Focused Ethnography of Diagnosis in Academic Medical Centers

Abstract

Background:

Views and approaches of attendings and residents to diagnosis in teaching hospitals are poorly understood. Identifying barriers and facilitators to diagnosis may help inform interventions in these settings.

Methods:

We conducted a focused ethnography of inpatient medicine teaching teams at two academic medical centers to understand what aspects might be targeted to improve diagnosis. Field notes regarding the diagnostic process (e.g., information gathering, integration and interpretation, working diagnosis) and work system (e.g., team members, organization, technology and tools, physical environment, tasks) were recorded. Following observations, focus groups and interviews were conducted to understand viewpoints, problems and solutions to improve diagnosis.

Results:

Between January 2016 – May 2016, four teaching teams (4 attendings, 4 senior residents, 9 interns and 12 medical students) were observed for 168 hours. Observations of diagnosis as care was being delivered led to identification of four key themes: (a) diagnosis is a social phenomenon; (b) data necessary to make diagnoses are fragmented; (c) distractions interfere with the diagnostic process; and (d) time pressures impede diagnostic decision-making. These observations suggest that interventions tailored to the academic setting such as team-based discussions of diagnostic workups, scheduling diagnostic time-outs during the day and strategies to “protect” learners from interruptions might prove useful in improving the process of diagnosis. Future studies that implement these ideas (either alone or within a multi-modal intervention) appear necessary.

Conclusion:

Diagnosis in teaching hospitals is a unique process in need of improvement. Contextual insights gained from this ethnography may be used to inform future interventions.

Introduction

Diagnostic error -- defined as failure to establish an accurate and timely explanation of the patient’s health problem or communicate that explanation to the patient -- is an important source of preventable patient harm.¹ While the precise burden of diagnostic errors is unknown, data suggest all patients will experience at least one such error in their lifetime.² Evidence from autopsy studies indicates that diagnostic errors account for approximately 10% of all patient deaths;^3,4 not surprisingly, then, they are among the leading categories of paid malpractice claims in the United States.⁵

Although common in all settings, errors in diagnosis have serious repercussions when they occur in the hospital.⁶ We have previously shown that the cost and morbidity of diagnostic errors in the hospital is substantial.⁷ Despite this, little is known about how diagnoses are made in hospital settings or how residents and learners approach decision-making when it comes to diagnosis. This knowledge gap is important, as efforts to improve diagnosis in hospitalized patients are unlikely to be successful without identifying barriers and addressing constraints faced by clinicians in academic centers.

Therefore, we conducted a focused ethnography of inpatient medicine teams (i.e., attendings, residents, interns and medical students) in two affiliated teaching hospitals to better understand how diagnosis might be improved in these settings. By pairing observations of patient care with focus groups, we aimed to develop rich insights into how medical attendings and clinicians in training perform the function of diagnosis in hospital settings.

Methods

We designed a multi-method, focused ethnographic study to examine diagnostic decision-making in inpatient settings.^8,9 In contrast to anthropologic ethnographies that study entire fields with open-ended questions, our study was designed to specifically examine the process of diagnosis from the perspective of clinicians engaged in this activity.⁹ This approach allowed us to capture diagnoses in a way currently lacking in the literature.¹⁰

Setting and Participants

We observed members of four inpatient internal medicine teaching teams at two separate, but affiliated teaching hospitals. We purposefully selected teaching teams for observation because: (a) they are emblematic of the structure of care delivery in academic settings; (b) we have expertise in hospital-based medicine; and, (c) we have extensive experience conducting observations in hospital settings.^11,12 Teaching teams typically consisted of a medical attending (senior-level physician that oversees the team), one senior resident (a second or third-year post-graduate trainee), two interns (a trainee in their first post-graduate year), and two to four medical students. Teams were selected at random using existing schedules and were followed Monday-Friday so that a variety of work routines including call and non-call days could be observed.

Data Collection

A multi-disciplinary team of researchers including clinicians (e.g., physicians, nurses), non-clinicians (e.g., qualitative researchers, social scientists) and healthcare engineers conducted observations. Observations of each teaching team were conducted before and during morning rounds and in the afternoon following rounds. Post-round observations consisted of shadowing the senior resident and one intern. In order to capture multiple aspects of the diagnosis process during observations, data were collected using field notes modeled on components of the National Academy of Science model for diagnosis.^1,13 This model outlines phases of the diagnostic process (e.g., data gathering, integration, formulation of a working diagnosis, treatment delivery and outcomes) and the work system (team members, organization, technology and tools, physical environment, tasks).

