Diagnostic Expertise in the Emergency Department

Abstract

The healthcare community has, in recent years, paid increased attention to errors in the diagnostic process, especially in emergency departments (EDs). However, the expertise of frontline professionals could be an important factor in mitigating risks, preventing diagnostic errors, and improving performance. The current research focused on identifying expertise in ED personnel, complementing efforts to examine errors in reasoning or diagnosis. Data were collected from a three-year, multi-site examination of various EDs. Through the analysis of 43 Critical Decision Method interviews (Klein, Calderwood, & MacGregor, 1989), we identified six aspects of ED expertise: technical, perceptual, organizational, teamwork, emotional, and sensemaking. We also identified barriers to the development of expertise in the ED, such as limited follow-up and feedback on cases. Our findings were consistent with other naturalistic examinations of expertise. Finally, we discuss implications for ED practice, diagnostic safety, and training.

Keywords

expertise emergency departments decision making diagnosis diagnostic errors

Get full access to this article

View all access options for this article.

References

Bisantz

A. M.

Pennathur

P. R.

Guarrera

T. K.

Fairbanks

R. J.

Perry

S. J.

Zwemer

Wears

R. L.

(2010). Emergency department status boards: A case study in information systems transition. Journal of Cognitive Engineering and Decision Making, 4(1), 39–68. https://doi.org/10.1518/155534310x495582

Borders

Klein

Besuijen

(2024). Mental model matrix: Implications for system design and training. Journal of Cognitive Engineering and Decision Making, 18(2), 75–98. https://doi.org/10.1177/15553434231226317

Elstein

A. S.

Shulman

L. S.

Sprafka

S. A.

(1978). Medical problem solving: An analysis of clinical reasoning. Harvard University Press.

Fisher

W. R.

(1985). The narrative paradigm: An elaboration. Communication Monographs, 52(4), 347–367. https://doi.org/10.1080/03637758509376117

Graber

M. L.

Franklin

Gordon

(2005). Diagnostic error in internal medicine. Archives of Internal Medicine, 165(13), 1493–1499. https://doi.org/10.1001/archinte.165.13.1493

Gurses

A. P.

Perry

S. J.

Eisenberg

Osei

Alam

Daodu

Peterson

Kelen

Newsome

Hoy

Klein

G. A.

(2023). Empirical investigation of the diagnostic process in emergency medicine. Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine. [Manuscript in preparation].

Hutton

R. J. B.

(2019). Macrocognitive models of expertise. In Ward

(Ed.), The oxford handbook of expertise (pp. 190–218). Oxford University Press. https://doi.org/10.1093/oxfordhb/9780198795872.013.9

Kahneman

Klein

(2009). Conditions for intuitive expertise: A failure to disagree. American Psychologist, 64(6), 515–526. https://doi.org/10.1037/a0016755

Klein

(2019). The curious case of confirmation bias. Psychology Today. https://www.psychologytoday.com/us/blog/se.eing-what-others-dont/201905/the-curious-case-of-confirmation-bias

10.

Klein

(2022). Snapshots of the mind. MIT Press. https://doi.org/10.7551/mitpress/14342.001.0001

11.

Klein

Fairbanks

R. J.

(2022). Mis-diagnosing the causes of diagnostic errors in healthcare. Psychology Today. https://www.psychologytoday.com/us/blog/seeing-what-others-dont/202205/mis-diagnosing-the-causes-diagnostic-errors-in-healthcare

12.

Klein

Jalaeian

Hoffman

R. R.

Mueller

S. T.

(2023). The plausibility transition model for sensemaking. Frontiers in Psychology, 14, Article 1160132. https://doi.org/10.3389/fpsyg.2023.1160132

13.

Klein

G. A.

Calderwood

MacGregor

D. G.

(1989). Critical decision method for eliciting knowledge. IEEE Transactions on Systems, Man, and Cybernetics, 19(3), 462–472. https://doi.org/10.1109/21.31053

14.

Leape

L. L.

Brennan

T. A.

Laird

Lawthers

A. G.

Localio

A. R.

Barnes

B. A.

Hebert

Newhouse

J. P.

Weiler

P. C.

Hiatt

(1991). The nature of adverse events in hospitalized patients: Results of the harvard medical practice study II. New England Journal of Medicine, 324(6), 377–384. https://doi.org/10.1056/NEJM199102073240605

15.

