"I can't find anything wrong: it must be a pulmonary embolism": Diagnosing suspected pulmonary embolism in primary care, a qualitative study.
BACKGROUND
Before using any prediction rule oriented towards pulmonary embolism (PE), family physicians (FPs) should have some suspicion of this diagnosis. The diagnostic reasoning process leading to the suspicion of PE is not well described in primary care.


OBJECTIVE
to explore the diagnostic reasoning of FPs when pulmonary embolism is suspected.


METHODS
Semi-structured qualitative interviews with 28 FPs. The regional hospital supplied data of all their cases of pulmonary embolism from June to November 2011. The patient's FP was identified where he/she had been the physician who had sent the patient to the emergency unit. The first consecutive 14 FPs who agreed to participate made up the first group. A second group was chosen using a purposeful sampling method. The topic guide focused on the circumstances leading to the suspicion of PE. A thematic analysis was performed, by three researchers, using a grounded theory coding paradigm.


RESULTS
In the FPs' experience, the suspicion of pulmonary embolism arose out of four considerations: the absence of indicative clinical signs for diagnoses other than PE, a sudden change in the condition of the patient, a gut feeling that something was seriously wrong and an earlier failure to diagnose PE. The FPs interviewed did not use rules in their diagnostic process.


CONCLUSIONS
This study illustrated the diagnostic role of gut feelings in the specific context of suspected pulmonary embolism in primary care. The FPs used the sense of alarm as a tool to prevent the diagnostic error of missing a PE. The diagnostic accuracy of gut feelings has yet to be evaluated.
Université de Bretagne Occidentale, Faculté de Médecine et des Sciences de la Santé de Brest, Département Universitaire de Médecine Générale, Brest, France.
Marie
M
Barais
Université de Bretagne Occidentale, Faculté de Médecine et des Sciences de la Santé de Brest, Département Universitaire de Médecine Générale, Brest, France.
Nathalie
N
Morio
Université de Bretagne Occidentale, Faculté de Médecine et des Sciences de la Santé de Brest, Département Universitaire de Médecine Générale, Brest, France.
Amélie
A
Cuzon Breton
Université de Bretagne Occidentale, Faculté de Médecine et des Sciences de la Santé de Brest, Département Universitaire de Médecine Générale, Brest, France.
Pierre
P
Barraine
Université de Bretagne Occidentale, Faculté de Médecine et des Sciences de la Santé de Brest, Département Universitaire de Médecine Générale, Brest, France.
Amélie
A
Calvez
Faculty of Health, Medicine and Life Sciences, Caphri School for Public Health and Primary Care, Department of Family Medicine, Maastricht University, Maastricht, The Netherlands; Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium.
Erik
E
Stolper
Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium.
Paul
P
Van Royen
Université Européenne de Bretagne, Faculté de Médecine et des Sciences de la Santé de Brest -Laboratoire de Santé Publique, Epidémiologie, Brest, France.
Claire
C
Liétard
D003948:Diagnostic Techniques, Respiratory System / Q000592:standards*; D005194:Family Practice / Q000379:methods* / Q000592:standards; D005602:France; D066296:Grounded Theory; D006801:Humans; D007407:Interviews as Topic; D019545:Intuition; D011320:Primary Health Care / Q000379:methods* / Q000592:standards; D011655:Pulmonary Embolism / Q000175:diagnosis*