title: Clinical reasoning of junior doctors in emergency medicine: a grounded theory study.
abstract: BACKGROUND
  Emergency medicine (EM) has a high case turnover and acuity making it a demanding clinical reasoning domain especially for junior doctors who lack experience. We aimed to better understand their clinical reasoning using dual cognition as a guiding theory.
  
  
  METHODS
  EM junior doctors were recruited from six hospitals in the south of England to participate in semi-structured interviews (n=20) and focus groups (n=17) based on recall of two recent cases. Transcripts were analysed using a grounded theory approach to identify themes and to develop a model of junior doctors' clinical reasoning in EM.
  
  
  RESULTS
  Within cases, clinical reasoning occurred in three phases. In phase 1 (case framing), initial case cues and first impressions were predominantly intuitive, but checked by analytical thought and determined the urgency of clinical assessment. In phase 2 (evolving reasoning), non-analytical single cue and pattern recognitions were common which were subsequently validated by specific analytical strategies such as use of red flags. In phase 3 (ongoing uncertainty) analytical self-monitoring and reassurance strategies were used to precipitate a decision regarding discharge.
  
  
  CONCLUSIONS
  We found a constant dialectic between intuitive and analytical cognition throughout the reasoning process. Our model of clinical reasoning by EM junior doctors illustrates the specific contextual manifestations of the dual cognition theory. Distinct diagnostic strategies are identified and together these give EM learners and educators a framework and vocabulary for discussion and learning about clinical reasoning.
authors.affiliation: Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK.
authors.forename: E
authors.initials: E
authors.lastname: Adams
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
authors.forename: C
authors.initials: C
authors.lastname: Goyder
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
authors.forename: C
authors.initials: C
authors.lastname: Heneghan
authors.affiliation: Emergency Department, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK.
authors.forename: L
authors.initials: L
authors.lastname: Brand
authors.affiliation: Centre for Research in Assessment and Digital Learning, Deakin University, Melbourne, Victoria, Australia.
authors.forename: R
authors.initials: R
authors.lastname: Ajjawi
mesh_terms: D000328:Adult; D003657:Decision Making; D004635:Emergency Medicine / Q000193:education*; D004739:England; D005260:Female; D017144:Focus Groups; D066296:Grounded Theory; D006801:Humans; D007396:Internship and Residency; D007407:Interviews as Topic; D008297:Male; D008505:Medical Staff, Hospital / Q000523:psychology*; D013850:Thinking
keywords: clinical assessment, education; education, teaching; emergency departments; teaching; training