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When thinking is hard: managing decision fatigue

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When Thinking is Hard: Managing Decision Fatigue
Brandon Oto
... we are what we repeatedly do. Excellence, then, is not an act but a habit ... — Will Durant
It was 5:00 PM on a Wednesday, and for the past twelve hours we’d been running non-stop. I’d
worked the overnight shift, napped for an hour, then picked up a double during the day; the milk
of human kindness was not exactly flowing through my venuoles.
We’d now been dispatched to a local nursing facility for an unspecified medical problem.
Turned out it was a new rehab patient who, after arriving several days before, had decided he
didn’t care for the meals there. He was refusing all treatment and demanding he be returned to
the large Boston hospital where he’d received his secondary care: “I’ll just stay there,” he
declares. I bite my tongue for the whole trip as we grind through traffic, and finally deposit him
in a hallway bed at the crowded ED. I then spend fifteen minutes staring bullets at the
registration clerk while she gabs with her coworker instead of handing me a demographic sheet.
When I finally escape, steam coming from my ears, my patient accosts me in the hall. “What’s
the hold-up? Just send me back to my room!”
I whirl on him—“I think there’s a sick person in there”—and storm out.
Not my finest moment.
Decision Fatigue
No matter how smart or diligent 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 that 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, 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. You will call it quits far earlier if you underwent the “cookie torture” beforehand 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 ourself 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 our 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, coined by Dr. Roy Baumeister in the late 1990s. It says that as
humans 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 fairly unique skill to humans
known as “executive function,” and is 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 basic 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 pulled 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 that 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 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 have to do so, you’ll have less
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. It’s those
challenges that aren’t meaningless, but aren’t clearly major that 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 even 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.
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 that can kill your sick patients, but it’s hard to truly imagine that outcome, and it
doesn’t seem very likely to you. At noon, you’ll do it. But how about at 5:00 am 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 know 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 that 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 at hour sixteen, or twenty four, or at midnight on your 80th hour of the
week? Everybody has a line, 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 drain 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 making
more work for yourself, because in some cases you’re doing more than is necessary. But the real
“work” is having to weigh the risks and benefits, and 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 that 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 sometimes 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 back-burnering the mundane stuff, you free up
resources for the things that actually need your attention—like the complex work of field
diagnosis, or dealing with 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 ten-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. Make
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 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 we see in the research that a quick snack of a glucose-
rich food can improve your control, it seems more sensible (and healthier) to maintain a sound
diet that keeps your blood sugar from dipping low in the first place.
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, 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 we are the products 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, just being aware of the realities of decision fatigue can help us avoid it.
SIDEBAR
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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... Research also finds that not all decisions require or exert equal quantities of internal resources. The more complex or difficult a decision, the more mental energy that is required and exerted during the decision-making process, and thus the more symptoms of decision fatigue, the decision-maker is expected to display during subsequent decision-making (Oto, 2012;Vohs et al., 2008). ...
... 15% by Judge Judy). Consistent with prior literature, higher quantities of decisions and more complex decisions ultimately lead to higher levels of decision fatigue (Oto, 2012). In other words, we speculate that Judge Karen, compared with Judge Judy, more likely assessed the facts of cases and reached her final bail amount decision without the guidance of recommendations provided by prosecutors, and thus was more heavily affected by decision fatigue, and its effects were displayed through a decline in engagement. ...
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The current study begins to answer the recent call for scholars to reinvigorate the use of observational data to understand courtroom decisions. Drawing on the psychological effects of decision fatigue, the current study examines 284 bail hearing cases from two New Jersey jurisdictions to explore the role of decision fatigue on judges' engagement, judicial deviations from prosecutors' recommendations, and set bail amounts. The results suggest that judicial fatigue, measured as case order and session duration, limited the engagement for one judge, affected set bail amounts for both judges, and that proceeding modality may play some role in fatigue and engagement. Findings also suggest that observational data can work in tandem with administrative data to give better insight into the court process and decisions. Limitations and future research are discussed.
... [2][3][4] The greater the difficulty of the decision, the more DF an individual may face. 5 The practice of medicine is cognitively intense, with internal medicine clinicians making an average of 15.7 decisions per encounter and hospitalists getting interrupted once every 8 minutes. 6,7 There are therefore profound implications in healthcare should decision quality erode with repeated decision-making. ...
