A Doctor's View

The Exhaustion You Can’t See: How Constant Choices and Noise Wear Us Down

• Dr Paul Polyvios • Episode 57

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Have you ever wondered why you struggle to decide what to have for dinner after a long day at work? That mental exhaustion has a name—decision fatigue—and it affects everyone, but takes a particularly heavy toll on healthcare professionals.

Decision fatigue refers to the deteriorating quality of our choices after prolonged periods of decision-making. While it might sound like an academic concept, its effects are profoundly practical and widespread. For doctors and nurses, decision fatigue isn't just an inconvenience; it's a daily challenge that can affect patient care and personal wellbeing.

Throughout a typical hospital shift, healthcare workers make hundreds of micro-decisions. When a nurse reports a patient's overnight blood pressure drop, this triggers a cascade of mental questions about causation and treatment options. Even seemingly simple requests like prescribing pain relief require careful consideration of drug interactions, patient history, and potential side effects. These continuous small decisions gradually erode mental reserves, leading to compromised judgment as the day progresses.

Compounding this challenge is what I call "noise fatigue"—the mental drain caused by constant exposure to beeping monitors, alarms, phones, and the general cacophony of busy wards. This sensory overload further taxes already strained cognitive resources. It explains why many hospital staff eat lunch in silence or why closing your front door at home becomes the most cherished moment of the day—finally experiencing silence and freedom from the pressure of constant decision-making.

Understanding these psychological phenomena helps explain seemingly irrational behaviours and underscores the importance of creating systems that minimise unnecessary decisions. While recognising decision fatigue doesn't excuse poor choices, it helps us develop strategies to preserve mental energy for critical decisions and create environments that support rather than deplete our cognitive resources.

Next time you feel inexplicably exhausted, consider how many decisions you've made recently and perhaps give yourself the gift of silence. Your brain will thank you.


Thank you for listening!
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Dr Polyvios:

Before we begin the episode, I just want to wish everybody who is starting a new job as it is changeover week in the United Kingdom for hospitals all over the country, and so for all the newly qualified doctors who are going into their first rotation I wish you all the very, very, very best of luck. And remember we've all been there and it's a stressful week. It's fun. Enjoy it. Remember there is a wealth of help and information all over the hospital, in the forms of your seniors, in the forms of your nurses, in the forms of your seniors, in the forms of your nurses, in the forms of anyone. Believe me, you will find help and assistance in the strangest of places, and don't be scared to ask for help. Everyone is rooting for you and you'll all do great. Welcome to doctor's view with me, dr bolivios. Join me as I discuss everyday topics in health and medicine and provide insights into everyday hospital life. Sit back and enjoy the show. Hello everyone and welcome to doctor's view. I'm Dr Polyvios.

Dr Polyvios:

Today, I want to talk about a silent force that affects all of us, but especially those of us in healthcare. It's called decision fatigue. Decision fatigue is a term that comes out of behavioural economics and also psychology, but you really don't need to be a psychologist to to understand it at all, and it's something that everyone can relate to in some way. So what is it? Well, decision fatigue refers to the deteriorating quality of decisions made by an individual after a long session of decision making, so say, like by the end of the day. So the more choices you make over a period of time, the more mental energy becomes depleted, and this leads to reduced willpower, impaired judgment, avoidance of decision making altogether, or even just a tendency to make impulsive or easy choices rather than the optimal ones. It's said that your human brain can only cope with a certain number of decisions per day before decision fatigue sets in. Now you might think well, this doesn't really affect me. I don't run a business or have to make difficult decisions for others or make important judgment calls in my typical day-to-day life, and that's where I believe anyone who thinks this is is wrong. What we might not realize is that from the moment we wake up, we actually start making decisions. They might be small, subconscious ones, but they are decisions. This can include whether to make a cup of coffee or a cup of tea, what to eat for breakfast, to wear today. Should I take the same route to work as I normally do? Even just checking your phone first thing in the morning is a decision, and it sets off a cascade of decisions. Do I respond to this email? Do I do it now or later? Should I like that post? Should I answer this message or just pretend that I haven't seen it yet? All these are small decisions that we have to take. The reason why I decided to make a podcast on this topic is that I found myself the other day feeling really exhausted and I wasn't sure why. The day wasn't especially busy, but I found myself having to make a lot of very small decisions and I realized that in a typical day in a hospital, I, like every other doctor or healthcare worker, actually have to make hundreds of micro decisions, and it doesn't matter if you've just qualified or if you've got 30 years experience. Decision fatigue is something that affects all of us. So, for example, when on call on a busy intensive care unit, the number of questions I can be asked on a typical day is absolutely immense. I think I would struggle to count them, and they could be simple questions that I would even ask myself when reviewing a patient, such as should I start this patient on some blood pressure medication? Or they could also be simple statements rather than questions by someone else, for example. So I just want to let you know, doctor, that the patient's blood pressure dropped overnight, but now it's okay.

