Achieving RCEM SLO 2: Support the ED team by answering clinical questions & making safe decisions

 

Achieving RCEM Specialty Learning Outcome (SLO) 2: Support the ED team by answering clinical questions and making safe decisions

Executive Summary

This briefing document outlines the core principles and practical strategies for achieving the Royal College of Emergency Medicine (RCEM) Specialty Learning Outcome 2 (SLO 2): "Support the ED team by answering clinical questions and making safe decisions" (1). SLO 2 is a cornerstone of emergency medicine practice, demanding expert decision-making, a profound understanding of diagnostic reasoning, and an unwavering commitment to patient safety in a high-stakes environment.

Achieving this outcome involves a clear progression through training: from asking sound, evidence-based questions at the Core level, to practising without direct supervision in Intermediate training, and ultimately to a deep, communicable understanding of diagnostic reasoning by the end of Higher Specialty Training (HST). The Emergency Department (ED) is described as a "perfect storm for diagnostic error" due to its hectic pace, frequent interruptions, high cognitive load, and the inherent uncertainty of managing undifferentiated patients (2).

Effective clinical decision-making requires a paradigm shift from the traditional, diagnosis-focused "bottom-up" approach taught in medical school to a "top-down" methodology suited for the ED. This expert approach prioritises resuscitating the unstable and identifying dangerous conditions in others, asking "What does this patient need from us right now?" rather than "What does this patient have?" (3).

Mastery of SLO 2 hinges on understanding the cognitive science behind decision-making. This includes an appreciation of dual-process theory (fast, intuitive System 1 thinking vs. slow, analytical System 2), the numerous cognitive biases that can lead to error, and the limitations of simply trying to "be more mindful" (4, 5). While individual metacognition is valuable, evidence suggests that systemic improvements, the use of cognitive aids like checklists, and strategies to build expertise and manage cognitive load are more effective at mitigating error (6, 7). This document synthesises these concepts, providing practical frameworks, mnemonics, and evidence-based strategies to develop and demonstrate competence in SLO 2.

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1. Understanding RCEM SLO 2

SLO 2 is designed to ensure clinicians develop into expert decision-makers who can navigate clinical uncertainty, apply evidence-based principles, mitigate cognitive errors, and formulate safe management and disposition plans (1).

1.1. Progression Through Training

The capabilities required for SLO 2 develop incrementally throughout training, with specific entrustment decisions made at key stages.

Training Stage	Key Capabilities & Entrustment Decisions
End of Core Training (Level 2b)	- Not yet entrusted to answer clinical questions independently.<br>- Must be entrusted to ask questions based on sound principles of diagnostic methodology, cognitive bias, and the application of decision rules and guidelines.
End of Intermediate Training (Level 3)	- Must be able to practice without direct supervision in this activity.<br>- Support is available from a consultant by phone.<br>- Must demonstrate awareness of limitations, with a faculty entrustment statement attesting to readiness.
End of HST (Level 4)	- Must demonstrate a profound understanding of diagnostic reasoning and its application in the ED.<br>- Must be able to communicate and teach key principles to others.<br>- Markers of excellence include a readiness to adapt and develop these skills.

1.2. Demonstrating Competency

Competency in SLO 2 is demonstrated through a combination of formative workplace-based assessments (WPBAs) and summative examinations. Reflection on clinical encounters where decision-making was challenging is highly valued (2).

• Formative Evidence: CbD, ESLE, FEG, RCEM App, ACAT, MCR (AM), Mini-CEX, MSF.
• Summative Assessment:
  • MRCEM: SBA, OSCE
  • FRCEM: SBA, MSO

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2. The Emergency Medicine Mindset: A Paradigm Shift

The fundamental role of the Emergency Physician is not to provide a definitive diagnosis for every patient. Many patients will leave the ED without one, as the primary focus is on resuscitation, identifying dangerous conditions, and appropriate resource management (2). This requires a shift in thinking from the traditional medical model.

2.1. From "Bottom-Up" to "Top-Down" Thinking

Dr. Reuben Strayer contrasts the traditional medical school approach with the expert emergency medicine approach (3):

• Bottom-Up Approach (Medical School): This method involves a comprehensive history, a thorough head-to-toe exam, generation of a lengthy differential diagnosis, and sequential testing to arrive at a final diagnosis. This is often inefficient and inappropriate for the time-sensitive and unstable nature of ED patients.
• Top-Down Approach (Emergency Medicine): This expert approach is driven by the question: "What does this patient need from us right now?". It focuses on a limited menu of relevant interventions and dangerous differential diagnoses applicable to the patient at hand. Your job is to resuscitate patients who need it and identify dangerous conditions in the rest (3).

