Correction to "Best practice guidelines for evaluating patients in custody in the emergency department".

[This corrects the article DOI: 10.1002/emp2.13143.].

Emergency Physicians' Ethical Issues with Hospital Business Models.

BACKGROUND: The changing hospital business model has raised ethical issues for emergency physicians (EPs) in a healthcare system that often prioritizes profits over patient welfare. For-profit hospitals, driven by profit motives, may prioritize treating patients with lucrative insurance plans and those who can afford expensive treatments. Private equity investors, who now own many for-profit hospitals, focus on short-term financial gains, leading to cost-cutting measures and pressure on EPs to prioritize financial goals over patient welfare. Nonprofit hospitals, mandated to provide charity care to the underserved, may fail to meet their community service obligations, resulting in disparities in healthcare access. OBJECTIVE: This review examines the ethical challenges faced by emergency physicians (EPs) in response to the evolving hospital business model, which increasingly prioritizes profits over patient welfare. DISCUSSION: Emergency physicians face ethical dilemmas in this changing environment, including conflicts between patient care and financial interests. Upholding professional ethics and the principle of beneficence is essential. Another challenge is equitable access to healthcare, with some nonprofit hospitals reducing charity care, thus exacerbating disparities. EPs must uphold the ethical principle of justice, ensuring quality care for all patients, regardless of financial means. Conflicts of interest may arise when EPs work in hospitals owned by private equity firms or with affiliations with pharmaceutical companies or medical device manufacturers, potentially compromising patient care. CONCLUSION: Emergency physicians must navigate these ethical issues while upholding professional ethics and advocating for patients' best interests. Collaboration with hospital administrators, policymakers, and stakeholders is vital to address these concerns and prioritize patient welfare in healthcare delivery.

Reflexive control in emergency medicine.

Emergency physicians (EPs) navigate high-pressure environments, making rapid decisions amidst ambiguity. Their choices are informed by a complex interplay of experience, information, and external forces. While cognitive shortcuts (heuristics) expedite assessments, there are multiple ways they can be subtly manipulated, potentially leading to reflexive control: external actors steering EPs' decisions for their own benefit. Pharmaceutical companies, device manufacturers, and media narratives are among the numerous factors that influence the EPs' information landscape. Using tactics such as selective data dissemination, framing, and financial incentives, these actors can exploit pre-existing cognitive biases like anchoring, confirmation, and availability. This creates fertile ground for reflexive control, where EPs may believe they are acting independently while unknowingly serving the goals of external influencers. The consequences of manipulated decision making can be severe: misdiagnoses, inappropriate treatments, and increased healthcare costs. Ethical dilemmas arise when external pressures conflict with patient well-being. Recognizing these dangers empowers EPs to resist reflexive control through (1) critical thinking: examining information for potential biases and prioritizing evidence-based practices, (2) continuous education: learning about cognitive biases and mitigation strategies, and (3) institutional policies: implementing regulations to reduce external influence and to promote transparency. This vulnerability of emergency medicine decision making highlights the need for awareness, education, and robust ethical frameworks. Understanding reflexive control techniques is crucial for safeguarding patient care and promoting independent, ethical decision making in emergency medicine.

Best practice guidelines for evaluating patients in custody in the emergency department.

Patients in custody due to arrest or incarceration are a vulnerable population that present a unique ethical and logistical challenge for emergency physicians (EPs). People incarcerated in the United States have a constitutional right to health care. When caring for these patients, EPs must balance their ethical obligations to the patient with security and safety concerns. They should refer to their institutional policy for guidance and their local, state, and federal laws, when applicable. Hospital legal counsel and risk management also can be helpful resources. EPs should communicate early and openly with law enforcement personnel to ensure security and emergency department staff safety is maintained while meeting the patient's medical needs. Physicians should consider the least restrictive restraints necessary to ensure security while allowing for medical evaluation and treatment. They should also protect patient privacy as much as possible within departmental constraints, promote the patient's autonomous medical decision-making, and be mindful of ways that medical information could interact with the legal system.

From magical thinking to suicide: Understanding emergency physicians' psychological struggle.