Focus Groups & Interviews

At the end of weekly observations, we conducted focus groups with residents and one-on-one interviews with the attendings. We interviewed attendings separately from residents and interns to ensure power differentials did not influence discussions. During focus groups, we specifically asked about challenges and solutions to improving diagnosis in hospital settings. Experienced qualitative methodologists (JF, MH, MQ) used semi-structured interview guides for discussions (Appendix).

Data Analysis

After aggregating and reading the data, three reviewers (VC, SS and SK) began inductive analysis by hand-writing notes and initial reflective thoughts in the margins of transcripts to create preliminary codes. Multiple team members then re-read the original field notes and focus group/interview data to refine preliminary codes and develop additional codes. Next, relationships between codes were identified and used to develop key themes. Triangulation of data from observations and interview/focus-group sessions was done (i.e., taking our summative findings back to team members) to compare what we surmised and how this was verbalized by the team. The developed themes were discussed to ensure consistency regarding major findings and learnings from the data.

Ethical and Regulatory Oversight

This study was reviewed and approved by the Institutional Review Boards at the University of Michigan Health System (HUM-00106657) and the VA Ann Arbor Healthcare System (1-2016-010040).

Role of the Funding Source

This project was supported by a grant from the Agency of Healthcare Research and Quality (P30HS024385). The funder played no role in the design or conduct of the project or the decision to submit the manuscript for publication.

Results

Between January 2016 – May 2016, 4 teaching teams (4 attendings, 4 senior residents, 9 interns and 14 medical students) were observed over 33 distinct shifts and 168 hours. Observations included morning rounds (96 hours), post-round shadowing during call days (52 hours) and post-round shadowing during non-call days (20 hours). Morning rounds lasted an average of 127 minutes (range: 48–232 minutes) and included an average of 9 patients (range: 4–16 patients).

Themes Regarding the Diagnostic Process

Observations of clinical care along with interviews and focus groups led to the identification of four main themes related to diagnosis in teaching hospitals: (a) diagnosis is a social phenomenon; (b) data necessary to make diagnoses are fragmented; (c) distractions undermine the diagnostic process; and (d) time pressures interfere with diagnostic decision-making (Appendix Table 1).

(A). Diagnosis is a social phenomenon.

Team members viewed the process of diagnosis as a social exchange of facts, findings and strategies within a defined structure. The opportunity to discuss and review impressions with others was valued as a means to share, test and process assumptions.

Rounds are the most important part of the process. That is where we make most decisions in a collective, collaborative way with the attending present. We bounce ideas off each other.

(Intern)

Typical of social processes, variations based on time of day, schedule and hierarchy were observed. For instance, during call days, attendings were removed from data gathering, integration or formulation of working diagnoses. Rather, learners gathered data and formed working diagnosis and treatment plans with minimal attending interaction. This separation of roles and responsibilities introduced a social hierarchy within diagnosis:

Yes, it is set up as a hierarchical process. The interns would not call me first; they would talk to the senior resident and then if the senior thought he should chat with me, then they would call. But, for the most part, they gather information and come up with the plan

(Attending)

The work system for diagnosis in hospitals was suited to facilitate social interactions for diagnosis. For instance, designated rooms (with team members informally assigned to a computer/workstation) provided physical proximity of the resident to interns and medical students. In this space, numerous informal discussions between team members (e.g., “what do you think about this test?” “I’m not sure what to do about this finding” “Should I call a [consult] on this patient?”) were observed. Yet, while proximity to each other was viewed as beneficial, dangers to the social nature of diagnosis in the form of anchoring (i.e., a cognitive bias where undue emphasis is placed on the first piece of information offered) were also highlighted.¹⁴ While the importance of avoiding anchoring bias was universally acknowledged, the paradox associated with social proof (i.e., the pressure to assume conformity within a group of colleagues) also emerged as a countervailing problem. Supportively, we only observed disagreement between team members and attendings twice and (in both cases), these occurred a few days after treatment and diagnosis decisions were made.

