Deciding to Death: On the Quiet Violence of Decision Fatigue

There’s an underestimated burden that comes with being a doctor — particularly now, particularly in isms and specialisms with high turnover and even higher complexity. So... all of them, then.

That burden is decision fatigue.

We Talk About Stress. We Rarely Talk About This.

Decision fatigue isn’t the sexy kind of burnout. It’s not trauma, or violence, or scandal. It’s just too many choices. Too many forks in the road. Too many questions where the answer actually matters.

There’s a famous study out of the US: judges were more likely to deny parole the longer they’d been working without a break. After lunch? They were suddenly more forgiving. It’s often cited as a lesson in bias, but really, it’s about glucose and mental depletion.

The brain is an obligate glucose organ. Push it through hours of high-stakes decision-making and the fuel runs dry.

What’s left is just friction, noise, reactivity and cognitive shortcuts.

In medicine, we’re expected to be above this. Always alert. Always empathetic. Always right.

So, Superhuman. F**k that.

Neurodivergence Makes This Worse. And More Visible.

Let me pause for gasps: I’m part of the now very TikTok-trendy neurodivergent club.

• I struggle to hold more than one or two ideas in mind at once.

• Knock me off track, and it’s genuinely hard to find my way back.

• I’ve got checklists for everything.

• I’ve started using AI Programs like Heidi to help me keep patient threads going.

Interruptions are kryptonite. And this job? This job is interruptions with a salary.

I once tried to take a shit in hospital. Got two bleeps and three knocks on the door. Had to find a secret toilet just to evacuate my dignity. It got unplumbed one day and I became the funniest Memo in Globals email history.

That’s what this job does to continuity of thought and working memory. And plumbing.

Decision-Making Doesn’t End When You Log Out

And it's not just clinical. You go home and your kids hit you with a hundred questions an hour:

“Do octopuses have three hearts?”

“Would you still love me if I was a butterfly and you accidentally squashed me?”

“How does Santa Claus know you're a boy? Can he see your winkle?”

Your bandwidth is gone. And that’s assuming everything at work went fine. No mistakes. No complaints. Just an endless stack of reasonable decisions — each one tiny, but collectively exhausting to the cognitive system.

It’s not the complexity that gets you. It’s the volume — and volume amplifies error.

What Patients Don’t See

I get why patients hate triage forms, or “one problem per consult” rules, or having to navigate eConsult like a CAPTCHA straight from the bowels of hell.

But what we don’t advertise well is that these systems exist for survival. Not yours — ours.

Every screener, every structured input is there to protect our thinking space. To help us focus. To stop us making the kind of errors that don’t show up in audits, but ruin someone’s week, or life, or career.

When patients subvert the system — or lie, or bend things to get seen faster — it might feel clever. But what it actually does is spike our cognitive load. Again.

And yes, we’re paid for this.Yes, we chose it.But being salaried doesn’t make you infinite.

The Weight of "Quick" Decisions

Most people think bad decisions come from ignorance or laziness.But often they come from urgency. From the hundred other decisions you made that morning. From the fact that you’ve only got five minutes left and three things still to cover.

Snap decisions become snap mistakes. And no, we don’t talk about them.Because most of them aren’t spectacular.They’re mundane. They’re human consequences of pressure.

Medicine trains us in hypothetico-deductive reasoning.Rule in, rule out. Build a tree. Collapse the tree. Use Occam’s Razor. But even Occam didn’t have 40 consults, 300 inbox actions, 2 DNAs, and 4 complaints by lunch — all contributing to invisible multitasking errors.

The Swiss Cheese is Melting

In safety science, we talk about the Swiss cheese model — layers of defence, each one catching a different type of failure. Nowadays, like lactose intolerace, it makes lots of people spout shit at a moments notice about their pet QIP.

But those slices are getting thinner. More holes. Fewer humans to fill the gaps. The pressure on decision-making is so high, so sustained, that the cheese has started to curl at the edges.

And still the decisions come. Like a Fondue party at an American Buffet.

The Fallout is Personal

I’ve known doctors whose relationships have collapsed because of this. You make 500 micro-decisions at work, then get home and your partner asks what you want for dinner — and you genuinely want to cry.

It’s not about the food. It’s about having nothing left. No flexibility. No softness. No “give.”

It’s part of what drove me out of renal medicine. I loved the work. I hated the bleep-based fragmentation. I needed more control.General Practice doesn’t fix it — it just changes the shape.

Now the decisions are still constant, but they’re mine. The interruptions are predictable. The fatigue is real, but it’s mine to manage.

So What’s the Point of This?

I guess it’s this:

Decision fatigue is invisible. But it’s not harmless.

It wears down judgement, patience, memory, empathy — all the things we’re supposed to have in abundance. It’s why your doctor sometimes seems distracted, or cold, or short. It’s not because they don’t care. It’s because they’ve cared already — about 80 things before you walked in.

So next time you’re tempted to game the system — or scoff at the structure — ask yourself if you want your GP making your call before or after lunch.

Because the answer might just depend on when we last had a snack.

Stay Cheesy

—DW