When Thinking is Hard: Managing Decision Fatigue

We are what we repeatedly do. Excellence, then, is not an act but a habit. — Will Durant

It’s 5 p.m. Wednesday, and after 24 grueling hours your shift is finally drawing to an end. Two MVAs overnight, a cardiac arrest in the wee hours of the morning and a non-stop day of being polite to “but my eyeballs itch!” patients has left you drained, and nothing could be sweeter than that feeling when you finally sink into the sofa and flip on the television. Of course, that’s when the tones go off.

You’re dispatched to the “chest pain,” which turns out to be a healthy 30-year-old male with a non-radiating epigastric burning sensation after eating a take-out taco. He looks barely uncomfortable, his vitals are textbook normal and he’s honestly a bit of a jerk. When he finishes telling you how he gets heartburn “all the time,” you suggest he take it easy on the tacos, put a pen in his hand and obtain his signature on a refusal form. OK, the textbook says to take a 12-lead, but come on—30-year-olds don’t really have heart attacks.

Now it’s two weeks later, and you’re standing in front of your clinical supervisor and medical director holding a CQI file. Your “heartburn” patient had a large, evolving STEMI and died at home early the next morning. They’d like to know why you decided he didn’t need a workup. Frankly, you’d like to know too. You’re not that guy. You’re a good medic.

Aren’t you?

Decision Fatigue

What makes a good EMT or paramedic?

You might say that it’s character. Or intelligence. Diligence, the willingness to put in hard work. Compassion. Experience. And these are all true. But many of these can be summed up by saying that a good provider makes good decisions. And there is research from the field of psychology that has surprising consequences for field providers: No matter how smart or hard-working we are, our ability to make good decisions eventually runs out.

Let’s say it’s Election Day, and you’re at the voting booth staring at your ballot. You’d like to think you give every item careful consideration and cast your votes based on sound reasoning, right? And maybe you do. But one study found that as you move further and further down the list, it becomes more and more likely that with each item, you’ll simply pick the easiest answer—voting for the incumbent, saying “no” to the new bill or just selecting the first choice you see. That doesn’t sound very rational, does it?

Or let’s say that we put you in a room. On a table sits a plate of delicious, fresh-baked chocolate chip cookies. Nearby are several radishes. We tell you to eat some radishes—and don’t touch the cookies—then we leave and return a few minutes later. You have dutifully refrained from touching the cookies, although it wasn’t easy. After this ordeal, we administer you a pencil-and-paper test that involves tracing a difficult outline. In reality, this task is impossible to complete, but we watch to see how long you try and how many attempts you make before giving up. If you underwent the “cookie torture” beforehand, you will call it quits far earlier than if you didn’t.

Studies of this type over the past several decades have consistently demonstrated a phenomenon known as decision fatigue. Basically, the idea is this: Our ability to force ourselves to do difficult things—that is, applying self-control or self-discipline—draws upon a certain limited resource within us. And when we’re forced to make tough decisions, it calls upon that same resource.

So, when self-control runs low, we start to make poor choices.

Why It Happens

The psychology and neurophysiology behind decision fatigue isn’t fully understood, but there are a few theories.

The emphasis on willpower and the ability to control your immediate desires comes from a theory called ego depletion, developed by Dr. Roy Baumeister in the late 1990s. It says that as human beings—endowed with independence and free will—we are frequently faced with a choice between obeying our basic, low-lying urges (eating a piece of cake, sleeping in, venting our anger), or suppressing them with higher-order, more responsible choices favoring long-term benefit (eating healthy, going to work, or biting our tongue). This sophisticated process of weighing opposing motivations and managing our priorities is a unique skill to humans known as “executive function,” thought to reside largely in the prefrontal cortex. The ego depletion theory tells us that whenever we have to perform this feat, it drains us a little; it “uses up” some internal energy. When that energy starts to run low, the power of our executive function diminishes, we become less able to override our raw desires and our decisions suffer.

For instance, one study looked at the rulings made by parole boards in Israel. Their job was to decide whether or not prisoners should be released on probation, which is always a tough call; it requires weighing many factors and a mistake could affect many lives. The result was that despite the best efforts of intelligent judges to make responsible decisions, as the day wore on, they became less and less likely to grant parole, eventually denying it to almost everybody. The more they made difficult decisions, the less they were willing or able to make more, so the default answer of “keep ’em behind bars” became their automatic choice.

And the activity doesn’t need to be an explicit decision. In another study, participants were asked to hold their arms in ice water for as long as they could—a task that’s simply unpleasant, and requires commitment and perseverance. Those who were forced beforehand to make a long series of arbitrary choices ended up pulling their arms out much earlier than those who weren’t drained by any prior decision-making.

For many of us, this phenomenon may sound familiar. Who doesn’t occasionally make bad decisions when they’re running out of steam? Have you ever rewarded yourself after a long day at work by skipping the gym and having an ice cream sundae? Or when a garbage truck is blocking the road back to base after a grueling shift, growled an obscenity and peeled across two parking lots rather than waiting another 30 seconds?

