Worse still, young physicians train in this environment. They are taught to trust the algorithm more than their instincts and to defer to the checklist rather than engage in clinical reasoning. Residency programs and medical schools increasingly prioritize protocol adherence over critical thinking, preparing doctors to function within a system that values uniformity over insight. The future of emergency medicine risks being populated by physicians and other health care providers who may excel at following orders but lack the skill to adapt to novel situations and make decisions under uncertainty.
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ACEP Now: Jan 01Patients Have Unique Needs
The rise of protocolization is not merely a shift in medical practice; it is a dehumanization of the profession of medicine. The physician–patient relationship is inherently personal, grounded in the physician’s ability to assess, adapt, and apply expertise to the individual under their care. Protocols treat patients as datapoints in a flowchart, not as human beings with unique needs. Although these guidelines can be helpful in clear-cut cases, they fall apart in the face of the complex, the unusual, or the unexpected—precisely the cases that make emergency medicine a vital and challenging specialty.
Emergency medicine’s roots are in the messy, the unpredictable, and the life-threatening. It is in these moments that a physician’s critical thinking and autonomy are paramount; it is where the loss of these skills is most felt. Protocols will never replace the clinician who recognizes that a patient with vague chest tightness and no other clear symptoms is actually having a silent myocardial infarction or a trauma patient who does not need a reflexive CT pan scan. An algorithm will not pick up on the subtle signs of sepsis in a patient who presents atypically. These moments, the ones that define medicine, risk disappearing in a sea of checkboxes and flowcharts.
Commit to Critical Thinking
It’s time to stop this slide toward medical mediocrity. Emergency physicians must reclaim their autonomy, resist the push for over-reliance on protocols, and reignite their commitment to critical thinking. Protocols are tools, not masters, and physicians must be trusted to exercise their expertise rather than merely follow a script. Health care administrators and policymakers must also recognize the danger in reducing medicine to a set of standardized procedures, understanding that true quality care comes not from mindless adherence to guidelines, but from empowering clinicians to think, adapt, and act.
If this trend is not reversed, the consequences will be dire. Emergency departments will become conveyor belts of impersonal care, churning out treatments that may be “correct,” according to the protocol, but wholly inadequate for the individual. Patients will suffer, and the field of emergency medicine will lose its soul.
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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”!