Recent literature has explored the psychological well-being of physicians, addressing conditions like perfectionism, imposter phenomenon/syndrome (IP), depression, burnout, and, less frequently, magical thinking. But recognizing the connections among these psychological factors is vital for developing targeted interventions to prevent or alleviate their impact. This article examines the often-sequential emergence of these five conditions within a physician's career, with a specific emphasis on their prevalence among emergency physicians (EPs), who must manage a diverse array of acute illnesses and injuries. The descent into psychological distress initiates with magical thinking-in this case, the belief that perfection is possible despite evidence to the contrary-leading to the pursuit of maladaptive perfectionism. If unaddressed, this trajectory may lead to depression, burnout, and in some cases, suicide. Understanding this continuum lays the groundwork for devising a systematic approach to enhance physicians' mental health. The article delves into detailed descriptions of these psychological conditions, encompassing their prevalence, individual impact, how they are integrated into this continuum and potential preventive or corrective methods. Recognizing unrealistic expectations as a major contributor to burnout, depression, and even suicide within the medical profession, the article advocates for the development of targeted interventions and support structures to assist medical students and professionals in managing IP. Practical strategies involve acknowledging unrealistic expectations, setting attainable goals, seeking support, taking breaks, and prioritizing self-care. Addressing this pervasive issue aims to cultivate a culture where medical professionals can thrive, ensuring optimal care for patients.

Informed consent for artificial intelligence in emergency medicine: A practical guide.

As artificial intelligence (AI) expands its presence in healthcare, particularly within emergency medicine (EM), there is growing urgency to explore the ethical and practical considerations surrounding its adoption. AI holds the potential to revolutionize how emergency physicians (EPs) make clinical decisions, but AI's complexity often surpasses EPs' capacity to provide patients with informed consent regarding its use. This article underscores the crucial need to address the ethical pitfalls of AI in EM. Patient autonomy necessitates that EPs engage in conversations with patients about whether to use AI in their evaluation and treatment. As clinical AI integration expands, this discussion should become an integral part of the informed consent process, aligning with ethical and legal requirements. The rapid availability of AI programs, fueled by vast electronic health record (EHR) datasets, has led to increased pressure on hospitals and clinicians to embrace clinical AI without comprehensive system evaluation. However, the evolving landscape of AI technology outpaces our ability to anticipate its impact on medical practice and patient care. The central question arises: Are EPs equipped with the necessary knowledge to offer well-informed consent regarding clinical AI? Collaborative efforts between EPs, bioethicists, AI researchers, and healthcare administrators are essential for the development and implementation of optimal AI practices in EM. To facilitate informed consent about AI, EPs should understand at least seven key areas: (1) how AI systems operate; (2) whether AI systems are understandable and trustworthy; (3) the limitations of and errors AI systems make; (4) how disagreements between the EP and AI are resolved; (5) whether the patient's personally identifiable information (PII) and the AI computer systems will be secure; (6) if the AI system functions reliably (has been validated); and (7) if the AI program exhibits bias. This article addresses each of these critical issues, aiming to empower EPs with the knowledge required to navigate the intersection of AI and informed consent in EM.

Magical thinking: Its effect on emergency medical care.

Magical thinking is a cognitive process characterized by beliefs in supernatural causality and the power of rituals. Grounded in personal convictions rather than objective reality, it involves subjective beliefs rather than magic tricks. Magical thinking's effects range from potentially positive, such as bringing hope and comfort, to negative consequences, including delays in seeking appropriate medical care and refusing evidence-based treatments. This article provides an overview of magical thinking, including its prevalence, diverse forms, and influence on patients, families, and emergency physicians (EPs). This article offers guidelines for recognizing signs of magical thinking and emphasizes the importance of respectful and empathetic interactions with patients and their families. Highlighting both the benefits and detriments of magical thinking in Emergency Medical (EM) care, the article discusses the knowledge and tools needed to optimize patient outcomes. It acknowledges the varying belief systems and cultural practices that contribute to the prevalence of magical thinking. For physicians and other EM professionals, addressing magical thinking requires cultural competence and empathetic engagement. Active listening and shared decision-making are essential to promote positive patient outcomes. By recognizing and understanding magical thinking and fostering effective communication, EPs can navigate the delicate balance of addressing patients' beliefs while delivering evidence-based care.

PHYSICIANS' MORAL DUTIES DURING PANDEMICS.

BACKGROUND: Pandemics with devastating morbidity and mortality have occurred repeatedly throughout recorded history. Each new scourge seems to surprise governments, medical experts, and the public. The SARS CoV-2 (COVID-19) pandemic, for example, arrived as an unwelcome surprise to an unprepared world. DISCUSSION: Despite humanity's extensive experience with pandemics and their associated ethical dilemmas, no consensus has emerged on preferred normative standards to deal with them. In this article, we consider the ethical dilemmas faced by physicians who work in these risk-prone situations and propose a set of ethical norms for current and future pandemics. As front-line clinicians for critically ill patients during pandemics, emergency physicians will play a substantial role in making and implementing treatment allocation decisions. CONCLUSION: Our proposed ethical norms should help future physicians make morally challenging choices during pandemics.

