When Thinking is Hard: Managing Decision Fatigue

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

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 farther and farther 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 aren’t fully understood, but there are a few theories.

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