It is 07:30 on a Tuesday morning
You’ve just arrived for your morning surgical list to find six out of ten operating theatres and all the recovery bays occupied. Not by anyone from today’s list, but by patients from the previous T&O list. Some are still being operated on and others are post-op, waiting to move to inpatient beds.
Patients booked for your morning’s list have started to arrive. Consented and prepared, they are now waiting in a queue that seems unlikely to progress at pace. The site manager asks why the surgical list is delayed.
That sounds absurd, right? I mean, outside a major incident or pandemic, this would be a very serious situation. Thankfully…
That was not about surgery
If you’ve not seen what I’ve done yet, let me reframe:
You’ve just arrived for your morning Emergency Department (ED) shift to find six out of ten majors bays and the whole corridor occupied. Not by anyone from today’s caseload, but by patients referred to specialties from yesterday. Some are still awaiting assessment and others are waiting to move to inpatient beds.
Patients with various illnesses and injuries are still arriving on foot and by ambulance. They are now waiting in a queue that seems unlikely to progress at pace. The site manager asks why there is such a delay to see patients.
This is called a cognitive bridge. A cognitive bridge helps me explain complex topics (like crowding) to a non-emergency medicine audience. Same principle, different setting. This particular one works well with a surgical audience. It is an invaluable tool when negotiating resources with teams who do not work in ED.
Communicating complexity
On any given day, thousands of patients occupy ED spaces while waiting for specialty assessment or inpatient beds that are not available. These delays cascade into further delays due to reduced access to staff, space and resources, worsening patient outcomes and placing further pressure on already compromised performance.
This is the daily reality of many EDs across England. It is also a genuinely difficult concept to communicate outside of emergency medicine. The problem ED staff face is not a knowledge problem. The people who commission, manage and scrutinise our care are not unintelligent. They simply lack the frame of reference to feel the weight of what crowding means in practice.
BBC journalist Ros Atkins, in his work on explanation, argues that effective communication begins by meeting your audience in a territory they already understand. This blog offers ED clinicians a practical tool for doing exactly that.
How the cognitive bridge works
Emergency Department staff are skilled explainers of clinical complexity. We can describe a deteriorating patient, a diagnostic dilemma, or a resuscitation decision with clarity and precision. What we often struggle to explain is the environment in which all of that clinical work takes place. The challenge is not articulacy: it is audience. A clinical picture lands differently when your listener has never stood in a crowded resus bay, made a decision in a corridor, or managed a service where most of majors are occupied by patients waiting for somewhere else to go.
The cognitive bridge is a three-step communication tool, that does not require the listener to imagine a foreign environment. It starts in territory they already inhabit, establishes a principle they already accept, and then walks them across to ED. The intellectual work is shared. And the conclusion, when it comes, feels like their own.
The three steps: Anchor, Span and Land
Anchor
The Anchor is where you begin. Before you say anything about ED, you identify the closest equivalent in your listener’s professional world. For a surgical colleague, that equivalent is a theatre suite. For a physician, it is an admissions ward or an outpatient clinic. For a chief executive, board member or a non-clinical manager, it may be a shared office or meeting space.
The Anchor does not need to be perfect. It just needs to be familiar enough that your listener can picture it without effort, and close enough to ED that the parallel will hold. That shared understanding is what makes the Anchor strong.
What is the closest professional equivalent to ED in the world of the person you are speaking to?
Span
The Span is the logical principle that already governs your listener’s Anchor. You are not introducing a new idea. You are naming something they already know to be true, and inviting them to confirm it out loud.
In the theatre example, the Span is: when capacity is reduced, expected output adjusts accordingly. If recovery is blocked, theatres cannot turn over. If theatres cannot turn over, the list stops. The constraint is visible, the logic is immediate, and the adjustment is automatic.
Name the principle in your listener’s language before you apply it to yours. Let them agree with it first.
Land
The Landing is where you bring the principle home. Having established the Anchor and named the Span, you now show your listener that the same logic applies in ED.
In the theatre example, the Landing is the shift in terminology we walked through in the opening of this blog. The principle has not changed. Only the postcode.
The Landing does not require a lengthy explanation. If the Anchor was well chosen and the Span clearly named, the Landing arrives with the weight of a conclusion the listener has already mostly reached themselves. Your role is simply to confirm it.
How much of the argument did your listener reach before you finished speaking?
