Welcome to question of the day #296

Welcome to question of the day #296

I’m working as an eye specialist in community practice. I have to make so many decisions every day that it tires me out. I’m worried about making the wrong decision. What should I do?

A practitioner’s working day is full of decisions. Some are clinical, others stem from everyday life. Here, I will concentrate on clinical decision-making.

In community practice, on average I see 18 patients per day. I carry out the following tests during the examination of a new patient who is over the age of 40:

History and symptoms (8)

Distance vision/visual acuity (4)

Near vision/visual acuity (4)

Cover test distance and near (4)

Retinoscopy (6)

Subjective refraction (8)

External eye examination (10)

Internal eye examination (16)

Intraocular pressure (4)

The figures in brackets are my estimates of how many decisions I make when examining two eyes. The total is 64. This is per patient. I know the number of decisions will vary from one patient to another and some will require more than this and others less than this but it’s a reasonable figure to work with.

So, if I see 18 patients per day I’m making around 1152 clinical decisions. This is on top of decisions like, what to wear for work, which route to take to get to work, where to go for lunch, and what to have for lunch.

The energy consumption required to make clinical decisions takes its toll and may result in decision fatigue. Decision fatigue refers to the deteriorating quality of decisions made by an individual after a long session of decision-making. A day in the clinic is definitely a long session of decision-making.

Here are some ideas to help practitioners prevent clinical decision fatigue:

Rest breaks-Arrange a mid-morning break of 15 minutes. This can be difficult for a locum practitioner but the decision-making process can be greatly improved and this is in everyone’s interest. Take a lunch break of at least 30 minutes and preferably an hour. Get out of the practice and get some fresh air if possible. If you have prepared your own lunch this cuts down on decisions about where and what to eat. Think about all the options and decision-making involved in simply buying a cup of coffee. If you haven’t prepped your own lunch then decide the night before where and what you will eat. Arrange a mid-afternoon break of 15 minutes.

Snacks and lunch-My own personal favourite is fruit for snacking. Fruit gives a long glucose release time and this is helpful when working in 3–4-hour clinics. When I worked for a big organisation, I used to eat an apple on the way from my desk to each meeting. I ate a lot of apples! Another favourite of mine is dates. Full of natural sugar and fibre, 6 or so during a mid-session break and/or lunch is far better than a chocolate bar and even better than most so-called healthy snacks. One study found that the decisions judges make are strongly influenced by how long it has been since their last break. The percentage of favourable rulings dropped gradually from ≈65% to nearly zero within each decision session and returned abruptly to ≈65% after a break. Any decent amount of fruit during the two short breaks and lunch will help improve decision-making.

Prepare properly and you give yourself the best chance of making good clinical decisions. It’s in everyone’s best interests.