Dr Polyvios:

Now you might not think this is something that will particularly lead to decision fatigue, but in just that simple piece of information, a number of thoughts are triggered. Why did this happen? Was the patient simply sleeping? Do we need to adjust the patient's blood pressure medication? Do I need to look into this further? Is this something that's actually that important and do I need to do anything at all? And other questions can be things like doctor, the patient is in pain. Can you please prescribe some analgesic medication, pain relief Again, a really simple task which can be completed really easy if you take it at face value.

Dr Polyvios:

However, that really simple question again triggers a cascade of questions in my own mind. Why is the patient in pain? How much pain relief has the patient already taken? Which is the best drug to put this patient on? What are the side effects of this drug? Do I need to give something else to counteract those side effects?

Dr Polyvios:

Again, a cascade of questions, cascade of decisions and much of my shift with stable patients are made up of these micro questions. And then, however, when there's a really especially unwell patient, these questions become harder. So, should we start a medicine to support the patient's heart? Do we need to anesthetize and intubate this patient to help with their breathing and then come further decisions to make? What drugs should I use to anesthetize the patient safely? And, you know, should I let the family know now or later that we need to put them on a breathing machine? This may be part of my job and, like every other anesthetist probably, I answer these questions even without thinking about them.

Dr Polyvios:

They happen subconsciously as soon as you take a view of a situation and we are always thinking about these, these, um, these type of questions in our in our normal day-to-day job, whether it's out loud or in our head. But, uh, after a whole day of making decisions, be it consciously or subconsciously, the toll it takes really can't be ignored. It's why humans are less rational as the day goes on, so they're less rational at the end of the day than at the beginning. It's why we get more fed up as the day goes on. It's the reason why judges aren't allowed to make a sentence, uh, aren't allowed to make a sentence, aren't allowed to sentence a criminal after a certain time of day, and why there's a separate sentencing date? And it's because they will not be in their best frame of mind to give a fair judgment and a fair sentence. So it's not just you and me, it really does affect everyone.

Dr Polyvios:

So decision fatigue is also the reason why we put off difficult tasks that we know require a lot of decisions or a lot of thinking. We say we'll do it tomorrow or later, and it's also the reason why after a long day at work, the last thing we can think about is what to cook for dinner, for example. We have to think what ingredients are in the fridge, what can I make, what temperature do I need to set the oven to? And sometimes all we can muster ourselves to do is actually just order a pizza, and even then we have decision fatigue. On deciding what to order, we'll scroll for 10 minutes trying to decide, you know, go through the menus and finally we just order the same thing we've always done, because it's easy and we eat it feeling mildly ashamed, but, you know, too tired to care.

Dr Polyvios:

And thankfully I work in a wonderful hospital where consultants and senior staff are always available and are very supportive, and this really does help to ease decision fatigue and the burden of it a huge amount. However, this hasn't always been the case and I know it's not the same for everyone. And I really do feel for doctors who have just qualified and are working on very busy units, some not as well supported as others, and I've been there and remember that very, very well. And I hope no one has to go through the same same difficulties and now imagine having that depleted willpower, that impaired reasoning, that mental exhaustion, but while you're still at work, still responsible for the patients, and still being asked to make decisions that actually matter. And these aren't questions like what shall I have for dinner. They're questions like should we restart the patient's blood thinners? Should I escalate this deteriorating patient now or should I try this first and then then wait? Or even a difficult question such as should I challenge this plan that my consultants made? Because there's something I don't agree with, even though I've only just qualified Hard decisions to make.

Dr Polyvios:

And so when we're tired we don't think clearly. We know that. But with decision fatigue it's not just tiredness, it's a specific mental weariness that can affect your judgment, in often actually quite predictable ways. You can either avoid the decision altogether, so, for example, you see a borderline blood result hemoglobin just on the cusp of of being anemic, for example, when you say maybe I'll just recheck it later and you might say that, rather than actually decide what to do and it's not laziness, it's often just fatigue in disguise it's too much mental effort to think, you know, should is this worth worrying about right now? Sometimes just checking it again.

