How many decisions do you make in a day? How many could you? Or should you?

Last weekend I moved house. A weekend full of decisions. Not massively meaningful decisions you might think, but you’ve probably not met my wife. What should we take first? Where should we put the sofas? Where should we put that box of things? Should we take that box of things to the skip? Or recycling? Or the charity shop? Or put it next to the other boxes in the hallway? After hours of deciding where to put stuff, I ran out.

Ran out of decisions.

“Where does that box need to go?” “Erm… Ah… I got nothing”

Recently there was a program on TV about decision making. Horizon, or some such. The program’s thesis went along the lines of this: the brain does not differentiate between a big decision, and small decision. Every decision takes the same ‘effort’, and we only have a certain amount of ‘effort’ to last each day. The implication was that we can only make a fixed number of decisions before we ‘run out’. The experiment shown in the program involved asking two matched groups of volunteers to make decisions in a test environment. One group were let into the room, and asked to sit the test. The other group were asked to make a number of ‘meaningless’ decisions prior to taking the test: which side of the room did they want to sit on, which way did they want their chairs to face, did they want a pen or a pencil, a blue or black pen, did they want coffee or tea after the test, with a biscuit or an apple. Those who were given fewer decisions to make prior to the test scored more highly.

Running out of decisions on the day I moved house wasn’t a big deal. We just put everything in the big room at the back of the house, and we’ll sort it sometime….

But what if I run out of decisions at work?

We make a lot of important decisions every day. Treatment choices. Decisions to keep a patient in hospital, or discharge them. Review in clinic, discharge to GP. Escalate therapy, or make a ceiling of treatment; palliate, withdraw therapy, or sit tight, and wait another day.

Who makes the decisions these days? Increasingly the decision making process has moved up the ladder; increasingly I see written in the notes: “Discuss with senior”, “Leave decision to day team” “Ask consultant about resus decision” “Discuss treatment options with consultant”. Our doctors in training seem to be less and less inclined to make treatment decisions. I suspect this is because the training we provide them re-enforces safety as the priory – and so it should, as we have a clear duty of care to do no harm to our patients. But not making a decision is not the same as being safe. Often the safest thing is to act, as making no action puts our patients in danger.

I get phoned a lot to make the same sort of decisions I used to make as a PRHO (remember those?). Can Mrs Miggins’ catheter come out? Can we change Mr Bloggs’ antibiotics from IV to oral? (does everyone else have the neo-verb “IVOST” now? “Can we IVOST Mr Bloggs?” Verbification of an acronym, the world has finally gone mad) Mrs Bloggs usually takes her aspirin at night with her supper, can it be re-written to be at 10pm? Mr Miggins has a headache, can he have some paracetamol? As consultants we can either sigh at this seemingly endless tide of decisions to make, and just make the changes as it’s easier than finding an FY-X doctor somewhere in a corridor, running around with a clipboard of jobs to do; or tell the nurses “No, I’m not making those decisions, find a doctor in training”, and appear as if we can’t be bothered to help.

I tend to do everything asked of me – even re-writing the treatment chart that’s run out, or writing up fluids that haven’t been prescribed, as well as making the decisions on the aforementioned paracetamol. One of my colleagues refuses to make these decisions, will not do jobs that he feels are clearly appropriate for doctors in training, and not to consultants, and often asks me why I capitulate, and do those jobs. I’ve always answered by saying that it takes little time, and is of no consequence to me, in the grand scheme of things; what harm could come of it?

But perhaps he’s right. Perhaps we should be storing up our decision making ‘effort’ for those more difficult decisions, those that require the additional training, experience, and expertise that we’ve acquired over the years? Perhaps making those smaller decisions is using up valuable ‘brain effort’. Perhaps we jeopardise more important decisions later in the day, by making these ‘Less important’ decisions?

Or maybe it’s bunkum. Perhaps I was just tired last weekend, just too tired to care about where we put the next box of books, or the bag of Summer clothes we’ll not need until the 24th July (the only day of Summer in the frozen North). Perhaps making those decisions for my junior colleagues frees them up to make more difficult decisions later on in the day? What if they can only make n decisions per day, but I can make 2n, or 3n? Maybe I’m just frustrated at making the same decisions now as I did 15 years ago when I was a house officer.

Whichever way I think about it, I still have to decide where we put that rug we used to have in the kids’ bedroom.