To our knowledge, this is the first study undertaken of questions in the ED. It confirms what many of us in emergency medicine believe. The questions that we have in the course of our practice are mostly about clinical matters that apply at the point of care. Notably absent are questions about community services, drug costs, and pathophysiology and legal questions (among others). The absence of questions about community services does not meet face validity because patient disposition is a major issue at both of these institutions, especially when discharging patients from the ED. It is likely that physicians did not consider disposition as a clinical question or consider this in the purview of others such as nursing or social work. A less likely, but more concerning, alternative explanation is that ED physicians do not consider what happens once patients leave the ED. The second notable lack is questions about drug costs, something that physicians are poorly informed about.3,4
Again, this has a couple of possible explanations. First, it is possible that ED physicians do not consider cost of care in their calculus. One recent study suggests that a majority of US physicians do not feel that it is their responsibility to help limit the amount of money that patients must pay for drugs (even though they believe costs should be controlled).5
The second possibility is that ED physicians are particularly cost conscious and already prescribe a predominant number of generic drugs. While we would like to delude ourselves into believing the second explanation, the correct interpretation is probably the first. Cost effective drug prescribing will require moving questions of cost onto the radar screen of practitioners. It would be interesting to see if physicians would consult a list of drug costs prominently posted at the point of care.
The lack of pathophysiology questions is surprising since one of the centres involved in this study was an academic institution. This likely reflects the immediacy of need in a busy ED. Time to ponder non‐clinical questions is a luxury that is often lacking.
This study also helps to point the way towards information resources that would be particularly useful in the ED. Not surprisingly, physicians' questions correlate well with the resources used to find answers.1
In our prior report, we found that drug information resources were the most commonly used resources to answer clinical questions.1
Rapid access to authoritative drug information would go a long way towards meeting the information needs of ED physicians.
There are several potential sources of error in our study. First, our study is vulnerable to the “Hawthorne effect”. Subjects who are being observed in a study tend to behave differently when they know they are being watched. It is possible that this study underestimated the number of questions that physicians have because the participants were unwilling to admit their lack of knowledge to a medical student. It is also likely that this study underestimated the total number of questions since it was impossible to capture every possible question during busy times in the ED. Finally, as noted above, it may be that physicians did not believe topics such as drug costs, patient services in the community and legal questions were in their sphere of practice.
This study was undertaken in only two moderate volume EDs in the US midwest and the results may not be generalisable to EDs with higher or lower volumes. We attempted to include a range of practices by including an academic and a non‐academic ED. The study followed 26 physicians in these two settings so that the overall number of questions reflects the practice of these 26 physicians. Even so, the external validity of this study is difficult to measure.