2.2. The Top-Down Toolkit

This model is built on two core concepts that focus attention on what is most critical in the ED (3):

1. The Wheel of Dangerous Conditions: This represents all conditions that can cause harm in the near term. For any given presentation (e.g., headache, chest pain), the clinician’s task is to use a focused, "knife-like" history and physical exam to sequentially cut away the slices of this "cake," ruling out the relevant dangerous conditions until only benign possibilities remain.
2. The Interventions Wheel: This encompasses every test, procedure, and medication routinely used in the ED. For the sickest patients, such as those in cardiac arrest, care is driven primarily by this wheel (e.g., chest compressions, electricity, epinephrine) before the "dangerous conditions" wheel (the H's and T's) is fully considered.

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3. The Science of Clinical Reasoning and Diagnostic Error

The ED environment—with its high decision density, frequent interruptions, and cognitive overload—is a "natural laboratory of error" (8). Understanding the cognitive processes that underpin decision-making is essential to mitigating this risk.

3.1. Dual-Process Theory: System 1 vs. System 2

The dominant theory of cognition posits two distinct systems of thinking (9):

• System 1 (Thinking Fast): This is an intuitive, unconscious, and rapid process that relies on heuristics (mental shortcuts) and pattern recognition. It is the default mode of thinking and accounts for approximately 95% of decisions (10). While essential for efficiency, it is prone to cognitive biases and errors.
• System 2 (Thinking Slow): This is a conscious, analytical, and deliberate process. It is slow, requires significant effort, and is generally considered less prone to error.

Expert practice involves a fluid interplay between these systems. Heuristics and pattern recognition are vital for expert resuscitationists, but an over-reliance on System 1 without checks from System 2 can lead to diagnostic failure, particularly in cases with atypical presentations or confounding data (5).

3.2. Cognitive Biases in the ED

Cognitive biases are predictable, systematic errors in cognition. The ED is a "perfect storm" for these biases to manifest (2). Being aware of them is the first step toward mitigation, but simply knowing about them does not confer immunity (the Blind-spot bias) (11).

Common Cognitive Bias	Description & ED Example
Anchoring	Prematurely settling on a diagnosis based on initial information and failing to adjust as new data emerges. E.g., A triage note of "anxiety" leads the clinician to discount new signs of hypoxia.
Availability Heuristic	Judging the likelihood of a disease by how easily examples come to mind (e.g., recent cases, emotionally charged cases). E.g., After missing a pulmonary embolism (PE), a clinician over-investigates low-risk patients for PE (12).
Confirmation Bias	Seeking or interpreting evidence in ways that confirm pre-existing beliefs, while ignoring contradictory evidence. E.g., Focusing on pleuritic pain to confirm costochondritis while discounting a new tachycardia.
Premature Closure	Accepting a diagnosis before it has been fully verified. "When the diagnosis is made, the thinking stops." E.g., Finding pneumonia on a chest X-ray and failing to consider a concurrent PE.
Diagnosis Momentum	Once a diagnostic label is applied by others (e.g., triage, EMS), it becomes difficult to remove. E.g., A patient labelled "drunk" is not assessed for a head injury.
Search Satisfaction	The tendency to stop searching once something has been found. E.g., Identifying a distal radius fracture and missing a concurrent scaphoid fracture on the same X-ray.
Base Rate Neglect	Ignoring the true prevalence of a disease when making a diagnosis. E.g., Routinely investigating for rare "zebra" diagnoses in low-risk populations.
Zebra Retreat	Backing away from a rare diagnosis only because it is rare, even when it fits the clinical picture. The opposite of base rate neglect.

3.3. Implicit Bias

Implicit biases are unconscious attitudes or stereotypes that affect our understanding, actions, and decisions. They are a product of our genetics, environment, and experiences, creating "blindspots" we are often unaware of (13).

• Impact on Care: Healthcare providers demonstrate the same levels of implicit bias as the general population, which can influence diagnosis and treatment, leading to disparities in care for marginalised populations (e.g., non-white patients receiving fewer pain medications) (13).
• Recognition: Identifying one's own biases is difficult but critical. A useful exercise is to reflect on one's "in-group" (close non-family members) and note how similar they are across categories like age, race, and socioeconomic status. Gaps may reveal potential blindspots. Another strategy is to listen to one's own emotional reactions (e.g., frustration with a language barrier) as a cue to apply a "second filter" to decision-making (13).

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4. Strategies for Improving Decision-Making and Mitigating Error

While cognitive science offers a framework for understanding error, the evidence for many "de-biasing" techniques is limited or mixed (7, 14). Research suggests that strategies focusing on systemic improvements, building expertise, and managing cognitive load are more effective than simply trying to consciously override bias (6).

4.1. Individual Strategies: Metacognition and Practical Tools

Metacognition, or "thinking about your thinking," involves actively examining and reflecting on the decision-making process. While mindfulness alone is an insufficient solution (6), structured cognitive tools can be helpful.