National Academics of Sciences, Engineering, and Medicine . (2015). Improving diagnosis in health care. The National Academies Press.

16.

Norman

G. R.

Grierson

L. E. M.

Sherbino

Hamstra

S. J.

Schmidt

H. G.

Mamede

(2018). Expertise in medicine and surgery. In Ericsson

K. A.

Hoffman

R. R.

Kozbelt

Williams

A. M.

(Eds.), The Cambridge handbook of expertise and expert performance (2nd ed., pp. 331–355). Cambridge University Press. https://doi.org/10.1017/9781316480748.019

17.

Patel

V. L.

Groen

G. J.

(1986). Knowledge based solution strategies in medical reasoning. Cognitive Science, 10(1), 91–116. https://doi.org/10.1207/s15516709cog1001_4

18.

Patel

V. L.

Kaufman

D. R.

Kannampallil

(2019). Diagnostic reasoning and expertise in health care. In Ward

(Ed.), The oxford handbook of expertise (pp. 618–641). Oxford University Press. https://doi.org/10.1093/oxfordhb/9780198795872.013.27

19.

Pelaccia

Tardif

Triby

Ammirati

Bertrand

Dory

Charlin

(2014). How and when do expert emergency physicians generate and evaluate diagnostic hypotheses? A qualitative study using head-mounted video cued-recall interviews. Annals of Emergency Medicine, 64(6), 575–585. https://doi.org/10.1016/j.annemergmed.2014.05.003

20.

Ross

Shafer

Klein

(2006). Professional judgments and “naturalistic decision making”. In Ericsson

Charness

Feltovich

Hoffman

(Eds.), The cambridge handbook of expertise and expert performance. Cambridge handbooks in psychology (pp. 403–420). Cambridge University Press.

21.

Sanders

(2010). Every patient tells a story: Medical mysteries and the art of diagnosis. Harmony.

22.

Schraagen

J. M.

Leijenhorst

(2001). Searching for evidence: Knowledge and search strategies used by forensic scientists. In Salas

Klein

(Eds.), Linking expertise and naturalistic decision making (pp. 263–274). Lawrence Erlbaum Associates.

23.

Schubert

C. C.

Denmark

Crandall

Grome

Pappas

(2013). Characterizing novice-expert differences in macrocognition: An exploratory study of cognitive work in the emergency department. Annals of Emergency Medicine, 61(1), 96–109. https://doi.org/10.1016/j.annemergmed.2012.08.034

24.

Shojania

K. G.

Burton

E. C.

McDonald

K. M.

Goldman

(2003). Changes in rates of autopsy-detected diagnostic errors over time: A systematic review. JAMA, 289(21), 2849–2856. https://doi.org/10.1001/jama.289.21.2849

25.

Singh

Meyer

A. N.

Thomas

E. J.

(2014). The frequency of diagnostic errors in outpatient care: Estimations from three large observational studies involving US adult populations. BMJ Quality and Safety, 23(9), 727–731. https://doi.org/10.1136/bmjqs-2013-002627

26.

Sklar

D. P.

Hauswald

Johnson

D. R.

(1991). Medical problem solving and uncertainty in the emergency department. Annals of Emergency Medicine, 20(9), 987–991. https://doi.org/10.1016/s0196-0644(05)82977-4

27.

Strauss

A. T.

Morgan

El Khuri

Slogeris

Smith

A. G.

Klein

Toerper

DeAngelo

Debraine

Peterson

Gurses

A. P.

Levin

Hinson

(2022). A patient outcomes–driven feedback platform for emergency medicine clinicians: Human-centered design and usability evaluation of linking outcomes of patients (LOOP). JMIR Human Factors, 9(1), Article e30130. https://doi.org/10.2196/30130

28.

Thomas

R. P.

Dougherty

M. R.

Sprenger

A. M.

Harbison

(2008). Diagnostic hypothesis generation and human judgment. Psychological Review, 115(1), 155–185. https://doi.org/10.1037/0033-295X.115.1.155

29.

Winters

Custer

Galvagno

S. M.

Colantuoni

Kapoor

S. G.

Lee

Goode

Robinson

Nakhasi

Pronovost

Newman-Toker

(2012). Diagnostic errors in the intensive care unit: A systematic review of autopsy studies. BMJ Quality & Safety, 21(11), 894–902. https://doi.org/10.1136/bmjqs-2012-000803