Obi Wan’s Guide to Emergency Medicine. Rich Carden at St.Emlyn’s

Screen Shot 2014-09-20 at 16.06.54Ok, so Obi Wan Kenobi, to my knowledge, never actually practiced emergency medicine, although he had some pretty awesome Jedi skills that would work a treat in the ED.  For those of you unfamiliar with his work, he was pretty instrumental in the Star Wars trilogy (original) and had some serious skills like the Mind Trick, which allowed him to influence the thoughts of others and coerce them into agreement.  What on earth are you on about, you might rightly ask?!  Well before medicine, I studied psychology, and although I didn’t have much of an appetite for its clinical practice, I have ever since remained fascinated with psychological theory and more recently how it can be used in emergency medicine.

Aside from the clinical skills and knowledge that it takes to be a great emergency physician there are a whole heap of non-technical and non-clinical skills that are vital.  To me it seems that two major parts of emergency medicine are sales and risk assessment.  We sell things all day long; sell an admission to the oncall team; sell a CT request to a radiologist; sell a diagnosis to a patient.  Now I’m not for a second suggesting that any old smooth talker could waltz into an ED and become a prolific physician, these sales are clearly in the context of your clinical judgement of what that patient needs.  As for risk assessment that it is obvious a huge part of what we do, and I hope to elaborate upon how good we actually are at a later date.

I have read some fascinating and insightful psychology-related books, which, although not aimed at the emergency physician per se, can, with a little latitudinal thought be directly applied to clinical work in the ED.  Have a read of behavioural psychology literature and you can be a veritable Obi-Wan in your department.

The Psychology of Influence, by Robert Cialdini

This book is a fantastic piece of work looking at the psychology of persuasion and why people say ‘yes’.  Essentially the book proposes six universal principles of persuasion:


1) Reciprocation: People feel an obligation to make a concession to someone who has made a concession to them.

·      Think about the time you fill in an inpatient drug card for the RMO (medical admitting team), they will thank you eternally and it will smooth the way for easier interactions to come, like the social admission that they really can’t be bothered clerking in.

·      Small concessions on your part require very little in physical or mental energy, but are psychological power plays.  It’s very difficult for people to be unreasonable to someone who has seemingly gone out of their way to help.

·      You can even feign this behaviour! For example, you say to the med reg ‘I did a gas for you’.  Have you done a gas for them?!  You did the gas because you were going to do a gas anyway but phrasing it a way that seems as though you have gone out of your way to help upsets the balance and initiates the need to reciprocate.


2) Commitment and Consistency: If you can get someone to make a commitment, you set the stage for consistency with that commitment.

·      An awareness of the human need for consistency is of particular use when you recognise it in yourself.  How many times have you been so sure of a diagnosis that you become blinkered to other information?  This is exemplified by a study by Knox and Inkster in 1968.  The pair of researchers found that after placing a bet at a racetrack, bettor’s confidence in the horse’s chance of winning significantly increases.  Clearly the horse doesn’t change in this time, but the mindset of the bettor does.  This is called Post-Decision Dissonance.

·      Post-decision dissonance is the phenomenon in which immediately after making a decision people find a conflict that the decision is in fact wrong.  Essentially it is a confirmation bias.  People then go on to change their perspectives to make the decision feel more acceptable.  The key here is to be aware that when you make a decision you will subconsciously look for further proof or validation that it is the correct decision.  If you are aware of this, you can keep and open mind to other possibilities and beat your own subconscious!


3) Social Proof: People determine what is correct by finding out what other people think is correct.

·      We validate our own differential diagnoses by ‘running them past people’.  I would hazard that for the most part, people already know what they think the differential diagnoses are but just want reassurance, i.e. obtaining a social proof.


4) Liking: People like to say yes to the requests of someone they know and like.

·      If you make friends, or even just be nice to everyone, you are much more likely to have an easier shift.

·      Think about the time you make your stressed out colleague a cup of coffee.  Such a small amount of effort on your part yields massive benefits.

·      How do you respond when, in the middle of the shift from hell, someone whips out the bag of Haribo (or moralibo if you’re in the British Army)?  That person recieves the adulation of a hero.


5) Authority: People have a terrifying obligation and obedience to authority.

·      As a junior doc, you have a patient that you know needs to be admitted, however the oncall team just are not accepting the referral.  As soon as the words ‘my consultant agrees’ or ‘can you speak to my consultant’ are uttered, there is a beligering acceptance of the referral.  No matter whether the oncall doctor agrees, there is often an almost blind obedience to the authority of the consultant.

·      As a doctor you are a figure of authority, and in no way should this be manipulated, but rather in acknowledging this fact you realise that patients (on the whole) will respect and obey your advice….without sounding too dictatorial.  Interactions with some of the more challenging patients can some times feel like negotiations, and applying these principles will help those interactions flow.


6) Scarcity: The idea of losing something valuable makes people want it more.

·      This could be nicely used to explain the enthusiasm of juniors to insert chest drains, arterial lines, central lines etc.  Although fairly common in the ED, they are rare opportunities for juniors and represent a valuable opportunity to do something ‘cool’ and a bit different.


So this all sounds quite manipulative and underhanded tactics for negotiating the ED and for dealing with colleagues and patients.  It is in no way intended in this way.  I hope to highlight how behavioural psychology impacts on everything we do in the ED.  It offers an explanation for why and how people behave.  This post is clearly on the basis of one book.  There are hundreds of others and reading around the subject and building an awareness of psychological factors is worthy endeavour.  In terms of human interaction and body language, which goes hand in hand with this topic, Joe Navarro’s “What every BODY is saying” is an awesome starting point.  Basically Joe Navarro is an ex-FBI agent and an expert at reading body language.  There are just too many snippets of great insight to write about without just copying his book!

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All of this seems like common sense, and it largely is, however it requires you to be aware of it.  If you stop and look around you then the ED turns into a hotbed of behavioural psychology.  These principles apply to your interactions with patients as well.  In the ED a huge number of patients want reassurance (social proof) that everything is ok, and this is why the ICE (ideas, concerns, expectations) mnemonic is so useful.  Not only does it show to the patient that you care why they are there and what they are hoping for, but it also allows you to set all these techniques of persuasion into action.  You can offer them a social proof; you can establish what they are going to be consistent with; you can get them to like you.  The patient interaction flows easier, whilst maintaining their concerns at the centre, and results in a satisfactory outcome for the patient and for you.

I hope to have shared some of my passion and enthusiasm for behavioural psychology with you!  Happy reading!





1 Comment

  1. Charles Bruen

    Obi Wan was a great ED doctor. He resuscitated Luke Sky Walker after he was attacked by Sand People on Tatooine in Episode IV. Great post!


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