Medical problem solving and uncertainty in the emergency department

Ann Emerg Med. 1991 Sep;20(9):987-91. doi: 10.1016/s0196-0644(05)82977-4.


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.

MeSH terms

  • Academic Medical Centers
  • Clinical Competence*
  • Clinical Protocols / standards*
  • Decision Support Techniques*
  • Emergency Medicine / methods*
  • Emergency Medicine / standards
  • Emergency Service, Hospital
  • Humans
  • Medical History Taking / standards
  • Physical Examination / standards
  • Problem Solving*
  • Prospective Studies