In reply:

Abstract

We appreciate the opportunity to respond to Dr. Pelaccia’s letter,1Pelaccia T. Decisionmaking in emergency medicine: experienced based and contextually anchored rather than evidence based and universal.Ann Emerg Med. 2018; 72: 624-625Abstract Full Text Full Text PDF Scopus (1) Google Scholar which sought to draw some important conclusions for the field of emergency medicine decisionmaking from our recent article.2Wright B. Martin G.P. Ahmed A. et al.How the availability of observation status affects emergency physician decisionmaking.Ann Emerg Med. 2018; 72: 401-409Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar On the whole, we generally agree with Dr. Pelaccia and thank him for bringing further attention to the importance of our work. Our findings certainly underscore that emergency physicians vary in their approach to decisionmaking as a result not only of their years in practice but also of their personal level of risk aversion, which, one might argue, is shaped in them well before they become physicians. Similarly, although not directly addressed in our study, we think it highly likely—and consistent with other research on bounded rationality3Feufel M.A. Bounded Rationality in the Emergency Department. Wright State University, Dayton, OH2009Google Scholar and naturalistic decisionmaking4Klein G.A. Calderwood R. Clinton-Cirocco A. Rapid Decision Making on the Fire Ground. Proceedings of the Human Factors and Ergonomics Society Annual Meeting. Sage Publications, Thousand Oaks, CA1986: 576-580Google Scholar—that the physician decisionmaking process will inherently differ in the resource-limited context of the emergency department compared with other, more relaxed medical settings. Although theoretically interesting, these findings also have very practical implications. In a recent study of physicians’ fear of malpractice as a driver of defensive medicine, the authors demonstrated that the largest driver of defensive medicine costs is not excess testing, but “a greater propensity to admit patients to hospitals,”5Reschovsky J.D. Saiontz-Martinez C.B. Malpractice claim fears and the costs of treating Medicare patients: a new approach to estimating the costs of defensive medicine.Health Serv Res. 2018; 53: 1498-1516Crossref PubMed Scopus (30) Google Scholar which most often is the domain of the emergency physician. Indeed, the ability of observation services to reduce unnecessary admissions is one of its greatest strengths. Yet the authors also demonstrated that emergency physicians are more concerned about malpractice than are physicians in any other specialty. As we found, this explains why some emergency physicians place patients in observation when they could have been safely discharged. Although using observation in such cases is inefficient, it nevertheless allays the physician’s fears without harming the patient. In closing, we underscore that although decisionmaking is highly individualized and context dependent, there remains a need to rigorously deploy evidence-based medicine, where the evidence exists, and to generate that evidence where it is lacking. Proper protocols, pathways, and guidelines can help to eliminate some of the variability in decisionmaking, even if they do not affect physicians’ decisions in entirely linear and consistent ways,6Gabbay J. le May A. Evidence based guidelines or collectively constructed “mindlines”? ethnographic study of knowledge management in primary care.BMJ. 2004; 329: 1013-1016ACrossref PubMed Scopus (684) Google Scholar leading to better care for patients and making the health care system more efficient. How the Availability of Observation Status Affects Emergency Physician DecisionmakingAnnals of Emergency MedicineVol. 72Issue 4PreviewThis study seeks to understand how emergency physicians decide to use observation services, and how placing a patient under observation influences physicians’ subsequent decisionmaking. Full-Text PDF Decisionmaking in Emergency Medicine: Experienced-Based and Contextually Anchored Rather Than Evidence Based and UniversalAnnals of Emergency MedicineVol. 72Issue 5PreviewIn 2006, Sandhu et al1 called for researchers to undertake more studies to understand how emergency physicians make their decisions. The study by Wright et al2 sheds new light on this field of research in terms of the weight of experience and the role of context in decisionmaking. Full-Text PDF