Clinical decision-making in psychiatric emergency services (PES).

摘要

Prior research suggests that stereotypes and bias may affect psychiatric diagnoses and disposition decisions. Findings are variable concerning the role of patient sociodemographic characteristics in clinical decisionmaking. Research on clinician characteristics is sparse. According to social-psychological and cognitive theories, patient and clinician characteristics may influence clinicians' tendencies to stereotype, especially under conditions of limited time and high patient pressures. Cognitive load refers to the magnitude of demands imposed within specific time constraints and limitations that restrict the amount of available cognitive resources that can be dedicated to a particular task. This study investigated the effects of clinician and patient sociodemographic factors on Psychiatric Emergency Service (PES) decisions, made under high and low levels of cognitive load.;Patterns of decisionmaking were examined through retrospective record reviews of 1240 psychiatric patients, treated by 75 clinicians in an urban PES in the Mid-west, and interviews with a sub-sample of clinicians. Patient records were randomly sampled according to the clinician's level of cognitive load, controlling for the average number of patients typically seen and the actual volume of patients seen by the particular clinician during that shift.;Multinomial logistic-regression analyses replicated previous diagnostic trends with Black and male patients receiving higher rates of Psychotic Disorder, and White and female patients receiving higher rates of Bipolar Disorder. Results suggest that cognitive load may affect PES decisionmaking, especially the assignment of bipolar disorder, no psychiatric dispositions, and scheduled PES followups. Effects of patient gender and clinician gender, race/ethnicity, and professional experience were accentuated under cognitive load, over and beyond the effects of clinical factors. Contrary to chart-review results, interviewed clinicians emphasized patient clinical factors versus non-psychiatric factors as most important to their decisionmaking.;Past studies may have shown varying results because contextual factors, like cognitive load, were not controlled. When clinicians have heavy patient loads and are busy, social stereotypes may be more likely to influence their decisions---even outside the awareness and conscious intent of the clinician. Inappropriate clinical decisions may result in negative long-term effects on patients. Further examination of these factors is critical to the delivery of quality mental health care across all subgroups of patient populations.