Decision fatigue: why less is more when making choices with patients.

Alexandra Moorhouse is currently an ST3 GP trainee in South Bristol.

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 6.30pm 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 does not just affect clinical members of the team, particularly with the rise of care navigation in surgeries; and negatively impacts 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

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 amongst the complex multi-morbid or frail elderly 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 complex patients. However only if the patent we see last in the day gets the same quality of care we were providing at 9am.

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.

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 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 this the way forward, to help us hit the reset button at least once in our day so we can face tomorrow invigorated.

Tips to ameliorate decision fatigue:

• Delegating 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.
• 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.

References:

1. Clinical decisions and time since rest break: An analysis of decision fatigue in nurses. Allan, J. L., Johnston, D. W., Powell, D. J. H., Farquharson, B., Jones, M. C., Leckie, G., & Johnston, M. (2019). Health Psychology, 38(4), 318–324. Available online at: https://doi.org/10.1037/hea0000725
2. Time of Day and the Decision to Prescribe Antibiotics. Jeffrey A. Linder, MD, MPH1,2; Jason N. Doctor, PhD3; Mark W. Friedberg, MD, MPP1,2,4; et al. JAMA Intern Med. 2014;174(12):2029-2031. doi:10.1001/jamainternmed.2014.5225. Available online at: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1910546