Decision fatigue is real, and more importantly, it has real implications for those of us in EMS. Although we like to think if we’re good at our job we’ll do a good job, the evidence says otherwise. And like any disease, understanding the problem is the key to managing it.

Characteristics of Decision Fatigue

To date, the literature surrounding this topic has described a number of common features. Here are a few of the most important.

• The relevant quality is self-control, that motivating fuel by which you direct your thoughts and actions. Anytime you commit to a decision or make yourself do something you’d rather not, you tax your supply of self-control, and the next time you need to do so you’ll have less of it to draw upon.
• Almost any decision-making or other task requiring self-control will drain your reserves of mental energy; however, the more weighty (high-stakes) or the more difficult (complex) the decision, the more it will cost you.
• The step in decision-making that actually drains you is not deliberating on the options, analyzing the problem or reflecting on the consequences. You only take the hit when you actually commit to one course of action; it’s when you can no longer change your mind, and all other avenues become closed, that you give up a little of your mojo.
• Although this is not yet demonstrated in any research I’ve seen, it seems true that even when you’re low on self-control, you can typically still execute extremely important tasks and decisions with reasonable fidelity; you simply “dig deep” and force yourself to rally. It’s those challenges that aren’t meaningless, but aren’t clearly major, which suffer the most.
• Your pool of self-control can be restored by adequate rest. For instance, as little as a 10 minute break between tasks restored test subjects to full performance in one experiment.
• This may sound odd, but several studies have shown that the impact of decision fatigue can be markedly reduced or eliminated by simply eating. For example, in the Israeli parole board study, when judges broke for meals, their cases immediately after the break returned to approval rates equally high as those at the beginning of the day. Other studies have shown that any intake of glucose, even an unpleasant gruel, can have a similar effect. (Sadly, although hypoglycemia seems to impair self-control, hyperglycemia doesn’t give you any superpowers.)

As for the consequences? Well, when you’re fatigued in this way, you tend to:

• Avoid unnecessary decisions. If you don’t have to make a commitment right this minute, you won’t. (This is better known as procrastination.)
• Choose the easiest of the available options. If “do nothing” is an option, you’ll do that. If one path is longer, harder or more complex, you’re unlikely to pick it. If sorting through the choices will take a great deal of thinking or analyzing, you may just pick the first thing that comes to mind or choose arbitrarily.
• Make decisions driven by immediate motivations, such as fatigue or hunger, ignoring long-term or difficult to observe consequences.
• Choose using inaccurate and inappropriately simplified algorithms, stereotypes or “rules of thumb,” rather than thinking through the full breadth of a problem.
• In general, lose your inhibitions and behave impulsively; you may, in fact, resemble someone who’s been drinking.

Implications for EMS

Although decision fatigue seems to affect nearly everyone, those of us who work on an ambulance are especially vulnerable.

For one thing, we have a great deal of responsibility, backed by relatively little training and experience. In another field, the equivalent of a green EMT would be an entry-level position, working directly under close supervision by managers and superiors. But in EMS, we do our work on the road—in homes, on the street, in facilities or hidden in the back of the truck. Most of the time there’s nobody to witness the decisions we make except a partner. So there’s no built-in system for enforcing good decisions, and if we make bad ones it may not yield any obvious feedback unless it happens to come back to our supervisors as a complaint or CQI.

And it’s not like we’re short on decisions to make. Not just the big stuff—even when we’re dragged-through-the-mud tired at the end of shift, we can usually muster up the energy to perform a bang-up job on the multiple shooting or cardiac arrest—but what about all the little things that happen before that? After the call an hour ago, did you take the time to sanitize your gear? Perhaps you know that you ought to, that cross-contamination causes infectious complications which can kill your sick patients, but it’s hard to truly imagine that outcome, and it doesn’t seem very likely. At noon, you’ll do it. But how about at 5 a.m. after a 24-hour shift?

Our job is full of decisions like this—things we can do or not do, where there is a clear “right” and “wrong,” but where the difference may not always seem profound, or where the harm seems too distant to care about. As one study worded it, the ramifications are “potentially real (though relatively minor).” If we have a weak moment, fail to sanitize that stretcher, carry over a MRSA colonization to another patient, and they end up with a two-week ICU stay, we will probably never hear about it—and even if we do, we still can’t be sure it was a consequence of our decision. (Maybe he picked it up elsewhere.) The same goes for intangible damages like contributing to inefficient systems, detracting from the professional respect in our field, and causing pain and suffering which could have been prevented.

Long story short, you can do everything right in this job, but every minute of every hour, you’ll have to freely choose to do so.