I mean, they’re the attending, right? It’s hard to argue with them when they want a test or something done. When I do push back, it’s rare that others will support me – so it’s usually me and the attending.

(Resident)

I would push back if I think it’s really bad for the patient or could cause harm – but the truth is, it doesn’t happen much.

(Intern)

(B). Data necessary to make diagnoses are fragmented.

Team members universally cited fragmentation in data delivery, retrieval and processing as a barrier to diagnosis. Examples of how such fragmentation affected care were readily offered. For instance, members indicated that test results might not be looked at or acted upon in a timely fashion. Residents and attendings universally pointed to the electronic medical record as a source of this challenge. One resident, in fact, described their role in the morning as “manning the computer,” simply to ensure all available data were available for rounds.

Before I knew about [the app for Epic], I would literally sit on the computer to get all the information we would need on rounds. Its key to making decisions. We often say we will do something, only to find the test result doesn’t support it – and then we’re back to square one.

(Intern)

Barriers to obtaining the necessary and appropriate data were contextualized in the setting of both individual factors and the work system. For example, information gathering by teams included not only myriad sources (e.g., patients, family members, electronic records), but also various settings (e.g., emergency department, patient rooms, discussions with consultants). Similarly, data such as laboratory results often appeared without warning. Thus, not only were data difficult to collate and synthesize, but information was poorly aligned with clinical duties.

They (lab) will call us when a blood culture is positive or something is off. That is very helpful but it often comes later in the day, when we’re done with rounds.

(Resident)

It seems as if the lab knows I’m about to discharge a patient or have a family meeting when they decide to page me with a critical value.

(Intern)

The work system was highlighted as being a key contributor to data fragmentation. Peculiarities of the electronic medical record (EMR) in how data were collected, stored or presented were described as “frustrating,” and “unsafe,” by team members. Correspondingly, we frequently observed interns asking for assistance for tasks such as ordering tests or finding key information despite being “trained” to use the EMR. Data retrieval thus occurred without data integration, as pieces of information were treated separately in time and space.

People have to learn how to filter, how to recognize the most important points and link data streams together in terms of causality. But we assume they know where to find that information. It’s actually a very hard thing to do, for both the house staff and me.

(Attending)

(C). Distractions undermine the diagnostic process.

We observed first-hand the problems posed by distractions when it came to diagnosis. One factor associated with distractions was communication inefficiencies. For instance, the unpredictable nature and volume of pages often interrupted thinking about diagnosis. To mitigate this problem, some team members developed their own strategies. For instance, one attending described how he would seek out nurses caring for his patients to proactively “head off” questions (e.g., “I will renew the restraints and medications this morning,” and “is there anything you need in terms of orders for this patient that I can take care of now?”) that might lead to pages. Another resident described his approach as follows:

I make it a point to tell the nurses where I will be hanging out and where they can find me if they have any questions. I tell them to come talk to me rather than page me since that will be less distracting

(Resident).

Team members also described distractions in the environment as contributing to inefficiency and being suboptimal for diagnosis. For example, conference rooms were usually cluttered, crowded and disorganized. Ambient noise, interruptions from neighbors working on other teams, and inability to access computers to review or enter data were cited as barriers to diagnosis. Additionally, we observed several team members using headphones to drown out ambient noise while working on the computer.

I know I shouldn’t do it (wear headphones), but I have no other way of turning down the noise so I can concentrate.

(Intern)

Sometimes the pager just goes off all the time and (after making sure its not an urgent issue), I will just ignore it for a bit, especially if I am in the middle of something. It would be great if I could finish my thought process knowing I would not be interrupted.

(Resident)

Most interns described documentation work such as writing admission and progress notes in negative terms (“an academic exercise,” “part of the “billing activity”). However, in the context of interruptions, some described this process as helpful.

The most valuable part of the thinking process was writing the assessment and plan because that’s actually develop my schema for all problems. It literally is the only time where I can sit and collect my thoughts to formulate a diagnosis and plan.

(Intern)

(D). Time pressures interfere with diagnostic decision-making.

All team members spoke to the challenge of finding time to consider diagnosis during the workday.

