In recent years, emergency medicine, once the bastion of quick decision making, clinical acumen, and patient-centered care, has been quietly succumbing to a different force—the slow but steady erosion of critical thinking. The culprit is the increasing reliance on protocolization and the diminishing autonomy of emergency physicians. This shift, intended to standardize care and mitigate error, is paradoxically undermining the very heart of medicine—the doctor’s ability to think critically, adapt to each patient’s unique needs, and make nuanced decisions.
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ACEP Now: Vol 44 – No 01 – January 2025At the core of the issue is the rise of clinical protocols, the rigid, step-by-step algorithms designed to guide physicians through nearly every conceivable situation. What began as a tool to aid clinicians and reduce variability has ballooned into a crutch, now threatening to replace the practice of medicine itself. Protocols have become the rule, not the guide, and their overuse fosters a dangerous mindset where blind adherence is favored over thoughtful consideration.
Emergency Medicine Is Not Routine
Although standardization has its place—particularly in ensuring consistency in routine or straightforward cases—emergency medicine is anything but routine. The essence of the field lies in its unpredictability. Every patient who walks (or is wheeled) through the door is a puzzle of human complexity. A one-size-fits-all approach cannot possibly account for the nuanced presentations of disease, the varied human responses to illness, or the subtle interplay of comorbidities, age, and lifestyle. Yet, the current culture of emergency medicine increasingly values the clinician who adheres to protocol over the one who exercises gestalt and clinical judgment. The result is a generation of physicians who are losing the ability, or worse, the desire, to think critically.
The argument in favor of protocolization is not without merit. Proponents argue that it reduces medical errors, decreases variability in patient care, and creates a safety net for less experienced clinicians. However, the cost of this safety net is mounting; it strips away physician autonomy and dilutes their role to that of a technician following orders rather than a trained professional making lifesaving decisions. The art of medicine—the intuitive, informed choices that differentiate a good doctor from a great one—is being lost.
Erosion of Autonomy
The erosion of autonomy is evident in how physicians are now viewed, both by administrators and even by themselves. The shift toward corporate-driven health care models has emphasized efficiency, cost effectiveness, and throughput, reducing physicians to cogs in a larger machine. In this system, there is little room for innovation or deviation from the established protocol. Physicians are encouraged, explicitly or implicitly, to comply with rigid guidelines, fearing retribution for stepping outside these parameters—even when clinical judgment tells them otherwise. The result is not better care but rather care that is often impersonal, mechanical, and, at times, dangerously inadequate for complex cases.
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6 Responses to “The Death of Critical Thinking in Emergency Medicine”
January 5, 2025
Norman BorlaugIs there a reference list for this article? The author makes what would be some excellent points, but without any citations it reads like an alarmist screed devoid of any supporting evidence about practice concerns that may only exist within the author’s system and/or may not be generalizable outside of Texas.
January 19, 2025
Paul Robinson MD, PhDIn my experience, this article is spot on. I have worked in emergency departments in Florida in which the physicians did not take histories or do physical exams. These critical endeavors were the bailiwick of the nursing staff. The physicians spent their time at desks following protocols and writing admitting orders on patients they did not understand. Their primary responsibility was to assure that data collection proceeded as the nursing and administrative staff dictated. Thus do physicians become glorified clerks.
January 19, 2025
Ian Staker“Emergency departments will become conveyor belts of impersonal care, churning out treatments.”
I wholeheartedly agree with the author, but sadly the ship has sailed on this one. My department (staffed by a medium sized democratic group) has a chest pain pathway. If I deviate from it and a patient has a bad outcome, I guarantee the first question raised in any peer review or lawsuit will be “does your department have a pathway for chest pain, and if so, did you follow it?”
So 25 year olds with chest pain get blanket troponin testing and anyone over age 50 with chest pain gets a d-dimer. Patient suffer, and emergency medicine loses its soul.
January 19, 2025
Ricardo MartinezI appreciate Dr Baker’s thoughts; we don’t want to be cogs in a machine and yes, critical thinking is very important. He may not remember why we rebuilt emergency medical care for time-sensitive conditions.
EM docs used to be the highest-paid ward clerks in the hospital – calling the cardiologist on call, for example, to see how they wanted to handle an MI that we diagnosed. Our job was to call for and assemble the resources. Cardiology would come to the ED when they got around to it. It took hours.
Each cardiologist also felt that clinical pathways/protocols were terrible, and each sought to make independent, autonomous decisions for EM to carry out. It was frustrating at best, with delays and constant variation. It was also not evidence-based.
There aren’t 40 “best ways” to care for stroke, MI, asthma, etc. so we learned to put aside our desire for autonomy and instead act as a team focused on the patient. Putting that approach in place has improved the timeliness and effectiveness of care. Everyone knows the game plan, and resources come to the patient or are available in a timely manner. The EM physician is the Captain of the ship until handed off
Similarly, it used to be that emergency physicians in the same ED each cared for patients differently, according to varied training and personal preferences. Patients with similar conditions had highly varied workups and treatments changed every shift depending upon who was working.
I appreciate Dr Baker’s thoughts on ensuring that EM physicians retain and apply critical thinking and remind our colleagues that we developed evidence-based pathways and protocols with intention. If there are reasons to deviate, then that is a professional obligation and under the purview of the EM physician.
January 19, 2025
Matthew LiptonExcellent article. I fully agree!! This lack of critical thinking is leading to the insane overuse of CT scans too.
January 20, 2025
Thomas H. Matese JrDr. Baker, as an EM residency PD I could not agree with you more, anecdotal evidence as it may be….However, in our program we spend considerable time and effort teaching our learners the curriculum of critical thinking and clinical reasoning so as to prepare them for those times when the electricity goes out and they have to “sink to the level of their training”!