EM Mindset: James Adams – Frameworks & Habits of an EP
- May 18th, 2015
- James G. Adams
- categories:
Author: James G. Adams, MD (Professor and Chair, Department of Emergency Medicine, Northwestern University) // Editors: Alex Koyfman, MD (@EMHighAK) and Manpreet Singh, MD (@MPrizzleER)
Having had the opportunity to work alongside skilled emergency physicians and contribute to the training of students and residents, I have had the pleasure of observing the way that great emergency physicians think and behave. Described below are the frameworks and habits that appear to be common.
Pattern Recognition and Automaticity
The emergence of expertise in emergency medicine appears to be coincident with the development of strong, automatic recognition and response to identifiable patterns. When a 60 year-old patient complains of chest pain, or a young pregnant woman reports nausea/vomiting, or even when a person passes out, an almost instinctive framework of thought and action is called into action. Each chief complaint and triage note seems to call up a mental model that creates an initial presumption or set of likely diagnostic possibilities and treatment interventions. At the same time that the EP begins action, experienced EP also knows that pattern recognition alone is just a start. Pattern recognition is insufficient, even potentially dangerous since it could lead to a seemingly satisfactory but insufficient or frankly incorrect conclusion. So the EP continues to search for additional information, whether confirmatory or contradictory. Whether a patient presents with a fever and altered mental status, a tearing chest pain of sudden onset, or even major depression/suicidal thoughts, the EP has a core initial frame that may trigger actions but not a conclusion. The patient with fever and body aches might have a viral illness, but they might also have Lyme disease or, even more worrisome, the rare case of Ebola Viral Disease in the United States. The EP is vigilant for both typical diseases and also rare disorders. The experienced EP recognizes the common patterns but has extended fund of knowledge, training, and experience to not rely too heavily on them.
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.
Thanks, well put. I am an old ER MD (24 years) who now works in a very large county jail system. These points are well made both ways, nice to see some support in the ways I have learned to deal with issues.
One of the tragedies of the modern ED encounter is that while electronic health encounter management systems (EHEMS, the combination of ordering, reporting, patient records, discharge, prescriptions, etc that exist in a computer-based environment) should allow many of these behaviors to be transmitted from the experienced and master physician to the less experienced physician, the inflexible kludginess (and the dominance of non-clinicians in dictating the electronic workflow and output) of most of these systems actually hamstrings the experienced EP. For example, there is no reason that I couldn’t build a weak and dizzy orderset that, if I fail to order a d-dimer, prompts me to consider the diagnosis AND, in the clinical decision making section of the EMR, insert a statement that I considered PE but felt it unlikely. There is no reason that every time I prescribe a narcotic I can’t get a prompt for a stool softener, have a monograph on the narcotic (including risks and warnings for driving, etc) automatically inserted in the discharge paperwork, and a line inserted into the EMR that the patient received instructions on the medications. Instead, EHEMS fight providers and make errors much more likely, force every automatic action into a deliberate choice, and fail to integrate across the elements of the system. In 1993 I was writing object-oriented meta-linked programs with the freebie software Apple included on every Mac that could have linked these actions together; why are clinicians forced in 2015 to use programs that would have been state of the art for user interface in the late-80’s (or late 90’s for non-Linix/Unix based programming)? I aspire in every encounter to perform these actions and more, to avoid errors, and to give patients good care but find myself fighting systems that should be running automatically in the background making things better, not worse.