They tell us we should go to morning report or noon conference but when I’m running around trying to get things done. I hate having to choose between my education and doing what’s best for the patient – but that’s often what it comes down to

(Intern)

When specifically asked whether setting aside dedicated time to review diagnoses and management would be valuable, respondents were uniformly enthusiastic. Team members described attentional conflicts as being the worst when “cross-covering” other teams on call days, as their patient load effectively doubled during this time. Of note, cross-covering occurred when teams were on call – and thus took them away from important data gathering or synthesis activities for patients they were admitting.

If you were to ever design a system where errors were likely – this is how you would design it: take a team with little supervision, double their patient load, keep them busy with new challenging cases and then ask questions about patients they know little about.

(Resident)

Discussion

Although diagnostic errors have been called “the next frontier for patient safety,”¹⁵ little is known about the process, barriers and facilitators in teaching hospitals. In this focused ethnography of teaching teams at two academic medical centers, we identified multiple challenges and potential strategies to improve diagnosis from clinicians as they engaged in this activity. These themes included: the social nature of diagnosis, fragmented information delivery, constant distractions and interruptions, and time pressures. In turn, such insights allow us to generate strategies with which to improve the diagnostic process in teaching hospitals.

Our study underscores the importance of social interactions in diagnosis. In this sense, morning rounds were the quintessential social gathering – where members of the team congregated to strategize and develop care plans. However, even though a collective approach to diagnosis was valued by team members, lack of dedicated time to think about diagnosis was identified as barrier to improve diagnostic decision-making. Indeed, studies of residents suggest that having time to reflect more often leads to correct responses on standardized tests.¹⁶ When asked, team members indicated that as little as 15–20 minutes of time dedicated to diagnosis each day would be valuable. Creating defined periods for individuals to engage in diagnostic activities such as de-biasing (i.e., asking “what else could this be)¹⁷ before rounds or at the end of the day may facilitate cognitive work. Interventions that schedule such enhancements and embed tools such as diagnosis expanders or checklists within these defined time slots,^18,19 may prove useful in preventing diagnostic errors.

An unexpected yet important finding from this study was the challenge posed by constant distractions and the physical environment when making diagnoses. Specifically, we saw residents and interns trying to “tune out” background noises and pager alerts so that they may better concentrate on patient care. Some staff and faculty developed workarounds to these interruptions, including updating nurses with plans to avert pages and creating a list of activities to ensure they do not forget key tasks.^20,21 Applying lessons from systems design and aviation where a focused effort to limit distractions during key portions of the day might be worth considering in this context.²² Similarly, changing the ergonomics in which diagnosis occurs – including spaces that are quiet, orderly and optimized for thinking -- might prove valuable.²³

Our study has limitations. First, our findings are limited to direct observations; we are thus unable to comment on how unobserved aspects of care (e.g., cognitive processes) might have influenced our views. Our observations of clinical care might also have introduced a Hawthorne effect. However, because we were closely integrated with teams and conducted focus groups to corroborate our assessments, we feel confident this was not the case. Second, we did not identify diagnostic errors or link processes we observed to errors as this was not the purpose of our work. Third, our approach is limited to two teaching centers, limiting generalizability of findings.

Our study also has important strengths. To our knowledge, this is the first study to examine diagnosis among inpatient teams in academic medical centers. The challenges faced by clinicians that are the artisans of diagnosis in teaching hospitals suggest new ways to improve diagnosis. Second, we used an intensive approach for data collection that spanned almost two hundred hours. Through focused ethnography techniques, we obtained a unique view on how clinical workflow, knowledge, and physical environment interact to influence diagnosis. Third, our observations help inform future interventions that may include defined “time-outs” for diagnosis, strategies focused on limiting distractions, and efforts to improve communication between team members.

As challenges to quantify diagnostic errors abound,²⁴ targeting and improving processes associated with diagnosis might be our best proxy to improve diagnostic safety. Targeting communication, concentration, organization and mindfulness appear to be important ways to improve medical decision-making in academic medical centers.

Appendix Table A.

