EM Mindset – Joe Lex – Thinking Like An Emergency Physician

Author: Joe Lex, MD (@JoeLex5 – Clinical Professor of Emergency Medicine, Temple University School of Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK – emDOCs.net Editor-in-Chief; EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Manpreet Singh, MD (@MPrizzleER – emDOCs.net Associate Editor-in-Chief; Assistant Professor in Emergency Medicine / Department of Emergency Medicine – Harbor-UCLA Medical Center)

“Emergency Medicine is the most interesting 15 minutes of every other specialty.”

– Dan Sandberg, BEEM Conference, 2014[1]

Why are we different?  How do we differentiate ourselves from other specialties of medicine?  We work in a different environment in different hours and with different patients more than any other specialty.  Our motto is “Anyone, anything, anytime.”[2]

While other doctors dwell on the question, “What does this patient have? (i.e., “What’s the diagnosis?”), emergency physicians are constantly thinking “What does this patient need?[3]  Now?  In 5 minutes?  In two hours?”  Does this involve a different way of thinking?

The concept of seeing undifferentiated patients with symptoms, not diagnoses, is alien to many of our medical colleagues.  Yes, we do it on a daily basis, many times during a shift.  Every time I introduce myself to a patient, I never know which direction things are going to head.  But I feel like I should give the following disclaimer.

Hello stranger, I am Doctor Joe Lex.  I will spend as much time as it takes to determine whether you are trying to die on me and whether I should admit you to the hospital so you can try to die on one of my colleagues.[4],[5] You and I have never met before today.  You must trust me with your life and secrets, and I must trust that the answers you give me are honest.  After today, we will probably never see one another again.  This may turn out to be one of the worst days of your life;[6] for me it is another workday.  I may forget you minutes after you leave the department, but you will probably remember me for many months or years, possibly even for the rest of your life.

I will ask you many, many questions.  I will do the best I can to ask the right questions in the right order so that I come to a correct decision.  I want you to tell me the story, and for me to understand that story I may have to interrupt you to clarify your answers.

Each question I ask you is a conscious decision on my part, but in an average 8 hour shift I will make somewhere near 10,000 conscious and subconscious decisions – who to see next, what question to ask next, how much physical examination should I perform, is that really a murmur that I am hearing, what lab study should I order, what imaging study should I look at now, which consultant will give me the least pushback about caring for you, is your nurse one to whom I can trust the mission of getting your pain under control, and will I remember to give you that work note when it is time for you to go home?  So even if I screw up just 0.1% of these decisions, I will make about 10 mistakes today.[7]

I hope for both of our sakes you have a plain, obvious emergency with a high signal-to-noise ratio: gonorrhea, a dislocated kneecap, chest pain with an obvious STEMI pattern on EKG.  I can recognize and treat those things without even thinking.  If, on the other hand, your problem has a lot of background noise, I am more likely to be led down the wrong path and come to the wrong conclusion.[8]

If you are interested in reading the rest of this and other EM Mindset pieces, please see “An Emergency Medicine Mindset,” a collection evaluating the thought process of emergency physicians. This book is available as ebook and print on Amazon.

 

17 thoughts on “EM Mindset – Joe Lex – Thinking Like An Emergency Physician”

  1. Dear Dr Lex,
    Dear Joe, (I read your post since so long, we’re old friends)
    thank you so much for this great, nope erase that !, this fantastic resume of our every day “way of thinking”.
    Thank you for being a so great teacher on how to explain what we’re doing daily.
    Can I get the authorization to translate and adapt your article in french to spread it here.
    Jerry
    PS: Thank to Axel Ellrodt who transfert it to me

  2. Dear Dr Lex,
    Dear Joe, (I read your post since so long, we’re old friends)
    thank you so much for this great, nope erase that !, this fantastic resume of our every day “way of thinking”.
    Thank you for being a so great teacher on how to explain what we’re doing daily.
    Can I get the authorization to translate and adapt your article in french to spread it here.
    Jerry
    PS: Thank to Axel Ellrodt who transfert it to me

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