395 - Investigating Emergency Department Physicians Diagnostic Decision Making by In-situ Video Ethnography

Monday, May 1, 2023

9:30 AM – 11:30 AM ET

Poster Number: 395
Publication Number: 395.406

Milisa Manojlovich, University of Michigan, Ann Arbor, MI, United States; Sarah J. Parker, University of Michigan Medical School, Ann Arbor, MI, United States; Prashant Mahajan, University of Michigan Medical School, Ann Arbor, MI, United States

Presenting Author(s)

Prashant Mahajan, MD, MPH, MBA (he/him/his)

Professor of Emergency Medicine and Pediatrics, Vice Chair and Section Chief PEM
University of Michigan Medical School
Ann Arbor, Michigan, United States

Background: Emergency departments (EDs) are prone to diagnostic errors, partially because physician decision-making processes operate at a habitual or subconscious level making it difficult to examine and possibly change diagnostic thinking. Understanding how expert clinicians think in real time may provide learning opportunities to improve diagnostic safety in the ED.

Objective: Use ED provider point of view video and subsequent review to map the ED diagnostic process.

Design/Methods: To recruit physicians, we held short information sessions and distributed one page study overviews via email. We fitted participating physicians with a head-mounted micro camera and microphone. A trained observer collected data on contextual factors that the camera did not capture. Physicians participated in individual recall interviews, where they “think aloud” while watching short video clips to provide insight into their diagnostic thought process. We used content analysis to qualitatively analyze the videos.

Results: To date 5 physicians video-recorded their activities, each for two hours (10 hours total), 3 were pediatric ED and two were general ED physicians. We used the theory of distributed cognition to deductively categorize video segments related to the diagnostic process and capture: (a) how physicians arrange their Workflow (68 examples), (b) Interactions with patients and ED team members (148 examples), and (c) the impact of electronic records and other artifacts on the diagnostic process (54 examples). During recall interviews, the physicians reviewed ~ 10 minutes of their own video. We identified themes related to use of cognitive aids, relationship building, and secondhand knowledge before assessing the patient (Table 1). Use of physical or electronic notes are common cognitive aids providers use to aid diagnosis and they rely on triage or transfer notes to assess patient needs and develop initial hypotheses. Providers also believed that building quick rapport, often using body language, with a patient is an important aspect to information gathering in the diagnostic process.

Conclusion(s): Use of real time video ethnography and follow up video reviews provide unique insights into the ED clinician’s diagnostic process. Future research should focus on identifying best practices among expert diagnosticians for training the next generation of providers.