Exemplary Quotes from Focus Groups and Field Notes

Domain	Clinician	Exemplary Quote	Field Note Example(s)
Diagnosis is a social phenomenon	Week 1: Intern	…it was also nice to talk to somebody who is also like an experienced senior resident, like whom I trust as well. I know he is very good clinically and diagnostically, I know he is good. And so being able to run it by him and then walk through it just to make sure that I’m not missing anything is extremely helpful.	Example 1: Resident (reading again on UptoDate) to Intern- “I’m reading about the symptoms of reactions to IVIG and it says that you can have generalized inflammatory reactions especially in patients with acute infections.” Intern 1– “I don’t know why she would be harboring an infection. We haven’t checked for pelvic inflammatory disease but she’s not complaining about pain. But I guess it’s something to think about.” Intern 2 – “She had an extensive negative work-up. Resident – “Her last CT was without contrast so something might have been missed. Hold off until we touch base allergy. I want to see what their thought process is.” Intern 1 – “Ok” Resident – “I’m thinking we do pre and post labs for t inflammatory markers at her next IVIG injection then a steroid and then the CT.”
	Week 1: Intern	So I spoke to the medical student and the intern. We have a plan. I feel like my plan is reasonable. I want to make sure I’m not missing something so I take it to a colleague…and so we go through it and then, if I feel reassured after that and we both come to a consensus that like this is a reasonable plan…But if during that interaction, if I’m still unsure and I feel like there is something missing that doesn’t still make sense, then I would talk to the attending.
	Week 3: Intern	So, usually, if we have questions, we usually discuss them among ourselves first before trying to seek further help
	Week 4: Intern	I kind of like working in the team room because there’s a lot of people there, there’s a lot of people to bounce ideas off of.
	Week 4: Resident	…the maximum source of information is in the team room with the computer and with the other physicians and residents and interns. They are all there. It’s the best source to get as much knowledge as possible in the shortest amount of time. You can just pose a question to the group and whoever knows the most would answer it.	Example 2: Intern [asks resident from other team] “How long was she on antibiotics when you guys treated her?” Resident from other team - “2 days.” Resident - “Oh, that’s it?” Resident from other team - “What are you guys thinking it is?” Resident “Attending thought of IVIG reaction” Resident from other team – “Oh yeah, we totally thought of that.” (Everyone laughs.) Resident – “Or immune reconstitution syndrome. There’s 3 things I’m going to ask allergy. 1) Type of reaction, 2) Can we move the injection up and 3) Can we do the pre/post labs with steroid and CT.”
Data necessary to make diagnoses are fragmented	Week 3: Intern	We try and get as much as we can from the patient - but, often, we need to rely on family that is there…Paramedics…ED staff is really helpful because they get an initial impression and can sometimes glean information that wasn’t passed to us. Chart review is also helpful. We try and go back to their previous encounters they have had with the hospital to see what situation or state they left in but we also get records from outside hospitals as well. So it’s a culmination of oral—rather, an amalgam of all these different resources, a lot of electronic records and a lot of, I guess, people that we try to get as much information from as possible.	Example 1: Resident is showing the medical student how to find a patient’s primary care physician in the electronic medical record. He is instructing the medical student where to find relevant information in the electronic medical record so as to compose an e-mail for the primary care physician. Resident – “make sure that you include all the relevant lab and pathology details in the note from the various sections of the chart. It’s really hard to find it all so a good summary is essential.” Medical Student – “[laughs] you don’t have to tell me that.” Resident – “and lets ensure he has a follow-up appointment in one week with new labs. He has a good understanding of his symptoms so he will know when to call in.”
	Week 3A: Intern	Gaps we are not aware of, usually, after we are done rounding, we come back to the team room as a group and we will just start wherever or just check back to see if the labs came back or studies came back and, at that point, we might just update the team and attending saying, oh, I mentioned this; in reality, it’s this.
	Week 1: Intern	…check labs just kind of on the fly while we are there so we don’t always have to either just not know and check it later and be delayed, or run to a different computer to check it.	Example 1: Attending – “They give contrast with venograms – were his labs okay before the study? Intern —”Im not sure – I haven’t checked labs yet. They weren’t back in the morning?” Attending: Just be careful. If you don’t know, find out. Remember, he’s starting an ACE inhibitor, aldactone and [now] getting IV contrast. No hurry in starting those meds and we don’t want to prolong his hospitalization because of renal failure.”
