If you haven’t heard the term decision fatigue, you need to familiarize yourself with it. In the psychology literature, decision fatigue refers to the reduction in quality of decisions made by a person after long periods of decision making. It is an interesting phenomenon. There are descriptions of it occurring in shoppers after long periods of intense decision making, ending in spontaneous or impulsive poor choices. There are also descriptions of it being used to manipulate people during interrogation. There are even descriptions of decision fatigue among presidents and famous chief executives. But, we work in medicine, and we care for patients. Is this something that really effects us?
The short answer is yes, perhaps even more than other careers. Here are some examples:
- You end a resuscitation after an hour of procedures and heroic efforts on a 20 yo male. It was unsuccessful and it is now time to turn your attention back to the rest of the ED. 5 patients are ready for disposition, one needs a procedure, and 3 need to be seen. What now?
- You are in the last two hours of your night shift and it has been busier than usual. 2 codes, 3 trauma alerts, and a series of geriatric abdominal pains with vague presentations. A 68 year old man presents with upper abdominal pain radiating to the back but his labs and CT are normal. You send him home and later on when you are in bed you wonder, did I miss an MI?
- You call the hospitalist for an admission and later find out that he sent your CHF patient home with a prescription for lasix and outpatient follow up. “It was straight forward CHF” he says. “No” you say, and explain again that this was new onset in a patient with no cardiac history. How could he confuse those two presentations?
There are numerous examples, but all of them involve a common theme. Our brains are exhausted from a high number of decisions in a short period of time and are now confronted with more decisions to make. Yet, we are surprised when these decisions go badly. It is predictable, and awareness is the first step in correcting the problem.
Make time to understand your work environment. Judges are noted to make more positive judgments earlier in the day and shoppers are noted to make wiser decisions when they have fewer choices requiring less time. Emergency physicians are asked to make complex medical decisions throughout the shift, but do we know when we are most prone to making errors? Typically, decision making is easy and swift early on in the shift and grows in difficulty further into the shift. We should understand that we make better decisions and are less prone to premature closure (drawling a conclusion too early) when we are more rested. We are also more patient, less judgemental, and more considerate of our patient’s illness when well rested. Recognizing when we have been faced with a high concentration of decisions is important in order to prevent errors. Also, recognizing that we are fatigued helps us to compensate with other strategies.
Once you recognize the problem, typically after an intense patient encounter or resuscitation, it is time to de-escalate the decision making for a short while and recover. This doesn’t necessarily mean we have to take a one hour nap, although that does sound very enticing. Most of us work in departments that do not allow for such luxury. But, there are several things we CAN do to help with recovery time:
- Take a 5 minute break. A real one. Step into a quiet office and just sit for a moment. Some even choose a power nap.
- Listen to a little music. This isn’t for everyone, but I find a 5 minute break with some quiet music invaluable.
- Eat something. Heightened brain activity uses up glucose. That needs to be replenished. Do not wait until the end of your shift to do this.
- Utilize your scribe, if you have one. Have the scribe make a list for you of the things that need to be addressed so you don’t have to keep running through it in your mind. This will reduce your mental work load.
- Consider building a list of priorities in advance so you know which item to tackle next once you are ready. For example: You have emerged from your break and there are patients waiting to go home, to be admitted, to have a procedure done, and to be seen. Who do you start with? If you can determine this priority ahead of time and jot yourself a little note, you will immediately offload that decision making and be able to get to work on the next task. In addition, when you get interrupted with another task, you can simply add it to the list where it belongs instead of stopping to rebuild the list each time.
This last item requires a little more unpacking. Regardless of your specialty (here we are focused on the emergency physician) you will undoubtedly have multiple tasks you need to complete. You can not perform them all at once, and there are certain tasks that should be completed first. Some of these will be obvious, the emergent things get done first. Some are not as obvious. For example: Do you discharge patients, then do procedures, then see new patients? Or should you see new patients and begin the work up, then discharge others, then complete the procedures? If none of them are “emergent” it can be a little confusing where to start and a task interruption will result in more mental workload. So, consider your practice and make a priority list ahead of time. If you work in a double coverage (or more) department and other physicians pick up the slack while you focus on a critical patient, then discharging patients should be your next task. This opens beds to see patients who are still waiting, and keeps the department flowing. If you are the sole physician, this seems like a burden since discharging patients only brings in others while you still have some you haven’t seen yet. In this case, you might consider wether or not your department utilizes nursing protocols ? If so, discharging patients and allowing nurses to start protocols on new arrivals is a good process. Flow is maintained and patients have treatment started even before you have time to get to them. You can engage nursing colleagues and tell them you are behind because of that critical patient and need some help getting things started. Admissions are typically waiting for you to call someone, which can be done in between talking to patients. Discharges take more effort as you explain home instructions and an outpatient plan. Procedures take you away from the department but also pull you away from the phone so you can’t speak to consultants. There is no perfect answer, but decide ahead of time on a priority (discharges, new patients, then procedures, then charting) and stick with it. When new tasks arise, place them in the appropriate slot and keep moving. Pull in your scribe and utilize them to help you stay on track.
I remember one of my attending physicians in residency sharing a similar thought at the end of a night shift. We had some complex decision making and when it ended I asked “so, does this patient have to be admitted?” His answer was “it is the end of a night shift and this is where we are going to make mistakes. There are enough things here to warrant an admission, let’s consult the medicine team to see the patient’’. It may sound like a sloughing of responsibility or passing the buck, but it is actually quite insightful. Recognizing when we are prone to make errors and knowing that those errors carry large consequences for our patients, my attending physician’s advice was to act conservatively and consult a second party to help with management.
It is also helpful to understand that the consultants may be in a similar position, at the 20th hour of a 24 hour call, exhausted, sleep deprived, and similarly decision fatigued. So, if their response is not what you are expecting, you should investigate further. Afterall, they are only human as well. We all get tired.
- Croskerry, P. (2014). ED cognition: Any decision by anyone at any time. Canadian Journal of Emergency Medicine, 16(1), 13-19.
- Avoiding Common Errors in the Emergency Department By Amal Mattu, Arjun S. Chanmugam, Stuart P. Swadron, Carrie Tibbles, Dale Woolridge, Lisa Marcucci
- Kovacs, G. and Croskerry, P. (1999), Clinical Decision Making: An Emergency Medicine Perspective. Academic Emergency Medicine, 6: 947-952.
- Oto B. When thinking is hard: managing decision fatigue. EMS World. 2012;41(5):46-50.
- NY Time Well Blog – Decision Fatigue
- EM:RAP – Decision Fatigue