Why we get it and how we beat it
Have you ever wondered why deciding what to have for tea can be so exhausting? Or why it’s so hard to decide which gym class to go to after work, and you end up not going at all?
We’ve all been there. Tired after a long and stressful day working as a busy paediatric emergency medicine (PEM) clinician. But what makes it so hard for clinicians to make further, often minor, decisions without feeling totally exhausted?
It’s decision fatigue.
What is decision fatigue?
Decision fatigue is a complex phenomenon experienced by medical and non-medical professionals. It is defined as “the impaired ability to make good-quality decisions after a prolonged period of decision-making.”
Decision-making, no matter how big or small the decision, uses finite internal resources. As you make more decisions, internal resources become depleted resulting in a state of ‘ego depletion’. Decision fatigue is simply a physical expression of that ego depletion.
The average person makes 35,000 decisions per day. The next time you’re at work, I challenge you to count the number of decisions you make in just one hour!
What does the literature say?
Emergency physicians commonly report decision fatigue. However, research in this group is limited and conflicting. Zheng et al. (2020) looked at the number of CT requests over an 8-hour shift as a marker of decision fatigue in EM clinicians. (3) They found no evidence of it. Fewer CT scans were requested as the shift went on.
But is this a valid measure of decision fatigue? Did the lack of CT requests simply reflect the type of patients in the department?
The lack of controlled confounders and external validity makes it difficult to extrapolate these findings, particularly to PEM clinicians. A lack of pre-defined criteria to measure decision fatigue makes research difficult. Thankfully, a recent study by Grignoli et al. (2025) proposes a new descriptive definition, specifically for clinical decision fatigue. This should improve the validity of future research.
So why are PEM clinicians at risk?
We make rapid and complex decisions in a fast-paced and stressful environment. The sheer volume and critical nature of these decisions make decision fatigue a hot topic for clinicians. Let’s look in more detail.
Responsibility
The more senior you get, the more responsibility you have. You expect junior clinicians to come to you with questions, so logically, you’re making more management decisions.
You also have greater responsibility over patient care. This can be daunting and instil a sense of imposter syndrome. You question your own decisions and capabilities, doubling the number of decisions you make.
These decisions add up, and when it involves acutely unwell children, the decision-making stress increases. You’re using more of those internal resources in one go; soon, they’ll run out, and you might only be two hours into your shift.
Shift length
The real impact of shift length on clinicians’ decision-making was revealed after the introduction of residency work hour regulations in the United States in 2003. The regulations were associated with a 3.75% reduction in the relative risk for death and a 0.25% decrease in absolute mortality. This isn’t just about well-being; it’s about patient safety.
Persico et al. (2018) found that processing speed, working memory capacity and perceptual reasoning were significantly reduced in EM clinicians by the end of a 24-hour shift. Interestingly, they found no difference in cognitive capacity between the start and end of a 14-hour shift. This suggests clinicians shouldn’t work longer than 14 hours at a time (thank goodness)!
Night shifts
Working night shifts disrupts the natural sleep cycle. Increased fatigue reduces our short-term memory, directly affecting doctors—for example, forgetting to hand over patients to the day team or forgetting to check results.
The pre-frontal cortex is particularly susceptible to sleep deprivation, an area of the brain responsible for decision making during uncertainty and time pressured scenarios. When fatigue sets in, we resort to other cortical areas of the brain that are less sensitive to sleep deprivation. However, these areas cannot facilitate complex, time-pressured decisions and are limited to well learned behaviour. This is why it is better for a complex patient who presents at 8 a.m. to be seen by the day team rather than you at the end of your 12-hour night shift!
The mistakes don’t just lie within patient care. The impact of fatigue on personal safety, particularly on the drive home, has sadly been well reported in the literature. A recent audit by Islam et al. (2024) concluded that two-thirds of doctors did not feel safe driving home after night shifts. (9) 32.9% reported hitting the curb, 16.4% swerved, 4.7% were in the wrong lane, and 2.4% reported crashes.
Frequent interruptions and multitasking
Bleep goes off
“Apologies sir, please excuse me whilst I reply to this”
As you walk out of the cubicle, the nurse calls you over.
“Doctor please can you review this ecg for the lady in 6, she’s come in with chest pain and looks really poorly”
Bleep goes off again.
“GET AWAY FROM ME!”
A shout comes from inside the next cubicle, from a confused elderly lady directed at your colleague, stood at the door.
Red phone rings
The above scenario will be familiar to many of you.
A noisy night shift in the emergency department with interruptions from patients, phones and bleeps. It leaves little space in your head for thinking. Studies have shown that interruptions and multitasking negatively impact decision-making. One study reported 9.7 interruptions per hour in the emergency department compared to 3.9 interruptions per hour in primary care.
You can’t control when emergencies come in. This means the interruption is generally for a sicker patient than the one you are currently looking after. You stop what you’re doing and divert your attention to the new patient. But the lingering thoughts about the previous patient mean you cannot fully focus on the new one. This is attention residue.
It’s “the persistence of cognitive activity about a Task A even though one stopped working on Task A and currently performs a Task B.” Those who experience attention residue demonstrate poor performance on subsequent tasks. Interestingly, Leroy (2009) found that decision-making in time-pressured scenarios helped close the cognitive activity related to a task, as there was less time to think of alternative options. By making rapid decisions, you are left with less attention residue and perform better.
You might think that multitasking would help here. However, multitasking increases the demand on working memory (12). It requires clinicians to process information unrelated to their primary task, increasing the cognitive load. An impairment to working memory reduces the ability to cope well with interruptions, which results in making more mistakes and taking longer to complete tasks. Both of these are detrimental to emergency clinicians.
