Wright State University CORE Scholar Browse all Theses and Dissertations Theses and Dissertations 2009 Bounded Rationality in the Emergency Department Markus Alexander Feufel Wright State University Follow this and additional works at: https://corescholar.libraries.wright.edu/etd_all Part of the Industrial and Organizational Psychology Commons Repository Citation Feufel, Markus Alexander, "Bounded Rationality in the Emergency Department" (2009). Browse all Theses and Dissertations. 949. https://corescholar.libraries.wright.edu/etd_all/949 This Dissertation is brought to you for free and open access by the Theses and Dissertations at CORE Scholar. It has been accepted for inclusion in Browse all Theses and Dissertations by an authorized administrator of CORE Scholar. For more information, please contact [email protected]. BOUNDED RATIONALITY IN THE EMERGENCY DEPARTMENT A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy by MARKUS ALEXANDER FEUFEL Dipl.-Ing. (FH), Hochschule der Medien, 2003 M.S., Wright State University, 2006 ________________________ 2009 Wright State University WRIGHT STATE UNIVERSITY SCHOOL OF GRADUATE STUDIES June 26, 2009 I HEREBY RECOMMEND THAT THE DISSERTATION PREPARED UNDER MY SUPERVISION BY Markus Alexander Feufel ENTITLED Bounded Rationality in the Emergency Department BE ACCEPTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF Doctor of Philosophy . John M. Flach, Ph.D. Dissertation Director John M. Flach, Ph.D. Department Chair Joseph F. Thomas, Jr., Ph.D. Dean, School of Graduate Studies Committee on Final Examination John M. Flach, Ph.D. Glenn C. Hamilton, M.D. Valerie L. Shalin, Ph.D. Scott N. J. Watamaniuk, Ph.D. Tamera R. Schneider, Ph.D. ABSTRACT Feufel, Markus Alexander, Ph.D., Human Factors and Industrial/Organizational Psychology, Department of Psychology, Wright State University, 2009. Bounded Rationality in the Emergency Department. 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 iii 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. iv TABLE OF CONTENTS Page I. INTRODUCTION.......................................................................................................... 1 Models of Bounded Rationality...................................................................................... 5 Optimization under constraints.................................................................................... 5 Biases and heuristics.................................................................................................... 6 Ecological rationality................................................................................................... 8 Bounded Rationality in the Emergency Department (ED)............................................. 10 Decision points in the ED............................................................................................ 10 Ecological rationality in the ED.................................................................................. 15 Sociocultural values in U.S. medicine..................................................................... 17 Emergency Medicine in the U.S.............................................................................. 18 Introduction Summary................................................................................................... 20 The present research and the concept of bounded rationality..................................... 21 The present research and the ED domain................................................................... 23 Research Overview........................................................................................................ 24 II. OBSERVATIONAL STUDY METHODS.................................................................. 26 The Observed Settings................................................................................................... 26 v Participants..................................................................................................................... 27 Procedure........................................................................................................................ 27 Attending-Resident interactions.................................................................................. 29 Data Evaluation.............................................................................................................. 30 III. OBSERVATIONAL STUDY RESULTS AND DISCUSSION................................ 34 Overview........................................................................................................................ 34 Prelude: The ED as an ill-structured domain.............................................................. 36 Part I: General Heuristics in ED Physicians' Adaptive Toolbox.................................... 39 Safe but (sometimes) inefficient: The 'worst case' heuristic....................................... 43 The 'worst case' search rule...................................................................................... 46 The 'worst case' stopping and decision rules............................................................ 49 Limitations of the 'worst case' heuristic................................................................... 54 The ecological (ir)rationality of the 'worst case' heuristic....................................... 62 Efficient but (more) risky: The 'common-things-are-common' heuristic.................... 65 Limitations of the 'common-things-are-common' heuristic...................................... 70 The ecological (ir)rationality of the 'common-things-are-common' heuristic.......... 71 Satisficing in the ED: Balancing the risk-efficiency tradeoff..................................... 72 Part II: Constraints on ED Physicians' Problem Space.................................................. 74 Categorization by subtypes of medical problems....................................................... 75 vi Categorization by physical appearance....................................................................... 76 Categorization by previous medical history (PMH).................................................... 78 Categorization by history of present illness (HPI)...................................................... 81 Categorization by demographic variables................................................................... 82 Categorization by multiple constraints........................................................................ 83 Part III: Constraints on ED Physicians’ Solution Space................................................. 86 Constraints pertaining to the health care system.......................................................... 88 Constraints pertaining to the ED/hopsital's organizational system.............................. 91 Constraints introduced by the physician's experience................................................. 94 Constraints introduced by the patient.......................................................................... 95 Summary of Part II and III: Constraints