There is a natural tension to decision-making in the emergency department. In a busy ED with multiple patients to assess and keep track of, it can be difficult to dissect every patient’s complaints and make clinical decisions both quickly and effectively.

Emergencies, by definition, must be dealt with fast. For this, whether they are fully aware of it or not, emergency physicians rely on their intuition, informed by their experience and education. In a book on how people process information called, “Thinking, Fast and Slow,” author Daniel Kahneman refers to this kind of fast, intuitive decision-making as System 1 thinking. 

System 1 Thinking: Intuitive Judgement

During most of our day, we deploy System 1 thinking to assess our surroundings and respond based on intuition and comfort. A drive to the office — one that you take every day, twice a day — is System 1 thinking. You don’t have to think about which turn you will make. You just go.

In the ED, physicians use System 1 thinking all the time. A chest pain patient comes in, and without even reading the chart, we know which tests to order and what questions to ask the patient. We deal with this chief complaint multiple times per shift and are easily able to rely on our intuition to identify next steps.

Going with our original, intuitive judgement often makes sense — but there are some times when it can result in a critical misdiagnosis. That’s why, in addition to System 1 thinking, emergency physicians need to cultivate a different type of thinking: System 2.

System 2 Thinking: Doubt and Analysis

Rather than intuitively reacting to situations, the System 2 thinker doubts and analyzes. System 2 is not about quickly coming to judgment; rather, it is about taking the time needed to focus, consider other alternatives, challenge assumptions, and in some cases, doubt.

If I’m driving and get lost, I often tell my kids to stop talking as I turn off the radio, while I’m trying to identify next steps and listen to the GPS. I do this to concentrate – limit distractions and focus on the task at hand. I am engaging System 2.

Systems Thinking in the ED

Being able to utilize both systems of thinking is critical in the ED. At the start of a shift, we see four or five patients within the first hour. Each patient encounter brings new hypotheses, and as good clinicians, in many cases, we are already arriving at conclusions.

Over the next 8-10 hours, we will accumulate somewhere around two dozen patients and must be able to quickly and effectively make decisions and diagnoses. Otherwise, we fall behind and are not able to provide care to the many patients waiting to see us.

We spend most of our shift using System 1 thinking; however, when it comes time for deliberation, it is critical to introduce System 2 thinking and question the natural clinical considerations we have been making. Without stopping to analyze the charts and question assumptions, the proper diagnosis isn’t always made.

Being an excellent clinician requires balance between the two. Too much focus on System 2, and we would get bogged down. We would fall behind and let our intuitions — the spark that makes us good, passionate doctors — fall apart.

System 1 helps us continue forward, order tests and make recommendations. System 2 reminds us to focus on the facts of the case, rather than relying solely on our experience. The trouble is, in a busy ED, when patients, test results, EKGs, nurse orders and medication reviews are flying at us from every angle, how are we supposed to shut the radio, limit distractions and just think?

Improving Patient Outcomes

Several years ago, infections resulting from a central line insertion were simply a known risk. No postmortem work was done to investigate the reasons.

But when Atul Gawande released, “The Checklist Manifesto: How to Get Things Right,” he challenged the healthcare industry to require physicians to use checklists to ensure clinical accuracy and reduce medical errors. There was considerable resistance to forcing physicians to slow down in this way, but hospitals that adopted the checklists saw steep declines in medical errors and preventable problems like hospital-acquired infections. The checklists Gawande advocated for are good examples of System 2 thinking.

At US Acute Care Solutions (USACS), we employ another System 2 thinking strategy in the ED called, “Discharge Time Out,” created by our Chief Quality Officer Jim McQuiston, M.D. The Discharge Time Out offers the perfect opportunity to slow things down, consider the patient’s initial chief complaints, reformulate a differential diagnosis, review abnormal physical findings and test results and reach a safe disposition.

Similarly, many hospitals now require nurses who are inputting medication orders into the Pyxis to step into a closed room or “box” indicated by tape. When nurses enter the box they are not to be disturbed, no matter what. This is protected time where the nurse can focus on the order to ensure it aligns with the chart and is cleared by the physician.

The attendant reduction in medication errors can be attributed to a culture shift, where nurses support one another in their quest for focused orders, while the physical separation of the box or room creates a visual reminder that the nurse needs to be left alone.

By implementing strategies that infuse the ED with System 2 thinking, hospital systems, physicians and — most importantly — patients will be better off for it.