An additional table file contains a complete list of the 78 informational concept and 46 cognitive process codes [See Additional file 1]
We identified several commonalities amongst cognitive processes including choosing, concluding, and information seeking and studying. All residents utilized adaptive expert cognition through similar strategies. For instance, epistemic distance defined as monitoring level of knowledge and identifying knowledge gaps (25) was observed amongst all participants.
Residents’ diagnostic reasoning
The narrative analysis of the chronology of diagnostic process of each informant was visualized into individual models of diagnostic reasoning. These models of diagnostic reasoning are illustrated in Figs. 1.1–1.7. They show a progression in thought processes and changes in hypotheses (color-coded).
Anne has been in residency for 5 months. In the observed patient encounter, she received a 60-year-old patient who had stepped on glass a week ago. The patient (Anton) is now referred to the ED with an inflammation.
In her first hypothesis generation, Anne comments that a physician has not seen Anton before being referred to the ED. This would have been common practice with this type of patient. Thus, her thinking is part of the cue collection in her first hypothesis generation. She reads the short referral note, which states that the patient had stepped on something while swimming in the ocean. The patient’s pain has increased since, and he has a hard time walking. Anne’s initial hypothesis is therefore, that the foot is inflamed. Anne observes that the patient’s walking is affected. However, during her clinical evaluation she rejects her initial hypothesis based on the cues that there is no swelling, redness or heat, and that he is able to lean on his foot. She therefore changes her hypothesis. To check further and evaluate her new hypothesis, she examines the wound more closely, finding no foreign bodies. This way she is confirming that the patient’s pain is due to soreness from a healing wound rather than an inflamed injury. After this diagnostic decision, she goes back to look for the referral note once again. Unfortunately, she once again must realize that there is no note. Anne’s behaviour shows signs of a relevant checking behaviour as evident by her retrospective comments on her rationale for checking the referral note after seeing the patient:
I just want to make sure I have not missed something, since [the referring physician] thought he should come in [to the ED].
The case continues with Anne becoming confused as to why the patient was referred to the ED. Anne did not deem that there was a justifiable cause, but she was not confident in acting on this due to her lack of experience.
Ellen has been in residency for almost 3 months. She is receiving a female 83-year-old patient (Mary), who reportedly has fallen in her own home. Initially the referral note suggests indications of a subdural haematoma, which Ellen settles on as her working hypothesis. Ellen thoroughly checks Mary’s history and medication in the electronic patient journal. Based on this investigation, she states that this is a rather classic case and that she is “fairly sure” that Mary is suffering from a subdural haematoma, based on the indication that the at home nurse has reported high blood pressure and a headache. She then goes on to examining the patient. The emergency medicine technicians inform that despite the home nurse reporting a high blood pressure, they were only able to detect a small increase in blood pressure. All other critical values are normal. Furthermore, they inform Ellen, that there are no neurological symptoms. This contradicts Ellen’s working hypothesis, and from the interaction with the emergency medicine technicians, she identifies a stress response in the patient, as the emergency medicine technician reports that Mary recently broke her arm, which has influenced her independence and daily routine. In the retrospective interview, Ellen describes how her working hypothesis changed from this information, to a stress response. However, during the physical examination, Ellen routinely explores the headache and it turns out to be rather severe if slowly building. In the retrospective interview, Ellen explains that concussions can be tricky, and to be sure, she changes her working hypothesis for the third time, wanting to investigate the probability of a concussion, as she knows from the referral, that Mary hit her head, when falling. She performs a quick neurological screening, and concludes that she is uncertain if the symptoms warrant a CT scan. Therefore, Ellen chooses to seek out a supervising physician, and they discuss that the small increase in blood pressure could be white coat syndrome (fourth hypothesis), but the supervising physician agrees that a CT scan and ECG would be a good idea. Both of these come out normal and Ellen conclude that Mary’s increased blood pressure is due to white coat syndrome.
