Medical problem solving and uncertainty in the emergency department.
OBJECTIVE
To compare the diagnostic processes of experienced emergency physicians with those of novices.


METHODS
Prospective, convenience sample of patients.


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


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


METHODS
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).


CONCLUSIONS
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.
Sklar
D P
DP
Division of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque 87131.
Hauswald
M
M
Johnson
D R
DR
D000046:Academic Medical Centers; D002983:Clinical Competence; D002985:Clinical Protocols / Q000592:standards*; D003661:Decision Support Techniques; D004635:Emergency Medicine / Q000379:methods* / Q000592:standards; D004636:Emergency Service, Hospital; D006801:Humans; D008487:Medical History Taking / Q000592:standards; D010808:Physical Examination / Q000592:standards; D011340:Problem Solving; D011446:Prospective Studies