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Sunday, August 28, 2011

Decision making and the upside to junk food

A colleague of mine sent me a link to an article in the NYT Sunday magazine from last week  It is based upon a soon to be release book entitled:  Willpower: Rediscovering the Greatest Human Strength by Roy F. Baumeister and John Tierney. I have not had a chance to read the book but I will order it as soon as it is release. However, the summary from the article resonated with my own experiences, particularly in my practice. 

The basic premise of the article is that decisions we make are highly influenced by the environment the decision maker is placed in and the volume of decisions they are called upon to make. People called upon to make many decisions suffer from what the authors refer to as decision fatigue. Those who suffer from decision fatigue generally end up making sub-optimal decisions where only the most basic data is considered.

Surprisingly, decision fatigue can be obviated to a great extent by the simplest of interventions; feeding the decision maker. Glucose appears to have a huge impact. Intuitively, I understand this. Some of the worst decisions I make are immediately before lunch when I am hungry. Additionally, the most intensive cognitive work decision making activities make me ravenously hungry and from personal experience, I find that sweets fuel my own productivity. 

In my own patient care work environment, one thing which is almost universally frowned upon is any sort of food or drink. There were likely good reasons for such rules based upon hygiene and a clean work environment. However, these, like all rules, are likely to have unexpected and negative impacts. In a fast paced ambulatory patient care environment, caretakers are at high risk for decision fatigue and prohibitions against food and drink apparently removes the most important possible intervention to alleviate decision fatigue.

This underscores two likely problems with how we structure our work environments .First, those who make the rules are almost always unaware of the impact of rules on how people do their jobs because those who make the rules rarely have even the slightest appreciation for how those at point of service do their jobs. Electronic medical records are pushed out without analysis of their effects on workflow. Mandates are created about communication with patients without understanding what tools are required to meet the mandates. Outcomes are mandated with the tools to collect, validate, or analyze the data required. 

Furthermore, those who do the actual work at point of service are likely not so reflective as to how they do their work. After reading this article, I realized that many of the actions of my colleagues in how they structure their offices and practices may be driven in part by their desire to avoid making decisions. Movement to specialist and procedure driven healthcare limits the range of decisions required. In particular, procedure focused medicine removes the requirements to make decision based upon incomplete information. Movement to checklists may be used to remove even more decisions from the workday and although I do not know whether anyone has compared fatigue from decision making to manual tasks, my own experience suggests that doing work with one's hands is more of an escape than a drain. I recall my experience in the Emergency department as an intern where we all craved the opportunity to sew up lacerations and escape the frantic bubble of ER demands. 

The observations regarding the impact of decision fatigue on various decisions was made possible by the ability to measure outcomes. These studies were done under controlled and artificial conditions and it will be a challenge to deploy these types of studies in a healthcare delivery environment. The effects of poor decisions will rarely result in such easy things to measure as life or death. We can be aware of studies of human decision making which yield data likely relevant to decision making in health care environments and make reasonable modifications to how we do our work. Maybe the first thing to do is to allow snacks as an antidote to decision fatigue. However, Diet Cokes will simply not do.   


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