Decisions, decisions, decisions. All day long, decisions...

A disappointing John Tierney article about decision fatigue in the New York Times magazine section is just the most recent in a collection of equally disappointing discussions of an issue that is both widespread and important. Others can be found inWikipedia, Lehrer’s book How Do We Decide?, in Neuroscience Marketing, in Malcolm Gladwell’s TED talk, in a piece on RadioLab, and countless others. (Google gives 28 million hits for Decision Fatigue.) It’s tiring.

Decision fatigue is not an isolated phenomenon. All of us know of it. Unless you live truly off the grid, you experience it daily, if not at work, then in the supermarket or pharmacy or box store or on line. And it isn’t new. My father told me an illustrative Count Bobby joke (Graf Bobby) from his pre-WW2 childhood in Vienna, about the man who leaves a series of rewarding and prestigious jobs because of burnout, and is advised by his doctor to find something stress-free. He starts work sorting apples (small, medium and large) into three bins from a conveyor belt. After two days, he quits. When asked why, he says: “I couldn’t take it. It was exhausting. Decisions, decisions, decisions. Al day long, decisions.”

It is commonly referenced in literature. One of my favorites is this, from Sylvia Plath (The Bell Jar):

"I saw my life branching out before me like the green fig tree in the story. From the tip of every branch, like a fat purple fig, a wonderful future beckoned and winked. One fig was a husband and a happy home and children, and another fig was a famous poet and another fig was a brilliant professor, and another fig was Ee Gee, the amazing editor, and another fig was Europe and Africa and South America, and another fig was Constantin and Socrates and Attila and a pack of other lovers with queer names and offbeat professions, and another fig was an Olympic lady crew champion, and beyond and above these figs were many more figs I couldn't quite make out. I saw myself sitting in the crotch of this fig tree, starving to death, just because I couldn't make up my mind which of the figs I would choose. I wanted each and every one of them, but choosing one meant losing all the rest, and, as I sat there, unable to decide, the figs began to wrinkle and go black, and, one by one, they plopped to the ground at my feet." 

With the increased speed and variety and complexity of modern life, aided and abetted by the information and electronic ages, it has gotten more pervasive. It is also better understood than it was by early writers like Freud.

The underlying principle is simple: making decisions involves mental work for which there are finite resources. Making decisions depletes the supply of glucose in the area(s) of the brain involved in decision making, resulting in progressively poorer performance in decision making tasks until the glucose supply is repleted. (Note: exercising willpower is a subset of decision making, so this applies to things like behavioral control, dieting, and the like.)

The phenomenon is predictable:

  • In any series of decisions, early decisions are better than later decisions.
  • More depletion occurs with more difficult and complex decisions, such as those involving trade-offs (all the options have both advantages and disadvantages which must be weighed and compared) or current vs. delayed consequences.
  • Glucose repletion improves performance, happens slowly spontaneously and more quickly with feedings. 
  • Good tasting food is not necessary - just glucose repletion.
  • Results of decision fatigue include hasty and superficial decision making, avoiding having to process salient information, using simplistic surrogates (price, color, brand) rather than performing true value assessments, risk aversion (stay with the status quo or make the smallest possible decision), delay and defer (decision paralysis).

Tierney, like most authors on the subject (and including those listed above) delights in recounting examples of the problems and harms that result from decision fatigue in business, law, computer science, and our personal lives. I certainly see it on a very personal level in my field, the practice of primary care medicine:

  • At the end of a busy day, deciding what sort of bread I want for my sandwich is overwhelming and makes me cranky. (Ask my wife. I often opt for a peanut butter and jelly sandwich rather than try to cope with picking among the many more tasty and nutritional options easily available in the fridge.)
  • I have developed routines to decrease the work of making certain kinds of recurring decisions: algorithms, nursing staff doing parts of the task, office work flows.
  • I have to get to work before I start seeing patients if I have complex labs or other results to review, because at the end of the day I ‘have nothing left’ for this. (This, of course, is part of a vicious cycle. I come in early and front load my day with 90 minutes of rapid fire decisions before I start with patient hours, ensuring that my depletion will start sooner and be more severe at the end of the day.)
  • If a patient presents with a clinical situation that is borderline for requiring a change in therapy (their blood pressure is 142/90 on their current med, for example) I am much more likely to suggest to the patient that we let it ride this visit and re-evaluate it at the next appointment if this is a late afternoon visit than an early morning visit.
  • If I have to add a complex patient to tomorrow’s schedule, my preference is always at the beginning of the day, and tacked on to the end of the schedule is my last choice.
  • The second half of both the morning and afternoon I have to repair to my desk several times for a quick snack to keep going. Candy is dandy, and diet soda doesn’t work.
  • Near the end of the day, if I see a patient of one of my colleagues with a change or flare in a chronic problem, I am always inclined to tell them we will get the evaluation process started and have them back to see their primary in a couple days to review results. This is especially true in the after hours acute slots following an 11 hour stint of decision making.

The article was well written, so why did I find it (and most of what I have read about this) so disappointing? Because it isn’t helpful. I don’t have the option of working for two hours and then taking an hour off to eat and play before returning to work. Tierney and others don’t provide practical suggestions. What is the smallest calorie snack that is effective? Does it help to exercise? What impact does it have if one changes subjects (makes decisions in a different field)? Are there any cognitive techniques (progressive relaxation, imagery, self hypnosis) which can speed to repletion process or delay the depletion process? What impact does caffeine have? Is there any impact from music or humor or social interactions?

 


 

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