“I Can't Find Anything Wrong: It Must Be a Pulmonary Embolism”: Diagnosing Suspected Pulmonary Embolism in Primary Care, a Qualitative Study

Abstract

BackgroundBefore using any prediction rule oriented towards pulmonary embolism (PE), family physicians (FPs) should have some suspicion of this diagnosis. The diagnostic reasoning process leading to the suspicion of PE is not well described in primary care.Objectiveto explore the diagnostic reasoning of FPs when pulmonary embolism is suspected.MethodSemi-structured qualitative interviews with 28 FPs. The regional hospital supplied data of all their cases of pulmonary embolism from June to November 2011. The patient's FP was identified where he/she had been the physician who had sent the patient to the emergency unit. The first consecutive 14 FPs who agreed to participate made up the first group. A second group was chosen using a purposeful sampling method. The topic guide focused on the circumstances leading to the suspicion of PE. A thematic analysis was performed, by three researchers, using a grounded theory coding paradigm.ResultsIn the FPs' experience, the suspicion of pulmonary embolism arose out of four considerations: the absence of indicative clinical signs for diagnoses other than PE, a sudden change in the condition of the patient, a gut feeling that something was seriously wrong and an earlier failure to diagnose PE. The FPs interviewed did not use rules in their diagnostic process.ConclusionThis study illustrated the diagnostic role of gut feelings in the specific context of suspected pulmonary embolism in primary care. The FPs used the sense of alarm as a tool to prevent the diagnostic error of missing a PE. The diagnostic accuracy of gut feelings has yet to be evaluated.

Ruling Out Pulmonary Embolism in Primary Care: Comparison of the Diagnostic Performance of "Gestalt" and the Wells Rule

“…Albeit speculative, experienced family physicians may take prior experience into account and thus might feel more confident in assigning a low disease probability, although the opposite may also be true if this prior experience included a missed case of PE. 16 Unfortunately, this information was not collected in our study. As such, we do not have insight into the individual range of scoring probabilities, years of experience, and level of training of all participating family physicians, and this may be subject for further research.…”

Diagnostic delay of pulmonary embolism in primary and secondary care: a retrospective cohort study

“…Barais et al described this first step in a qualitative study where they determined that, among other factors, 'gut feeling' played an important role in raising suspicion for PE. 12 Nonetheless, pulmonary embolism appears to be one of the most missed diagnoses in primary care. 13 The primary objective of this study was to document and quantify the various stages of diagnostic delay of pulmonary embolism in patients referred to hospital from primary care.…”

Diagnostic prediction models for suspected pulmonary embolism: systematic review and independent external validation in primary care

“…This causes pulmonary embolism to be a diagnosis that is easily missed. 1 2 As a result, physicians have a low threshold for suspicion and subsequent referral for further diagnostics. 3 4 Referred patients will be exposed to the burden, costs, and even potential iatrogenic damage of diagnostic techniques such as spiral computed tomography or contrast nephropathy.…”