MEdIC: Case of Cognitive Overload – Expert Review and Curated Community Commentary


cognitive overloadThe Case of Cognitive Overload outlined a scenario of a junior resident dealing with the harsh realities of working in emergency medicine when she experiences the negative impacts of cognitive overload while caring for a sick patient. This month, the MEdIC team (Tamara McColl, Teresa Chan, Sarah Luckett-Gatopoulos, Eve Purdy, John Eicken, and Brent Thoma), hosted a discussion around this case with insights from the ALiEM community. We are proud to present to you the Curated Community Commentary and our 2 expert opinions. Thank-you to all participants for contributing to the very rich discussions surrounding this case!

MEdIC Series

This follow-up post includes:

  • Responses from our solicited experts:
    • Dr. Amy Walsh is an emergency physician as well as the Global Emergency Medicine Fellowship Director at Regions Hospital in St. Paul, MN.
    • Dr. Jimmie Leppink is a postdoctoral researcher in education and is also a statistician at the School of Health Professions Education, Maastricht University, the Netherlands.
  • A summary of insights from the ALiEM community derived from the Twitter and blog discussions
  • Freely downloadable PDF versions of the case and expert responses for use in continuing medical education activities
Expert Response 1: Cognitive Overload and Communication Breakdown (Dr. Amy Walsh)
Expert Response 1: Addendum from Dr. Walsh & her father
Expert Response 2: Check, Communicate, and Check Again (Dr. Jimmie Leppink)
The Case of Cognitive Overload: Curated from the Community (Dr. Sarah Luckett-Gatopoulos)

Case and Responses for Download

Click here (or on the picture below) to download the case and responses as a PDF (882 kb).

Tamara McColl, MD FRCPC MEd(c)

Tamara McColl, MD FRCPC MEd(c)

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba
  • amywalsh

    My dad, Bob Walsh, who spent his career in nuclear power, had some interesting thoughts on the case as well, so I thought I’d share them here.

    You mentioned in your response when the ER is busy there is “a balance between efficiency and error prevention”. We were taught in Nuclear Power that when it came to Nuclear Safety human error was unacceptable. I am not sure that all human error is preventable but that is what was drilled into us.

    This philosophy morphed into if you are following procedures you can not make human errors. Again I think that can be taken to an extreme which lead to problems just as bad as human errors. It got to the point where technicians did not think about what they were doing they just followed the procedure. If the investigation found they followed the procedure, they had done nothing wrong. This reinforced that way of thinking.

    Anyway, I do not think the issue is balance between efficiency and error prevention. I think the issue is whether the condition that brought the person to the ER can wait on a thorough troubleshooting process or does something need to be done now or the condition will worsen.
    In my mind the ER Doctors sometimes need to make decisions based on the information they have, They cannot always wait for all the information they need to make an informed decision.
    Once the decision is made, the process should ensure the risk of Human Errors is minimized.

    Some of the techniques we used that could be applicable to you are:
    Briefing-once the decision is made, brief the involved staff.
    1. Patient condition
    2. Explanation of required treatment
    3. Expected results of required treatment
    4. Expectations for being notified
    5. Determine parameters to me monitored and determine thresholds for further action
    6. Discussion of what is the worst thing that can happen and any mitigating actions
    7. Discuss any actions that require Independent or ConcurrentVerification
    Three-Way Communication
    All communication between doctors and staff should be three way.
    In the case of doctors giving orders the doctor should explain what is expected, the nurse should repeat what the doctor said and then the doctor should confirm the nurse is correct or clarify the order based on what the nurse said.
    All staff performing an activity that will impact the health of a patient should use STAR
    Stop a moment to think about what you are about to do
    Think about what you are about to do an about how you are going to do the task.
    Act according to the plan you developed
    Review what you did to ensure the desired results were obtained
    Post Job Review for critical task
    Review the critical task with everyone involved
    Discuss what went right and what you need to do to ensure it is always a good result
    Discuss what went wrong and discuss what you need to do to prevent a bad result.
    Determine if any of the lessons learned need to be institutionalized.

    There is also the “expert complex” doctors need to deal with. In some cases doctors don’t want to hear feedback on orders. In other cases staff is afraid to give feedback on the orders because the doctor is the expert. The doctor and staff need to be receptive to providing and receiving feedback. If there is disagreement the doctor wins but the discussion will at least ensure the doctor has considered alternatives.

    • Wow Amy! Your dad’s response should be put in the expert peer review. I will speak to Tamara about putting it in along yours maybe??