title: Clinical gestalt and the diagnosis of pulmonary embolism: does experience matter?
abstract: OBJECTIVE
  We sought to determine whether the accuracy of pretest assessment of the likelihood of pulmonary embolism (PE) was related to physician experience. We compared the accuracy of the subjective pretest probability assessment made by senior physicians (postgraduate year [PGY]-4+) to that of interns (PGY-1) and residents (PGY-2 and PGY-3) working in the emergency department of a large teaching hospital.
  
  
  METHODS
  Prospective observational study.
  
  
  METHODS
  Urban, academic emergency department with an annual census of 48,000 patient visits.
  
  
  METHODS
  Five hundred eighty-three adults evaluated for PE in the emergency department.
  
  
  METHODS
  Eligible patients had at least one diagnostic test ordered to workup PE. The physician treating the patient was asked whether he or she considered PE the most-likely diagnosis or whether an alternative diagnosis was most likely. This result was compared to the ultimate diagnosis. Physician experience was categorized by the number of years of training since medical school graduation.
  
  
  RESULTS
  There was a trend toward increasing accuracy with increasing experience, demonstrated by the frequency of true-positive assessments (17% vs 20% vs 25%), true-negative assessments (89% vs 94% vs 96%), and likelihood ratio (1.49 vs 2.34 vs 3.33), respectively.
  
  
  CONCLUSIONS
  Accurate determination of the pretest probability of PE appears to increase with clinical experience. However, the difference in accuracy between inexperienced and experienced physicians is not sufficiently large to distinguish between the two when determining whether clinical gestalt or a clinical prediction rule should be used to determine the pretest probability of PE.
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St, Clinics Building 115, Boston, MA 02114, USA. ckabrhel@partners.org
authors.forename: Christopher
authors.initials: C
authors.lastname: Kabrhel
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Camargo
authors.forename: Samuel Z
authors.initials: SZ
authors.lastname: Goldhaber
mesh_terms: D000328:Adult; D002983:Clinical Competence; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007396:Internship and Residency; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000175:diagnosis*