• Cognitive Forcing Strategies: These are deliberate checks designed to trigger System 2 thinking.
  • SPOT Dx Method (2): A structured approach for refining the ED workup.
    • Serious: Must-not-miss diagnoses requiring immediate consideration.
    • Probable: The most likely diagnoses.
    • Outliers: What fits? What doesn't? What else could it be?
    • Time out: A cognitive pause to consider biases (e.g., HALT - Hungry, Angry, Late, Tired) and sources of error.
  • SPIT Differential Diagnosis (4): Expands the differential to avoid premature closure.
    • Serious
    • Probable
    • Interesting
    • Treatable
• Routine Questions: Incorporate a simple checklist into every encounter: "What else can this be? Is there anything that doesn't fit? Do I need to slow down?" (4).
• Cognitive Stop Points: Develop a routine of pausing to reflect at critical junctures, such as before ordering major investigations, before disposition, and during patient handovers (4).

4.2. Systemic and Expertise-Based Strategies

The most effective interventions are often systemic changes that make it easier for clinicians to do the right thing (6).

• Cognitive Aids: These are external tools that reduce cognitive load and prompt memory recall. They emerged from high-reliability organisations like aviation (15).
  • Checklists: Prevent errors of omission (e.g., Surgical Safety Checklist, intubation checklist). They should be designed with minimalist principles, containing only essential information (15).
  • Emergency Manuals: Contain guideline-based protocols for crises. They are designed to be used in real-time by a delegated "reader," offloading the team leader and improving team performance (15).
• Managing Cognitive Load: The ED is an environment of high decision density and frequent interruptions, which overloads working memory and increases error rates (14). Strategies to manage this include:
  • Offloading Tasks: Write things down ("write more, remember less"), use lists, and delegate appropriately (14, 16).
  • Avoiding Task Switching: Complete tasks sequentially ("one patient at a time") where possible (14, 16).
  • Planning for Negatives: At the initial encounter, anticipate the plan for negative test results. This is when you are thinking most clearly about the patient (3, 16).
• Improving Expertise and Feedback: Diagnostic error is often linked to a lack of readily accessible knowledge or experience (14).
  • Routine Feedback: The key to improving judgement is regular, routine feedback on "normal flight," not just on "crashes" (adverse events) (17). Trainees should actively seek this by reviewing discharge summaries and lab results for their patients 4-6 weeks after the ED visit (18).
  • Peer Review: Working alongside colleagues provides an opportunity for direct observation and feedback (17).
  • The Vigilance Pendulum: A poor outcome increases vigilance and testing for a specific diagnosis. After many negative tests, vigilance wanes. With experience, the magnitude of these swings diminishes as practice becomes better calibrated (18).

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5. Practical Application: Documentation, Disposition, and Planning

Applying these principles culminates in safe and effective patient management plans.

5.1. Formulating and Documenting the Plan

Documentation should serve communication and risk management, not just billing. The primary goal is to "buff your brain, not the chart" by using documentation as a tool to clarify thinking (18).

• Real-time Documentation: Document immediately after seeing a patient to improve accuracy and as part of the workflow. Deferring documentation until the end of a shift is a bad practice (3, 16).
• Documenting Rationale: Explicitly state the reasoning for pursuing or not pursuing specific pathways. Be careful with assigning specific benign diagnoses (e.g., costochondritis, migraine); do not convey more certainty than you have (3, 18).
• DdAVIDds Mnemonic (2): A mnemonic to structure a comprehensive plan.
  • Drugs
  • diet
  • Activity
  • Vitals
  • Investigations/Interventions
  • Disposition
  • dNACPR/TEP
  • social/Safeguarding

5.2. Safe Disposition Planning

Decisions to admit or discharge are a core responsibility and a major source of risk.

• HOME Safe? Mnemonic (2): A checklist for safe discharge.
  • Health literacy (does the patient understand?)
  • Organise follow-up
  • Medications
  • Explanation & Advice/Red flags understood
  • Safe: Social/Safeguarding issues considered
• Frameworks for Uncertainty:
  • The 2-10% Rule: For a dangerous condition, if the pre-test probability is <2%, the harms of testing likely outweigh the benefits. If it is >10%, the test should be ordered. The 2-10% "plaintiff's gap" is where shared decision-making is key (18).
  • Preferred Error: Consider which potential error—overtreatment versus undertreatment—would result in less harm to the patient. Choose the course of action that "fails better" (18).

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6. Resources for Ongoing Learning

Continuous learning is required to develop and maintain the skills for SLO 2.

