The cognitive imperative: Thinking about how we think

There are three domains of expertise required for consistently effective performance in emergency medicine (EM): procedural, affective, and cognitive. Most of the activity is performed in the cognitive domain. Studies in the cognitive sciences have focused on a number of common and predictable a biases in the thinking process, many of which are relevant to the practice of EM. It is important to understand these biases and how they might influence clinical decision-making behavior. Among the specialities, EM provides a unique clinical milieu of inconstancy, uncertainty, variety, and complexity. Injury and illness are seen within narrow time windows, often under pressured ambient conditions. These operating characteristics force practitioners to adopt a distinctive blend of thinking strategies. Principal among them is the use of heuristics, a form of abbreviated thinking that often leads to successful outcomes but that occasionally may result in error. A number of opportunities exist to overcome interdisciplinary, linguistic, and other historical obstacles to develop a sound approach to understanding how we think in EM. This will lead to a better awareness of our cognitive processes, an improved capacity to teach effectively about cognitive strategies, and, ultimately, the minimization or avoidance of clinical error.