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Life & Times

Decision fatigue: less is more when making choices with patients

Alexandra Moorhouse
British Journal of General Practice 2020; 70 (697): 399. DOI: https://doi.org/10.3399/bjgp20X711989
Alexandra Moorhouse
ST3 GP trainee in South Bristol. Email:
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  • For correspondence: alexandra.moorhouse@doctors.org.uk
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Decision fatigue is something we have all experienced. Perhaps when you’re looking at the 40th script request of the day or the blood results that have come back at 6.30 pm and you can’t seem to think what to do next.

We each have a finite amount of mental energy that we can expend on decision making before our brain starts to look for a shortcut. It at least partially explains why weekend shoppers impulse buy and elite athletes make unaccountable decisions at the end of a game. Decision fatigue is also a well recognised reason behind poor clinical decision making, decision avoidance, and as a precursor to burnout. It doesn’t just affect clinical members of the team, particularly with the rise of care navigation in surgeries; and negatively impacts the patient experience. Clinicians suffering from decision fatigue are more likely to make more conservative management plans1 and also to offer inappropriate treatment options, such as unnecessary prescriptions for antibiotics, to take the path of least resistance.2

BURNOUT AND DECISION MAKING

Decision fatigue in specialties such as emergency medicine is taken seriously. Breaks are rigorously enforced in many emergency departments (EDs) as it is acknowledged that clinicians making multiple decisions without a dedicated break (not using that break to check results or type notes) reach a point of diminishing returns where their decision making can become unsafe.

On reflection, compared with my average working day in ED as a trainee, in primary care we are seeing around three times the number of patients in the same length of time. Added to this, we have script requests to process, letters to write and act on, and blood results to review — administrative tasks that amount to triple figures in addition to seeing the patients themselves. This is not unusual in primary care. In days gone by among the complex multimorbid or frail, older patients there might be a few patients with urinary tract infections, coryzal illnesses, and a few pill checks, now it is infrequent that a session includes any of these patients at all. In many ways it is a good use of our time and skills that GPs are increasingly managing more patients with complex needs. However, this is only true if the patent we see at the end of the day gets the same quality of care we were providing at 9.00 am.

Figure1

Alexandra Moorhouse

There are signs that burnout and related issues are being taken increasingly seriously. There seems to be a gradual shift towards recognising that however dedicated you are, that you are human, and pushing harder is not always the answer. Also that self awareness is an asset rather than something to be paid lip service to as part of training and subsequently ignored.

DEDICATED BREAKS

We cannot avoid making complex decisions in order to care for our patients, but looking at how these decisions are made and in what circumstances may yield useful insights into how we can move forward. Strategies such as incorporating short dedicated breaks into each session or introducing debriefing into the working day beyond training in a sustainable way could hold some promise. In the aftermath of the exceptional circumstances around the COVID-19 crisis we are presented with a unique but time-limited opportunity to rethink the way we shape our working environment, including our working day, for the benefit of both our colleagues and patients.

At least one local practice has incorporated mindfulness into its weekly meeting schedule. Maybe this is the way forward, to help us hit the reset button at least once in our day so we can face the next day invigorated.

Tips to ameliorate decision fatigue

  • delegate tasks to other appropriate members of the team;

  • use guidelines to decide on treatment strategies — these at least narrow down your choice to one or two options;

  • discuss cases with other members of the team when you are struggling to make a decision or doubting your choices;

  • come back to it at a later date — looking at a problem with fresh eyes the next day if it is able to wait can be very helpful;

  • recognise that some tasks can actually wait until you have thought about the options fully;

  • reduce the overall number of decisions you make in a day — preparing clothing and meals in advance for the working week can free up some much-needed mental energy; and

  • try to break your working day into manageable chunks of time, divided up with at least some time on your feet and away from a computer screen.

Footnotes

  • This article was first posted on BJGP Life on 2 June 2020: bjgplife.com/decision-fatigue

  • © British Journal of General Practice 2020

REFERENCES

  1. 1.↵
    1. Allan JL,
    2. Johnston DW,
    3. Powell DJH,
    4. et al.
    Clinical decisions and time since rest break: an analysis of decision fatigue in nursesHealth Psychology2019384318324
    OpenUrl
  2. 2.↵
    1. Linder JA,
    2. Doctor JN,
    3. Friedberg MW,
    4. et al.
    Time of day and the decision to prescribe antibioticsJAMA Intern Med20141741220292031
    OpenUrl
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British Journal of General Practice: 70 (697)
British Journal of General Practice
Vol. 70, Issue 697
August 2020
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Decision fatigue: less is more when making choices with patients
Alexandra Moorhouse
British Journal of General Practice 2020; 70 (697): 399. DOI: 10.3399/bjgp20X711989

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Decision fatigue: less is more when making choices with patients
Alexandra Moorhouse
British Journal of General Practice 2020; 70 (697): 399. DOI: 10.3399/bjgp20X711989
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