Evaluating the Diagnostic Process for Neurological Complaints in the Emergency Setting Using Targeted Ethnography
Manasi Sastry1, Radhika Sundararajan2, Hooman Kamel3, Lillie Lanphier3, Ava Liberman3
1College of Medicine, SUNY Downstate Health Sciences University, 2Department of Emergency Medicine, 3Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine
Objective:
Use targeted ethnography, a qualitative method, to understand how Emergency Medicine (EM) clinicians evaluate patients with neurological complaints.
Background:
Diagnostic errors are an increasingly recognized source of direct patient harm(s) in neurology, but little is known about how differential diagnoses are formulated in real-time by EM clinicians.
Design/Methods:
We conducted a prospective, qualitative study at a single, academic medical center (7/2025-8/2025). Adult patients with neurological complaints were identified at triage based on their recorded chief complaint. Observations of the full clinical encounter followed by brief, semi-structured interviews of clinicians were conducted by a single researcher during on- and off-hours. Interviewees were asked: (1) what diagnoses are you currently considering? (2) when/how during the course of the encounter did you generate these diagnoses? and (3) what will be your next steps to test or confirm your hypotheses? All interviews were audio-recorded and transcribed. We plan to use conventional content analysis to identify themes from interviews, observations, and field notes.
Results:
A total of 38 semi-structured interviews were conducted and nearly 50 hours of care observed including 17 patient encounters (7 headache, 2 generalized weakness, 2 focal weakness, 3 confusion, 1 numbness, 1 dizziness, 1 unsteady gait). Our preliminary review of data, prior to planned content analyses, indicates that the time clinicians developed differential diagnoses varied considerably and that the content of their differential was impacted by access to patients’ medical record. We noted that many physicians transitioned from open to close-ended questions as encounters progressed over time; close-ended questions were especially relied on to test diagnostic hypotheses. A basic, screening neurological exam was performed in most patients.
Conclusions:
Using targeted ethnography, we preliminarily found that history taking and chart review rather than targeted physical examination play a prominent role in developing and testing diagnostic hypotheses in patients with neurological complaints for EM clinicians.
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