Paul

I do think that emergency physicians think and act differently. Speed is a key element to solve the problems that is usually absent or less marked in other specialities. But some times EM physicians, particularly in some countries, need to discharge the patients from the ED soon which in some occasions may led to an incorrect therapeutic evaluation. For instance it may led to an excess of antimicrobial treatments.

I don't think so for everyone - I think it can be different for general physicians and surgeons who don't do emergency cases, however I think surgeons with trauma-critical care training (many outside Australia do this) or any other discipline who does a fair amount of emergency work develop the right mindset - keep in mind not every country has emergency medicine as a speciality

Thanks, why did I boot ask this question?

The reason is UK NHS "Their flagship is sinking". In 2000, they allowed nurses to work as front line staff in emergency and out of hours service and allowed them to prescribe drugs. Major mistake, because the nurses are trained to follow protocol, they cannot think like doctors who work in medical emergency physicians and the most difficult branch "Paediatrics". You can read two papers published in Arch Dis Child, May 2013. The admission to hospitals has rocketed up by 35%. Majority short stay. Dr Gill has been blunt and said "This is systemic failure, both primary care and hospital emergency department". Mid Staffordshire hospital enquiry reported 1200 deaths that could have been avoided. (22 hospitals are investigated). WHY?

This is what the pundits sitting in posh office and giving lectures have not understood. They are mostly theory masters and not practical. I think academics can blabber out a big list of conditions, mention list of publications and talk about research but do not know nor acquired the skill to find shortcuts to derive at a diagnosis. In paediatrics you need additional practical skill, if not you cannot survive.

Certainly YES. I worked as the registrar and senior registrar and staff paediatrician in emergency, intensive and neonatal care for almost 25 years. Now I am compiling a tool to pass on my experience because publishing a book will only add more garbage in the environment. The knowledge and experience I have acquired cannot be thought and not one that every doctor can learn or cope.

As the 2nd on call, you do not have or get help, advice or support from another senior or colleague. We have to listen (brief history), observe the patients or child, start ordering what you need and simultaneously think what can I do next. If I make one mistake, the result is catastrophic - frankly Death!!

We have to have the knowledge, remember lots of disease (in kids syndromes, metabolic disorders, congenital anomalies) and mastered practical skills. You have to be innovative and have some knowledge of how equipments work because you may be in a helicopter or an ambulance when some equipment goes wrong.

The adrenaline rush is like addiction, you need the buzz and so I continued working and I loved it. You may find my blog drsri.net interesting because I am now criticising the system and institutions for allowing this to happen. I predicted this coming in 1996, when I criticised Preprinted Assessment sheet.

Surgeons do not think like physicians, they are master few techniques and skill. As a physician, we have to think what is going on and so must master physiology and biochemistry, pathology, pharmacology, immunology and microbiology. We must also know every test and also have some knowledge of imaging (X ray, Scan, MRI and CT).

Please check out my tool developed to help junior doctors, nurses and patients decide how unwell the child or patient is. I am attaching the poster to see. I think I have said enough and want to know what others think!! Thanks

This is the poster presentation that may help reduce wrong doings and complications

I am sorry about some spelling mistakes. I clicked to add the attachment but the reply got posted, sorry

What a fascinating question. Yes, I think they do - but I would very much like to see some objective evidence, for example from cognitive psychology. As Dr. Smithson notes there is a time imperative, at least in North American EDs to "move the meat". This appalling terminolgy reflects significant differences, some profoundly disturbing, others paradoxically good. The need to push patients through with maximum speed leads to a loss of "caring", (just as the pressure on the house officers in the book House of God had this effect. ) Patients become widgets to be processed as rapidly and efficiently as possible. On the other side of this coin, however, this same pressure to reach a diagnosis and disposition as rapidly as possible forces a reliance on clinical accumen, (over "tests") which has been lost in much of medicine. (I am reminded of a cartoon I saw a good 20 years ago, with a distraught Emerg Doc on the phone, and the caption, "OK.I've done the cerumen zinc and the serum porcelain. NOW will you come to see the patient?")

Yes, or at least they should do. The different disciplines of medicine should always incorprate different thought processes based on the situation and the personal knowledge that the clinician find themselves in. Emergency medicine has a unique set of problems. These include; a far from perfect working environment (for example if you work in the pre-hospital environment), many different insults to be prioritised and treated, un-cooperative patients, and most importantly TIME. The time constraints in emergency medicine will always figure in the clinicians mind and influence the decision making process, and the clinicians that work in emergency medicine will have been trained to 'play the percentage' game to do what is best at that moment in time for the patient.

I think also that ED doctors have a different approach of the patient. Going further I would say that ED doctors treating various age groups have particular behavioural patterns. I am a pediatrician in the ED of a teaching hospital and I can tell that same patient is analysed in different perspective in ED and on the ward.

Another major factor of changing perspective is age of doctor and time [months and years] spent in ED. Emergency physicians tend to "burn-out" much faster than regular physicians and they should rotate in various segments of the hospital [or between hospitals] like in transport teams, in ICU or other areas of research / teaching [like simulation...] in order to maintain focus and coherence of approach.

