Thinking Like an Emergency Physician

by Joe Lex

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

– Dan Sandberg, BEEM Conference, 2014

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.”

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? 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. Yet 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. 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; 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 ten mistakes today. I hope for both of our sakes you have a plain, obvious emergency with a high signal-to-noise ratio: gonorrhea, a dislocated knee cap, 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. I am glad to report that the human body is very resilient. We as humans have evolved over millennia to survive, so even if I screw up, the odds are very, very good that you will be fine.

Voltaire told us back in the 18th century that “The art of medicine consists of amusing the patient while nature cures the disease.” For the most part, this has not changed.  And Lewis Thomas wrote: “The great secret of doctors, learned by internists and learned early in marriage by internists’ wives, but still hidden from the public, is that most things get better by themselves. Most things, in fact, are better by morning.”  Remember, you don’t come to me with a diagnosis: you come to me with symptoms.

You may have any one of more than 10,000 diseases or conditions, and – truth be told – the odds of me getting the absolute correct diagnosis are not good. You may have an uncommon presentation of a common disease or a common presentation of an uncommon problem. If you are early in your disease process, I may miss such life-threatening conditions as heart attack or sepsis. If you neglect to truthfully tell me your sexual history or use of drugs and alcohol, I may not follow through with appropriate questions and come to a totally incorrect conclusion about what you need or what you have.

The path to dying, on the other hand, is rather direct – failure of respirations, failure of the heart, failure of the brain, or failure of metabolism.

You may be disappointed that you are not being seen by a “specialist.”  Many people feel that when they have their heart attack, they should be cared for by a cardiologist.  So they think that the symptom of “chest pain” is their ticket to the heart specialist. But what if their heart attack is not chest pain, but nausea and breathlessness; and what if their chest pain is aortic dissection? So you are being treated by a specialist – one who can discern the life-threatening from the banal, and the cardiac from the surgical. We are the specialty trained to think like this.

If you insist on asking “What do I have, Doctor Lex?” you may be disappointed when I tell you “I don’t know, but it’s safe for you to go home” without giving you a diagnosis – or without doing a single test. I do know that if I give you a made-up diagnosis like “gastritis” or “walking pneumonia,” you will think the problem is solved, and other doctors will anchor on that diagnosis, and you may never get the right answers.

Here’s some good news: we are probably both thinking of the worst case scenario. You get a headache and wonder “Do I have a brain tumor?” You get some stomach pain and worry “Is this cancer?” The good news is that I am thinking exactly the same thing. And if you do not hear me say the word “stroke” or “cancer,” then you will think I am an idiot for not reading your mind to determine that is what you are worried about. I understand that, no matter how trivial your complaint, you have a fear that something bad is happening.

While we are talking, I may be interrupted once or twice.  See, I get interrupted several times every hour – answering calls from consultants, responding to the prehospital personnel, trying to clarify an obscure order for a nurse, or I may get called away to care for someone far sicker than you.  I will try very hard to not let these interruptions derail me from doing what is best for you today.

I will use my knowledge and experience to come to the right decisions for you. But I am biased, and knowledge of bias is not enough to change my bias. For instance, I know the pathophysiology of pulmonary embolism in excruciating detail, but the literature suggests I may still miss this diagnosis at least half the time it occurs.

And here’s the interesting thing: I will probably make these errors whether I just quickly determine what I think you have by recognition or use analytical reason. Emergency physicians are notorious for thinking quickly and making early decisions based on minimal information (Type 1 thinking). Cognitive psychologists tell us that we can cut down on errors by using analytical reasoning (Type 2 thinking). It turns out that both produce about the same amount of error, and the key is probably to learn both types of reasoning simultaneously.

After I see you, I will go to a computer and probably spend as much time generating your chart as I did while seeing you. This is essential for me to do so the hospital and I can get paid. The more carefully I document what you say and what I did, then the more money I can collect from your insurance carrier. The final chart may be useless in helping other health care providers understand what happened today unless I deviate from the clicks and actually write what we talked about and explained my thought process.  In my eight hour shift today I will click about 4000 times.

What’s that? You say you don’t have insurance? Well, that’s okay too. The US government and many other governments in the world have mandated that I have to see you anyway without asking you how you will pay. No, they haven’t guaranteed me any money for doing this – in fact, I can be fined a hefty amount if I don’t. A 2003 article estimated I give away more than $138,000 per year worth of free care related to this law.

But you have come to the right place. If you need a life-saving procedure such as endotracheal intubation or decompression needle thoracotomy, I’ll do it.  If you need emergency delivery of your baby or rapid control of your hemorrhage, I can do that too.  I can do your spinal tap, I can sew your laceration, I can reduce your shoulder dislocation, and I can insert your Foley catheter. I can float your temporary pacemaker, I can get that pesky foreign body out of your eye or ear or rectum, I can stop your seizure, and I can talk you through your bad trip.

Emergency medicine really annoys a lot of the other specialists.  We are there 24 hours a day, 7 days a week. And we really expect our consultants to be there when we need them. Yes, we are fully prepared to annoy a consultant if that is what you need.

I have seen thousands of patients, each unique, in my near-50 years of experience. But every time I think about writing a book telling of my wondrous career, I quickly stop short and tell myself “You will just be adding more blather to what is already out there – what you have learned cannot easily be taught and will not be easily learned by others. What you construe as wisdom, others will see as platitudes.”

As an author, Norman Douglas once wrote: “What is all wisdom save a collection of platitudes.  Take fifty of our current proverbial sayings– they are so trite, so threadbare.  None the less they embody the concentrated experience of the race, and the man who orders his life according to their teachings cannot be far wrong.  Has any man ever attained to inner harmony by pondering the experience of others?  Not since the world began!  He must pass through fire.”

Have you ever heard of John Coltrane? He was an astonishing musician who became one of the premiere creators of the 20th century. He started as an imitator of older musicians but quickly changed into his own man. He listened to and borrowed from Miles Davis and Thelonious Monk, African music and Indian music, Christianity and Hinduism and Buddhism. And from these disparate parts he created something unique, unlike anything ever heard before. Coltrane not only changed music, but he altered people’s expectations of what music could be. In the same way, emergency medicine has taken from surgery and pediatrics, critical care and obstetrics, endocrinology and psychiatry, and we have created something unique. And in doing so, we altered the world’s expectations of what medicine should be.

Now, how can I help you today?

References and Further Reading

1. EM Mindset – Joe Lex – Thinking Like An Emergency Physician. http://www.foamem.com/author/joe-lex/
2. How to think like an emergency physician – link
3. How Emergency Physicians Think – link