Author: D. Mark Courtney, MD (Associate Professor, Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University) // Edited by: Manpreet Singh, MD (@MPrizzleER – Clinical Instructor & Ultrasound/Med-Ed Fellow / Harbor-UCLA Medical Center) and Alex Koyfman, MD (@EMHighAK – EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital)

The Emergency Medicine doctor as “The Decider”

It is obvious that the emergency medicine mindset includes things like “look for a life threat”….. “be prepared to take care of anything that comes in the door”. And I admit that when I was first starting out in EM almost 20 years ago, these were the things I would mention as what attracted me to the field. But now… I have a different perspective. The challenge and reality of these catch-phrases is diminished. What I now do is function as a resource allocator. On the surface, this seems unromantic and perhaps even a bit self-effacing. But take a moment to realize the significant power and responsibility that this is. We in emergency medicine decide who gets what tests and when? who gets admitted and why?… on a minute by minute basis. So yes, that is probably the phrase that best describes my mindset in day to day activities… “The Decider”. I am asked to make decisions with mind-numbing frequency on everything from if a CBC is ordered to whether or not to continue resuscitation efforts on a particular patient. We often see the people whom other doctors cannot make a decision on… “Is this chest pain in my young healthy clinic patient something to be worried about?… for the patient? for med-mal risk? who knows?… send them to the ED for them to make a decision”… It can be a bit overwhelming and certainly mentally fatiguing. And it is even more acute in an academic center where in addition to patients and RNs there are layers of residents, medical students, and consultants asking you for your attention to make a decision. It is for this reason at times I go home and am asked what I want for dinner and I say with consternation… “I don’t care…” It is easy at times to get fatigued with being “The Decider.”

If you are interested in reading the rest of this and other EM Mindset pieces, please see “An Emergency Medicine Mindset,” a collection evaluating the thought process of emergency physicians. This book is available as ebook and print on Amazon.