	Week 2: Intern	… and because every time more information is re-introduced, it causes you to stop, like rethink it, make sure that’s a consistent fact versus a fact that we need to reassess and readdress and bring up. And so by doing it in little stages like that, it allows you to kind of sift through the information, as opposed to be like overwhelmed without a road map of where you are going. That way, it becomes less overwhelming, more direct and focused.
Distractions impair diagnosis	Week 2: Attending	Our current paging system has lots of problems.	Example 1: Observing in team room: Intern receives a page, picks up the phone and calls the number back. There is no answer. Intern -- “What is the point of sending a number if you’re never going to pick up?” Other intern responds -- “Welcome to my life.”
	Week 1: Intern	Or even paging. It’s annoying. If I have to page on the fly, I have to pull out my phone, go to the website, enter in all their information, and that just takes more time than if, you know, you already had it up on the screen, you could just paste in [stuff] so	Example 2: (Several pages and calls observed within a short period of time) 1:28PM Intern is paged about discharge plan for a patient. Leaves room to discuss with nurse on the floor as there are remaining issues or clarifications needed. 1:32PM resident paged by ED 1:34PM resident returns ED call about first admission 1:38PM resident ends call with ED 1:40PM resident returns another page from ED regarding a second admission 1:43 resident receives another page, tells intern about another admission they will take. (Week 3, Day 1)
	Week 2: Intern	And I guess now that we are talking about that, the one thing that sort of interrupts our work when we are actually doing like our rounding is sometimes one of us will have to run to the nearest computer to look up something or run to the nearest phone—which is usually by the nearest computer—to call a different attending or a consult
	Week 4: Resident	I think one thing is when you’re too busy with other things going on, like during admitting day, either one of the new ones or one of your other patients is like very active, then you tend to devote less time to this new one and you start to, and when you start to rush things is when you make mistakes or you don’t look through enough of the notes or you just start, …
	Week 4: Intern	…yeah, interruptions are huge setbacks and I think the expectation is that, oh, you send a quick page; it’s nothing. But like every page that you get is very distracting….
	Week 3: Resident	there are some mornings where I am holding that admission pager and they are presenting the—we are doing the card flip, giving updates, and I, basically, miss all the updates because I am triaging all the pages from the ER, sit and try to determine who to accept, who not to accept, say who is stable, who is not stable, seeing—trying to go down to see a patient immediately or if they can wait so we start rounding. In those situations, I miss some of the conversations that these two are having with (attending).
Time pressures interfere with diagnostic decision-making	Week 2: Resident	And if things don’t get done at certain times, patient care is affected so I don’t think there is like one time for me that I just think about everything. I literally have to do multiple things at one time but need more time to do them.	Example 2: Intern is doing several tasks at once to discharge a patient – she is writing progress notes on the computer but also flicking back and forth and, writing orders. She is toggling back and forth between screens simultaneously working on 4 patient charts at a time. I sometimes see her going to the laboratory tab and looking up test results to find information. While doing these activities, her pages goes off and she is now answering pages… She then turns and says, “I forgot I have to go to morning report – I have no time to do the discharge papers now.”
	Week 3: Intern	we have minimized the number of conferences we go to just because of the work and how much there is to do.
	Week 4: Intern	It’s stressful…because when we are admitting patients and then, sometimes, when we are the late team, we also get the cross cover so the interns have their own however many patients they have plus the other teams that are signing out so some maybe have less time to piece things together but, ultimately, before we end up leaving the hospital, we piece everything together because that’s the best thing for patient safety. So that just means that we stay there later to make sure that things are pieced together, that our work is completed, that we have thought through these things.
	Week 4: Resident	I think one thing is when you’re too busy with other things going on, like during admitting day, either one of the new ones or one of your other patients is like very active, then you tend to devote less time to this new one and you start to, and when you start to rush things is when you make mistakes or you don’t look through enough of the notes or you just start, …

