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

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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!
email: [e-mail]
instagram: @adoctorsview
twitter: @DrPolyvios

Episode Transcript

Dr Polyvios (00:00):
Before we begin the episode, I just want to wish
everybody who is starting a newjob as it is changeover week in
the United Kingdom for hospitalsall over the country, and so
for all the newly qualifieddoctors who are going into their
first rotation I wish you allthe very, very, very best of

(00:22):
luck.
And remember we've all beenthere and it's a stressful week.
It's fun.
Enjoy it.
Remember there is a wealth ofhelp and information all over
the hospital, in the forms ofyour seniors, in the forms of

(00:43):
your nurses, in the forms ofyour seniors, in the forms of
your nurses, in the forms ofanyone.
Believe me, you will find helpand assistance in the strangest
of places, and don't be scaredto ask for help.
Everyone is rooting for you andyou'll all do great.
Welcome to doctor's view withme, dr bolivios.

(01:11):
Join me as I discuss everydaytopics in health and medicine
and provide insights intoeveryday hospital life.
Sit back and enjoy the show.
Hello everyone and welcome todoctor's view.
I'm Dr Polyvios.
Today, I want to talk about asilent force that affects all of
us, but especially those of usin healthcare.
It's called decision fatigue.
Decision fatigue is a term thatcomes out of behavioural

(01:35):
economics and also psychology,but you really don't need to be
a psychologist to to understandit at all, and it's something
that everyone can relate to insome way.
So what is it?
Well, decision fatigue refersto the deteriorating quality of
decisions made by an individualafter a long session of decision

(01:56):
making, so say, like by the endof the day.
So the more choices you makeover 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 atendency to make impulsive or

(02:17):
easy choices rather than theoptimal ones.
It's said that your human braincan only cope with a certain
number of decisions per daybefore decision fatigue sets in.
Now you might think well, thisdoesn't really affect me.
I don't run a business or haveto make difficult decisions for
others or make importantjudgment calls in my typical

(02:40):
day-to-day life, and that'swhere I believe anyone who
thinks this is is wrong.
What we might not realize isthat from the moment we wake up,
we actually start makingdecisions.
They might be small,subconscious ones, but they are
decisions.
This can include whether tomake a cup of coffee or a cup of

(03:00):
tea, what to eat for breakfast,to wear today.
Should I take the same route towork as I normally do?
Even just checking your phonefirst thing in the morning is a
decision, and it sets off acascade of decisions.
Do I respond to this email?
Do I do it now or later?
Should I like that post?

(03:21):
Should I answer this message orjust pretend that I haven't
seen it yet?
All these are small decisionsthat we have to take.
The reason why I decided tomake a podcast on this topic is
that I found myself the otherday feeling really exhausted and

(03:42):
I wasn't sure why.
The day wasn't especially busy,but I found myself having to
make a lot of very smalldecisions and I realized that in
a typical day in a hospital, I,like every other doctor or
healthcare worker, actually haveto make hundreds of micro
decisions, and it doesn't matterif you've just qualified or if

(04:03):
you've got 30 years experience.
Decision fatigue is somethingthat affects all of us.
So, for example, when on callon a busy intensive care unit,
the number of questions I can beasked on a typical day is
absolutely immense.
I think I would struggle tocount them, and they could be

(04:26):
simple questions that I wouldeven ask myself when reviewing a
patient, such as should I startthis patient on some blood
pressure medication?
Or they could also be simplestatements 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.

(04:46):
Now you might not think this issomething that will particularly
lead to decision fatigue, butin just that simple piece of
information, a number ofthoughts are triggered.
Why did this happen?
Was the patient simply sleeping?
Do we need to adjust thepatient's blood pressure
medication?
Do I need to look into thisfurther?
Is this something that'sactually that important and do I

(05:10):
need to do anything at all?
And other questions can bethings like doctor, the patient
is in pain.
Can you please prescribe someanalgesic medication, pain
relief Again, a really simpletask which can be completed
really easy if you take it atface value.
However, that really simplequestion again triggers a

(05:32):
cascade of questions in my ownmind.
Why is the patient in pain?
How much pain relief has thepatient already taken?
Which is the best drug to putthis patient on?
What are the side effects ofthis drug?
Do I need to give somethingelse to counteract those side
effects?
Again, a cascade of questions,cascade of decisions and much of

(05:55):
my shift with stable patientsare made up of these micro
questions.
And then, however, when there'sa really especially unwell
patient, these questions becomeharder.
So, should we start a medicineto support the patient's heart?
Do we need to anesthetize andintubate this patient to help
with their breathing and thencome further decisions to make?