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Background “Decision Fatigue” (DF) describes the impaired ability to make decisions because of repeated acts of decision‐making. Objectives We conducted a scoping review to describe DF in inpatient settings. Methods To be included, studies should have explored a clinical decision, included a mechanism to account for the order of decision making, and be published in English in or after the year 2000. Six databases were searched. Retrieved citations were screened and retained studies were reviewed against the inclusion criteria. References of included studies were manually searched, and forward citation searches were conducted to capture relevant sources. Results The search retrieved 12,781 citations, of which 41 were retained following screening. Following review, 16 studies met the inclusion criteria. Half were conference abstracts and none examined hospitalists. Emergency medicine and intensive care settings were the most frequently studied clinical environments ( n = 13, 81%). All studies were observational. The most frequently examined decisions were about resource utilization ( n = 8, 50%), however only half of these examined downstream clinical outcomes. Decision quality against prespecified standards was examined in four (25%) studies. Work environment and patient attributes were often described but not consistently accounted for in analyses. Clinician attributes were described in four (25%) investigations. Findings were inconsistent: both supporting and refuting DF's role in the outcome studied. Conclusions The role of clinician, patient, and work environment attributes in mediating DF is understudied. Similarly, the context surrounding the decision under study require further explication and when assessing resource use and decision quality, adjudication should be made against prespecified standards.
... One of the risk factors that predict decision fatigue is the complexity of the decisions and their consequences. Complex and consequential decisions have a higher impact on decision fatigue [22]. Situational factors such as the time of the day [23], making decisions before or after lunch [1], and sleep deprivation [24] may also impact the level of decision fatigue. ...
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Being compassionate and empathic while making rational decisions is expected from healthcare workers across different contexts. But the daily challenges that these workers face, aggravated by the recent COVID-19 crisis, can give rise to compassion and decision fatigue, which affects not only their ability to meet these expectations but has a significant negative impact on their wellbeing. Hence, it is vital to identify factors associated to their exhaustion. Here, we sought to describe levels of compassion and decision fatigue during the pandemic, and to identify factors related to these forms of exhaustion. We collected data using self-reported questionnaires to measure compassion fatigue, decision fatigue, and grit in five intervals from April to November, 2020 (N = 856). Our results showed a negative correlation between grit and compassion and decision fatigue. We also found that under the circumstances studied grit tends to be higher in technicians, nurses, other professionals (psychologists, social workers), and workers at the Emergency Room (ER), and lower in general practitioners. Compassion fatigue tend to be higher for technicians, whereas decision fatigue was lower for specialists, general practitioners, and technicians, and higher for those working at private hospitals.
... Other factors associated with decision fatigue include chronic exposure to stress and complexity of work (Shirey et al., 2013), low knowledge and experience for independent decision-making and lack of direct supervision of managers, reduced problem-solving ability, and retention of clinical information (Oto, 2012). In addition, problems and obstacles in decision-making such as clinical settings laws, physician and nurse participation in decision-making, lack of support from nursing managers and lack of teamwork, high workload, and lack of time are other related factors (Mosavinasab et al., 2015). ...
... Because there was no reliable data point in the EMR system that accurately reflected actual appointment end times, we made the assumption that the duration of the appointment was the scheduled duration. Additionally, literature has suggested that the greater the difficulty of the decision, the more decision fatigue an individual may face [26]. We attempted to control for decision complexity using the Charlson comorbidity index as a proxy, but this may be an imperfect measure. ...
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Background Time of day has been associated with variations in certain clinical practices such as cancer screening rates. In this study, we assessed how more general process measures of physician activity, particularly rates of diagnostic test ordering and diagnostic assessments, might be affected by time of day. Methods We conducted a retrospective chart review of 3,342 appointments by 20 attending physicians at five outpatient clinics, matching appointments by physician and comparing the average diagnostic tests ordered and average diagnoses assessed per appointment in the first hour of the day versus the last hour of the day. Statistical analyses used sign tests, two-sample t-tests, Wilcoxon tests, Kruskal Wallis tests, and multivariate linear regression. Results Examining physicians individually, four and six physicians, respectively, had statistically significant first- versus last-hour differences in the number of diagnostic tests ordered and number of diagnoses assessed per patient visit (p ≤ 0.04). As a group, 16 of 20 physicians ordered more tests on average in the first versus last hour (p = 0.012 for equal chance to order more in each time period). Substantial intra-clinic heterogeneity was found in both outcomes for four of five clinics (p < 0.01). Conclusions There is some statistical evidence on an individual and group level to support the presence of time-of-day effects on the number of diagnostic tests ordered per patient visit. These findings suggest that time of day may be a factor influencing fundamental physician behavior and processes. Notably, many physicians exhibited significant variation in the primary outcomes compared to same-specialty peers. Additional work is necessary to clarify temporal and inter-physician variation in the outcomes of interest.
