An estimated 9% of all stroke patients are initially misdiagnosed in the emergency department (ED). Efforts to improve diagnosis should be informed by an assessment of the knowledge, attitudes, and beliefs of ED physicians about neurologic diagnosis.
We conducted semi-structured interviews of ED physicians practicing at 4 different urban sites in the USA. Conventional content analysis was used to identify themes. Interview transcripts were entered into NVivo qualitative data management. Each transcript was independently coded by two researchers via an iteratively derived code book with consensus used to resolved coding differences. Interviews continued until thematic saturation was reached.
Sixteen physicians were interviewed. We identified two broad themes: (1) challenges unique to neurological complaints and (2) those related more broadly to diagnostic decision making. Subthemes relevant to neurology included: (1) knowledge gaps and uncertainty about aspects of neurological evaluations, (2) patient related barriers to diagnosis (e.g. atypical presentations, low health literacy), and (3) perceived lack of ground truth in clinical neurology. Subthemes relevant to diagnostic decision making included: (1) cognitive biases, (2) comfort with diagnostic uncertainty, (3) diagnostic error identification, (4) comfort with non-neurological diseases, and (5) ED system/environmental issues (e.g. pace of care, communication between providers). Physicians reported relying on patients’ medical co-morbidities and clinical gestalt to guide diagnostic decision making, particularly when index neurological complaint was subjective or transient.
Physicians identified a number of diagnostic challenges unique to neurological disease, many of which must be accounted for when designing interventions to improve stroke diagnostic accuracy in the ED.