Over the past few years, I have found that towards the end of a long working day, I am far less able to make even simple clinical decisions that I know I am fully capable of. This is a phenomenon known as “decision fatigue”, and it is probably one of the greatest challenges facing traditional General Practice at present.
Failure to understand and address the issue risks patient safety, and may even be contributing to burnout and early retirement. It is often traditional to blame individuals for poor decision-making, rather than understanding the cause.
Understanding the context
General Practice is facing unprecedented pressures as the elderly patient population grows, many of whom are living with a chronic illness. At the same time, the number of General Practitioners has been falling in real terms, as has real term funding. This has been accompanied by a shift in workload from secondary to primary care, and by the fracturing of mental health and social care systems. In short, the current system is failing to invest in the longer-term future of primary care—the fallout of which is already perceptible in the falling numbers of medical students and junior doctors choosing primary care in the first place.
For most common conditions, there are many options for treatment, plenty of conflicting evidence on the benefits and harms of these treatments, and guidelines that seem to change regularly, with information that is accessible from a quick—but sometimes incorrect—Google search. In addition, we are facing the phenomenon of a society which is intolerant towards both error and waiting times.
So, what is my solution to this intractable problem?
We need to understand that a General Practitioner is a skilled decision-maker with at least ten years of training—and should be valued as such. They should be freed from tasks which can be handled by others. The most obvious examples include:
- Letters from everyone else need to be coded and condensed, so that only relevant information is passed on to the GP
- NHS 111 and discharge letters should change, so that the relevant information is presented clearly, and not buried within a stream of tick boxes on 3 sides of A4
- Blood results: better clinical decision support within the software to highlight only abnormal/relevant results and present options for further management at the time
- We should stop the myth that the GP is ideally placed to deal with every medical and social issue that afflicts society at no charge
As General Practitioners, we need to accept that we must pass on tasks we would have traditionally handled if we are to spend more time on complex cases. Taking a routine follow-up COCP check, and then replacing it with a patient with multiorgan failure and polypharmacy is simply NOT equivalent. We will need more time with these patients—and a safe space—to discuss these more complex cases with colleagues in both primary and secondary care.
As General Practitioners, we need to feel valued and supported by the system itself, and put in a position where we are given the appropriate information to make the best decisions for patients. If things do go wrong, then we need to try and address an initial blame reaction that focuses on individuals rather than the underlying cause.
If we do nothing, we will not be able to cope with the number of decisions that the traditional model of General Practice expects of us without a corresponding number of new General Practitioners; we need to face reality. This new army of fresh-faced recruits is not going to materialise soon, so we need to start pragmatically offloading simple decisions to avoid the dangers of decision fatigue.
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