Insights into emergency physicians’ minds in the seconds before and into a patient encounter

Abstract

Clinical reasoning is a core competency in medical practice. No study has explored clinical reasoning occurring before a clinical encounter, when physicians obtain preliminary information about the patient, and during the first seconds of the observation phase. This paper aims to understand what happens in emergency physicians' minds when they acquire initial information about a patient, and when they first meet a patient. The authors carried out in-depth interviews based on the video recordings of emergency situations filmed in an "own-point-of-view-perspective". 15 expert emergency physicians were interviewed between 2011 and 2012. Researchers analysed data using an interpretive approach based on thematic analysis and constant comparison. Almost all participants used a few critical pieces of information to generate hypotheses even before they actually met the patient. Pre-encounter hypotheses played a key role in the ensuing encounter by directing initial data gathering. Initial data, collected within the first few seconds of the encounter, included the patient's position on the stretcher, the way they had been prepared, their facial expression, their breathing, and their skin colour. Physicians also rapidly appraised the seriousness of the patient's overall condition, which determined their initial goals, i.e. initiating emergency treatment or pursuing the diagnostic investigation. The study brings new insights on what happens at the very beginning of the encounter between emergency physicians and patients. The results obtained from an innovative methodological approach open avenues for the development of clinical reasoning in learners.

Does the unexpected death of the manikin in a simulation maintain the participants’ perceived self-efficacy? An observational prospective study with medical students

“…The fact of drawing participants’ attention to this possible outcome may indeed lead them to increase their vigilance over the occurrence of this event, even though they would not have done so in a real situation. This could therefore compromise their clinical reasoning by pointing it to the signs to pay attention to during the sequence, even though recognizing the nature of the problem in a simulated or real clinical environment by picking up the relevant information is central to the medical expertise, particularly in the emergency medicine practice [28, 29]. This implies, if we want to train students to develop this skill, not to reveal the solution to the problem (e.g.…”

A Novel Approach to Study Medical Decision Making in the Clinical Setting: The “Own‐point‐of‐view” Perspective

“…30,37,38,41,42,50 Clinical Setting, Data Collection, and Data Analysis We carried out our research in three hospitals: a hospital in the region of Paris (France), a university hospital in a large French city, and a nonuniversity hospital in a medium-sized French city. Five physicians were enrolled in each place to reach data saturation.…”

“…51,52 Among these is the fact of having been trained and of practicing as an emergency medicine specialist, of being a full-time hospital practitioner with exclusive practice in emergency medicine, and of having been designated as "experienced" by the hierarchical superior. 37,38 We interviewed each subject about a single potentially life-threatening situation that they had to manage in their usual clinical environment. The physicians were equipped with a microcamera mounted at their eye level (HORUS).…”

“…37,38 Items that were related to the method used were specifically encoded using the code "spoke about wearing the camera." Subcodes were then assigned to identify more precisely the effects of using this technique, according to the interviewees.…”

“…37,38 • During the interview following the recording of the activity, and which is based on this, the external perspective sometimes leads the person interviewed to note information that had escaped him at the time because he had not seen it during the action, rather than reporting the information actually taken into account during the reasoning process. 39 • The fact that the external perspective is different from the physician's perspective may interfere with his ability to recall and explain his reasoning.…”