Pattern recognition in the ER

February 24, 2010

ER doctors (and nurses) rely on pattern recognition to practice the type of medicine that is forced upon us when we take control of 75 patients all crammed into a space designed to hold 48 (with another 30 in the waiting room).

ER doctors (and nurses) rely on pattern recognition to practice the type of medicine that is forced upon us when we take control of 75 patients all crammed into a space designed to hold 48 (with another 30 in the waiting room).

As Malcolm Gladwell described in his wonderful book “Blink,” good ER physicians develop reliable intuitive senses regarding the myriad ways that different diseases can present in different people and subconsciously search for patterns that guide clinical judgment. Many times, ER physicians “blink” instead of “think” (although I like to believe that we spend an awful lot of time thinking) and we learn to rely on and to trust our clinical judgment and our ability to recognize subtle patterns while caring for our patients.

What becomes really difficult to do over time, is to not bring that habit home and begin making instantaneous judgments about our spouses, our families, friends, and neighbors.

I can recall many times that I’ve been introduced to someone outside of the ER and my first thought is, “My gosh, this guy is a tool. I bet he loves to watch grass grow, believes in global warming, and picks at mosquito bites until they bleed.” All that from a handshake and a “How do you do!” I genuinely feel sorry for any guy that my daughter brings home (I’ve got a couple of years before that becomes a serious concern) because the guy has about 11 seconds to convince me that I shouldn’t squeeze his head like a zit.

Pattern recognition is an inexact science and some are better at it than others. As a resident I used to think, “I can smell diabetes as soon as I walk in a room.” That’s not really true, I can’t “smell” diabetes, but I learned pretty quickly how to recognize the subtle clues of poorly controlled occult diabetes that might escape a non-emergency medicine trained or less astute clinician; the sticky film of sweat on the back of the neck, the two or three soft drinks consumed while waiting for me to get in the room, obesity, the general state of being unkempt and sloppy (because the constant interruptions to the daily routine caused by the disease do not allow for meticulous grooming), the thin film of greasy sheen under the eyes. There is no science behind this – these are observations that I’ve made over the course of a 15-year career in emergency medicine and caring for dozens of patients that have not yet received the diagnosis of diabetes mellitus.

During emergency medicine residency, the young physician is trained to do amazing things. One colleague told me that when he graduated residency, he believed he could sew somebody’s head back on (he has since modified his own inflated sense of his abilities). One of the most valuable things we can teach young ER physicians is to apply their intuitive ability to “blink” instead of “think” correctly, because, according to Gladwell, good clinicians are more often than not correct in their “snap judgments” which can probably lead to less testing, less time wasted, and less cost to the healthcare system. A good “blink” reflex comes in handy outside the ER when dealing with salesmen, auto mechanics, and (especially) lawyers.

What is not so easy to learn is how to turn off the “blink” and getting to know friends and acquaintances outside of the ER on a deeper level. Forming opinions of people with little or no exposure to them is not a great way to develop long-lasting and meaningful relationships.