Increasing Solid Organ Donation: A Role for Emergency Physicians.

BACKGROUND: More than 100,000 Americans with failing organs await transplantation, mostly from dead donors. Yet only a fraction of patients declared dead by neurological criteria (DNC) become organ donors. DISCUSSION: Emergency physicians (EPs) can improve solid organ donation in the following ways: providing perimortem critical care support to potential organ donors, promptly notifying organ procurement organizations (OPOs), asking neurocritical care specialists to evaluate selected emergency department patients for death based on established neurologic criteria, participating in research to advance these developments, implementing automatic OPO notification technologies, and educating the professional and lay communities about organ donation and transplantation, including exploration of opt-out (presumed consent) organ recovery policies. CONCLUSION: With future improvements in organ preservation and DNC assessment, EPs may become even more involved in the donation process. EPs should support and engage in efforts to promote organ donation and transplantation.

Ethics, Personal Responsibility and the Pandemic: A New Triage Paradigm.

BACKGROUND: How much of a role should personal responsibility play in triage criteria? Because voluntarily unvaccinated people are not fulfilling their societal obligations during a pandemic, the ethical principle of justice demands that they reap the egalitarian consequences. These consequences could include lower priority for care, an increasing number of employer and government mandates, and restrictions to entering many entertainment venues. DISCUSSION: Voluntarily unvaccinated individuals increase the chance that the COVID-19 virus will mutate and spread, endangering the entire population, but especially those who cannot get vaccinated for medical reasons, children for whom vaccines have yet to be approved, and older adult and immunocompromised people for whom the vaccine is less effective. When voluntarily unvaccinated individuals seek medical treatment for COVID-19 (94% of patients with COVID-19 in U.S. intensive care units), they use resources needed for those with non-COVID-related illnesses. CONCLUSIONS: A method to balance resource allocation between those patients who refuse vaccination and patients who need the same health care resources is necessary. An ethical solution is to give those who are voluntarily unvaccinated a lower priority for admission and for the use of other health care resources. Current in-hospital triage models can easily be modified to accomplish this. This substantive change in practice may encourage more people to get vaccinated.

Applying Bioethics Across Cultures.

BACKGROUND: In our multicultural society, as well as when working internationally, emergency physicians (EPs) frequently see patients from cultures with communitarian or hierarchal structures. These groups may rely on traditional medical practices and view health care decisions through a lens other than patient autonomy. This leads to uncertainty about who can legitimately make decisions for patients and how to apply basic ethical principles. Because the commonly taught ethical principles (autonomy, beneficence, nonmaleficence, and distributive justice) are loosely defined, they provide little help to EPs when working with cultures that de-emphasize Western individualism. CASE REPORT: The case illustrates this complexity by detailing how visiting EPs dealt with leaders from a communitarian culture who demanded that a preteen be treated for a femur fracture by a traditional bone healer rather than with modern techniques. DISCUSSION: The Western-trained clinicians struggled with their ethical responsibility to protect the child's welfare within the social setting: What should beneficence look like in this situation and to whom did it apply? More broadly, this paper examines the bases on which health care professionals might justify overruling parental decisions. It also asks whether the lack of clarity of the most used Western ethical principles suggests the need to broaden clinical ethics education to include issues from other cultures and settings. CONCLUSIONS: Despite principlism's shortcomings, the ease of teaching ethics to health care providers by grouping basic philosophical ideas suggests that we continue to use its structure. As educators and practitioners, we should, however, expand the concept of principlism to better address ethical values and issues found across different cultures.

Should We Use Expired Drugs When Necessary?

