T.M. Chan is assistant professor, Division of Emergency Medicine, Department of Medicine, Michael G. DeGroote School of Medicine, program director, Clinician Educator Area of Focused Competence program, and adjunct scientist, McMaster Education Research, Innovation and Theory (MERIT), McMaster University, Hamilton, Ontario, Canada; ORCID: 0000-0001-6104-462X. M. Mercuri is assistant professor, Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada. K. Van Dewark is clinical instructor, Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada. J. Sherbino is associate professor, Division of Emergency Medicine, Department of Medicine, Michael G. DeGroote School of Medicine, and assistant dean of education research, and director, McMaster Education Research, Innovation, and Theory (MERIT), McMaster University, Hamilton, Ontario, Canada. A. Schwartz is Michael Reese Endowed Professor of Medical Education, associate head, Department of Medical Education, and research professor, Department of Pediatrics, College of Medicine, University of Illinois at Chicago; ORCID: 0000-0003-3809-6637. G. Norman is professor emeritus, Department of Clinical Epidemiology Biostatistics, and founding member, Program for Education Research and Development, and scientist, McMaster Education Research, Innovation and Theory (MERIT), McMaster University, Hamilton, Ontario, Canada. M. Lineberry is director, Simulation Research, Assessment, and Outcomes, Zamierowski Institute for Experiential Learning, and assistant professor, Department of Health Policy and Management, University of Kansas Medical Center, Kansas City, Kansas.
Acad Med. 2018 May;93(5):786-793. doi: 10.1097/ACM.0000000000002081.
Emergency physicians (EPs) regularly manage multiple patients simultaneously, often making time-sensitive decisions around priorities for multiple patients. Few studies have explored physician cognition in multipatient scenarios. The authors sought to develop a conceptual framework to describe how EPs think in busy, multipatient environments.
From July 2014 to May 2015, a qualitative study was conducted at McMaster University, using a think-aloud protocol to examine how 10 attending EPs and 10 junior residents made decisions in multipatient environments. Participants engaged in the think-aloud exercise for five different simulated multipatient scenarios. Transcripts from recorded interviews were analyzed inductively, with an iterative process involving two independent coders, and compared between attendings and residents.
The attending EPs and junior residents used similar processes to prioritize patients in these multipatient scenarios. The think-aloud processes demonstrated a similar process used by almost all participants. The cognitive task of patient prioritization consisted of three components: a brief overview of the entire cohort of patients to determine a general strategy; an individual chart review, whereby the participant created a functional patient story from information available in a file (i.e., vitals, brief clinical history); and creation of a relative priority list. Compared with residents, the attendings were better able to construct deeper and more complex patient stories.
The authors propose a conceptual framework for how EPs prioritize care for multiple patients in complex environments. This study may be useful to teachers who train physicians to function more efficiently in busy clinical environments.
急诊医师（EP）经常同时管理多个患者，经常围绕多个患者的优先级做出时间敏感的决策。很少有研究探讨过医师在多患者情况下的认知。作者试图开发一个概念框架来描述 EP 在繁忙的多患者环境中是如何思考的。
2014 年 7 月至 2015 年 5 月，麦克马斯特大学进行了一项定性研究，使用出声思维协议来研究 10 名主治 EP 和 10 名初级住院医师如何在多患者环境中做出决策。参与者在 5 种不同的模拟多患者场景中进行出声思维练习。对记录访谈的转录本进行了归纳分析，由两名独立的编码员进行迭代过程，并在主治和住院医师之间进行比较。
主治 EP 和初级住院医师在这些多患者场景中使用类似的过程来确定患者的优先级。出声思维过程展示了几乎所有参与者都使用的类似过程。患者优先级排序的认知任务包括三个组成部分：简要概述整个患者群体以确定一般策略；对个人图表进行审查，参与者从文件中（即生命体征、简要临床病史）可用的信息中创建一个功能患者故事；并创建一个相对优先级列表。与住院医师相比，主治医生能够更好地构建更深层次和更复杂的患者故事。
作者提出了一个概念框架，说明 EP 如何在复杂环境中为多个患者确定护理优先级。这项研究可能对培训医生在繁忙的临床环境中更有效地工作的教师有用。
