Decision fatigue: A subtle sign may indicate burnout
Click Here to Manage Email Alerts
“Hey D. White! How come you’re not using XYZ to heat up the meibomian glands?”
“Dr. White, I know you typically use XYZ when you prescribe an amniotic membrane. What can I do to get you to try our ABC?”
“We can get you a much better price on IOLs if you switch over to our 123 line.”
“DEW, so-and-so from Big Pharma wants to bring in lunch and talk to you about their new dry eye drug.”
“Honey, have you made that hotel reservation for the conference yet, or would you like me to do it?”
I had been on a bit of cruise control at work, at least when it comes to the dry eye disease (DED) part of my office practice. My team and I had it dialed. Straightforward, actionable historical prompts from our patients leading us to equally well-established treatment pathways for all levels of DED severity. Our protocols were working in a very high percentage of cases, and when called upon to improvise, our quiver was filled with both diagnostic and therapeutic arrows we were confident would hit the mark. Even the annoying stuff like figuring out how to get medicine into our patients’ eyes without gouging their purses was fine-tuned to the point where we rarely had to ad-lib, making even this part of the DED clinical experience relatively painless.
And then, as more and more things like the quotes above trickled into my day, I found it more and more difficult to make a call if a case veered even just a bit outside the middle lane.
There is a condition well known to afflict professionals who are tasked with making countless decisions that affect not only themselves but people who depend on them. Decision fatigue, the state in which making just one more decision, after the dozens or hundreds that preceded it, becomes almost overwhelming. Doctors are a classic example of the kind of professional at risk. Judges, mayors and front-line managers all share this. It is often a sign of burnout, that insidious and mysterious state we hear so much about. All of a sudden, it becomes super hard to do the simplest, most straightforward thing: make a decision. Most of the time, it is not happening to us at work but in the “overflow” decisions we make outside of the clinic or OR.
I like to think of myself as possessing three distinct, finite “spaces” that encompass my daily lived experience. TimeSpace is easy: how many minutes I have over the course of my waking day. BrainSpace is a little more complex: the amount of “carrying capacity” I have in my brain for the combination of accessible information storage and “computational” power to apply to that memory. Lastly is EmotionalSpace, the most complex of them all. This describes where I am on the proverbial “happy to sad” scale, my emotional resilience (how likely I am to be able to withstand negative events or vibes), and my emotional carrying capacity or empathy.
In my mind, I see these three spaces as buckets, each a particular size at any given moment, and each filled to a level that corresponds to whatever state in which I find myself and the world around me. TimeSpace is mostly fixed, of course; my bucket can never hold more than 24 hours worth of minutes. I only get to determine how many of them I will be awake to use.
Both BrainSpace and EmotionalSpace are more elastic. There are some days when it seems like I can bring up any fact or notion I have ever acquired and then work it effectively to carry out whatever task I have been presented. The BrainSpace bucket just seems a bit bigger sometimes.
The same for the EmotionalSpace bucket. There are days when I am just feeling on top of the world. I am happy, and I am happy to spread some of my joy. Treating DED can be very trying emotionally. On these days, I can withstand the emotional currents, both internal and external, that buffet each of us as we sail along. On days like this, my EmotionalSpace bucket is as big as a swimming pool. On others, it is quite the opposite; each tiny bit of negativity goes into a bucket that shrinks with every passing minute.
Until tiny demands like those above cause one or two or all three of my buckets to overflow.
That is when stuff gets dicey, when the buckets overflow. It is rather rare that you wake up with huge buckets, with all of your spaces sitting there and all kinds of volume available, and something comes along that floods one or more, producing what we might call “acute stress.” Chronic stress is what brings most of us down. The accumulation of tiny microtraumas, little moments of tension, discord or anxiety over time. Tiny drops in your buckets.
Maybe you have something going on outside of your practice that is filling up one or more of your buckets. Could be almost anything. My Mom is not doing all that well in her retirement facility, a situation that produces a chronic drip that fills all three of my buckets. I barely know it is there most of the time, but that is a part of why stuff like that is so insidious and therefore dangerous. Unlike the tsunami that will ensue when Mom eventually passes away, the daily drip, the microstress of having her be less than well slowly fills my buckets and leaves less room for, well, everything else.
We each live our lives in a constant state of filling and emptying our buckets. “Burnout,” the inability to roll with the mundane in our lives, occurs when one or all of our buckets is so full that a single additional drop affects us as if it were that tsunami. My buckets were so full from microtraumas like my Mom’s situation that the seemingly benign queries about whether I would consider four entirely reasonable DED modalities brought me to a place of injury no less hurtful than if I had gotten there all at once.
I knew I was close. Treating DED patients requires a ton of empathy and patience. In a recent column, I noted that no one has an unlimited capacity for empathy; the “empty space” above the water in my buckets is where patience and empathy live, and I had been getting short of both. My skin seemed to become paper thin. Comments and complaints that would usually be water off a duck’s back grated like sandpaper. Making a hotel reservation became a nearly overwhelming task.
Understanding burnout and stress and how they affect each of us means understanding that the breaking point is more often a tiny drop into a bucket filled to the brim. There is no space left above to breathe. One way it manifests itself is decision fatigue. Doctors, judges and people who are called upon to make dozens of significant, meaningful decisions can find themselves literally paralyzed by the need to make that one additional call, however trivial it may be.
I still need to make that hotel reservation.
Editor’s note: This column is based on an essay first published on drdarrellwhite.com on April 23, 2023.
- Reference:
- Cultivate, curate culture of compassion in your practice. https://www.healio.com/news/ophthalmology/20230215/cultivate-curate-culture-of-compassion-in-your-practice. Published Feb. 20, 2023. Accessed May 24, 2023.
- For more information:
- Darrell E. White, MD, of SkyVision Centers in Westlake, Ohio, can be reached at dwhite@healio.com.
Collapse
Read more about
Click Here to Manage Email Alerts