09-05-2025
Is Decision Fatigue Sabotaging Your Clinical Choices?
The decision-making process is a fundamental activity in the medical field. It translates into diagnosis, treatment selection, examination choices, provision of relevant information, follow-up scheduling, or the decision not to intervene.
In recent years, decision-making processes in medicine have faced increasing pressure to comply with regulatory standards such as evidence-based medicine, patient-centered care, and patient safety. This context has made medical decision-making cognitively more intense, with internists making an average of 15.7 decisionsduring each patient visit. Consequently, for physicians operating in high-complexity clinical settings with heavy workloads and significant cognitive demands, the quality of their decisions may be compromised owing to fatigue resulting from repeated decision-making processes.
Decision fatigue (DF) refers to the concept that making decisions is mentally taxing and impairs the quality of subsequent decisions. It is hypothesized that humans have a finite cognitive reserve for decision-making, and as this reserve depletes, executive function and self-control diminish, ultimately affecting the decisions that follow.
Clinical Implications
DF is of particular concern in medicine because of the critical nature of the decisions made by physicians and the potential consequences of suboptimal decision-making. In clinical practice, decision fatigue has been linked to various outcomes related to sequential decision-making processes, often concerning the timing or order of appointments.
Notable examples include increased rates of antibiotic prescriptions later in the day, more conservative surgical recommendations with increased case prescriptions just before lunch, and a higher likelihood of physicians prescribing painkillers, such as opioids, later in the workday.
However, most studies available to date have utilized retrospective observational designs, lacking preregistration or external validation. Additionally, the definitions of DF are often vague or inconsistent, resulting in weak cumulative evidence despite numerous reports on its effects.
Research Insights
A systematic review and meta-synthesis summarized the existing literature on DF in medicine, focusing on its definitions, determinants, and implications for clinical practice while attempting to address some unresolved questions.
DF has been broadly defined as a reduced capacity to make decisions and regulate behavior following repetitive decision-making tasks. Although qualitative studies have not directly investigated DF, many have indirectly explored its impact on physician performance or patient outcomes.
DF has been described as a consequence of cognitive overload, time pressure, acts of omission, and interprofessional disagreements.
No qualitative study has analyzed DF by asking participants to define it or by observing its cognitive, emotional, or behavioral components. Nonempirical articles have examined the concept of DF more directly than empirical studies, describing its possible determinants and associated outcomes.
These studies have shown that DF includes ego depletion, physical fatigue, burnout, and repeated or difficult decision-making. Other contributing factors include workload, dysfunctional work environment; implementation of new procedures; and pressure from colleagues, patients, and their families.
Risk and Protective Factors
At the individual level, risk factors include ego depletion or willpower exhaustion, where repeated DF depletes mental resources; self-perceived medical errors, which can increase stress and anxiety; uncertainty and inherent risks in medical practice; ethical challenges requiring careful reflection; and emotional challenges such as dealing with patient suffering or death. Female sex and residency status were notable sociodemographic risk factors. At the contextual level, the healthcare environment plays a crucial role, with high patient volumes, time pressure, inadequate support, and organizational culture exacerbating the pressure on healthcare professionals, making them more prone to DF.
Protective factors against DF include various individual, sociodemographic, and contextual elements. At the individual level, effective communication skills, effective coping strategies, empathy and compassion, trust in one's instincts, motivation, a strong professional identity, the ability to seek advice, self-control and awareness in DF, high self-esteem, and tolerance for ambiguity contribute to greater resilience. At the sociodemographic level, being male, maintaining good mental health, a good quality of life, and good sleep quality were protective factors. At the system level, communication and ethics training, collaborative work environments, decision-making support tools, autonomy, professional experience, and a safe work culture provided resilience against DF.
Key Considerations
Clinical DF is a complex and multifaceted phenomenon with significant implications for clinical practice and patient outcomes. No current study has comprehensively defined clinical DF within a theoretical framework supporting hypotheses or research questions or provided a definition that could be used systematically.
The analysis of risk and protective factors for clinical DF has identified contextual and individual factors with interrelated psychological dimensions. Given the results of this review, it is plausible to assert that clinical DF is a multifaceted cognitive and motivational process that influences a physician's decision-making capacity, driven by contextual and individual factors. These, in turn, are closely linked to psychological distress and an increased risk for errors in healthcare.