Appendix B. Semi-Structured Interview (Attendings) and Focus Group Discussion Guide (Residents and Students)

Introduction:

• Introduce project team and describe what their role will be.

• Explain the purpose of the focus group.

• Guarantee confidentiality from the research team and ask participants to also maintain confidentiality.

• Ask if anyone has any questions.

• Tell them when the recorders will be turned on.

• Review the information letter with each participant to make sure they are fully informed; answer any questions before beginning the focus group

If you could tell us:

• Title/position

• How long have worked here

• Type of license (medical, trainee, other)

• Area of expertise

• Unit/Work location

• Years of experience

• 1Can you please describe your role within your organization and give a brief description of what you do from day-today?
  Interviewer Probes:

  1. How many years have you been in this position?
  2. What did you do before this position?

  NOTE: if subject has recently participated in field observations than you may not need to spend much time on these intro questions.

Straight forward Diagnosis

• 2
  Thinking about a patient you had this week that had a straight forward diagnosis:

  • What was the decision-making process through which a diagnosis was made?

    • What were the main sources of information?
    • What did you learn from the patient and family that helped in making the diagnosis?
    • What source of information had the greatest influence on decision-making, and why?
    • How much time did you have to think about this patient? When was the best time to think.
    • How was the diagnosis discussed within the team?
    • What were the roles of other health professionals that were involved in the diagnosis process (for example, nurses, radiologists, therapists)?

Difficult Diagnosis

• 3
  Can you tell us about a patient you had this week where the process of diagnosis was difficult?

  • What was the process through which a diagnosis was made?

    • Why was this case challenging?
    • Do you think certain aspects may have made this easier? If so, what?
    • What were the main sources of information?
    • What did you learn from the patient and family?
    • How was the diagnosis discussed within the team?
    • What were the roles of other health professionals that were involved in the diagnosis process (for example, nurses, radiologists, therapists)?
    • At what point(s) do you think a misdiagnosis might have happened?

Error in Diagnosis

• 4
  Can you tell us about a time where there was a delayed or missed diagnosis (not necessarily on this team)

  • What factors do you think contributed to the delayed or missed diagnosis?
  • Was there a substantial period of time during which the diagnosis was uncertain?
  • How was the misdiagnosis discovered?
  • What happened after it was discovered
  • Did anything within the team change after this happened

Summary Questions

• 5What are the parts of the diagnostic decision-making process that are most vulnerable to error? Why?
• 6What can be done, in your opinion, to improve the process of diagnosis for interns/residents/attendings
• 7Would having a set amount of time carved out each day to think through diagnoses for your patietns be helpful?
• 8Are certain technology tools potentially barriers to making diagnosis?
• 9What about technology tools that are facilitators? Do you use any of them?
• 10
  What are your ideas on improving diagnostic accuracy?

  • Process through which diagnoses are made
  • System factors (e.g., team communication, IT)
  • Individual factors (e.g., training, attending behavior and skills)
• 11Now think about your patients that present with shortness of breath. What are some of the strategies you use when deciding on an appropriate diagnostic and care management and treatment plan? How do you come up with this strategy? What information sources may you use?
  Interviewer Probes:

  1. additional symptoms,
  2. severity of illness,
  3. available time,
  4. prior antibiotic exposure,
  5. Laboratory tests
  6. Imaging studies
  7. Others?
• 12What factors do you consider in ordering diagnostic tests for patients who present with shortness of breath?
  Interviewer Probes:

  1. Risks/Benefits of the test
  2. Severity of illness
  3. Patient comorbidities
  4. Patient preferences
  5. Cost of the test
  6. Expected clinical or diagnostic yield
  7. How test results may influence decision making?
  8. Others?
• 13What factors do you consider when deciding on medical treatment for patients who present with shortness of breath?
  Interviewer Probes:

  1. Risks/Benefits of the treatment
  2. Severity of illness
  3. Patient comorbidities
  4. Patient preferences
  5. Cost of the treatment
  6. Expected clinical or diagnostic benefit of the treatment
  7. How treatment outcomes may influence decision making and care
  8. Others
• 14What resources do you use to help with medical decision-making in patients who present with shortness of breath?
  Interviewer Probes:

  1. Colleagues
  2. Specialists
  3. Previous similar cases
  4. Technology (please specify)
  5. Reference materials (please specify)
  6. Others
• 15Please discuss instances where distractions, disruptions, policy or culture influenced your approach to caring for patients who present with shortness of breath?

[QUESTIONS 11 THRU 15 ABOVE WILL BE REPEATED FOR EACH OF THE FOLLOWING PATIENT TYPES:

• Patients who present with chest pain

• Patients who present with abdominal pain

• Patients who require antibiotic treatment for urinary tract infections

SUMMARY QUESTIONS:

• 4Is there anything else that you would you like to tell us about caring for patients that present with common cardinal symptoms or patients that require antibiotic treatment for UTIs?

That is the end of the questions that we have for you. Now do you have any questions for me or any other comments on anything that we have discussed today? Thank you very much for taking the time to participate in this interview/focus group.