Christina has been in residency for 3 months. She is receiving a female 70-year-old patient (Karen) who has twisted her ankle. From reading the electronic patient journal and referral note alone, Christina verbalize that her first hypothesis is that there is a fracture, based on the patient history, because she has osteoporosis, and has previously had fractures related to this disease. However, when Christina meets Karen, Christina becomes uncertain of this diagnosis. Thus, Karen presents with only limited swelling and no indirect pain on indicative pressure points. Based on this information, she explains in the retrospective interview, that at this point, she only expected a sprayed ankle, as none of the symptoms indicated a fracture. However, here Christina demonstrates adaptive expertise as she orders an x-ray despite this hypothesis and no indicative symptoms. She reflects that her rationale builds on the hypothesis that Karen has osteoporosis:
I usually do that if I have a patient where I’m like: should or should I not? Then I’m like: okay would I be able to go to sleep tonight without thinking about it?
This indicates a strategy of using her emotional response to scaffold self-regulation when she experiences gaps in knowledge (epistemic distance). Consequently, from this x-ray she notices a possible fracture and changes her diagnosis back to the original, and seek out a specialized physician to get her hypothesis confirmed.
It is an evening shift and Julie is taking over a male, 73-year-old patient (Karl) from the other resident, Daniel. Julie has been in residency for almost 3 months. Karl had fallen during clean up from a celebration dinner and cut himself on his lower leg, and Daniel had conferred with a supervising physician, who said to sow the open wounds and admit Karl, as he had many comorbidities. Julie confirms that she goes with the Daniels’ hypothesis that Karl has to be admitted due to his injuries, as Daniel also informs her, that Karl is suspected to be intoxicated. Daniel explains that he is tired and knows that he is providing unorganized information. Julie explains in the retrospective interview what make it particularly confusing:
Here I’m thinking that I need to see the patient… I have the feeling that I have many things in my head that is not sorted. So, I hope that when I see the patient, everything will fall into place.
By the end of the handover a supervising physician, who has a surgical specialty, is interrupting the handover, arguing that they should discharge Karl. Julie demonstrates self-regulatory practice in response to this interruption, explaining that:
"…especially with elderly patients and the very medical… it’s good to talk to the emergency physician instead, because they look for the more medical problems…"
As this supervising physician continues to interrupt the handover, Julie retrospectively describes her emotional response to such interruptions:
Then the supervising physician comes in and says that if there has been given a plan [in consultation with a supervisor], one should never ‘shop around’ for other treatment possibilities… but I feel like, if there have been over 12 new patients since, then I want to make a new evaluation, and then I will have to consult again
She adds to this, describing the emotional impact on her performance:
“So, I feel like giving up. [Like] am I alone, then? Just because [the previous resident] has already conferred the patient with another supervising physician? In addition, what if I myself make a new judgement that is not consistent with that… I feel uncomfortable backing a decision I did not make… [so I] become irritated, because it is arrogant [of her to put me in that position] … the feeling of being a little helpless…. powerless is a good word for it.”
After this chaotic handover, Julie decides to go see Karl and from this interaction, she verbalizes in the retrospective interview that she immediately recognises that Karl is lucid, has no severe pain and she hypothesize that there is no need for admitting him as the injuries are only superficial. She seeks out another supervising physician to have him see Karl and assess the severity of his injuries. This supervising physician agrees with her diagnosis and plan for treatment (sewing and dressing the wound) and her decision to discharge Karl.
Mark is in his 5th month of residency and is treating a 75-year-old female patient (Eden). He does not have time to read up on Eden, as his priorities to get the handover from the emergency medicine technicians. Mark knows from the referral that the patient has fallen and remarks while walking to the patient room that he should always expect a fracture in the hip or pelvis area, due to the age and injury. However, during the patient interaction, he quickly recognizes that there is no indicative pain and his first hypothesis is that there is no fracture to her pelvis or elbow area (which were the areas mentioned by the emergency medicine technicians). Mark decides on performing an x-ray to be sure, due to Eden’s age, which confirms his hypothesis and he diagnose her with no fractures to the pelvis or elbow, and discharges her.
Casper is in his third month of residency and is seeing a 72-year-old male patient (Hans) with dementia. Hans has fallen and the referring physician has written that he suspects a colles fracture and that Hans’s leg is rotated, which Casper mentions is a sign of such a fracture. While Casper is reading up on Hans, a nurse interrupts him several times, which he comments on retrospectively:
You become removed from your line of thoughts… the process that you are in.
