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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
REFERENCES
Augenblick N, Nicholson S. Ballot position, choice fatigue, and voter behavior. July 2011.
Retrieved from http://faculty.haas.berkeley.edu/ned/Choice_Fatigue.pdf
Baumeister RF, Bratslavsky E, Muraven M, Tice DM. Ego depletion: is the active self a limited
resource? J Pers Soc Psychol, 74(5):1252–1265, 1998.
Danziger S, Levav J, Avnaim-Pesso L. Extraneous factors in judicial decisions. PNAS, 108(17):
6889–6892, 2011. Published ahead of print April 11, 2011, doi:10.1073/pnas.1018033108
Gailliot MT, Baumeister RF. The physiology of willpower: linking blood glucose to self-control.
Pers Soc Psychol Rev, 11(4):303–327, 2007.
Job V, Dweck CS, Walton GM. Ego depletion—is it all in your head?: implicit theories about
willpower affect self-regulation. Psychol Sci, 21(11):1686–1693, Nov 2011.
Laran J, Janiszewski C. Work or fun? How task construal and completion influence regulatory
behavior. J Consumer Research, 37:967–983, April 2011.
Schmeichel BJ, Vohs KD, Baumeister RF. Intellectual performance and ego depletion: role of
the self in logical reasoning and other information processing. J Pers Soc Psychol, 85(1):33–46,
2003.
Tierney J. (Aug 17, 2011). Why you need to sleep on it. The Sixth Floor. Retrieved from http:/
/6thfloor.blogs.nytimes.com/2011/08/17/why-you-need-to-sleep-on-it/
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.
Vohs KD, Baumeister RF, Schmeichel BJ, Twenge JM, Nelson NM, Tice DM. Making choices
impairs subsequent self-control: a limited-resource account of decision making, self-regulation,
and active initiative. J Pers Soc Psychol, 94(5):883–98, May 2008.