I fully agree with Mihai. We do have different approaches!!

Emergency physicians use Boolean logic, because they work with less data and little time. the others use algorithmic dichotomous logic, yes and no then the next step...

On Prof Ted's comments regarding Boolean logic, may I point out an interesting study recently out in the EMJ: Claessens Y-E, Wannepain S, Gestin S, Magdelein X, Ferretti E, Guilly M, et al. How emergency physicians use biomarkers: insights from a qualitative assessment of script concordance tests. Emerg Med J [Internet]. 2013 Apr 4 [cited 2013 Apr 10]; Available from: http://emj.bmj.com/content/early/2013/04/03/emermed-2012-202303

Much as I do agree that some thought processes regarding clinical decision making may differ, I think it is at times harmful one starts to differentiate oneself to much from the "other specialties". We all adapt according to the environments we practice, and we constantly learn and respect the differences of others so that we may work as a team. I do not believe belittling others would help.

Error: "...at times harmful when one starts..." ; "differentiate oneself too much..."

Thanks to everyone for their insightful and fascinating additions to the conversation. I felt I had to make a quick response here given Dr Harunarashid's contribution. I posed the question not to throw up differences, or to discriminate between medical specialties, but because I am fascinated about the differing cognitive processes that occur.

We process information in the emergency department and use it to assign a level of potential urgency, or even of alertness to possible diagnoses, however there is often dissonance between the levels of perceived urgency or alertness between us and colleagues from inpatient specialties. This may, in the worst of situations, interfere with patient care, but with good relations and respect this may be avoided.

Leaving that aside however, investigating whether we actually use differing cognitive models, especially in terms of assignment of potential risk or probability of disease (I think everyone who works in an emergency department would have seen the contortions performed sometimes to escape Occam's sharp edge, or to fit the untidy reality of simultaneous pathologies into one tidy box described in Harrison or Kumar & Clarke!) It is also sometimes a matter of seniority or experience, but my perception is that we think in quite different ways, even though we all went through the same hypothetico-deductive intellectual training in the first place.

The paper quoted by Dr Harunarashid is a great example, commenting on the use of intuition and experience as well as Bayesian reasoning by senior emergency physicians, and there have also been fascinating fMRI studies looking at brain structure and cognitive processing between Democrats and Republicans. I think the more we interest ourselves in these topics, and the more we spread our intellectual net to take in other disciplines such as cognitive psychology, the sooner the young medical specialty of emergency medicine will find its proper place.

Don't stop contributing...

Thanks Paul. I certainly did not mean to cut this discussion short by any means, nor do I question the relevance of this very interesting topic. Being a clinical epidemiologist working in the confines of Academic Emergency Medicine does put me at times in a very difficult isolated place when arguing certain aspects of Evidence-based practice. I felt, like you, the need to respond to contributions in this thread that I felt that are in the "same flavor".

Hi Paul, as I am a former Emergency Surgeon I would like to say that emergency physicians effectively think differently to other Doctors. This is related both to the pressure of diagnosing the case asap and to arrange faster appropriate intervention / treatment. This doesnt' imply that Doctors not involved in Emergency are not able to do what it is to be done in case of delayed emergency or when an acute event occurs to the patient when recovered. Probably GPs are less ready to take initiative in emergency (with the due respect) because their medical routine is somewhat different than hospital doctors. Your question raises also the supposed difference between surgeons and internal medicine doctors. In my opinion this difference does exist effectively. Nevertheless, I would like to say that being an experienced clinician probably gives chance to overcome any inconvenient related to emergency / acute events, independently of being a surgeon or a medical doctor. Last but not least I guess it is true that often any doctor in emergency should consider first the emerging clinical problem rather than the underlying pathology. This is to be taken into account immediately after, whatever the case. Thanks.

Emergency Medicine physicians also become expert at true multi-tasking and "thin-slicing" information. For a book that explains the concept of thin-slicing, read "Blink".

Emergency doctors are interested in saving you and not in the quality of life that you may lead after the medical emergency. As a TBI survivor, quality of life is my main thought. I have worked in with TBI individuals since my injury and I am very lucky considering the length of time I was in a coma and turned out as well as I have as far as I live independently, drive, work, and have attended graduate school since my injury. I realize how blessed I am today.

Hi all; at the end of the day emergency doctors are not super doctors but people trained to face any real threat to the human life / human wellbeing suddenly occurred.

They are on duty to serve and protect injured / severely sick patients. That's all. This is supposedly any Doctor's job.

I think it is essential to understand that different strategies are necessary to solve different kinds of problems. This can improve rather than impair the respect between collegeaus of different specialties, because it is part of team work to appreciate this diversity. This helps to accept individual contributions as components of success rather than as a source of competition.

