Soon after match day, I became concerned. I knew I was going into emergency medicine. However, I felt unprepared to manage a clinical encounter with limited time and incomplete information. At the time I entered residency, the only published guides available on “how to be an intern” reviewed the medicine I already knew. The only books available on decision-making included statistics, which I knew wouldn’t be immediately useful in a time-sensitive situation. I searched for guidance on decision-making in time-sensitive clinical scenarios and found no resources. At that point, I decided that my fear was unsubstantiated. I blamed the fear on the lack of clinical experience before medical school. I started residency and ultimately learned to manage these time-dependent clinical scenarios. The mechanism for learning was immersion and trial and error. These methods hardly seem the best way to achieve the safest and best outcomes for our patients. Since then, I have learned that I was not alone. Many other interns felt the same way – grossly unprepared to evaluate and manage clinical emergencies limited by time.
Currently, pre-medical students submit their applications with significant variability in the quality and quantity of decision-making experiences. A small percentage may have experience with decision-making in emergencies. Examples of those that may have this experience include paramedics, pilots, military personnel, and nurses. Medical school does very little to cultivate the skills necessary to manage an emergency. Sitting in a classroom for two years does very little to create decision-making experts. Sitting in a classroom does not teach urgency or respect for the consequences of time. Previous mentors have guided us to understand the benefits of “a tincture of time.” We know that time is myocardium, brain cells, and any other organ that can fail without adequate blood flow. The traditional SOAP model of diagnosis and evaluation insufficiently prepares medical students to navigate the healthcare system and save time.
The construct of time is rarely incorporated into clinical education. While there is no standard for teaching decision-making in time-sensitive clinical scenarios in either undergraduate medical school, all physicians in training will face these circumstances. “Recognizing and managing emergencies” was included in the AAMC EPA document in 2014. However, little progress has been made to develop a decision-making framework that is effective. By the time physicians make it to residency, the newly minted physician is expected to possess these skills of managing a time-sensitive clinical diagnosis. The young physician is sent to the bedside at 2 a.m. and while technically “supervised,” they remain physically alone. It is during these moments that minutes matter, mistakes are made, and oxygen debt accrues. Resident physicians need early and explicit training with more advanced models of clinical decision-making.
After residency, it is expected that physicians are experts at decision-making in clinical emergencies. Some hospitals have continuing education that addresses decision-making in emergencies (i.e., TeamSTEPPS). However, this is typically after a physician has learned many dysfunctional techniques (i.e., procrastination, mis-triage) in addition to possessing unrecognized cognitive biases. What if I were to tell you that there is a science behind how decision-making occurs in emergencies? What if I were to tell you that other disciplines such as aviation and the military teach novices how to decide in emergencies before they are placed in those situations? Pilots require their students to complete course work on decision-making in emergencies before flying a plane. The Army has decision-making in time-constrained environments incorporated into its field training guide. Lack of training on this specific task leaves the practitioner unprepared and may be related to the moral injury we endure in healthcare.
The science behind decision-making in emergencies developed at the same time as emergency medicine was born as a specialty. In 1978, Amos Tversky and Daniel Kahneman published their work on Prospect Theory, which evaluated decision-making in the setting of risk. Tvesrky and Kahneman ultimately won the Nobel Prize for their work in 2002. In 1978, the University of Cincinnati opened the first emergency medicine residency program. That year, physicians experienced first-hand, decision-making in the riskiest of situations. Emergency physicians became experts in the “emergency mindset.” It is what we live and breathe in our clinical practice.
If the “emergency mindset” can be considered the cognitive processes and nontechnical skills responsible for managing a clinical situation with limited time and limited information, all physicians, regardless of specialty, deserve the chance to learn it. Some of us take this emergency mindset for granted. Training in the emergency mindset will require new models of medical decision-making that account explicitly for time. Such time-sensitive models of medical decision-making would bring medical training up to date with other fields, such as aviation and the military. This would, in turn, arm physicians with the cognitive processes and skills to optimize patient care when faced with limited time and incomplete information.
Teresa Camp-Rogers is an emergency physician.
Image credit: Shutterstock.com
