Everything You Should Know About Emergency Doctors But Were Too Afraid to Ask

Every year, one in five Americans cycles through the doors of an emergency department (ED). That’s over 155 million patient visits annually and climbing. I should know — I’ve been an emergency physician for a quarter century. A majority of us — yes, that includes you, doctor — will at some point become either a patient in an ED or the companion of someone who is.

For me, that moment came a few months ago, when I found myself checking into an ED on a Friday evening.

I had plenty of time to think that night, sandwiched between someone spewing vomit and someone else spewing obscenities. What I found myself wondering was how emergency physicians make decisions. We constantly navigate uncertainty, imperfect data, and a chaotic environment. How does that environment influence our decision-making? My doctor that night was gracious — albeit somewhat harried — and appeared at regular intervals to update us. Would another physician have done the same? Made the same decisions, ordered the same tests? What if I’d arrived on a Tuesday night instead of Friday?

In other words, how do emergency physicians think and how fallible is that thinking? So here it is: everything you should know about emergency physicians but were too afraid to ask. And, as both clinicians and patients, what we can do about it.

Clinician Confidential

There are almost 50,000 clinically active emergency physicians in the U.S: their median age is 50 and about 70% are men. Unlike primary care — where you can select your physician based on experience or word-of-mouth — in the ED, you will be treated by the physician who is there.

Does your doctor’s gender affect your care? Slightly. The evidence suggests that female emergency physicians order more tests and hospitalize more patients — about 3%-to-5% more. However, their patient mortality rates are no different.

Does your doctor’s age affect your care? It might. This comes down to the question of whether we get wiser or more forgetful as we age. One study found a steady, small, but statistically significant increase in patients’ mortality as their doctors got older — 0.1% higher for physicians over 60 compared with those under 40. This suggests that for every 1,000 patients treated by physicians over 60, one died who would have survived with a younger doctor. As with any observational study, this difference might be real or might be due to unidentified confounding. Unlike other high-stakes professions, there is no mandatory retirement age for emergency physicians.

Does emergency medicine attract the best and brightest? Historically, yes — emergency medicine has long been one of the more competitive specialties. But in 2022, the number of residency applicants plunged. In 2023, the bottom fell out — almost half of all training programs went unfilled — likely due to burnout, the corporatization of medicine, and an expansion of residency program spots. How this will impact bedside care remains to be seen.

All in a Day’s Work

Does it matter if your doctor is at the end of a shift? What if it’s a particularly long shift? Emergency physicians — during an 8-, 12-, or 24-hour shift — continuously make rapid, high-stakes decisions. In one study, they were more likely to admit patients to the hospital in the final hour of a shift. In another, the number of laboratory studies a doctor ordered increased as the shift progressed. The suggestion is that, by the end of a shift, some doctors may develop a form of impaired decision-making called decision fatigue and rely more heavily on lab data to inform diagnosis.

That said, longer shifts aren’t necessarily associated with worse patient outcomes. In fact, an intensive care unit study in 2020, with findings that extend to the ED, demonstrated significantly more physician errors on shorter shifts, despite those physicians getting more sleep and working fewer hours. The reason? For one, physicians on shorter shifts tended to treat more patients, suggesting that above a certain workload, the risk of error increases. The other reason was shift change, a handoff fraught with potential communication errors. Despite multiple safeguards, shift change remains one of the more dangerous moments in the ED. And shorter shifts mean more handoffs.

When is the best time to present to an ED? In many health facilities, staff and services decrease on weekends, leading to a potential “weekend effect.” Studies of heart attack, stroke, and surgical patients suggest increased adverse outcomes in patients admitted over the weekend compared to business hours. This might be due to reduced staffing and diagnostics, or it might reflect higher acuity among weekend patients. Happily, the “July effect” has been mostly debunked — July being the month that new, inexperienced residents start. It’s also worth noting that ED overcrowding and boarding have a far greater impact on patient outcomes than time of presentation.

Trial and Error

But faced with the same patient, different emergency physicians will pursue the same course of action, right? Well … there’s actually a surprising level of variability from one physician to the next, even among physicians in the same ED and across patients with similar symptoms, like chest pain. This transcends local institutional culture (which has a strong impact on a doctor’s decision-making). Some doctors simply have a lower threshold to order tests and admit patients.

This gets to the heart of how emergency physicians make decisions. True, we complete years of schooling, rigorous residencies, and frequent recertification. We have guidelines, protocols, clinical pathways, and peer review. And we are constantly in dialogue with other physicians. But ultimately, we are profoundly human, subject to the same heuristics and decision-making vulnerabilities that everyone else is.

State of the Art Care

So, what’s the best way for all of us, when we inevitably become patients, to navigate this uncertainty?

My advice is to ask questions. Perhaps like you and your colleagues in other specialties, emergency physicians often use a process called shared-decision making, which means we want to know the patient’s opinion. We also increasingly ask about goals of care, which helps clarify a patient’s top priorities — be it pursuing treatment, staying pain-free, or remaining at home as much as possible.

It’s also reasonable to bring in your ChatGPT research. In fact, emergency physicians are increasingly using their own artificial intelligence-based tools. But be judicious: one of the most valuable commodities in the ED is your doctor’s attention, so use the time to discuss what concerns you most. Remember that an emergency physician’s goal is to identify if the patient is having an emergency; they’re likely to defer management of chronic illnesses to your primary care team. Above all, be open to discussion — there are often several reasonable treatment options for every medical scenario.

Ultimately, emergency physicians’ decision-making isn’t fixed. And it never occurs in a vacuum. Rather, it’s shaped by umpteen internal and external factors — of which many of us are blissfully unaware. This is an unsettling realization, but there’s good news. Open communication and collaboration between the doctor and patient can go a long way in mitigating this influence. It’s something all of us should keep in mind the next time we find ourselves spending an evening in an ED as a patient rather than as a physician.