(06:19):
What drugs should I use toanesthetize the patient safely?
And, you know, should I let thefamily know now or later that
we need to put them on abreathing machine?
This may be part of my job and,like every other anesthetist
probably, I answer thesequestions even without thinking
about them.
They happen subconsciously assoon as you take a view of a

(06:43):
situation and we are alwaysthinking about these, these, um,
these type of questions in ourin our normal day-to-day job,
whether it's out loud or in ourhead.
But, uh, after a whole day ofmaking decisions, be it
consciously or subconsciously,the toll it takes really can't

(07:06):
be ignored.
It's why humans are lessrational as the day goes on, so
they're less rational at the endof the day than at the
beginning.
It's why we get more fed up asthe day goes on.
It's the reason why judgesaren't allowed to make a
sentence, uh, aren't allowed tomake a sentence, aren't allowed
to sentence a criminal after acertain time of day, and why

(07:28):
there's a separate sentencingdate?
And it's because they will notbe in their best frame of mind
to give a fair judgment and afair sentence.
So it's not just you and me, itreally does affect everyone.
So decision fatigue is also thereason why we put off difficult

(07:49):
tasks that we know require a lotof decisions or a lot of
thinking.
We say we'll do it tomorrow orlater, 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 whatingredients are in the fridge,
what can I make, whattemperature do I need to set the

(08:09):
oven to?
And sometimes all we can musterourselves to do is actually
just order a pizza, and eventhen we have decision fatigue.
On deciding what to order,we'll scroll for 10 minutes
trying to decide, you know, gothrough the menus and finally we
just order the same thing we'vealways done, because it's easy
and we eat it feeling mildlyashamed, but, you know, too

(08:31):
tired to care.
And thankfully I work in awonderful hospital where
consultants and senior staff arealways available and are very
supportive, and this really doeshelp to ease decision fatigue
and the burden of it a hugeamount.
However, this hasn't alwaysbeen the case and I know it's

(08:56):
not the same for everyone.
And I really do feel fordoctors who have just qualified
and are working on very busyunits, some not as well
supported as others, and I'vebeen there and remember that
very, very well.
And I hope no one has to gothrough the same same

(09:19):
difficulties and now imaginehaving that depleted willpower,
that impaired reasoning, thatmental exhaustion, but while
you're still at work, stillresponsible for the patients,
and still being asked to makedecisions that actually matter.
And these aren't questions likewhat shall I have for dinner.

(09:41):
They're questions like shouldwe restart the patient's blood
thinners?
Should I escalate thisdeteriorating patient now or
should I try this first and thenthen wait?
Or even a difficult questionsuch as should I challenge this
plan that my consultants made?
Because there's something Idon't agree with, even though
I've only just qualified Harddecisions to make.

(10:05):
And so when we're tired we don'tthink clearly.
We know that.
But with decision fatigue it'snot just tiredness, it's a
specific mental weariness thatcan affect your judgment, in
often actually quite predictableways.
You can either avoid thedecision altogether, so, for
example, you see a borderlineblood result hemoglobin just on

(10:30):
the cusp of of being anemic, forexample, when you say maybe
I'll just recheck it later andyou might say that, rather than
actually decide what to do andit's not laziness, it's often
just fatigue in disguise it'stoo much mental effort to think,
you know, should is this worthworrying about right now?
Sometimes just checking itagain.

(10:52):
It's the easiest and often thesafest thing to do.
You can choose the easiestoption which, when it comes to
prescribing and this is where wedo we cover things.
Just in case we giveantibiotics, just in case we
leave catheters in.
We order unnecessary scansbecause it's easier than just

(11:16):
thinking about a difficultdifferential or sometimes just
not questioning someone else'splan because it'll take too much
brain power to challenge it.
So we just go along with things.
It's the path of leastresistance 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'tneed, and this is how treatment

(11:39):
inertia creeps in.
You know, we see a slightlyraised blood result.
We order a CT scan, becausethat's what we did the last time
this happened.
And and you just go on autopilotand the number of the number of
bleeps I would get when I firststarted, um, just to prescribe
another bag of fluid at two inthe morning for a patient.

(12:01):
And actually there's, there's alot to prescribing a bag of
fluid.
You have to think to yourselfdoes the patient need this liter
bag of of Hartman solution oror saline?
And you know you think okay,they've been on it all day.
And are they nil by mouth?
No, are they asleep?

