Using Video Ethnography and Stimulated Recall Interviews to Describe the Diagnostic Process in the Emergency Department.

Abstract

Understanding how physicians make diagnoses is challenging because cognitive processes are unobservable and partly unconscious, making it difficult for physicians to describe how they arrived at a diagnosis. Physicians who work in emergency departments (EDs) are especially vulnerable to making diagnostic errors because the ED is a fast-paced, dynamic setting where complex decision-making occurs under severe time, information, and resource constraints. The purpose of our study was to describe how the diagnostic process evolves for ED clinicians in both pediatric and adult ED settings. We used a qualitative, video ethnography study design to capture in situ, real-time ED physician practice for 11 participants from February 2022 to July 2023. Participants wore a head-mounted video camera while providing care to ED patients, and in subsequent stimulated recall interviews, revealed their thinking throughout the diagnostic process. We recorded 24.42 h of video overall (average 2.22 h per participant). We identified four major themes in the ED diagnostic process: (1) quality communication facilitates information flow, (2) cognition is complex and distributed across patients and the ED team, (3) artifacts can enhance the diagnostic process, and (4) there is a need to balance efficiency with safety and accuracy. Illustrating physicians' cognitive processes through video ethnography coupled with stimulated recall interviews helped advance our understanding of the diagnostic process and is a foundational step for identifying improvement opportunities.