Decision Aids, Doorknob Moments, and Physician-Patient Solidarity in EDs

Abstract

Potential benefits of decision aids and technology, such as artificial intelligence, used at the bedside are many and significant. Like any tools, they must be used appropriately for specific tasks, since even validated decision aids have limited utility when they are misapplied, overly relied upon, or used as a substitute for thinking carefully about clinically and ethically relevant questions. Patients are more than data points in human form, as they come to emergency departments with stories. As technology casts ever-lengthening shadows over patientclinician interactions, a key question is: How should clinicians cultivate relationships with technology so it functions in solidarity with patients?The American Medical Association designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™ available through the AMA Ed Hub TM . Physicians should claim only the credit commensurate with the extent of their participation in the activity. CaseSomething does not sit right about this emergency department (ED) patient. His asthma flare-ups have brought him to the ED multiple times for shortness of breath, despite escalating asthma medication interventions by his pulmonologist. The emergency medicine intern, who is a few months into her training, listens to his lungs. He's wheezing, but mildly. His symptoms could fit an asthma exacerbation, but he appears comfortable. Does asthma explain his visit to the ED? Could it be a pulmonary embolism (PE)? What about risk factors for heart disease?The intern knows a senior resident physician will ask for her differential diagnosis. The patient's heart rate is over 100, so a common decision tool validated for use with patients at low risk will not rule out PE. 1 She considers ordering a d-dimer to further stratify his risk for PE. He could have underlying pneumonia, so she orders a chest x-ray. There's also a clinical decision rule for assessing the 6-week likelihood that a patient like this one (eg, with symptoms suggesting an acute cardiac syndrome) will experience an adverse cardiac event. 2 The intern finishes examining the patient. Now about to leave, with her hand on the doorknob, she asks, "Sir, what do you think is causing your shortness of breath?"