The Cognitive Imperative Thinking about How We Think

Abstract

Abstract. There are three domains of expertise required for consistently effective performance in emergency medicine (EM): procedural, affective, and cognitive. Most of the activity is performed in the cognitive domain. Studies in the cognitive sciences have focused on a number of common and predictable biases in the thinking process, many of which are relevant to the practice of EM. It is important to understand these biases and how they might influence clinical decision-making behavior. Among the specialities, EM provides a unique clinical milieu of inconstancy, uncertainty, variety, and complexity. Injury and illness are seen within narrow time windows, often under pressured ambient conditions. These operating characteristics force practitioners to adopt a distinctive blend of thinking strategies. Principal among them is the use of heuristics, a form of abbreviated thinking that often leads to successful outcomes but that occasionally may result in error. A number of opportunities exist to overcome interdisciplinary, linguistic, and other historical obstacles to develop a sound approach to understanding how we think in EM. This will lead to a better awareness of our cognitive processes, an improved capacity to teach effectively about cognitive strategies, and, ultimately, the minimization or avoidance of clinical error. Key words: emergency medicine; cognition; errors; decision making; heuristics. ACADEMIC EMERGENCY MEDICINE 2000; 7:1223-1231 T HERE are three major skill sets in the performance repertoire of emergency physicians (EPs): procedural, affective, and cognitive.1 It may appear to outside observers, as well as to many within the profession, that emergency medicine (EM) is predominantly action-oriented and that procedural skills are, therefore, the most important of the three. Indeed, during training, a considerable emphasis is directed at the acquisition and retention of skills such as intubation, wound repair, the insertion of chest tubes and central lines, diagnostic peritoneal lavage, lumbar puncture, and cast application. This procedural skill set is tangible, well defined and teachable. While procedural skills are important and integral to an effective performance in the emergency department (ED), they comprise a relatively small part of the overall activity of EPs. Most of our time, in fact, is engaged in cognitive behavior; it is the preponder- ant substance of EM. Surprisingly, it has attracted relatively little attention, perhaps because of an undervalued regard for the importance of exactly how we think. In a recent report, medical educators concluded that EM health care workers were often ''. . . not consciously aware of how they evaluate evidence and cope with decision complexity. '' 2 Proficiency in the cognitive domain, compared with that in procedural skills, is less easily defined, involves a much broader range of possibilities, and would appear to be less easily taught. Kassirer, in 1995, recognized the problem very clearly:Research in the cognitive aspects of clinical problems...

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