SLO 2 – Support the ED team by answering clinical questions and making safe decisions

EM clinicians need to be expert decision makers. This Specialty Learning Outcome incorporates an understanding of the key steps in diagnostic reasoning, how clinicians make decisions and the factors that have a negative or positive impact on this fundamental skill. The trainee will develop an understanding of how to recognise and mitigate against cognitive errors that can cause harm and threaten patient safety. Good clinical knowledge remains key and the trainee will be able to apply the core principles of evidence based medicine to everyday clinical problems. This will extend to understanding how safe plans can be formulated, including deciding to discharge patients.

Domain 1: Professional values and behaviours

Domain 2: Professional skills:

• communication and interpersonal skills
• dealing with complexity and uncertainty
• clinical skills (history taking, diagnosis and medical management; consent; humane interventions; prescribing medicines safely; using medical devices safely; infection control and communicable disease)

Domain 3: Professional knowledge 

• professional requirements
• national legislation
• the health service and healthcare systems in the four countries

Domain 4: Capabilities in health promotion and illness prevention

Domain 5: Capabilities in leadership and teamworking

Domain 6: Capabilities in patient safety and quality improvement

• patient safety

Key ACCS capabilities

At completion of ACCS a trainee will:

• Understand how to  apply clinical guidelines
• Understand how to use diagnostic tests in ruling out key pathology, and be able to describe a safe management plan, including discharge where appropriate, knowing when help is required.
• Be aware of the human factors at play in clinical decision making and their impact on patient safety

Key EM capabilities

At completion of Intermediate training a trainee will be:

• able to support the pre-hospital, medical, nursing and administrative team in answering clinical questions and in making safe decisions for discharge, with appropriate advice for management beyond the ED. 
• aware of when it is appropriate to review patients remotely or directly

with Supervisor ‘on call’ from home for queries, able to provide directions via phone and able to attend the bedside if required to provide direct supervision

At completion of higher training a trainee will be:

• able to support the pre-hospital, medical, nursing and administrative team in answering clinical questions and in making safe decisions for discharge, with appropriate advice for management beyond the ED. 
• aware of when it is appropriate to review patients remotely or directly and able to teach these principles to others.

and would be able to manage with no supervisor involvement

ACCS descriptors

• Proficient in ECG and plain film interpretation, as relevant to acute care
• Aware of the cognitive psychology of decision making
• Understand basic diagnostic test methodology
• Understand the fundamentals of decision rule design
• Aware of the strengths and limitations of using guidelines e.g. NICE
• Demonstrate capabilities in dealing with complexity and uncertainty
• Share decision making by informing patients, prioritising patient’s wishes, and respecting their beliefs, concerns and expectations

Intermediate & Higher Descriptors 

All ACCS descriptors apply in intermediate and Higher training 

• Aware of the human factors at play in clinical decision making and their impact on patient safety
• Aware of key steps in diagnostic reasoning including

• • Cognitive processing and dual process theory – “how we make decisions”
  • The anchor and adjust heuristic
  • Factors that affect our decision making
  • How to use diagnostic tests effectively
  • How to make therapeutic decisions effectively for the benefit of individual patients

• Be competent in ECG, clinical image and biochemical assay interpretation 
• Understand diagnostic test methodology
• Be able to recognise and describe strategies to reduce the incidence of cognitive error
  • To include metacognition and cognitive debiasing techniques

• Be able to describe strategies for dealing with uncertainty. To include 

• • The use of pre and post-test probabilities 
  • Bayesian analysis 
  • Risk stratification or decision rule design
  • Use of guidelines

• The Emergency Physician should always demonstrate appropriate professional values and behaviours, supporting colleagues, respecting difference of opinion, and working as a collaborative member of a team

• Able to provide effective feedback on clinical reasoning and decision making