• RCEMLearning: The RCEM provides numerous learning sessions, SBAs, SAQs, and clinical cases directly mapped to SLO 2 and its descriptors (19).
• Further Resources:
  • Blogs/Podcasts: St. Emlyn's, First10EM, LITFL, EM Cases, EMOttawa Blog, The Clinical Problem Solvers.
  • Checklists/Schemas: Resources are available from institutions such as the University of Toronto (pie.med.utoronto.ca) and the University of Calgary (blackbook.ucalgary.ca) (2).
  • Local Resources: Familiarity with local guidelines (e.g., ExED) and referral pathways (e.g., HUB) is essential for efficient and safe patient management (2).

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References

1. Royal College of Emergency Medicine. SLO 2 – Support the ED team by answering clinical questions and making safe decisions - RCEMCurriculum [Internet]. 2019 [cited 2024 Jul 15]. Available from: https://rcemcurriculum.co.uk/slo-2/
2. Excerpts from "Achieving RCEM Specialty Learning Outcome 2.pdf".
3. Strayer R. Dr. Reuben Strayer - Emergency Thinking [Internet]. Emergency Medicine London; 2015. Available from: YouTube.
4. Morgenstern J. Cognitive errors in medicine: Mitigation of cognitive errors. First10EM [Internet]. 2015 Sep 21 [cited 2024 Jul 15]; Available from: https://first10em.com/2015/09/21/mitigation-of-errors/
5. Morgenstern J. Cognitive theory in medicine: A brief overview. First10EM [Internet]. 2015 Sep 14 [cited 2024 Jul 15]; Available from: https://doi.org/10.51684/FIRS.736
6. Douros G. The trouble with mindfulness [Internet]. LITFL • Life in the Fast Lane Medical Blog. 2020 [cited 2024 Jul 15]. Available from: https://litfl.com/the-trouble-with-mindfulness/
7. Morgenstern J. Cognitive theory in medicine: Some problems. First10EM [Internet]. 2015 Sep 22 [cited 2024 Jul 15]; Available from: https://doi.org/10.51684/FIRS.742
8. Croskerry P. ED cognition: Any decision by anyone at any time. CJEM. 2014;16(1):13–9.
9. Kahneman D. Thinking, Fast and Slow. New York: Farrar, Straus and Giroux; 2011.
10. May N. When is a Door Not a Door? Bias, Heuristics & Metacognition [Internet]. St.Emlyn’s. 2017 [cited 2024 Jul 15]. Available from: https://www.stemlynsblog.org/when-is-a-door-not-a-door/
11. Morgenstern J. Cognitive errors in medicine: The common errors. First10EM [Internet]. 2015 Sep 15 [cited 2024 Jul 15]; Available from: https://doi.org/10.51684/FIRS.726
12. Morgenstern J. Decision Making in Emergency Medicine: Availability Bias. First10EM [Internet]. 2022 Mar 7 [cited 2024 Jul 15]; Available from: https://doi.org/10.51684/FIRS.125778
13. Syed S. Healthcare’s Implicit Bias Problem [Internet]. EMOttawa Blog. 2022 [cited 2024 Jul 15]. Available from: https://emottawablog.com/2022/03/healthcares-implicit-bias-problem/
14. McKinney M, Malette J. Reducing Diagnostic Errors: Using Cognitive Science [Internet]. EMOttawa Blog. 2021 [cited 2024 Jul 15]. Available from: https://emottawablog.com/2021/05/diagnostic-errors-what-cognitive-science-has-to-say/
15. Borshoff D. Cognitive Aids in Healthcare [Internet]. LITFL • Life in the Fast Lane Medical Blog. 2021 [cited 2024 Jul 15]. Available from: https://litfl.com/cognitive-aids-in-healthcare/
16. Helman A, Weingart S, Betzner M, Strayer R. Ep 200 How EM Experts Think: Strategies for Pre-Shift, Arrival Ritual, Staying Focused, Managing Interruptions, Cognitive Load & Negative Emotions, Resuscitation Mindset, Post-Resuscitation Recovery [Internet]. Emergency Medicine Cases. 2024 [cited 2024 Jul 15]. Available from: https://emergencymedicinecases.com/how-the-em-experts-think-part-1/
17. Carley S. Making good decisions in the ED. #RCEM15 #EuSEM15 [Internet]. St.Emlyn’s. 2015 [cited 2024 Jul 15]. Available from: https://www.stemlynsblog.org/making-good-decisions-in-the-ed-rcem15/
18. Helman A, Weingart S, Betzner M, Strayer R. Ep 201 How EM Experts Think Part 2: Data Gathering, Diagnostic and Treatment Decision Making, Test Ordering and Interpretation, Documentation, Emotional Resilience [Internet]. Emergency Medicine Cases. 2025 [cited 2024 Jul 15]. Available from: https://emergencymedicinecases.com/how-em-experts-think-part-2/
19. RCEMLearning. SLO2 Archives - RCEMLearning [Internet]. [cited 2024 Jul 15]. Available from: https://www.rcemlearning.co.uk/curriculum/slo2/

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