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This issue brings together a collection of papers that, in different ways, ask us to look harder at the patients requiring high-stakes decision-making, underserved populations whose needs are routinely missed and the systems that need redesigning before the next wave arrives. Emergency medicine has always been about pattern recognition, but several of these papers remind us that the patterns we rely on are only as good as the data we choose to collect, the people we choose to listen to and the structures we build around the next clinical encounter.