Dr Polyvios:

It's the easiest and often the safest thing to do. You can choose the easiest option which, when it comes to prescribing and this is where we do we cover things. Just in case we give antibiotics, just in case we leave catheters in. We order unnecessary scans because it's easier than just thinking about a difficult differential or sometimes just not questioning someone else's plan because it'll take too much brain power to challenge it. So we just go along with things. It's the path of least resistance and finally, you can do what you did the last time. You just repeat the same thing, and that's how patients stay on medications that they don't need, and this is how treatment inertia creeps in. You know, we see a slightly raised blood result. We order a CT scan, because that's what we did the last time this happened.

Dr Polyvios:

And and you just go on autopilot and the number of the number of bleeps I would get when I first started, um, just to prescribe another bag of fluid at two in the morning for a patient. And actually there's, there's a lot to prescribing a bag of fluid. You have to think to yourself does the patient need this liter bag of of Hartman solution or or saline? And you know you think okay, they've been on it all day. And are they nil by mouth? No, are they asleep? Yes, what's their kidney function doing? What's their electrolytes doing? What's their urine output doing? All these different things. They look like they're dehydrated. Are they behaving like a dehydrated patient? Was there sodium? All these things? And yet the number of times we would literally just just prescribe another bag of of this, of fluid because, well, they've been on it for all day and it's run out.

Dr Polyvios:

So logic dictates we just continue the bag and it's not again. It's, it's part of least resistance, it's not. Um, we, we all know that. You know we need to spend a bit of time to to look at whether the patient needs fluids or not, but, um, sometimes doing that when you've got a busy night shift, um, the it takes. It takes sometimes a bit of bravery to not prescribe that bag of fluid when and to take the time to to question, um, a judgment from um, from someone who's been been on the on the much longer than you have. But I do urge juniors to actually do question things, um, not just take things at face value. If you are asked to prescribe bag of fluid, do have a look at the, at the blood results, do have a look at the patient. Uh, don't just go on autopilot.

Dr Polyvios:

And but again, decision fatigue. We've all done it, um. And if you're not in a hospital setting, I guarantee there's an equivalent to what you, to what I've just described, in your work too. It could even be just responding to an email in a hospital setting. I guarantee there's an equivalent to what I've just described. In your work too. It could even be just responding to an email in a certain way, a certain template, whatever it might be. So anyway, we've talked a bit about decision fatigue in certain situations.

Dr Polyvios:

And just think about all the staff in the hospital, all the different specialties and all the thousands of decisions that happen every day. And then you have emergency situations, doctors who are in intensive care unit, in A&E, in acute specialties, and you have to make these decisions very rapidly and in a very stressful situation. So, for example, a patient arrives with a fever, low blood pressure, fast heart rate. You have to decide do I give fluids, do I start antibiotics, which ones? What investigations? And do I refer the patient now to a high dependency unit or intensive care unit, or do I wait for something else to happen first? Do I break the news to family now? Or who do I break the news to? You know, all these, all these things are not just one decision. They are a cascade of things and when you're in a bit of a state of hunger and dehydration and some sleep deprivation and you're often faced with inadequate staffing, you can see how life can get a bit stressful very quickly in a in a hospital situation.

Dr Polyvios:

And whilst these are clinical decisions, they do also tap into an emotional bandwidth. Am I delivering this news well? Am I being kind to the patient? Am I being kind to the relatives? Am I doing the right thing for this person right now? And this is just one patient, never mind the bleeps you get about putting a cannula in, and you know, um, and I was asking you to prescribe a laxative a a patient asking you about a discharge letter. You're expected to switch cognitive gears between the mundane and the life-altering dozens of times a day, and this isn't multitasking, this is cognitive fragmentation. This is exhausting, and the more fragmented you are, the more you lean on your mental shortcuts. And so, whilst I'm making it sound like a hospital is an incredibly dangerous place, it's somewhat reassuring that research has shown that, despite decision fatigue, patient care is actually minimally affected.

Dr Polyvios:

So who is it that suffers? Well, it's pretty much the doctors themselves, and that's not, and that's one of the reasons why medicine is is so difficult. It's not the difficulty of the degree, it's not the difficulty in diagnosing a patient, it's the difficulty of being able to act professionally and competently at the end of the day, as you did at the start, and and treating patients with dignity and respect. Even when your patience has run out, even when you are going going through a difficult time, you have to recalibrate your thoughts and think that that patient in front of you or that set of relatives in front of you are going through a lot worse, and sometimes that's easy to forget. Medicine is difficult from a mental arithmetic point of view, from the mental burden it can pose on the people that undertake it. It's a lot of mental strain, and it doesn't just come from decisions. There's actually other hidden mental drains that we can talk about, and one of those is noise fatigue.

