"Take two aspirin and call me in the morning" may be really good advice after all. That's because a doctor's decision-making abilities may be related to the time of day. Making decisions, choices, seems highly affected by what social psychologists call "decision fatigue," or the gradual deterioration in decision making as mental exhaustion sets in. A doctor's diagnosis after a stressful day may not be as well contemplated as it was first thing in the morning or after some rest, nourishment and not having plowed through a thousand decisions.
New York Times science columnist John Tierney wrote about the phenomenon of "decision fatigue" in an essay adapted from Willpower: Rediscovering the Greatest Human Strength, a new book he co-authored with social psychologist Roy F. Baumeister (New York Times Magazine, Aug. 17, 2011). Tierney concludes that the mental energy dedicated to carefully weighing options and making good decisions can be affected by "ego depletion." Decision making ability is like a muscle: It is fueled by glucose, strengthened by self-control, enhanced with practice and fatigued by overuse. The more decisions we make, the more likely we will deplete our mental energy, a finite -- but renewable -- resource.
Tierney and Baumeister contend that decision making can be broken down into stages. They offer as an example Julius Caesar's defiant (and treasonous) march on Pompey's Rome after having triumphed in Gaul. The authors cite "the Rubicon model of action phases," referring to Caesar's crossing of the river Rubicon and his decision to declare war. Their model has three parts: a "pre-decisional phase" (what are the risks and benefits of waging civil war?), a "decision" (the declaration of war itself, which is based on this risk/benefit analysis), and a "post-decisional phase," in which "the die is cast," as Caesar put it.
The pre-decision phase is the most exhausting. The ability to consider, or speculate, requires energy. The more decisions one has to make in a day, the more depleted and less contemplative one becomes. Caesar came, saw, considered and then decided. Decision fatigue is the greatest enemy at this point in the process.
A jaw-dropping example of an Israeli parole board that heard three similar prisoners' appeals and arrived at vastly different outcomes illustrates decision fatigue. The board granted parole earlier in the day, when its decision making reserves were most robust, and denied appeals as the day progressed, as low glucose and high mental exhaustion eroded their mental capacities. Mental fatigue can produce impulsive, less than fully considered decisions. Even worse, mental paralysis (when we cannot make a choice) can also occur. The members of the parole board were no more cruel or prejudiced; as their minds flagged, they just could not deliver at the level needed. Not only does the early bird find the worm, the late-day judge may make decisions that are for the birds.
So it is for doctors too. Sound decision making is the cornerstone of medical care. Evaluating symptoms, ordering diagnostic tests, selecting treatments and managing complexity -- and uncertainty -- are crucial to our well-being and necessary to win our trust as patients and family members. Increasingly, health care professionals use technology in decision making: computer programs that tell doctors about dangerous drug interactions or that medication doses may be too high or low, electronic medical records that help to ensure that information about you is available in emergencies and shared among all caregivers, and detailed medical, surgical and mental health checklists ("Is Your Doctor Using A Checklist?"). Some hospitals are already tackling the risk of fatigue by having complicated surgeries at the crack of dawn, team rounds with senior physicians in the morning and mandated on-call limits for interns and residents. Decision fatigue, however, needs more safeguards to combat its dangers.
That's where you come in. Doctors increasingly are interested in "shared decision making," where patients and clinicians (of all disciplines, not just doctors) work together as partners in making health care decisions. In shared decision making, both patient (and family) and doctor are responsible for honestly expressing their goals, personal values and opinions. Uncertainty is shared. Having more informed people engaged in a decision is not only enlightened -- it can also be an antidote to decision fatigue.
Here's what you can do:
- Communicate with your doctor and form a partnership. You need to be clear and honest with your doctor. Go to appointments prepared (see below) and try to bring someone with you to help you communicate and understand. The doctor, in turn, owes it to you to communicate effectively. Don't be afraid to ask for more information when you don't understand.
- Try to schedule doctor's appointments early in the day. Decisions require energy to synthesize information and consider choices. Each successive appointment may affect the doctor's ability to make sound decisions, and your own mental acuity may also be a bit zapped after a long day.
- Manage the decision-making process. Ask focused questions, prepare carefully for the appointment and prioritize your concerns. Learn about your condition by using reliable sources of information, including trustworthy Internet sites. Write down what you want to say and ask. Many doctors are pressed for time, and a targeted summary of questions will help both you and your doctor optimize decision making.
Let's try to be like Caesar and create the circumstances for successful decision making. Let's have the wisdom to cross the Rubicon in the morning.
The opinions expressed here are solely those of Drs. Erlich and Sederer, as physicians and public health advocates. Neither receives support from any pharmaceutical or medical device company.
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