Medical problem solving and uncertainty in the emergency department

Study objective: To compare the diagnostic processes of experienced emergency physicians with those of novices. Design: Prospective, convenience sample of patients. Setting: Emergency department of a county university medical center in a large southwestern urban community. Participants: Experienced emergency physicians (attending and senior residents) and novice clinicians (junior residents and senior medical students). Interventions: 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). Conclusion: 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.