Bounded rationality in the emergency department.

摘要

This research aimed at understanding bounded rationality---that is, how simple heuristics result in satisfactory outcomes---in a naturalistic setting where agents have to meet environmental demands with limited resources. To do so, two methodological approaches were taken, an observational and an experimental study of U.S. emergency physicians who have to provide a satisfactory level of care while simultaneously coping with uncertainty, time and resources constraints. There are three major findings. First, based on observations of 12 resident and 6 attending physicians at two Midwestern emergency departments (ED), ED physicians use at least two general heuristics. One heuristic exploits symptom-disease relationships with the goal to rule out 'worst cases' that would require immediate medical attention. The other heuristic aims at identifying diseases that are commonly associated with a set of symptoms. Thus, whereas the former heuristic emphasizes medical safety by aiming at identifying even unlikely 'worst cases,' the latter stresses efficiency by aiming at separating typical worst from common benign cases to allocate resources appropriately. Second, the selection of general heuristics is situated in an environmental context. This context is reflected in epidemiological constraints that delimit the range of patients' potential medical problems as well as sociocultural constraints that delimit the range of potential, desirable, or required care solutions. ED physicians' exploit these constraints to actively (re)formulate the problem to-be-solved and select strategies that satisfy requirements for safe and efficient care. Third, based on observations and data from 39 clinicians-in-training who participated in the experimental study, emergency care delivery is the solution of medical problems in a socially dynamic setting. ED physicians aim at understanding their patients' needs and circumstances to obtain salient information about potential (medical) problems and, ultimately, adapt the selection of general heuristics to a particular situation/patient. Thus, a caring attitude and safe and effective emergency care are not contradictory but dynamically intertwined. The descriptive-exploratory methodology chosen does not allow conclusive statements. However, findings point to promising avenues for future research such as the impact of sociocultural constraints on the selection of safe and efficient care strategies or the clinical relevance of the social connection between patient and physician.