To make things worse, we habitually work long hours and draining schedules, which as we’ve seen is a recipe for testing your self-control. You may be an angel for four hours, or six hours, but what about in hour 16, or 24, or at midnight on your 80th hour of the week? Everybody has a limit, and once you reach it you should probably go home. But we don’t. On top of that, we tend to maintain poor dietary habits, and by playing yo-yo with our blood glucose we further tax our mental resources.

Finally, although the moment-to-moment business of EMS gives us ample freedoms, many times we may feel confined by the larger framework we work in—our employers, our protocols, or even the shape and direction of our industry as a whole. And the evidence suggests that when we perceive our actions as autonomous or enjoyable, our tolerance for decision “drain” is greater. How empowered do you feel in your job? Do you always enjoy every call?

Solutions

How can we combat this tide of will-draining, energy-sapping ego depletion?

The single best way is to reduce our decision load to begin with. One of the most interesting findings in the studies on decision fatigue is which types of people seem to manage it best. By and large, those individuals who could conserve willpower the longest and maintain the highest quality in their decisions weren’t doing it by being tougher than the rest of us. They weren’t adhering to higher principles or demonstrating stronger character. Instead, they simply set up their circumstances to minimize the amount of self-control they’d need to exert. They planned ahead. They scheduled, made lists, finished to-do’s early, and handled problems before they escalated. They built their lives so that they wouldn’t need to make as many decisions.

In other words, they had good habits.

You see, if a certain action is a habit, then it doesn’t drain any self-control. This is both intuitively true and demonstrated by the research: Thoughtful, complex analyses require an investment from our internal reserves, but rote memorization or execution requires none. So, the more of your daily activities that you can lock into a fixed, unchanging routine—something you simply do, every time, without debate—the more mental energy you can conserve. Should you clean off the stretcher? No need to ask, you’ve already done it. It may seem like you’re creating more work for yourself, because in some cases you’re doing more than is necessary. But the real “work” is weighing the risks and benefits, burdening yourself with the choice.

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. Are you the paramedic who always takes a clean set of vitals, or are you the paramedic who sometimes does and other times doesn’t bother? I am a strong advocate for intelligent field providers who can use their judgment on a case-by-case basis, but much of what we do simply needs doing, not debating, and all of those things can be automated by turning them into habits. And in creating some mental slack for yourself by placing the mundane stuff on the back burner, you free up resources for the things that actually need your attention—like the complex work of field diagnosis, or managing unexpected emergencies.

You can even try to habituate some of the non-clinical, non-operational choices during your day. We all need occasional variety, but you can control how much of it you introduce and keep the rest of your routine tightly locked-in to avoid sapping your resources with a 10 minute debate over where to buy lunch. Take the same roads to work or to your post locations, follow the same morning routine each day, put your pen back into the same pocket it came out of. Keep the easy stuff easy so the hard stuff is possible.

Exercise your adult capacity to plan ahead. Much of what we deal with is predictable, and can therefore be dealt with in a managed way. If there are things you don’t want to do, do them early—before you’ve started running low on self-discipline—because if you put them off, you may do a lousy job or never address them at all. Go talk to the supervisor first thing, shine your boots now, fuel the rig or give it a wash. Procrastination is bad in two ways, because not only does it push your problems back into the worst part of the day, it also stacks them up so you end up doing everything at once. Do you think you’ll write better reports if you complete them after each call, maintaining a steady pace throughout the day, or if you let them accumulate and have to write six in a row? Rather than procrastinating, grease your path downhill so your shift gets easier and easier as you become less and less equipped to deal with it.

Nutrition can help as well. Although it may be tempting and occasionally helpful to turn to quick carb-rich snacks when our self-control dips, a diet of real food, which maintains a steady blood sugar, is a better choice than riding the glucose roller coaster. It also won’t promote diabetes, which is itself associated with impulsiveness and moodiness!

Finally, just try to keep tabs on your mental state and know when to bow out. Try as you might, sometimes you’re going to end up in a bad place. If you’re aware of it, you can avoid dangerous situations while you’re vulnerable. Let your partner tech the call or have your supervisor talk to the irate staff member—and if you find that you’re consistently getting burned out, consider shifting your schedule or cutting back your hours.

Final Thoughts

We all like to believe that our behavior, work ethic and quality of care are products of who we are. But who we are is the product of the decisions we make, and we’re fooling ourselves to think that our decision-making never falters. Habits may seem boring, but by relegating our mental busywork to mindless routine we can be fresh and ready for the true challenges of the job. And if nothing else, simply being aware of the realities of decision fatigue can help us avoid it.

Good Habits

• Always park the ambulance to allow rapid egress.
• Check and prepare all of your equipment at the start of shift.
• Restock and clean your truck at the end of shift.
• Clean and sanitize all patient devices as indicated.
• Bring your basic equipment with you onto every scene.
• Plan your meals and eat before you’re hungry.
• Perform your basic assessment on every patient.
• Present a professional appearance every day.
• Develop a standard system for writing your reports.

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