Blog | Monday, March 3, 2014

Decision fatigue in physicians and medicine: the importance of routines and habits


“Everything must be made as simple as possible. But not simpler.” — Albert Einstein

One of the most mentally fatiguing actions that physicians face on a daily basis is the number of decisions we must make. Although we likely only make 1 or 2 major decisions for every patient encounter, in total we make hundreds (or maybe thousands) of decisions every day. This includes deciding what labs, imaging, and other studies to order, followed by what those results mean, a diagnosis or list of possible diagnoses, treatments, monitoring, patient follow up, etc.

Unfortunately, it has been shown that the more decisions that we make over the course of a day, the worse we become at it.

The New York Times article, ”Do You Suffer From Decision Fatigue?“ (highly suggested; approximately 22-minute read), begins by describing the rulings of parole board judges over the course of a year, finding that the pattern of their decisions fluctuated throughout the work day, favoring the prisoners who appeared early in the day.

“The more choices you make throughout the day, the harder each one becomes for your brain, and eventually it looks for shortcuts, usually in either of 2 very different ways. One shortcut is to become reckless: to act impulsively instead of expending the energy to first think through the consequences.”

“The other shortcut is the ultimate energy saver: do nothing. Instead of agonizing over decisions, avoid any choice.”

Decision fatigue was described by Dr. Roy F. Baumeister, who demonstrated that humans have a finite store of mental energy for making decisions, which can be broken down into the Rubicon model of action phases:
1. Predecisional Phase: assessing wishes and forming intended goal
2. Preactional Phase/Making a Decision: planning and choosing goal-directed actions
3. Actional Phase: implementing chosen actions
4. Postactional Phase: evaluating whether goal was achieved.

It turns out that a number of studies have shown that the act of making the decision and committing to action is more mentally demanding than any other phase.

The idea of decision fatigue is explained by Dr. Baumeister through a theory called ego depletion, where decisions are higher level executive functions thought to occur in the prefrontal cortex, and every decision we make, no matter how important or unimportant, expends some of the energy of this system, until our ability to make decisions deteriorates.

“Once you’re mentally depleted, you become reluctant to make trade-offs, which involve a particularly advanced and taxing form of decision making. In the rest of the animal kingdom, there aren’t a lot of protracted negotiations between predators and prey. To compromise is a complex human ability and therefore one of the first to decline when willpower is depleted.”

This reluctance to make trade-offs explains why the parole judges were reluctant to decide to give prisoners parole at the end of the day. As physicians, we need to be aware of the tendency for decision fatigue to occur during our long days. Unfortunately, there is no telltale symptom of when willpower to make decisions is low, and the best method to avoid decision fatigue is planning routines to avoid it:

“‘Good decision making is not a trait of the person, in the sense that it’s always there,’ Baumeister says. “‘It’s a state that fluctuates.”‘ His studies show that people with the best self-control are the ones who structure their lives so as to conserve willpower. They don’t schedule endless back-to-back meetings. They avoid temptations like all-you-can-eat buffets, and they establish habits that eliminate the mental effort of making choices. Instead of deciding every morning whether or not to force themselves to exercise, they set up regular appointments to work out with a friend. Instead of counting on willpower to remain robust all day, they conserve it so that it’s available for emergencies and important decisions.”

Any opportunity to learn from extreme cases can offer incredible insight, and an extraordinary example of a decision maker to study is President Obama in Michael Lewis’ article, ”Obama’s Way,” where he discusses routines with the President, who is well aware of the effects of decision fatigue:

“You also need to remove from your life the day-to-day problems that absorb most people for meaningful parts of their day. ‘You’ll see I wear only gray or blue suits,’ he 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. It’s why shopping is so exhausting. ’You need to focus your decision-making energy. You need to routinize yourself. You can’t be going through the day distracted by trivia.’”

An article from EMSWorld, ”When Thinking is Hard: Managing Decision Fatigue,” discussed the implications of decision fatigue for EMTs and paramedics and agreed that trying to reduce overall decision load was the best way to manage this problem, and noted that individuals who were able to do this had routines and habits that included thoughtful planning, which reserved willpower for when it was needed most. As health care professionals, they noted the importance of having these planned routines:

“We tell ourselves it’s how we perform under pressure that counts most, but the sum of who we are as professionals is just as much determined by the everyday habits which make up our work.”

The idea that having specific routines to improve productivity is not new. The American philosopher and physician William James (1842-1910) wrote in detail about the importance of forming regular routines and the subsequent effect of allowing our brains to remain productive in his book Habit (open domain; review on Brain Pickings).

The book, Daily Rituals: A Guided Tour of Writers’ and Artists’ Creative Habits, which describes the routines of 161 famous and inspired minds (also reviewed on Brain Pickings), is another opportunity to learn from extreme thinkers, and also quotes one of William James’ 1892 lectures from the book Habit:

“The great thing, then, in all education, is to make our nervous system our ally instead of our enemy. It is to fund and capitalize our acquisitions, and live at ease upon the interest of the fund. For this we must make automatic and habitual, as early as possible, as many useful actions as we can, and guard against the growing into ways that are likely to be disadvantageous to us, as we should guard against the plague. The more of the details of our daily life we can hand over to the effortless custody of automatism, the more our higher powers of mind will be set free for their own proper work.”

At this point, the effect of decision fatigue in medicine needs further research for both physicians and patients. The University of Pennsylvania currently has 2 studies ongoing on this topic, one looking at its role in the ICU and another looking at its role in patients’ and patient surrogates’ end-of-life choices. The Journal of Palliative Medicine has written about the problem of decision fatigue for patients who are already exhausted from severe illness, acting as a reminder to give patients and their families a chance to regroup before making important decisions.

As doctors, we will always be required to make numerous daily decisions, so we need to do what we can try reduce our own decision fatigue, which might actually improve our work as a physicians and lives in general:
• Spend some time thinking about your routines at home and at work to avoid making additional decisions. Many of the routines described in Daily Rituals included repeating meals, dressing/grooming habits, and setups for getting work done.
• Make important or difficult decisions first in the morning. Many of us have a habit of checking e-mail first thing in the morning, which is often filled with a number of unimportant decisions that can wear us down. Instead, save this time of day for the tough ones.
• When possible, put off difficult decisions that come up at the end of the day until the next morning. In the field of rheumatology, we are often faced with complex decisions, but luckily, the majority of them are not extremely time-sensitive, allowing us time to research and discuss with collagues.
• I find it difficult to say anything to the effect of “workup every case of x with tests a, b, and c”, but I do think that as physicians, we do need to have a good understanding of the workup and management for the common conditions in our fields, such that we are able to reserve decision making energy throughout the day.

Any suggestions on routines or other habits that you have found helpful? Mention them in the comments.

Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine. This post originally appeared at his blog.