How and When Do Expert Emergency Physicians Generate and Evaluate Diagnostic Hypotheses? A Qualitative Study Using Head-Mounted Video Cued-Recall Interviews - 20/11/14

Doi : 10.1016/j.annemergmed.2014.05.003

Thierry Pelaccia, MD, PhD ^a,^c,^⁎ , Jacques Tardif, PhD ^d, Emmanuel Triby, PhD ^b, Christine Ammirati, MD, PhD ^e, Catherine Bertrand, MD ^f, Valérie Dory, MD, PhD ^g, Bernard Charlin, MD, PhD ^h
^a Centre for Training and Research in Health Sciences Education (CFR-PS), Department of Medical Education, Faculty of Medicine, University of Strasbourg, Strasbourg, France
^b Faculty of Educational Sciences, University of Strasbourg, Strasbourg, France
^c Prehospital Emergency Care Service (SAMU 67)–Centre for Emergency Care Teaching (CESU 67), Strasbourg University Hospital, Strasbourg, France
^d Department of Pedagogy, Faculty of Education, University of Sherbrooke, Sherbrooke, Québec, Canada
^e Department of Emergency Medicine, Amiens University Hospital, Amiens, France
^f Prehospital Emergency Care Service (SAMU 94), Henri-Mondor Hospital, Public Hospitals of Paris, Créteil, France
^g Institute of Health and Society (IRSS), Catholic University of Louvain, Brussels, Belgium
^h Centre of Pedagogy applied to Health Sciences (CPASS), Faculty of Medicine, University of Montreal, Montréal QC H3T 1J4, Québec, Canada

^∗Corresponding Author.

Abstract

Study objective

The ability to make a diagnosis is a crucial skill in emergency medicine. Little is known about the way emergency physicians reach a diagnosis. This study aims to identify how and when, during the initial patient examination, emergency physicians generate and evaluate diagnostic hypotheses.

Methods

We carried out a qualitative research project based on semistructured interviews with emergency physicians. The interviews concerned management of an emergency situation during routine medical practice. They were associated with viewing the video recording of emergency situations filmed in an “own-point-of-view” perspective.

Results

The emergency physicians generated an average of 5 diagnostic hypotheses. Most of these hypotheses were generated before meeting the patient or within the first 5 minutes of the meeting. The hypotheses were then rank ordered within the context of a verification procedure based on identifying key information. These tasks were usually accomplished without conscious effort. No hypothesis was completely confirmed or refuted until the results of investigations were available.

Conclusion

The generation and rank ordering of diagnostic hypotheses is based on the activation of cognitive processes, enabling expert emergency physicians to process environmental information and link it to past experiences. The physicians seemed to strive to avoid the risk of error by remaining aware of the possibility of alternative hypotheses as long as they did not have the results of investigations. Understanding the diagnostic process used by emergency physicians provides interesting ideas for training residents in a specialty in which the prevalence of reasoning errors leading to incorrect diagnoses is high.

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Plan

Introduction

Background

Importance

Goals of This Investigation

Materials and Methods

Study Design

Selection of Participants

Data Collection and Processing

Primary Data Analysis

Results

Characteristics of Study Subjects

Main Results

Limitations

Discussion

	Supervising editor: David L. Schriger, MD, MPH
	Author contributions: TP, JT, ET, and BC conceived the study. TP, CA, and CB obtained research funding. TP supervised the conduct of the study and conducted the interviews. TP, CA, and CB coded data. TP, JT, ET, CA, CB, VD, and BC were involved in interpreting the study findings. TP drafted the article, and all authors contributed substantially to its revision. TP takes responsibility for the paper as a whole.
	Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). The authors have stated that no such relationships exist and provided the following details: This study was supported by a grant from the French Society for Emergency Medicine.
	The study sponsor had no role in the study design, data collection, analysis and interpretation, and decision to write and submit this article. The researchers are independent from the sponsor.
	Please see page 576 for the Editor's Capsule Summary of this article.
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