A&E Perspective: Decision Fatigue and Avoiding Burnout

Dr Dan O'Carroll


July 08, 2019

Last weekend whilst helping to set up for my youngest daughter's birthday party, I was tasked with sorting out the drinks for the children in advance. I found myself dithering and unable to make the choice between blackcurrant or orange. This simple decision was beyond me and I sought instruction from the 'boss' to help me out of this somewhat unexpected predicament!


Dr Dan O'Carroll

I reflected on what happened and realised that the very heavy on-call commitments of the preceding 2 weeks had taken their toll. I realised that I was suffering from decision fatigue. I was not aware of any problems regarding this whilst at work, and had managed to maintain my focus, but once I was no longer in that stressful environment, I found that I was happy to defer making even the simplest decisions or choices. This made me think about burnout, and whether this was, currently, a problem for me.

Year-Round 'Winter Pressures'

It seems like a long time has passed since my first article when I was concerned for the UK's Emergency Departments (EDs) and the 2018/19 winter which proved to be as bad as anticipated with record poor performance reported by the UK EDs in respect of their Government targets. Game of Thrones has finished, and many of the inhabitants of Westeros survived their winter. Winter does not seem to have passed for those of us working in the ED. Record numbers are still attending departments throughout the UK, and many trusts are setting unwanted records on an almost weekly basis.

Those of us working in the ED have always been used to dealing with the busy winter periods, usually in the knowledge that in the summer months the pressure eases off giving the staff the chance to recuperate, recharge their batteries and lick their wounds in anticipation of the next busy winter. Something has changed though: last summer saw numbers that exceeded previous winters and this worrying trend seems to have continued into this year

I'm aware of two emergency medicine colleagues who have been adversely affected by the pressures that modern EM puts on people. And Dr Simon McCormick should be thanked for sharing his story in his honest and enlightening blog. Thankfully, Simon's writing skills are better than I remember his goalkeeping ability to have been.

If we were to be perverse and do a thought exercise to imagine how we could design a system that put incredible pressure on staff and threatened patient safety, I'm sure that we would end up with a system that looks remarkably like the current ED crisis in the UK.

Ever increasing demand. Staffing levels that have not kept pace. Many rota gaps across all levels of seniority for medics. A huge reliance on agency or locum staff, both medical and nursing, with the inherent downsides of not being your regular workforce, with all their development and governance in place. Increasingly complex frail patients with multiple problems and co-morbidities, continual interruptions and of course the now overdue recognition of the shortage of in-patient beds

Knowing Where To Get Help

The GMC's National Training survey now includes questions on burnout and the latest report shows that more than a fifth of trainers and trainees feeling burnt out to a high or very high degree, with no significant changes over the year. The report states that high workloads, the impact of rota gaps, and lack of supportive environment may be associated with burnout and that this can impact on patient care, lead to mistakes and prevent individuals from performing to the best of their ability. It is perhaps concerning that in such an environment a third of trainees don't know who to approach if concerned about their own health and well-being

The NHS staff are its greatest asset. There needs to a be a covenant between the government and the staff that pushes the onus back onto the government to ensure that the staff do not come to harm whilst trying to do their jobs and that the Government provides working conditions and processes that allow the staff to fulfil their potential. Emotional and physical well-being of staff needs to be prioritised as highly as patient safety because they're intrinsically linked. Tired, burnt out and stressed doctors are much more likely to make mistakes.

I shudder when I hear the suggestion that staff need to be more resilient - because we are resilient. We are used to dealing with pressure, stresses and often tragic situations. To suggest that it's the staff that need to 'toughen up' rather than recognise that it's the system that's the problem is offensive.

Preventing Burnout

Obviously, there is a good case for self-care and taking steps to try to prevent burnout. The first and most important of which, I believe, is recognition of the symptoms. At a recent conference, a university peer explained how he ended up having a prolonged period away from work, off sick, due to the effect of burnout. The symptoms he described I recognised in myself and many of my colleagues to various degrees. Many trusts are running training for dealing with stress, including mindfulness and meditation

Hobbies, exercise, social lives and most importantly quality time with family are the mainstay of trying to maintain personal wellbeing and to help to package the stresses that come with working in modern emergency medicine. We need to recognise that the problems in the departments can't be solved by breaking oneself or one's colleagues; that the solution does not lie within our own hands, and that it will require a fundamental shift both in government policies and societal expectations.

A friend, a lot closer to retirement than me, explained it with a football analogy. He's coming to the end of a long season, there are no longer any trophies up for grabs, and the games are just being played out in the hope that there are no serious injuries (obtained or caused) before the players are on the beach. Is this really the best that we can hope for when doing Emergency Medicine? Getting to the end of our career without any 'broken legs'?

After some consideration, I don't think that I am burnt out, but I can easily see that I could be. My decision fatigue passed quickly enough and the (scheduled) time off work to recuperate has done the job, once again. But the summer solstice passed with a slight concern that the nights are getting longer, and we're heading back towards winter.


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