(12:22):
Yes, what's their kidneyfunction doing?
What's their electrolytes doing?
What's their urine output doing?
All these different things.
They look like they'redehydrated.
Are they behaving like adehydrated patient?
Was there sodium?
All these things?
And yet the number of times wewould literally just just

(12:45):
prescribe another bag of of this, of fluid because, well,
they've been on it for all dayand it's run out.
So logic dictates we justcontinue the bag and it's not
again.
It's, it's part of leastresistance, it's not.
Um, we, we all know that.
You know we need to spend a bitof time to to look at whether
the patient needs fluids or not,but, um, sometimes doing that

(13:09):
when you've got a busy nightshift, um, the it takes.
It takes sometimes a bit ofbravery to not prescribe that
bag of fluid when and to takethe time to to question, um, a
judgment from um, from someonewho's been been on the on the
much longer than you have.

(13:30):
But I do urge juniors toactually do question things, um,
not just take things at facevalue.
If you are asked to prescribebag of fluid, do have a look at
the, at the blood results, dohave a look at the patient.
Uh, don't just go on autopilot.
And but again, decision fatigue.
We've all done it, um.

(13:51):
And if you're not in a hospitalsetting, I guarantee there's an
equivalent to what you, to whatI've just described, in your
work too.
It could even be justresponding to an email in a
hospital setting.
I guarantee there's anequivalent to what I've just
described.
In your work too.
It could even be justresponding to an email in a
certain way, a certain template,whatever it might be.
So anyway, we've talked a bitabout decision fatigue in

(14:11):
certain situations.
And just think about all thestaff in the hospital, all the
different specialties and allthe thousands of decisions that
happen every day.
And then you have emergencysituations, doctors who are in
intensive care unit, in A&E, inacute specialties, and you have

(14:33):
to make these decisions veryrapidly and in a very stressful
situation.
So, for example, a patientarrives with a fever, low blood
pressure, fast heart rate.
You have to decide do I givefluids, do I start antibiotics,
which ones?
What investigations?
And do I refer the patient nowto a high dependency unit or

(14:55):
intensive care unit, or do Iwait for something else to
happen first?
Do I break the news to familynow?
Or who do I break the news to?
You know, all these, all thesethings are not just one decision
.
They are a cascade of thingsand when you're in a bit of a
state of hunger and dehydrationand some sleep deprivation and

(15:15):
you're often faced withinadequate staffing, you can see
how life can get a bitstressful very quickly in a in a
hospital situation.
And whilst these are clinicaldecisions, they do also tap into
an emotional bandwidth.
Am I delivering this news well?

(15:37):
Am I being kind to the patient?
Am I being kind to therelatives?
Am I doing the right thing forthis person right now?
And this is just one patient,never mind the bleeps you get
about putting a cannula in, andyou know, um, and I was asking
you to prescribe a laxative a apatient asking you about a

(15:58):
discharge letter.
You're expected to switchcognitive gears between the
mundane and the life-alteringdozens of times a day, and this
isn't multitasking, this iscognitive fragmentation.
This is exhausting, and themore fragmented you are, the

(16:20):
more you lean on your mentalshortcuts.
And so, whilst I'm making itsound like a hospital is an
incredibly dangerous place, it'ssomewhat reassuring that
research has shown that, despitedecision fatigue, patient care
is actually minimally affected.
So who is it that suffers?
Well, it's pretty much thedoctors themselves, and that's

(16:45):
not, and that's one of thereasons why medicine is is so
difficult.
It's not the difficulty of thedegree, it's not the difficulty
in diagnosing a patient, it'sthe difficulty of being able to

(17:06):
act professionally andcompetently 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 runout, even when you are going
going through a difficult time,you have to recalibrate your

(17:33):
thoughts and think that thatpatient in front of you or that
set of relatives in front of youare going through a lot worse,
and sometimes that's easy toforget.
Medicine is difficult from amental arithmetic point of view,

(17:59):
from the mental burden it canpose 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 hiddenmental drains that we can talk

(18:19):
about, and one of those is noisefatigue.
Now, noise fatigue is alsocalled listening fatigue or
auditory fatigue, and it'sbasically what happens when you
are exposed to noise for toolong, especially if it's loud or
constant, over time, and itwears you down mentally and

(18:40):
physically.
You just it's usually whenyou're in a factory, a
construction site, airport, evenjust loud, busy offices.
It's that background noise,constant beeps or whatever.
And it's the reason why it's sofatiguing to listen to a
podcast or a video with badaudio, and it's why podcasters

(19:02):
usually work really hard to tryand make their audio quality
sound good.
I'll give you an example.
So now you're hearing methrough the microphone on my
mobile phone, you'll notice thebackground noise and the poor
audio quality.
And now I'm back to my studiomicrophone.
Hopefully it's easy to see thatit's much easier to listen to

