What defines the unique mindset of an emergency clinician? It’s not just the fast pace or the chaotic environment—it’s the deliberate, top-down thinking that prioritizes patient safety over diagnostic certainty. This approach, though deceptively simple, often flies in the face of traditional medical training, which emphasizes comprehensive differentials and exhaustive workups. In emergency medicine, knowing what the patient needs often matters more than knowing exactly what they have.
In this episode, we explore the emergency medicine mindset, the pitfalls of the bottom-up approach, and why experienced clinicians focus on acute interventions and dangerous conditions. Finally, we discuss how humility and strategic communication with patients can make all the difference in mitigating risk and building trust.
Guest bio: Reuben Strayer is an emergency physician based in Brooklyn, at Maimonides Medical Center. He tweets @emupdates and blogs at EMupdates.com on a variety of emergency medicine topics. His clinical areas of interest include airway management, analgesia, opioid misuse, procedural sedation, agitation, decision-making, and error. His extra-clinical areas of interest include sweeping generalizations and jalapeño peppers.
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We Discuss:
Critique of Medical School Training and the Bottom-Up Approach
- The medical school system trains students for a methodical “bottom-up” approach, suited for non-urgent settings.
- This approach relies on exhaustive histories, full physical exams, and broad differential diagnoses.
- Emergency medicine demands speed and precision, making the bottom-up method inefficient in critical situations.
- Bottom-up assessments often fail in urgent cases, like respiratory distress, where immediate actions are required.
- Many clinicians unknowingly rely on the bottom-up approach, which can compromise patient safety and efficiency in emergency settings.
Top-Down Approach and Ophthalmology Insights
- The top-down approach focuses on narrowing possibilities to essential interventions rather than exhaustive diagnostics.
- Inspiration for top-down thinking came from ophthalmology, where assessments are standardized and therapy-focused.
- Emergency clinicians, like ophthalmologists, prioritize actions and treatments over diagnoses.
- The goal is to identify which “arrow from the quiver” is needed rather than what the ultimate diagnosis might be.
- Top-down thinking ensures the clinician determines what the patient needs immediately, not what they have.
The 8 Responsibilities of Emergency Physicians
- The emergency physician has eight responsibilities, and there’s a hierarchy to them. The hierarchy is important to understand because our responsibilities are often in conflict. When competing priorities exist, we need to know which priority is the priority.
- The eight key responsibilities:
- Resuscitating patients when necessary.
- Identifying dangerous conditions.
- Providing symptom relief.
- Determining appropriate dispositions.
- Managing ED flow.
- Delivering strong customer service.
- Practicing resource stewardship.
- Contributing to public health.
- Our job is not to determine what the patient has. Our job is to determine what the patient needs. Patient safety, not diagnosis, is the primary responsibility.
- Determining a final diagnosis often falls into the customer service category rather than the patient safety mandate. When you recognize this, it becomes a lot easier to negotiate the gap between what the patient wants and what we can provide.
- Clear communication with patients about uncertainties can prevent malpractice and build trust. However, we can run into trouble by assigning a final diagnosis when we don’t know it (which we usually don’t).
The Wheel of Dangerous Conditions
- The “Wheel of Dangerous Conditions” outlines 126 critical conditions that emergency clinicians must consider.
- For any given presentation, only a few of these conditions are typically relevant, reducing cognitive overload.
- For example, knee pain has seven dangerous causes (e.g., fracture, septic arthritis) that take precedence over non-urgent possibilities.
- Identifying and addressing these conditions ensures safety while deferring less critical diagnoses to outpatient settings.
- The wheel reinforces top-down thinking by focusing assessments on life-threatening conditions.
Top-Down Thinking in Practice
- People who practice emergency medicine already understand and use the top-down approach. But when you know explicitly that this is how you think about your patients, you can do it better.
- In critical scenarios like respiratory distress, the focus narrows to a short list of interventions: oxygen, non-invasive ventilation, intubation, etc.
- Top-down thinking applies to treatment as well as diagnosis, emphasizing immediate life-saving actions.
- Clinicians benefit from knowing the “menu” of interventions for specific emergencies, streamlining decision-making under pressure.
- Recognizing patterns of dangerous conditions reduces overwhelm and improves care for undifferentiated symptoms.
- The practice of “playing not to lose” ensures that the clinician prioritizes patient safety over diagnostic accuracy.
Humility and Communication in Emergency Medicine
- Providing a specific, benign diagnosis (e.g., GERD) without certainty can lead to missed dangerous conditions.
- A safer approach is to reassure patients while acknowledging the limitations of testing and the potential for evolving conditions.
- Example phrasing: “I think your chest pain is caused by acid reflux, but if symptoms worsen, return immediately.”
- Partnering with patients in their care fosters vigilance and reduces the likelihood of missed diagnoses.
- Emergency medicine is not about “winning” with a diagnosis—it’s about ensuring no critical condition is overlooked.
- Don’t convey certainty that you don’t have. Be humble about chest pain, abdominal pain, and other undifferentiated symptoms. You will miss appendicitis. The key is to let the patient in on that little secret so they become your partner in picking up the touch cases.
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