Adapting the Anchor
The cognitive bridge works because its logic is universal. Capacity constraints reduce output. Blocked flow affects the whole system. Performance expectations should reflect operational reality. These principles hold in every corner of a hospital, and in most professional environments beyond it.
The Anchor is chosen for your listener, not for you. Before a difficult conversation with a medical director, a board presentation, or an operational debrief, the most useful question you can ask is: what does this person or group already understand that is closest to what I am trying to explain?
What changes is not the argument. It is the door you walk through to begin it.
Three common audiences and their Anchors:
Any surgeon will understand a list that cannot run because the previous list’s patients were still taking up a large portion of theatre space.
Any physician will recognise an outpatient list that cannot run because the previous clinic’s patients were still taking up most of the clinical outpatient space.
Any non-clinical manager will recognise an important meeting that cannot start because the meeting room (they booked) is still occupied by the previous group. Other attendees are awkwardly gathering in the corridor outside. The agenda cannot progress. (I tend to add: and they now have to make do in a cramped staff kitchen with no table space.)
In each case, the Span is identical: capacity that is consumed by patients or people who cannot move on is capacity that cannot be used for new arrivals. You can adjust the Anchor as you like. I’ve found the surgical Anchor effective for most audiences. Adding: and this has been happening repeatedly for months, can strengthen your Anchor, but is often unnecessary, and risks dragging it out too long.
Building the Bridge
Emergency Department staff are not poor communicators. We work in an environment that is genuinely difficult to convey to people who have never inhabited it. Also, crowding is chronic rather than episodic, which makes it easy to normalise. And it doesn’t help that we make managing the status quo look so effortless (see my blogs on design as repair and an EPiC mental model).
These constraints are invisible to those who do not work within EDs. And the consequences, measured in patient harm, staff harm and staff attrition, accumulate slowly enough that they rarely generate the urgent institutional response that a single visible crisis would demand.
The cognitive bridge does not solve crowding. It also does not fix flow, create inpatient beds, or reduce ambulance demand. What it does is give ED clinicians a way to be heard by the people who have the authority to address those things.
Explanation is not a soft skill peripheral to the negotiating process. It is central to it.
A few caveats
The cognitive bridge is a communication tool, not a debating tactic. A few things are worth bearing in mind before you use it.
It works best when the Anchor is genuinely familiar to your listener. A poorly chosen Anchor confuses rather than connects. If in doubt, ask a question before you bridge: what does a typical day look like in your service? The answer will usually tell you where to begin.
It is not a substitute for evidence. Analogies make arguments legible; data makes them credible. The bridge opens the conversation. The numbers need to follow (see my blog on Model ED Capacity and Demand)
It is a starting point, not a solution. Understanding the problem is necessary but not sufficient. The cognitive bridge is most useful when it leads somewhere: a decision, a commitment, a shared acknowledgement that the situation requires a different response. If the conversation ends with your listener nodding sympathetically and returning to the same expectations, the bridge has been crossed but no one has acted on the view.
A note on emotional bridges
Emergency Department staff carry a significant emotional burden. Crowding causes harm, and working within it daily takes a toll that is entirely legitimate to name. But leading with that emotion in conversations with managers and executives will rarely produce the understanding you are looking for.
This is not because those audiences lack empathy. It is because chronic problems blunt emotional responses over time. When distress is the signal, and the problem never resolves, the signal loses force. The listener learns to manage the emotion without acting on it.
The cognitive bridge deliberately sidesteps this dynamic. It does not ask your listener to feel what you feel. It asks them to recognise a logic they already accept. That recognition is more durable than sympathy, and more likely to lead somewhere useful.
If there is a place for emotion, it is after the bridge has landed. Once the listener understands the situation on its own terms, the human cost becomes something they can hold without deflecting. Understanding first; feeling follows.
Summary
The model is simple enough to use without preparation. Identify your listener’s Anchor before the conversation begins. Name the Span clearly and let them confirm it. Land in ED without apology. The argument does not change. Only the starting point does.
Ros Atkins argues that a good explanation is a utility: something the listener can use, not just receive. The cognitive bridge is offered in that spirit. It is a tool for ED staff who know what they are dealing with and need others to understand it too. Not to win an argument, but to build enough shared understanding that the right conversations can finally begin.
If you have used a cognitive bridge like this in practice, or found a better Anchor for a particular audience, please share in the comments below.