Lack of resources
On shift last week, no rooms were free to see a patient.
I’d already read the triage and had her ECG in hand. The other doctor in the ‘in and out’ room needed the bladder scanner, but it was broken, so she had to go to the surgical unit to borrow theirs.
I decided to see a patient with chest pain in the meantime, but they were waiting in triage because the ECG machine had run out of paper.
So, I went back to the first room and waited.
Lack of resources is linked to increased decision fatigue. When you cannot find the equipment you need, you make lots of decisions before conducting what should have been a simple task. In the example above, lack of space and equipment resulted in multiple back-and-forths. I had to make multiple decisions unrelated to treating the patient.
What are the implications of decision fatigue?
Decision fatigue manifests in many ways.
For some, it can look like making impulsive decisions. For others, it can look like avoiding making decisions altogether. Some tend to err on the side of caution by choosing a more conservative management plan, even if it isn’t the most appropriate one. This is often because you don’t have the internal resources to help risk stratify like you usually would at the start of a shift. It also may be why you got Gerald and Gerard mixed up last week. They both came in towards the end of your shift, presenting with falls. This can have devastating consequences.
Linder et al. (2014) found that doctors are more likely to prescribe antibiotics at the end of their shift compared to the start. The cognitive short cut here is simply giving the antibiotics instead of explaining to Mum why the child doesn’t need them. You’re more likely to take this option if you have four more children in the waiting room with a viral upper respiratory tract infection waiting to be seen. You may also doubt your diagnosis when fatigue sets in, so providing antibiotics feels safer.
Another example is inappropriately referring to specialities when they may be suitable for discharge. A study by Al-Arimi et al. (2023) found EM clinicians were likelier to refer to a specialty inappropriately in the afternoon than in the morning (65% vs 35%, respectively). This results in overrun services and increased length of stay for patients.
So, how do we beat decision fatigue?
In the ED, many systemic problems that are out of one’s control contribute to decision fatigue.
| Patient Factors | Staff factors | Environmental factors |
| – Volume of patients – Illness acuity – Timing of presentations (normally 6-10pm)! – Diverse presentations – Diagnostic challenges | – Poor teamwork – Lack of support from seniors – Staff health (mental and physical) | – Nights – Long shifts – Lack of breaks – Stressful and noisy environment – Lack of beds |
However, like with many self-improvement techniques, the focus should be on what you can control in these scenarios to optimise outcomes and well-being. This will help reduce stress levels and ultimately the burden of decision-making, saving your internal resources for those unavoidable difficult scenarios.
By focusing on what you can control, you can simplify decision making, instilling confidence in your ability and improving resilience.
Steps you can take to reduce decision fatigue
Take your break. This isn’t just a break from work; think of it as a break from making decisions, too. For that reason, decide where you’ll go for break before your shift starts. If possible, make sure big decisions regarding patient management are made before your break. You don’t want to spend your whole break worrying about it. Go off the shop floor, and in daytime hours, try and get outside to get some fresh air.
Reduce decision-making before and after work. Plan or prepare meals ahead of shifts and decide on your route to work the night before. This may seem simple, but it’s effective!.
Use checklists. Having pre-arrival trauma checklists ensures preparation for high-stress and chaotic environments (such as resus). Following a checklist reduces cognitive demand, optimising safe decision-making.
Delegate where you can. Redirect queries to other, capable staff members when appropriate. This could even be planned and decided in the morning handover. For example, ‘If we get two pre-alert patients at the same time, Fred, I’d like you to help cover resus.’ Know your team, their skills, and who can help.
Reduce interruptions. An example is using a whiteboard or a notepad for non-urgent tasks and communications. Be clear about what constitutes a non-urgent task before introducing this!
Try not to let previous decisions impact your next patients. For example, you have cannulated two children in a row for suspected sepsis. If the next child presents with an infection, you may cannulate and treat as sepsis, but not necessarily for the right reasons. Nudge theory is a concept of behavioural economics where you are influenced to make a particular choice. Did you cannulate the third child because they needed it? Or was it because you had just cannulated the two previous, similar cases? Here, it’s about recognising the similarity in presentations, acknowledging it and trying to reset before making an impulsive and potentially incorrect plan.
On the other hand, you may feel that you can’t cannulate again because it will be the third child in a row. If the child is sick and needs a fluid bolus, you cannot avoid cannulation just because you’ve already done it.
Decision fatigue may favour these choices. Be aware of it, and remember to see each patient with a fresh perspective.
Shared decision-making. For example, rather than blindly referring the patient to a speciality and wondering whether it was the right decision, picking up the phone to discuss with them may be more beneficial. Between you and me, an appropriate management plan can be formulated, one that you know is specialty approved. Shared decision-making has been found to improve clinician wellbeing and reduce decision fatigue. It can also be used with parents as it empowers them to make decisions regarding their child’s management plan, improving the patient (and parent) journey.
Simplify decision making. This skill is developed through exposure, good engagement with EM training, and experience. You will learn how to prioritise, helping you identify the sickest patients to be seen first. This simplifies decision-making.
Document in a timely fashion. Saving everything until the end of your shift is likely to result in error due to overreliance on short-term memory, which we know becomes less reliable when fatigue sets in. Get it down early to reduce cognitive load.
Take home notes
Ultimately, making decisions is part and parcel of working as a busy PEM clinician.
The variability and unpredictability of the job lend itself to stressful shifts, and decision-making can become impaired.
Knowing when you are most at risk from decision fatigue is imperative to reducing the impact of poor decision making.
More research, specifically into PEM clinicians and how to reduce decision fatig,ue is needed to help support clinicians and improve patient care.
In the meantime, don’t try to be the hero. Keep things simple, stay focused and communicate with your team.
References
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