Decision Fatigue and Good Habits

Editor’s note: this post was eventually expanded into a cover feature in the May 2012 edition of EMS World.

There’s a concept from psychology that’s recently made the jump to the world of popular science (that misty realm ruled over by a benevolent Malcolm Gladwell; Bill Nye is his jester) known as decision fatigue.

The idea is that human beings have a limited reserve of willpower. Willpower isn’t a physical substance, something stored in a sac in your abdomen, but nevertheless it’s a real quantity. Every time you’re forced to make a decision, especially important or consequential decisions, it drains a little of this resource. Certain restorative acts, like sleep or eating, can help restore it. But if you start running low, then you start losing the ability to make weighty or difficult choices — you tend to pick the easy option, the default answer, the path of least resistance. Rather than the big picture, the long term, you start seeing only the immediate payoff. That little mental push that lets you do the right thing… well, if you spend all day pushing, by 9:00 PM you just might be out of push.

This phenomenon may ring intuitively true, but understand that it’s not horoscopes or tarot cards — this is a real behavior exhibited by all or most people. This is something you do right now, whether it’s obvious or not.

And this is very pertinent to those of us in EMS. Due to the nature of our work, we carry an unusually large burden of decisions. For the level of training and experience our job requires, we are granted a great deal of independent responsibility; in other industries, we would be working with a supervisor over our shoulder, a hands-on boss ensuring that we toe the line. Not so on the ambulance; we perform our duties on the road, alongside one partner, and typically have no direct oversight for the vast majority of our day. If you mess up badly enough, you’ll hear about it later; but to quote the luminary Peter Gibbons, “that will only make someone work just hard enough not to get fired.” We all know a few EMTs and paramedics who have learned all the hot spots, the danger zones, know exactly what they need to do (and what to avoid) in order to stay under the radar — and as long as they dance those steps, they can otherwise do, or skip doing, whatever the heck they want.

The point is, in this job you can do everything right. . . but only if you decide to.

Many of our decisions are small. When it comes down to it, even Old Man Lazybones, the 400-year-old medic who only wakes up to punch out and sometimes eat animal crackers, will generally mobilize for the cardiac arrest and the multiple stabbing. That stuff comes packaged with motivation. But what about all the little things in between? Do you change the stretcher linen between calls, or leave it? Do you sanitize that blood pressure cuff after using it on your “recent VRE” patient? Are you professional, caring, and thorough in your patient interviews, or are you starting to lapse into taxi driver mode? Do you document thoroughly, or cut a few corners? Is everything on the truck restocked for the next crew, or are you out the door? And so on, and so forth. There’s doing your very best, there’s just barely “not getting fired,” and there are many points in between, but no doubt, each time you’ll have to decide where you fall.

It’s tempting to say that what matters is simply the kind of person you are. The “good” EMT, the true professional, that guy will do the right thing. He’ll make the right choices. And the slacker, the hack, he’ll blow it off. And maybe that’s often true.

But the lesson of decision fatigue is that none of us is a saint, or an infallible machine. Every time we make one of those little decisions, every time we exert ourselves to do the right thing, we use up a little bit of our motivation. And after 8 hours, 12, 24 hours, five calls, ten calls, you’re going to start scraping the bottom of that well. The good medic will last longer, the hack won’t make it past lunchtime, but eventually, everyone starts cutting corners. Be honest with yourself, and you’ll see that it’s true. You can care, and you do care, but at some point, you’ll stop caring quite so much. In the long-term, we call it burnout, but in the short term we just call it “time to go home.”

One of the valuable observations from the research on decision fatigue is how the most successful subjects tended to cope with it. By and large, those with the best self-control didn’t survive by being the most stoic, just standing there and weathering a stream of decisions that would shake the best of us. Instead, what they did was set up their lives to minimize the drains on their self-control. They recognized that if they have to spend all day consciously choosing to do the right thing, eventually they’re going to start slacking. So whenever possible, they arrange their circumstances so that no decision needs to be made. When they grocery shop, they don’t just “buy what looks good,” because that’s a constant barrage of “cookies or carrots?” They go in with a list, and they buy what’s on the list, and that leaves no decisions to be made. And then, on the way home when they have to decide whether to yield for the slow-walking granny in the crosswalk, they aren’t already worn out from the battle of the cookies.

Good habits. Good habits will save us.

You can’t go through your shift constantly deciding to do the right thing. But you can create good habits, wherein you do the right thing automatically. This may sound like you’re creating work for yourself, but in fact it’s the opposite. “Work” is choosing to do it. Habits just happens. Waking up, brushing your teeth, driving to work, you don’t complain about having to do these, you just do ’em; they’re things you do, not things you decide to do. If every time you drop off a patient, you change the linen, then this stops being an “issue”; it’s just part of the call, part of your routine.

Setting up habits takes work, but maintaining them takes none, and you’ll quickly find that the type of EMT you are is defined by your habits as much as your decisions. Although I’m a huge proponent of good judgment, critical thinking, and wide leeway for field providers to make good decisions, the truth is that much of our work is routine. And the more of your routine you can manage by habit, the more willpower you free up for the tougher stuff. This doesn’t tie you down. It liberates you to think bigger, and aim higher.


  1. Excellent article! I agree completely. Great work! 🙂

  2. Brandon,

    Very timely post. Just last week a medical director was telling me about this concept. I would encourage you to pitch an article to EMS Magazine on this topic of decision making fatigue. I would be glad to introduce you to the editor. More in-depth on the science behind it and more strategies to cope with it.

  3. Excellent article, Brandon!


  1. […] I get so tired of making decisions that I have a dream of a restaurant where I walk through the door and they say, “Please be seated. We will bring you good food that you will like eating.” Decision making fatigue is a very real thing that leads to errors in healthcare. Brandon Otto has written a nice introduction, Decision Fatigue and Good Habits. […]

  2. […] things simply need to get done, do them simply. Use minimal effort and rote habit-execution to minimize decision fatigue, bunt the easy pitches, and save your mental energy for the tough diagnoses, gray areas, and […]

  3. […] novel and requires contemplation and second-guessing, it’ll require more bandwidth, time, and mental effort to navigate. With time, more and more situations become routine. Competence is the tide that lifts […]

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