| Using the combined strategies of observational analysis and in-depth interviewing, this dissertation examined clinical decision-making in two urban hospital emergency departments in Atlantic Canada---one a large tertiary-care facility, the other a smaller community hospital. In particular, I was interested in achieving a qualitative understanding of how institutional and organizational elements influence this decision-making process. My data revealed that process to be, fundamentally, one of uncertainty. The nature of emergency medicine and emergency departments is such that physicians experience many different forms of uncertainty. To manage this uncertainty, physicians were found to engage in the following strategies: managing risk, gathering information, avoiding closure and relying on experience. Increasingly, however, rationalization of both the environment in which physicians work, and the profession of which they are a part, has challenged the emergency physician's ability to manage the uncertainty inherent in their work. For instance, attempts to make the health-care system both more efficient and cost-effective, have resulted in added difficulties in terms of clinical decision-making. Furthermore, in response to demands for greater accountability for their actions, their decision-making, physicians too have adopted rationality, in the form of evidence-based medicine. Ultimately, however, such rationality whether imposed upon, or adopted by, the profession significantly undermines physicians' ability to make decisions that are in the best interests of their patients. |
