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Information for people contemplating
a career in emergency medicine and
other medical specialties

By Kevin Pezzi, MD


Doctors, judges, and time pressure

by , MD

Supreme Court Chief Justice John Roberts botched the administration of Barack Obama's Presidential oath of office. He should have said:

"I do solemnly swear (or affirm) that I will faithfully execute the Office of President of the United States, and will to the best of my Ability, preserve, protect and defend the Constitution of the United States."

  1. The phase "So help me God" is not specified in the Constitution, but has been commonly used after one of my relatives, Chester A. Arthur, appended it when he was sworn in as President.
  2. It is now also customary to insert the President's name between "I" and "do."

So there you have it: Just one 35-word sentence, yet he flubbed it in a few places. Interestingly, such mistakes are common—this is hardly the first time the Presidential oath was mangled. How does this pertain to medicine?

A political pundit excused Roberts' mistakes by pointing out how many people were watching—hence he was under a lot of pressure. Justice Roberts is a Harvard Law grad and a very intelligent man, so he unquestionably has the mental capacity to correctly recite the Presidential oath. Thus, pressure clearly explains those mistakes. Research has shown that people work better under slight pressure, but not marked pressure, which can decimate the intellectual capacity even of geniuses.

So why is this relevant to the practice of medicine?

Imagine that you are an ER doctor. You have patients stacked to the rafters. Seconds ago, paramedics brought in several more severely injured victims of a traffic accident. Just when you think things couldn't get any worse, a mother runs into the ER with her baby seizing and turning blue as she screams, "My baby is DYING! Help me, God help me!" You'd like to help, and you could help, but you have several equally ill and injured patients. In the split-second that it takes you to contemplate this, two nurses dash toward you. One says, "One of the trauma victims is posturing [a sign of increased intracranial pressure that can quickly kill]. You need to see him NOW." Another nurse said that a middle-aged woman with an infection is crashing: "Her blood pressure is falling. I think she's in septic shock." Just then, a student nurse working on that latter patient runs into the room and breathlessly announces, "She just started seizing!" Incidentally, if you think it never gets that bad in the ER, you're wrong; it can be even worse (read this for a snapshot into one of my night shifts).

Two patients seizing, another dozen who need attention stat . . . now that is pressure! In comparison, reciting a simple 35-word sentence that could be mentally rehearsed hundreds of times in advance is an absolute breeze . . . yet some of the smartest people in the country, our Supreme Court Chief Justices, cannot do it reliably even when they have virtually unlimited time to rehearse it, get plenty of sleep the night before, and drink lots of coffee in advance.

While I am gracious enough to overlook the flub of Justice Roberts, I've never heard of a malpractice case in which a judge gave a doctor a similar pass even when the doc was working under ungodly pressure. Imagine if a judge had to simultaneously manage dozens of high-complexity cases and quickly make decisions under intense time pressure. If even one of those decisions was less than perfect, the judge could be sued for every penny he had and would ever earn. Judges would, of course, not stand for being subjected to such impossible demands, yet that is exactly what they do to ER doctors, who often work under such pressure.

Just something to think about.

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