Medical problem solving and uncertainty in the emergency department.

STUDY OBJECTIVE

To compare the diagnostic processes of experienced emergency physicians with those of novices.

DESIGN

Prospective, convenience sample of patients.

SETTING

Emergency department of a county university medical center in a large southwestern urban community.

PARTICIPANTS

Experienced emergency physicians (attending and senior residents) and novice clinicians (junior residents and senior medical students).

INTERVENTIONS

Participants developed initial diagnostic impressions after reviewing the chief complaint, nurse triage notes, and vital signs. Tests were then selected, and a final diagnostic impression was identified after results were known. Clinicians also marked a visual analog scale corresponding to their estimate that each diagnostic possibility was correct.

RESULTS

Experienced physicians increased their certainty more than novices (P = .014). They deviated from a standard history-physical-laboratory sequence more often than novices (P = .008).

CONCLUSION

Expertise in medical decision making is characterized by a moderate initial level of certainty concerning a diagnosis that significantly increases as the experienced clinician follows a flexible strategy of testing to arrive at a final diagnosis.