(19:24):
me for a long period of time.
At least I hope so, and what Iwant to talk about noise fatigue
about is is imagine just acommute, to say, say, my commute
to the hospital on LondonUnderground, with decibel levels
of around 86 to 91 decibels onthe average, and they peak about

(19:46):
110.
I've got a short recording now,so this is what my typical
commute sounds like over a briefperiod of time.
So now imagine that noisepeaking much louder and uh and

(20:21):
lasting for around 30 minutes.
Noise cancelling headphones orearplugs are not a luxury on the
london underground, they are anabsolute necessity.
And, on a serious note, I thinkthe noise pollution and an
actual air pollution and theheat of the London Underground
are just absolutely ridiculous.
I have, I have no doubt thatusing the underground every day
for commuting has serious healthrisks.

(20:43):
But I'll say that debate and arant for another day, and if
anyone can arrange a meetingwith the mayor of London and
myself, I have many, manyquestions to ask and complain
about.
Okay, so now think of thehospital the beeps, the alarms,
the machines, the phones, theconstant background chatter, the

(21:06):
operating theatres, theunderground commutes, it all
adds up and so here's sometypical hospital noises that I
literally hear day in, day out,throughout the whole day.
Now we've learned um, asdoctors, as anesthetists, to

(21:44):
filter out these noises and theybecome background noises and
you detect uh changes in thetones.
So, for example, it becomes abackground noise that you can
completely ignore up until thepoint where the oxygen tone
changes and then you knowthere's a problem and you
automatically just justsubconsciously fire up and you
know exactly what, what to lookat on the monitor.

(22:05):
Um, but it is fatiguing over awhole day listening to these
noises and I've noticed as timegoes on that more and more
hospital staff eat lunch insilence, and I don't think it's

(22:25):
because everyone just wants tobe on their phones and are
addicted to their phones.
They are, but this is adifferent situation.
This is not what I'm getting at.
I think people actually don'twant to talk to anyone and to
have a break from the noisefatigue and and the decision
fatigue and and I think that'swhy they're on their phones in
their lunch break, not not somuch the other way around.

(22:47):
And nowadays talking to peopleincurs a risk of having their
problems offloaded to you andeven adding to yours or giving
you more work to do, andsometimes it can feel like
everyone wants something fromyou and after a long day, even a
friendly chat can sometimesfeel like a demand, and

(23:12):
sometimes people actually willonly talk to you because they
want something from you.
And I actually get quite a lotof requests from prospective
podcast guests, usually a verygeneric email we love your show.
They'll compliment an episodethat they've probably never
listened to and then they'll asusually a publicist asking for

(23:36):
their client to come on the showand they'll be a perfect fit
for the show.
And you know, you read theblurb and they just want to
advertise a book that they'vegot for sale and that book has
absolutely nothing to do withthe show, nothing to do with
medicine, nothing to do withliterally anything I've ever
spoken about.
So you know that's annoying.

(23:58):
At least have the courtesy tolisten to an episode or even
just the description, just tosee that it's not a fit for you.
Anyway, so you've got decisionfatigue coupled with noise
fatigue and you can imagine howtiring a normal day can be.
One of the nicest parts of myday is the moment I come home

(24:20):
and close the front door, thatsilence, not having to decide
something just for a few minutes.
It's a moment of peace.
And when I used to drive towork and I had a an hour plus
commute in the car.
It's why I would sit in the carfor five to ten minutes before

(24:41):
actually coming through thefront door.
It was just a a moment tounwind and actually hear your
own thoughts and and your ownsilence.
It was actually just a form ofrespite, and I didn't care how
weird it looked.
You know, and one bad habit I'vedeveloped over the years was is

(25:04):
to stay up as late as possible.
When I didn't have to be upearly the next day, I would
literally stay up till till 3amand sometimes 4, and I could
just be doing somethingenjoyable like just play
computer games, read a book,sometimes actually just
listening to music, literallyjust nothing else, just walking

(25:27):
around the house listening tomusic till 3, four in the
morning with headphones on.
And the reason for doing this?
Because I knew everyone aroundme was asleep and I wouldn't be
disturbed.
And it felt like a time where Icould unwind without any guilt
because I knew no one woulddisturb me or ask me to do

(25:50):
anything.
And so the next time you feelexhausted and don't know why,
have a think about how manydecisions you've had to make in
the last hour and maybe thinkabout having a moment of silence
after a busy day at work orafter a busy journey.
Silence is powerful, it'scleansing and it's therapeutic.

(26:12):
Just don't use it as apunishment.
And with that I will leave you.
As always, please look afteryourself.
I'm Dr Polyvios.
Goodbye.