EM Mindset: Pik Mukherji – Three Defining Factors of EM

Author: Pik Mukherji, MD (@ERCowboy) // Editors: Alex Koyfman, MD (@EMHighAK) and Manpreet Singh, MD (@MPrizzleER)

Emergency Medicine (EM) mindset: To discuss what makes up an EM mindset you must first appreciate just what it is that differentiates the specialty. EM has been defined as “the initial evaluation, diagnosis, treatment, and disposition of any patient requiring expeditious care.”  Just what is it that makes this seemingly general and encompassing scope of practice unique among specialties? 

If I’m having chest pain and it’s a heart attack, I want a Cardiologist fast, okay?! Not some ED doc!

Uh-huh. So how do you KNOW if it’s a heart attack?…

I was exposed to the above vignette as a resident, and for me, it crystallized many of the notions I had about the field in which I was training. It also likely took on a mythic quality in my mind since the EM physician in question was purported to be Peter Rosen. It was as if my Zen master had smacked me on the head with a stick and for a brief moment, I saw all. This particular parable was from a time when there was a question of whether a unique EM skillset even existed, and multiple specialties opposed the establishment of a primary Emergency Medicine board. Reflect on this as we discuss what sets EM apart.

Over the years, I have come to believe that there is no truly unique EM mindset. Rather, all physicians approach patients similarly and they inevitably adapt their practice to their environment. This evolution has made us more skilled practitioners of slightly less practiced arts. We are different, and in my mind, there are three defining factors.

1. The Undifferentiated Patient – Anyone

Undifferentiated patients offer a master class in discerning signal from noise. In the early days, surgeons were afraid their trainees would lose access to these patients if EM became a specialty. They knew that seeing a certain volume of “fresh” patients was invaluable to developing clinical skills and appreciating the nuances that differentiated similar disease processes. Medicine is taught as a system-based, organ-based or disease-based schema, but patients generally don’t present complaining that their organs are bothering them. Physicians, especially generalists, quickly realize that they need to reorganize their knowledge around signs and symptoms, not textbook chapters. Thinking in parallel to discriminate between multiple differentials is the only reasonable approach to the undifferentiated patient. To a physician training in EM, knowing all the “classic” symptoms of MI is a far less useful thing than knowing a single thing that can distinguish it from a dissection. In addition, the huge breadth of practice allows us to contrast similar presentations from wildly varying fields. (I think my list of things that present as vomiting is up to 30 or so.)

While we enjoy an excellent environment to produce high order diagnosticians, there is a downside to seeing these presentations. There is great uncertainty. There are patients who we just have no shot at. Diagnoses that are obvious with additional data gathering, time course to evolve an illness, and testing results, may be complete mysteries to the ED physician. We are able to operate within a framework of doubt, proceed with incomplete information, and make the best possible timely decisions. These best possible decisions may be wrong.  This is a tough field.

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.