Background: The last 30 years have seen considerable growth in the scope of emergency medicine and the size, scale and expectations of emergency departments (EDs) in the USA and other countries, including Australia. The emphasis has changed from direct referral to departments in the hospital to treatment in and disposition from the ED. At the same time, emergency clinicians face increasing pressure to address patient needs with greater efficiency. Within this context, this project describes the character of the unique domain of work and collective identity that emergency clinicians carve out in their interactions with other emergency clinicians and with clinicians from other departments. Methods: Fieldwork was conducted over 10 months in the EDs of two tertiary referral hospitals in Sydney, Australia. It comprised approximately 535 hours of unstructured and structured observation, as well as 56 field interviews. Results: Emergency clinicians have a unique role as "gatekeepers" of the hospital. This ensures that their clinical work is inherently organisational - that is, interdepartmental and bureaucratic work. Emergency clinicians explicitly and implicitly negotiate the "patient pathway" through the hospital which is organised according to the "fragmented" body. This role demands previously under-recognised and complex immaterial work. Emergency clinicians seek to reconcile the individual trajectories of patients present in the ED with the ED?s broader function as a "carousel" in order to seek to provide the greatest good for the greatest number of future patients. The research uniquely charts the socialisation processes and informal education that produce tacit organisational expertise with which emergency nurses and doctors, both separately and jointly, negotiate the bureaucracy of the hospital. Conclusion: EDs are destined to struggle to provide the greatest good for the greatest number, reconciling shortcomings in the structure and provision of public and community health care. However, recognition and support for the unique clinical-organisational domain of ED care presents an opportunity for improved holistic care at the front door of the hospital. Our ageing population and its promise of more patients with complex health issues demand further research on the interdepartmental work of other whole-body specialties, such as Aged Care.

Background: The last 30 years have seen considerable growth in the scope of emergency medicine and the size, scale and expectations of emergency departments (EDs) in the USA and other countries, including Australia. The emphasis has changed from direct referral to departments in the hospital to treatment in and disposition from the ED. At the same time, emergency clinicians face increasing pressure to address patient needs with greater efficiency. Within this context, this project describes the character of the unique domain of work and collective identity that emergency clinicians carve out in their interactions with other emergency clinicians and with clinicians from other departments. Methods: Fieldwork was conducted over 10 months in the EDs of two tertiary referral hospitals in Sydney, Australia. It comprised approximately 535 hours of unstructured and structured observation, as well as 56 field interviews. Results: Emergency clinicians have a unique role as "gatekeepers" of the hospital. This ensures that their clinical work is inherently organisational - that is, interdepartmental and bureaucratic work. Emergency clinicians explicitly and implicitly negotiate the "patient pathway" through the hospital which is organised according to the "fragmented" body. This role demands previously under-recognised and complex immaterial work. Emergency clinicians seek to reconcile the individual trajectories of patients present in the ED with the ED?s broader function as a "carousel" in order to seek to provide the greatest good for the greatest number of future patients. The research uniquely charts the socialisation processes and informal education that produce tacit organisational expertise with which emergency nurses and doctors, both separately and jointly, negotiate the bureaucracy of the hospital. Conclusion: EDs are destined to struggle to provide the greatest good for the greatest number, reconciling shortcomings in the structure and provision of public and community health care. However, recognition and support for the unique clinical-organisational domain of ED care presents an opportunity for improved holistic care at the front door of the hospital. Our ageing population and its promise of more patients with complex health issues demand further research on the interdepartmental work of other whole-body specialties, such as Aged Care.