Certaintly. They have to work in shorter terms schedules and more acurate quick desicions differnt from the colleagues who have the time to take a decision in more elective ways . The emergency physicians thinks in flow charts to come to efficient and precise diagnosis and treatment. In the golden hour you haven't time to make an analysis or synthesis of all diagnostic possibilities but the most critical and essential ones. So you can't lose time to look for all subdiagnoses there are possible to find .

Here is a telling example in my opinion of how ER physicians think differently (and I also agree with the above responses), and one not always so positive is that in America the ONLY demographic wherein women are more successful then men at suicide is the female ER physician. It is a tough business and one that often requires patience, understanding, compassion, empathy, quick thinking, logical deduction, a careful attention to detail, deft motor skills, personality assessment, a blunting of personal feelings, highly acute senses of smell, touch, vision, and many many more.......all within a 10 minute time frame. D.B. ER Physician Assistant (PA-C)

Great Dale, thank you for this. I guess the best explanation of the very ultimate definition of the striking difference existing between ER Doctors and those who have never had (lived) such a professional experience. Thanks.

Definitely there is different thinking among different experts it depends on their training

I've been an emergency nurse for seven years and the difference is night and day. ER practitioners have engrained a triage methodology- rule out the "killers". In my experience, the best ER providers have a sense of humor and a sense of urgency. Emergency professionals are more cynical then other specialities and have the ability to separate their emotions from their practice early on. They (like first responders) go into "autopilot" when the most tragic of emergencies presents itself. The E.D. is the gateway to the hospital and has to be prepared for the next emergent patient to roll through the door. For this reason, we are trained to focus on constantly moving patients; either stabilize and ship (inpatient or transfer) or "treat and street".

I guess Andrea is completely right.

As an EP with neraly 10 years experience, I think the wost important skill for an Emergency doctor is "Continuos attempt to organize her/is mind in a extremely chaotic situation". An EP has to try hardly to make the best decisions during the worst and the most critical situations, should keep focusing on every details in the most distracting atmospheres, must control her/imself during the most irritating moments. Because of that an emergency doctor always faces with a collection of "Conflicts" and for managing them, needs a special attitude which will be stablished gradually with prolong confrontation

I have been a Board Certified Emergency Physician for almost 30 years and work at a Level 1 Trauma Hospital with over 100,000 volume per year. Any time a patient comes in, within our thought processes are first to stabilize the patient and if stable, to work them up. During that process, we are concerned 1: What will kill them first or what is a life threatening illness or injury, and 2: what is the "fastest" work up needed to come to a diagnosis and that diagnosis is a "preliminary diagnosis" not always a definitive diagnosis because that is not always possible within a few hours. We also work as a TEAM. We also relay on consultants of all specialties which is essential to stabilize and to work up the patient simultaneously. We also work with patients who don't give a good history or no history; patients under the influence of alcohol or drugs and have an altered mental status. We relay on vital signs and changing vital signs. We don't wait for blood gases to intubate always. It they are hypoxic or about to "crash" we intubate, put in central lines, and start pressors (or blood) if needed. We also realize a stable patient on presentation can subsequently crash. When "clinic type" patients come in, we treat them with kindness and they are explained that they will be worked up and will wait, and treated by level of seriousness not by chronology. We don't insult them by asking them why they didn't go to their doctor (or to the clinic). We take care of them, all hours of the day and night. Who ever comes in gets seen. We never ask insurance. It is something I am proud to for closed to thirty years. My residents enter the specialty well prepared. They know they will always be the "front line" to the masses.

Exactly there is a difference because EP are always work under stress and dealing with the most valuable time of the endangered human life. There are smart in making quick decisions with minimal resources and doing a wonderful job to make death alive. Who else can face such a wide range of experiences in such a little time? I hope all doctors should work in a A & E in their life time to understand how differ the EP from other specialties and to have the fun of being a BOSS with a smile and kindness.

I read with interest the views of the above colleagues. I agree with most of their points as emergency medicine is a specialty which unite and has a common concept," help those who need help most, whenever they are in urban or rural areas". I would like to highlight another point , I am working in an underdeveloped country, in a large capital ED where we know , we can act, but no facilities or equipments to save life exist. Imagine a walking patient presenting with chest pain , and while doing his ECG which showed an acute MI, he collapsed. Look around no Peripheral IV cannulae, or even disposable syringes for the adrenaline injection in your other hand. No available ordinary simple oxygen masks, venturi varieties are dreams. An asthmatic patient and you run out of Salbutamol solution. A multiple injured patient, and no IV fluids (not thinking should , I give colloids or crystalloids). This is not an extra-ordinary situation, but your daily fight for the patient right to have at least their basic needs. From my view, TB, Malaria, HIV programmes are WHO responsibility where huge amounts of money are spent on them, but an emergency patients which might still be suffering from any of this disease may die out of dehydration because of the nonavailability of drip-sets. I perceive that ED are the primary care unit during disasters, and this concept should be adopted for any one who plan to be prepared for any sort of disaster. WHO and other agencies should collaborate to prepare these PHC units, because it is a human right to live and die in dignity.