... The study titled "Decision fatigue: Making multiple decisions depletes the self " conducted by Vohs, Baumeister, and the study titled "Decision fatigue: Choices influence self-regulatory resources" could not be reached. The study titled "The cure for decision fatigue" conducted by Sollisch (2016) could not be reached; The study titled "When thinking is hard: managing decision fatigue" conducted by Oto (2012) in the field of health science has not been reached; The study carried out by Howard (2019) on errors related to decision fatigue in the field of health has not been reached. In addition, the study carried out by on decision fatigue in the computer field could not be reached and the study published by in the field of health could not be reached. ...
Chapter
Unfortunately, the most important result of the literature review made in the Google Scholar database is that there are no studies on decision fatigue in areas such as business management, organizational behavior, and management organization. Although decision-making is one of the most important functions for managers to be successful, it is surprising that there has not yet been any study on the concept of “decision fatigue” in the literature, and it has not yet attracted attention. As a result of the literature study, 41.9 % of the total studies were in the field of health. Psychology follows the field of health with 12.9 %. Therefore, it has been revealed that the most attention to the concept of “decision fatigue” has been given in the last years (especially between 2018 and 2020) in the field of health. However, the conclusions and suggestions reached in line with the general information obtained as a result of searching the literature on the concept of decision fatigue are as follows; • As a result of the literature review; it was concluded that after long-term tasks, poor performance and decision fatigue may occur (Campagne et al., 2004; Kecklund and Akerstedt, 1993; Torswall and Akerstedt, 1987). As stated by MacDonald et al. (2000), it is imperative to monitor the actions in order to behave in a consistent and harmonious manner in order to prevent errors due to low performance and decision fatigue. In doing so, information is obtained that can be used to adjust the behavior in progress. • As stated by Huang (2019), decision fatigue can be prevented by using motivation strategies. Applied research studies can be conducted on this proposal, and motivation tools or strategies that prevent decision fatigue can be shared in the world of science and business. • Since cognitive capacity is limited, increasing options may cause decision fatigue (Mathew & Joseph, 2014; Olsen 2015). Accordingly, it can be said that it would be beneficial to reduce the number of options to prevent decision fatigue. • Overloading information about products on e-commerce websites can cause decision fatigue (Mathew & Joseph, 2014). When there is a lot of information, the decision can be troublesome and this leads to depletion of mental resources. When the mental resources are exhausted, bargaining power is weakened, the possibility of making the right decision decreases, satisfaction decreases and more regrets may be experienced due to the choices made. • In the informatics field, a study by Dubbey (2019) on critical thinking, e-learning and decision fatigue, it was concluded that increasing daily average decisions is proportional to mental fatigue. • As stated by Hirshleifer et al. (2019), it was observed that professionals went to reduce the number of options especially in their daily decisions in order to eliminate decision fatigue. As also stated by Mathew and Joseph (2014), as the number of options increases, it will be difficult to make decisions and lead to depletion of mental resources. In addition, it may be beneficial to take breaks at regular intervals to employees to get rid of the negative effects of decision fatigue and to rest their habitats away from unnecessary stimuli in order to get rid of the negative effects of decision fatigue. • In addition, it has been determined that fatigue of decision affects especially financial representatives (Hirshleifer et al., 2019). However, it has been concluded that the studies carried out are limited to very few fields and sectors. It can be suggested that future studies on decision fatigue should be carried out especially in the fields related to business administration and on managers at all stages of management levels. In fact, organizational and managerial can be associated with many concepts and bring more beneficial results to the studies. • However, the concept of “decision fatigue” can be examined separately on the basis of sectors and professions. As decision fatigue increases, professions in which the cost of error can increase can be determined. What are the administrative actions to reduce the effect of decision fatigue can be researched on the basis of sector and profession. All these applications can shed light on business managers, human resources managers, financial managers and other line managers and other researchers. This study has its limitations. Although it was published on Google Scholar, even the summary of 16 studies could not be reached. Some of the studies are in a pacified state, while others are available for a fee. Unfortunately, it is an important difficulty for academics to overcome that studies made for the scientific world are available for a fee. The free access of information presented to the benefit of all people, especially other scientists, will make science more important and useful for the entire universe.
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Do you suffer from decision fatigue? The New York Times Retrieved from http://www.nytimes.com/2011/08/21/magazine/do-you-suffer-from-decision-fatigue.html Tyler JM, Burns K. After depletion: the replenishment of the self's regulatory resources
  • J Tierney
Tierney J. (Aug 17, 2011). Do you suffer from decision fatigue? The New York Times. Retrieved from http://www.nytimes.com/2011/08/21/magazine/do-you-suffer-from-decision-fatigue.html Tyler JM, Burns K. After depletion: the replenishment of the self's regulatory resources. Self and Identity, 7(3):305–321, 2008.