Table 2.

Systems Vulnerabilities to Patient‐Centered Care in the ED as Identified by First‐year Medical Students in Systems Ethnography Roles

Categories	Description	Example Quotation
Patient experience	Issues related to the patient's experience of care received, which primarily focused on the diminishing of patient satisfaction, dignity, or understanding of care processes or plans.	For every patient with whom I was paired, the waiting was a problem. Combined with the few number of physicians I actually observed interact with my patients (i.e., two), if I were to receive a satisfaction survey, I would be rating 90% of the day on time not spent with a healthcare provider. Once a patient is triaged in a room, there is a flurry of action. The patient is generally seen somewhat quickly by a physician. After that, things tend to slow down. Labs are ordered, meds are started, imaging studies scheduled. In the meantime, the patient could be unattended for a while. Physicians claim they will be “right back,” [but] do not reappear for hours. The presence of a new face in the room just means repeating answers to the same questions that a patient already answered for the previous person. From the patient's perspective, repetition results in frustration, as patients feel they spend the first few hours of their visit describing symptoms to various physicians without receiving any answers or relief.
Communication and collaboration	Issues related to breakdowns or insufficiencies in communication and collaboration between providers or between providers and patients.	With the volume overload, hours of waiting, and the unobservable hierarchy, I would definitely not be able to distinguish the roles of each team member. It felt more like a watercolor painting in there, sort of a blurry transient flow of patients and staff with an absence of demarcated lines. The team informed the family that the patient was “brain dead.” The family dealt with this information as best they could, and requested a chaplain before the patient was to be removed from life support. However, 20 minutes later, a physician informed the family their plan was to observe the patient for another 72 hours. Perhaps the [two] teams discussed the patient's case and agreed on this plan, but the family was very confused. [Patients] were walked into the room, and numerous tests were done, all without explaining [their purpose]. I observed multiple patients nodding along. When the doctor left, they would get together with their families and ask: “Why are they doing that?” or “I don't know why they'd be giving me this test, it doesn't seem to have anything to do with my problem. Many patients felt that there was NO communication between the healthcare team. They felt like they had to repeat themselves every time a new doctor, nurse or physician entered the room.
Processes, physical space, and resources	Issues related to insufficient ED processes, which were described as slow, untimely, or redundant.	The singularly most used verb in my observations is ‘wait,’ which is hardly a verb at all. In the roughly twelve hours I spent next to the patients’ bedsides, I saw two physicians. I used to think that the most time‐consuming part of the ED visit was seeing the physician, getting labs drawn/tests, and waiting for the results. I was surprised to see that the discharge took longer than everything else. But I was in the patient's room so I'm not sure how the discharge process works, and when I went back to the triage area, the ED had certainly gotten busier.
Professionalism	Issues related to professionalism lapses or incidents that occurred between providers or between providers and patients.	The patient's wife requested that I step out of the bay while her husband had his physical exam. Someone scribing on a cart approached me and said, “Do you know how he hurt himself? I always feel so awkward going and asking over and over again.” She took my word for it. It felt like I had stepped into the Twilight Zone. For the majority of the visit, there were two nurses gossiping about their financial circumstance and complaining about their jobs in the emergency room.