Managing Chaos: Lessons Learned From the Emergency Department

By: Teresa Chan, MD, FRCPC, MHPE

T. Chan is assistant professor, Division of Emergency Medicine, Department of Medicine, Michael G. DeGroote School of Medicine & Faculty of Health Sciences, and program director, Clinician Educator Area of Focused Competence Program, McMaster University, Hamilton, Ontario, Canada.

“We need a doctor in Resusc 1 STAT!”

“I’m worried that my child has an ear infection.”

“Dr. Chan, can you take a look at this ECG for Bed 8?”

“Doc, do you think I have cancer?”

In a single shift, I may hear all of these … and more. As an academic emergency physician (EP), I might see two dozen patients or more in a single 8-hour shift—and that is on a slower day! In my province of Ontario, our emergency care systems are constantly under pressure.

As a result, the emergency department (ED) is now well-known as a busy, chaotic environment, but is, by and large, the main portal for patients to enter into modern acute care hospitals. EDs are rife with complex and increasingly sick patients, and the modern EP is tasked with organizing care for many patients simultaneously.

The skill of managing the multiplicity of patients in a single ED, however, was a bit of a mystery to me. To be honest, I still recall one day in my final year of residency training when I looked at the ED tracker board and was struck by the realization that I knew all the details and plans for all 16 patients listed.

As medical students, we are taught the traditional case analytic method. You take a history, perform a physical exam, develop the “differentials,” and from that you generate an initial plan to arrive at a diagnosis and for subsequent management. This method served me very well in my first clerkship rotation (internal medicine) and continued to serve me well throughout my medical school training when I only had to manage one patient at a time. Then as a junior resident, I generally had to actively manage a small portfolio of 2–3 patients that I got to know really well. That process was hard: having to toggle between the needs of multiple patients at once meant that I had to make decisions between all of them and prioritize what things needed to be done by whom. Fascinated by my own educational experience, I decided to spend some time exploring the phenomenon of multi-patient environments for my thesis.1

Then, in our first paper on this topic, I explored how junior residents and attending physicians learned and taught, respectively, in multi-patient environments. We found that in busy environments, attendings tended to focus on macro-level issues around patient flow and ensuring the system was working well, while residents focused on the complexities of individual cases. Attendings also felt it was essential that junior residents demonstrate their ability to take care of smaller groups of patients well before they could effectively learn to coordinate care for many more patients simultaneously.

In our next paper, recently published in Academic Medicine, we explored the actual thinking processes of attending physicians and residents as they talked their way through setting priorities in a multi-patient environment. We discovered that the clinicians (even the most junior ones) read the triage notes and partial charts that were available to them to generate functional patient stories. These stories allowed them to organize and parse the information about each of the patients, and consequently allowed them to compare relative priorities and begin setting a list. Interestingly, like the chess masters who were studied by De Groot with a similar technique, the physicians we studied engaged in “chunking” to organize the information they were presented.

Putting both of our papers in context, the intuitive emphasis that attendings put on understanding each patient case well makes sense. As a junior trainee, it is important to build functional patient stories that allow one to understand how the various patients in play would “move” around our board. In contrast with chess, which has a finite number of pieces and moves, sick patients are always subtly different, and as such, it may take much more exposure to become aware of the more subtle differences between cases. However, learning to anticipate how a high-risk chest pain patient might differ from a low-risk chest pain patient or from a patient with abdominal pain would be critically important for junior trainees to master before they proceed on to managing multiple patients.

When managing multiplicity, however, it is important to know that this chunking phenomenon occurs as a necessary and adaptive step within multi-patient environments. To handle multiple patients, clinicians must chunk data to form new bundles of more easily memorizable information. This process, while necessary and adaptive for these complex environments may explain how or why certain types of cognitive errors may occur in busier situations.

And yet, to date, studies of diagnostic error and clinical decision-making have mostly focused on environments where clinicians are faced with single patients. We hope our work might help to provide more conceptual grounding for those interested in combatting diagnostic error and improving clinical decision-making.



  1. Chan T. What’s Next? Cognitive Task Analysis of Emergency Physicians’ Experience in Multi-Patient Environments [thesis]. Chicago, Ill: University of Illinois at Chicago; 2016. Available at and Accessed February 8, 2018.