As a result, Casper does not settle on a hypothesis before seeing Hans. While reading the electronic patient journal, Casper is thorough, and despite noting several relevant information that could indicate a fracture, he verbalizes that he should ‘investigate’ or ‘be suspicious of’ several different symptoms. However, Casper still does not settle on a hypothesis and several times iterates that “we will know when we see the patient” or “then I know I will need to be extra thorough” Indicating that he uses this preparation more as an overview and way of prioritizing his investigation, rather than narrowing down the hypothesis. Casper goes to examine Hans who is accompanied by a caregiver from his residential facility. In the retrospective interview, Casper comments that he initially suspects that there is no fracture based on the physical examination, but that this hypothesis is disrupted by a conflict with the caregiver. Casper informs the caregiver that he does not suspect a fracture and will possibly discharge Hans. The caregiver protests and Casper comments retrospectively:
She might be worried, because she had previously experienced that the ED overlooking a fracture of one of her other senior residents… Nevertheless, I will not order an x-ray although she is very worried… If I examine the patient and cannot find anything, [then I will not order an x-ray]. Otherwise, I could just order an x-ray without seeing the patient.
Here, Casper is mindful of a conflict of interest. But he is also aware of his role as the physician and the authority associated herewith. He initially justifies the value of his assessment through his role as a physician, which can be seen as a strategy of drawing confidence from the expected role that he is occupying:
I think it is my responsibility [to take the lead]. I’m the doctor so I’m the one in charge.
However, as the caregiver continues to question his decision, Casper gives in to this pressure and orders an x-ray. This x-ray confirms Casper’s initial hypothesis and his diagnosis of with no colles fracture, and therefore discharges Hans.
Daniel is in his fourth month of residency and is receiving an 83-year-old female patient (Lisa). The referral note suggests a luxated hip. Daniel goes to greet Lisa in order to get a handover from the emergency medicine technicians before reading her patient journal. The emergency medicine technicians explains that Lisa has had an increasing pain and that she can walk, but that they assess that she has a high pain tolerance. When examining the patient, Daniel identifies low mobility, and despite Lisa describing low pain, his first hypothesis is that she has a luxated hip, as Lisa also informs him that she had a hip replacement surgery fifteen years ago. As seen with Mark, Daniel also reflected upon his role and were cognizant of his inexperienced disposition in this regard. Lisa asks Daniel if it could be due to her hip replacement, and he responds: “I have to be honest and say that I don’t know [about the risks of 15-year-old hip replacement surgeries,]” adding in retrospect that: “I shall in no way pretend I know more than I do. It does not serve me, nor the patient.”
Daniel chooses to order an x-ray to confirm his hypothesis, but when the x-ray presents atypical, he seeks out a second opinion from one of the other residents, Ellen, who happens to be in the room with him. Here, Ellen explains that she has seen it before, and that it looks like a luxation. However, Daniel is still not sure and therefore choses to confer an online medical handbook and look closer into typical treatment plans for a luxated hip. He settles on the hypothesis of a luxated hip, despite retrospectively reflecting that:
…because we fail to look at the x-ray picture of the side profile, where we would expect that the hip joint was outside of the socket, we mistakenly think that it is a luxated hip.
Explaining that after consulting Ellen he:
…has blind faith in her, because she is very convincing and has seen patients with luxated hips before… I haven’t seen it before… she has seen it before, took a look at the picture and said ‘it clearly looks like it’s luxated’ and I jump on that.
Daniel continues to plan the treatment and routinely goes to confer his decision with the supervising physician to get confirmation of his diagnosis and plan. Here, Daniel shows the x-ray pictures to the supervising physician, who disagrees with Daniels’s diagnosis. He asks to see the side profile and identifies that the plastic liner of the artificial hip socket has broken. Daniel explains in the retrospective interview: “I have never heard of a plastic liner before he mentioned it”. The supervising physician calls to consult an orthopaedic specialist and is confirmed in the hypothesis and they settle on this diagnosis. Lisa is then transferred to the orthopaedic department for further examination.