What Cognitive Psychology Tells Us About Emergency Department Physician Decision‐making and How to Improve It

In this issue of Academic Emergency Medicine, Gorski et al.1 report a link between two measures of emergency department (ED) crowding—ED census and physician load—to hospital admission decisions. Disposition appeared to change based both on the degree of ED crowding and on how many total patients the physician making the admission decision was carrying at the time. This translated to important swings: an average admission rate of 35% with an empty waiting room and zero patient load, which increased to 40% with 12 patients waiting or physician was carrying 16 ED patients. They concluded that disposition decisions were significantly impacted by workflow concerns of both the provider and the department. Crowding is one of the major issues facing EDs and problematic in nine in 10 U.S. hospitals. Prior studies have associated ED crowding and impairments in care processes, including delays in antibiotics and pain medication.2 ED crowding is also linked to poorer outcomes: higher error rates, complications, and mortality.3, 4 This literature in part fueled the development, approval, and promulgation of ED flow metrics currently used in national quality measurement programs: listed on Medicare's Hospital Compare website and included in the 2016 Value-Based Purchasing Program and in the Medicare Star rating system. Nearly every ED provider would agree that reducing crowding would make EDs safer, but what is less clear is the actual mechanism by which crowding wreaks its havoc. Crowding clearly impacts waiting times, but how crowding impacts clinical decisions and why people tend to make more mistakes is elusive. The article by Gorski et al. sheds some light on this question, demonstrating a sizable shift in the most important, costly, daily decision that ED physicians make: the decision to admit. It also confirms data from another academic ED where similar associations were reported.5 A simple explanation: during episodes of crowding, there is less available time to spend coordinating care for "gray area" patients who could potentially be admitted or discharged. Gray area patients include those with conditions not serious enough to warrant immediate admission but still concerning and, if discharged, require very close follow-up. Given high patient load, physicians may default to admission as the pathway of least resistance as opposed to investing additional time to help coordinate complex outpatient plans. However, for deeper explanations of how the ED physician brain might be impacted by crowding, we can explore the cognitive psychology literature where the impact of "stress" on performance and judgment has been the focus of decades of research.5 A major theme is that acute stress—such as managing a crowded ED or high patient load—impacts how the brain makes decisions. Specifically, people tend to make more unsystematic decisions and sometimes fail to consider all the options during stressful situations.6 Stress increases distraction, narrows attention, and worsens working memory, impacting problem recognition, information search, the assessment and selection of alternatives, implementation of plans, and finally, feedback. Importantly, "stress" research provides a potential explanation for the findings of Gorski et al., as the many human behaviors impacted by stress (i.e., crowding) can be theoretically linked a higher likelihood of admitting gray area patients. It also may explain higher rates of observed medical errors when crowding occurs.8 A related psychological concept is "cognitive load" or the total mental energy used in working memory at a given time. Compared to pretty much every other medical field, cognitive load is highest for emergency physicians who sometimes juggle dozens of active patients while enduring a steady stream of interruptions and unanticipated diversions. The degree of crowding—or carrying higher numbers of patients—is directly related to cognitive load. Similar to the more general concept of stress, cognitive load is linked to factors important in ED decision-making. In a study where participants simultaneously engaged in a digit memorization task along with a variety of other tasks involving choices, higher cognitive load was associated with more risk-averse behavior, as well as a higher likelihood to anchor.9 ED physician risk aversion is associated with admission decisions in chest pain.10 "Anchoring" is the tendency to rely heavily on early information (i.e., an anchor) and ignore subsequent information and is a recognized issue in the ED.11 Early information can sometimes initiate an admission decision even if later data refute initial data or impressions. Despite these observed associations, emergency physicians also can learn from cognitive psychology when it comes to mediating the tendency to make poorer decisions under stressful situations. What the literature clearly shows is that the relationship between stress and performance varies. For many, stress diminishes performance. Yet for others, stress can minimally impact performance, and sometimes stress can even improve it. Individuals can initiate either compensatory or noncompensatory strategies for decision-making under time pressure: some can rapidly sort through all the options of a particular decision, while others when stressed deliberately choose the simplest strategy.12 What drives this is how the individual perceives and responds to stress. Therefore, by learning from emergency physicians handle stress—crowding/high patient load—better, we may be able to construct generalizable approaches for others. In cognitive psychology, "balance sheet" exercises have also proven useful to mitigate the effects of stress.13 This involves forcing an explicit step during the decision-making process where the individual answers specific questions (e.g., the risks and benefits of various approaches). This active step allows the decision-maker under duress to slow down and more thoroughly consider all the options. An explicit risk/benefit approach could potentially be developed for gray area ED admissions. Specifically, questions could be answered by the ED physician, such as anticipated inpatient care, what the patient might benefit from admission, and the risks of discharge and probabilities of those risks occurring. Using this information along with shared decision-making, the physician and the patient, may make a more informed decision.14 Checklists and decision support systems are also recommended by psychologists, impact ED decisions around advanced radiography, and could be adapted for admission decisions.15 Finally, psychologists recommend explicit training or simulation to observe how individuals react to stress and provide direct feedback about how to improve task prioritization. For ED physicians, this sort of deliberative practice could be achieved through more explicit feedback during residency training or workshops on task prioritization for experienced physicians or through simulated cases. Over the past two decades, ED physicians have become accustomed to making rapid decisions, often with incomplete information during crowded situations, where there is high stress and cognitive load. Mitigating the effect of crowding on this decision-making should be a major priority for the specialty. In the future, there will be an increased focus on ED clinical decisions with the push toward value-based care and new payment models.16 In particular, admission decisions will increasingly receive scrutiny because they vary considerably among physicians and are also impacted by ED crowding.17 Looking to the psychology literature, emergency physicians may be able to learn about ways to improve our decisions under stress and ultimately deliver higher-quality, lower-cost care.