decision because “the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.”
Gawande argues that modern medicine, like other complex professions such as financial managers and lawyers, has become far too complex to effectively and safely perform by memory alone.
I use checklists in my daily practices, from something as simple as making sure recent vital signs are uploaded into my medical note to going through a checklist with my nurses before a conscious sedation to reduce a dislocated hip.
5. Exercise
A recent study in the British Journal of Sports Medicine found that thirty minutes of moderate-intensity aerobic exercise in the morning improves the brain’s cognitive function and associated with better decision-making for the rest of the day.
As clinicians, we know the value of exercise, yet many struggle to consistently stick with a routine. Rather than hoping to make a decision to exercise–schedule a time to exercise.
James Clear, a habit expert, agrees. In his words, “…I am not hoping that I will have enough willpower to make it to the gym. It’s just where I go on Mondays as 6 pm.”
Additionally, not only does exercise benefit us in the long term, it has short-term benefits, too. In a 2004 study (3), the authors found that higher levels of physical activity related to decreased decrements in quality of work performed and overall job performance.
6. End the Day with Evening Ritual
My evening SLEEP Ritual has been a critical part of my overall well-being. This, along with my morning ARISE ritual, bookend my days. The evening ritual helps me review the decisions I made throughout the day and look for ways to improve them.
These strategies have significantly reduced the decision fatigue that I encounter during a work shift. While I can’t predict everything that I will encounter, I rely on my checklists and routines to focus my energies on the unpredictable and automate the other decisions.
Additionally, I prepare for the following day. I try to predict whatever decisions that may come up in the morning and write them down. This helps me identify any barriers that might come up, and since I have already thought about them, I don’t have to waste mental energy trying to devise an answer.
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