BACKGROUND: Medication shortages commonly occur in resource-poor settings. The relatively short expiry dates on many medications exacerbate these shortages, often requiring clinicians to choose between providing needed medications to the patient and violating rules governing drug dispensing. CASE REPORT: A patient presented to an emergency department in a resource-poor setting with an acute anterior myocardial infarction. Standard of care required using thrombolytics due to the unavailability of percutaneous coronary intervention. The only available thrombolytic, streptokinase, was 2 weeks past its labeled expiration date. The physicians faced the ethical dilemma of violating regulations and using the medication vs. failing to provide the patient with the best available therapy. DISCUSSION: The physicians in this case needed to weigh their obligation to improve the patient's health against the professional danger to themselves, their colleagues, and their institution for violating a health care regulation. The information they needed to make this decision and to provide the patient with factual informed consent requires an understanding of the myths, regulations, and science surrounding drug expiry dates. Two myths about medications pervade both the professional and lay communities-that they are uniformly effective and that medications taken past their expiry dates may be ineffective or even harmful. Scientific studies have demonstrated that both are false. CONCLUSIONS: Ethically, physicians have a duty to place their patient's welfare above their own self-interest. In a time of increasing medication shortages around the globe, clinicians need to push rule makers to synchronize drug expiry dates with scientific findings.

Ultrasound diagnosis of dissecting thoracic aortic aneurysms: procedure with a handheld device and a video-illustrated case.

Acute thoracic aortic dissection is an uncommon, although not rare, life-threatening condition. With protean signs and symptoms that often suggest more common cardiac or pulmonary conditions, it can be difficult to diagnose. Ultrasound has proven useful in making the correct diagnosis. This case demonstrates that training gained using standard ultrasound machines can be easily and successfully adapted to newer handheld ultrasound devices. The examination technique using the handheld device is illustrated with photos and a video.

Bioethical Issues in Antarctica.

This paper describes the Antarctic environment, the mission and work setting at the U.S. research stations, the general population and living conditions, and the healthcare situation. It also dispels some common misconceptions that persist about this environment and about the scope and quality of medicine practiced there. The paper then describes specific ethical issues that arise in this environment, incorporating examples drawn from both the author's experiences and those of his colleagues. The ethics of providing healthcare in resource-poor environments implies two related questions. The first is: What can we do with the available resources? This suggests that clinicians must not only know how to use all available equipment and supplies in the standard manner, but also that they must be willing and able to go beyond standard procedures and improvise, when necessary. The second question is: Of all the things we can do, which ones should we do? This paper addresses both questions in relation to Antarctic medical care. It describes the wide range of activities required of healthcare providers and some specific ethical issues that arise. Finally, it suggests some remedies to ameliorate some of those issues.

SARS-CoV-2 (COVID-19) Vaccine Development and Production: An Ethical Way Forward.

The world awaits a SARS-CoV-2 virus (i.e., COVID-19 disease) vaccine to keep the populace healthy, fully reopen their economies, and return their social and healthcare systems to "normal." Vaccine safety and efficacy requires meticulous testing and oversight; this paper describes how despite grandiose public statements, the current vaccine development, testing, and production methods may prove to be ethically dubious, medically dangerous, and socially volatile. The basic moral concern is the potential danger to the health of human test subjects and, eventually, many vaccine recipients. This is further complicated by economic and political pressures to reduce government oversight on rushed vaccine testing and production, nationalistic distribution goals, and failure to plan for the widespread immunization needed to produce global herd immunity. As this paper asserts, the public must be better informed to assess promises about the novel vaccines being produced and to tolerate delays and uncertainty.

Empowering Clinician Education With Patient-outcome Feedback.

Emergency physicians (EPs) often lack the information they need about their patients' outcomes so that they can both optimally adjust and refine their diagnostic and treatment processes and recognize their clinical errors. Patient-outcome feedback (POF) provides that information by informing clinicians about a patient's clinical course after that clinician's evaluation and treatment. This feedback may encompass the period after the EP has transferred a patient's care to another EP or after the patient has left the ED or hospital. EPs obtain POF through various active and passive methods, depending on their institutional and medical record systems. Active methods require that clinicians or others spend time and effort acquiring the information; passive methods deliver it automatically. POF is an excellent performance-based measurement that helps clinicians to stimulate their learning and to build their own validated mental library of outcomes with which to make clinical decisions, i.e., heuristics and System 1 thinking. POF offers especially useful feedback about patients who have been admitted, were referred to specialists, had major interventions, had potentially significant tests pending on discharge, or were handed off to another EP. The current health care system makes it difficult for EPs to discover their patients' outcomes, squandering significant educational opportunities. Three stimuli to improve this situation would be to require EPs to receive passive POF as part of hospital accreditation, for reviewing POF to be classified as a Category 1 Continuing Medical Education activity, and to reimburse clinicians for learning activities related to POF. Research indicates that our health care institutions and systems would be well served to provide clinicians with ongoing automatic information about their patients' outcomes.