Decision Fatigue

We’re all suffering from information overload.  More projects with fewer staff on shorter timeframes mean more email, texts, blogs, online meetings, and phone calls.

We make more decisions and have more accountability than ever before.  Regulatory complexity and the need for risk management has increased.  We’re pressured to make decisions faster and there is less tolerance for mistakes.   Making all those decisions in a high stakes environment like healthcare leads to decision fatigue,  that numbness you feel at the end of an overloaded day when you decided what to spend, who to hire, and what to do, hundreds of times.

I believe decision fatigue is an escalating threat to our ability to manage the events of each day and keep balance in our lives.

When I think back on my early career as a leader, in the 1980’s, there was no email, no overnight shipping, and limited numbers of fax machines.

Issues were escalated by writing and mailing a letter.    The time it took to compose, type, mail, and deliver a letter meant that many problems solved themselves.  Since the effort to escalate was significant, many problems were never escalated.

Today, everyone can escalate everything to anyone.  The barrier to communicating is nearly zero and communication is real time.   There is no mail room or team of middle management filters between you and the CEO.

This creates an interesting conundrum for leaders.  Should everything be answered in a very timely way with Solomon-like decisions about every issue?   Should everything be ignored unless truly emergent with the hope that someone else will solve the problem?  Should everything be deflected to those in middle management who would have read paper-based mail?

My goal is to never be the rate limiting step.  That means that I make hundreds of decisions every day.   Some are right and some are wrong, but they are the best answers given the information that I have.   In the IT industry,  timely action that is good enough is often more important than a delayed perfect action.

Thus at the end of every day my brain is whirring with thousands of inputs, and hundreds of decisions made.   I’m not physically tired after any workday, but I can feel mentally tired from decision fatigue.

The problem with decision fatigue is the that quality of decisions can diminish as the quantity of issues increases.

There are two ways to address decision fatigue

1.  Reduce the scope of your authority and hence the decisions you need to make and the risks you need to manage.  I’ll post a blog next week about span of authority and risk management.

2.  Spread decisions over a wider group of people, reducing the volume of decisions that fall to any one person.

#2 depends upon having a great boss, who is supportive, responsive, and willing to share decision making risk with you.    #2 also requires great staff whom you can empower to make decisions on their own.

Thus, I make the decisions that I am uniquely qualified to make, while pushing others up and down the organizational hierarchy so that risk is mitigated (seeking approval up the org chart) and trusted staff are given the resources and authority to solve problems on their own (delegating down the org chart).

Here’s an example of how I managed decision fatigue today.   Between 3pm and 4pm, I was asked to make several decisions:

1.  The regional poison control center sought my input on a mushroom ingestion case.   A 1 year old  had taken a large bite from a mushroom growing in a backyard.   Since I uniquely have mushroom toxicology knowledge, this was my decision.   The mushroom was a harmless Lactarius Fragilis and I decided that the child would be fine.

2.  A leak in the Longwood Medical Area chilled water supply caused a 5 degree rise in our disaster recovery data center.   What should we do?   I ensured that all appropriate facilities and IT people were organized to address the problem, and asked to be informed if the temperature exceeded 90F.     The incident management decision making was delegated to others.

3.  A researcher in one of the Harvard buildings suspected that the network had been hacked because www.ups.com was unavailable.  Should I page security and networking staff to urgently investigate this on a holiday weekend?   I used my Blackberry to replicate the problem and escalated it to IT security, who found the problem was unrelated to our network/DNS servers.    The incident management decision making was delegated to others.

In the next few months, I’ll be finishing the FY12 Operating Plan for BIDMC IS, so there will be plenty of decision making to spread among governance committees and executive management.

One other cure for decision fatigue that I recommend is a “time out”.   On my way home in the evening, I stop at our community garden space to sit on the small bench we’ve placed there, eat a few cherry tomatoes wrapped in basil, and watch the birds peck at our sunflowers.   I leave my Blackberry in the car.   By the time I get home, the decision fatigue of the day has passed, so when my wife and I discuss dinner choices, I’m ready to act boldly.

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6 replies »

  1. That’s what’s infuriating about it. As someone who is faced with a hundred trivial decisions a week that are somehow important enough to be escalated to me, what makes it exhausting is that I don’t care either way 80% of the time but have to somehow establish a policy on how to handle the dumb issue du jour.

    They’re often not important to the decision maker, they’re important to the person who decided he needed to make a decision.

  2. There were a few deaths at MGH that recently made headlines that were caused by technologies devices and alert overload. There were EMR associated dead babies in a Sarasota ER, a Philadelphia hospital, a Chicago hospital, and hepatits C transmission in a Pittsburgh Hospital. These are the tip of the iceberg.

  3. Medical care circa 2016:

    patient walks into a room and stands in front of a big machine that scans him with some infrared beam, then has the patient talk into a microphone to list the symptoms, then after lots of bings and beeps, a piece of paper slips out of a slot and lands on the floor. The patient picks it up and reads:
    “you have cancer, and you will die within 6 months.”

    Then the robotic voice from said machine says in monotonal voice “have a nice day”. Obamacare has become the future. And all you dumbass supporters will one day have to face the machine.

    Maybe it won’t be until 2016?

  4. “think of all the patients who have died because of cognitive bewilderment by the users of poorly usable and unvetted (for safety and efficacy) EMR and CPOE instruments of medical care.”


    (not anecdotes, btw, aggregate scientific data)

  5. OMG, what important decisions, but, I guess they are important to you. On the garden bench one day, relax and think of all the patients who have died because of cognitive bewilderment by the users of poorly usable and unvetted (for safety and efficacy) EMR and CPOE instruments of medical care.

    That is the sweet spot of decision and information overload.

    Smell the roses, John.