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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.

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Acknowledgments

We thank all the physicians who took part in the interviews. Their contribution to the research is invaluable. We thank physicians who helped us to recruit. We thank Pierre Paillé, senior qualitative researcher, for his contribution to the study design. We also thank Annick Bourget, Associate Professor and Nicolas Pelaccia, Consultant, for their contribution to this research.

Funding

This study was supported by a grant from the French Society for Emergency Medicine (SFMU). The grant was used to buy the camera and to pay TP’s travel expenses needed for data collection.

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Correspondence to Thierry Pelaccia.

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The authors declare that they have no conflict of interest.

Statement of human and animal rights

All procedures performed in this study were in accordance with the ethical standards of the institutional or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by both a university ethics committee (Education and Social Sciences Research Ethics Committee of the University of Sherbrooke, Canada-#CER-ESS 2010-71) and a hospital ethics committee (Committee for the Protection of Persons Northwest 2, Amiens University Hospital-#A01586-37).

Informed consent

Written informed consent was obtained from all physicians included in the study. Oral informed consent was obtained from all patients or a trusted third party.

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Pelaccia, T., Tardif, J., Triby, E. et al. Insights into emergency physicians’ minds in the seconds before and into a patient encounter. Intern Emerg Med 10, 865–873 (2015). https://doi.org/10.1007/s11739-015-1283-8

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Keywords

  • Clinical reasoning
  • Decision making
  • Emergency medicine
  • Hypotheses generation
  • Dual-process theory