Dr Polyvios:

Now, noise fatigue is also called listening fatigue or auditory fatigue, and it's basically what happens when you are exposed to noise for too long, especially if it's loud or constant, over time, and it wears you down mentally and physically. You just it's usually when you're in a factory, a construction site, airport, even just loud, busy offices. It's that background noise, constant beeps or whatever. And it's the reason why it's so fatiguing to listen to a podcast or a video with bad audio, and it's why podcasters usually work really hard to try and make their audio quality sound good. I'll give you an example. So now you're hearing me through the microphone on my mobile phone, you'll notice the background noise and the poor audio quality. And now I'm back to my studio microphone. Hopefully it's easy to see that it's much easier to listen to me for a long period of time.

Dr Polyvios:

At least I hope so, and what I want to talk about noise fatigue about is is imagine just a commute, to say, say, my commute to the hospital on London Underground, with decibel levels of around 86 to 91 decibels on the average, and they peak about 110. I've got a short recording now, so this is what my typical commute sounds like over a brief period of time. So now imagine that noise peaking much louder and uh and lasting for around 30 minutes. Noise cancelling headphones or earplugs are not a luxury on the london underground, they are an absolute necessity. And, on a serious note, I think the noise pollution and an actual air pollution and the heat of the London Underground are just absolutely ridiculous. I have, I have no doubt that using the underground every day for commuting has serious health risks. But I'll say that debate and a rant for another day, and if anyone can arrange a meeting with the mayor of London and myself, I have many, many questions to ask and complain about.

Dr Polyvios:

Okay, so now think of the hospital the beeps, the alarms, the machines, the phones, the constant background chatter, the operating theatres, the underground commutes, it all adds up and so here's some typical hospital noises that I literally hear day in, day out, throughout the whole day. Now we've learned um, as doctors, as anesthetists, to filter out these noises and they become background noises and you detect uh changes in the tones. So, for example, it becomes a background noise that you can completely ignore up until the point where the oxygen tone changes and then you know there's a problem and you automatically just just subconsciously fire up and you know exactly what, what to look at on the monitor. Um, but it is fatiguing over a whole day listening to these noises and I've noticed as time goes on that more and more hospital staff eat lunch in silence, and I don't think it's because everyone just wants to be on their phones and are addicted to their phones. They are, but this is a different situation. This is not what I'm getting at. I think people actually don't want to talk to anyone and to have a break from the noise fatigue and and the decision fatigue and and I think that's why they're on their phones in their lunch break, not not so much the other way around. And nowadays talking to people incurs a risk of having their problems offloaded to you and even adding to yours or giving you more work to do, and sometimes it can feel like everyone wants something from you and after a long day, even a friendly chat can sometimes feel like a demand, and sometimes people actually will only talk to you because they want something from you.

Dr Polyvios:

And I actually get quite a lot of requests from prospective podcast guests, usually a very generic email we love your show. They'll compliment an episode that they've probably never listened to and then they'll as usually a publicist asking for their client to come on the show and they'll be a perfect fit for the show. And you know, you read the blurb and they just want to advertise a book that they've got for sale and that book has absolutely nothing to do with the show, nothing to do with medicine, nothing to do with literally anything I've ever spoken about. So you know that's annoying. At least have the courtesy to listen to an episode or even just the description, just to see that it's not a fit for you. Anyway, so you've got decision fatigue coupled with noise fatigue and you can imagine how tiring a normal day can be.

Dr Polyvios:

One of the nicest parts of my day is the moment I come home and close the front door, that silence, not having to decide something just for a few minutes. It's a moment of peace. And when I used to drive to work and I had a an hour plus commute in the car. It's why I would sit in the car for five to ten minutes before actually coming through the front door. It was just a a moment to unwind and actually hear your own thoughts and and your own silence. It was actually just a form of respite, and I didn't care how weird it looked.

Dr Polyvios:

You know, and one bad habit I've developed over the years was is to stay up as late as possible. When I didn't have to be up early the next day, I would literally stay up till till 3am and sometimes 4, and I could just be doing something enjoyable like just play computer games, read a book, sometimes actually just listening to music, literally just nothing else, just walking around the house listening to music till 3, four in the morning with headphones on. And the reason for doing this? Because I knew everyone around me was asleep and I wouldn't be disturbed. And it felt like a time where I could unwind without any guilt because I knew no one would disturb me or ask me to do anything.

Dr Polyvios:

And so the next time you feel exhausted and don't know why, have a think about how many decisions you've had to make in the last hour and maybe think about having a moment of silence after a busy day at work or after a busy journey. Silence is powerful, it's cleansing and it's therapeutic. Just don't use it as a punishment. And with that I will leave you. As always, please look after yourself. I'm Dr Polyvios. Goodbye.

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