PE triggers anxiety for physicians | I don’t think you would call it a barrier, a challenge, is um so kind of like suspicion… suspicion creeps. We talk about PE a lot in the emergency department … (ID16) Fear. I think that many physicians are afraid of the negative impact of missing a pulmonary embolism. (ID42) PE is kind of bad because you know as the risk of being, you know, life threatening and fatal including in younger people, its signs and symptoms of it can really blend with a lot of other presentations including benign things and third, its relatively common so all those things together can kind of be the bogey man of emergency department diagnosis right? (ID4) |
PE is a dangerous diagnosis | In the emergency department, when you hear hoofbeats, you’re supposed to think of 2 things. The first thing is zebras, which are rare, off the wall things, because if you don’t think about it, no one else will, and 2, are hippos. Big lumbering animals which if you miss them will crush you to death, or in this case the patient. (ID37) |
Barriers to using the evidence |
Time pressure | When it’s low risk they suggest getting a d-dimer first and then get a follow-up testing. Um … which can be, which unnecessarily increases the time the patient is in the department. (ID16) |
Knowledge | Stuck out in my mind in the sense that she was you know essentially zero on the Wells score and … she had a PE. (ID4) You only need one positive risk and then that automatically dumps you into high or moderate risk category. (ID 62) |
Patient influence | If you’re already going down the hole of, like the rabbit hole of the patient insisting on a test, the rules aren’t, the rules no longer apply. (ID26) Skip the step of the clinical decision rule and order what they want because with the patient in front of you, you are worried about them and it doesn’t help that they were Wells score negative and they went home and died from a PE so sometimes we have to skip it. (ID3) |
Divergent views on evidence-based PE testing |
Clinical decision rules are useful | I think they’re useful when there is diagnostic uncertainty, this helps put some, some objectivity in your decision process, umm … it also can help with cost effectiveness, so to minimize the number of tests you order and you can justify not doing that. (ID 46) So, I think if you want to use them [clinical decision rules], then you will take the time and do it. (ID31) |
Skepticism about clinical decision rules | All evidence-based medicine can do is give you more information, but ultimately the decision you make cannot be based on the evidence, it has to be based on the individual characteristics of the patient in front of you. So when you do large population-based studies that give you the evidence to base your decision-making, that applies to a gazillion patients, but it’s never specific enough to apply to the patient who’s actually in front of you. (ID22) Maybe I don’t have faith in [clinical decision rules] … not that it was not good research or it doesn’t provide good information, but is this going to advance this particular case in an efficient and effective way and maybe I have already got enough information to move on to an appropriate conclusion. (ID44) Interviewer: Do you find any advantages or challenges to using this decision roles? Participant: Only in that I don’t tend to use them, all of them. I mean because the new residents are being taught it I have to know it. But my own clinical decision-making already incorporated most of that. (ID 50) |
Inherent Wells score problems |
| Taking the time to look up the tool and what have you, because you obviously can’t remember everything, … what point value goes with every item, so like sitting down and looking at it, or looking it up might only take a minute, but it’s a minute where you could be on to the next patient or finishing up your charting. (ID29) It’s not something that’s easily memorable. Um and uh sometimes it just takes time to go through the process. (ID2) And the score, the numeric scores are not easy to remember. (ID16) I think rules that have a lot of different components to it, I tend to use less. (ID10) I think perhaps one barrier may be the fact that there are conflicting rules, with PE. (ID2) There are a lot of modifications and, you know, things will just keep changing, I think that would be also a barrier for most of us. (ID55) |
PE testing must include CT |
CT is an end point | You know, the d-dimer is not likely going to be useful that he’s so high risk. If the d-dimer if it was done in triage, if it was negative, I would consider you know …. the scan. (ID04) Interviewer: Are there any other tests you have considered? Participant: I think uh you gotta go where the money is, so CT. (ID04) In my mind, that was the only path for this patient. There was no other substitute test and all the other reasoning paths would’ve led me straight to CT. (ID43) So, we would actually just go and CT his chest. (ID63) Uh and the need for definitive diagnosis is so um … high that I would probably proceed to [CT]. Only CT will give a definitive answer. (ID28) Because you already know that patient’s getting a CT. You don’t need a decision rule to tell you that. (ID31) If I was working at [a community hospital] I would just get the CT and say that’s fine thank you, because I’m dealing more with people who are experienced in understanding how the world works as opposed to more junior people who feel like you have to go through it in this algorithmic way. (ID53) |
Gestalt drives testing and inflates PE probability |
| One of the most important scoring factors is your clinical judgment. So, I don’t have to look at a scoring system to know that my clinician judgment is still going to be up to me. (ID27) I think for some of us even if the rule were to score them in a certain category, if our clinical gestalt tells us differently based on potentially a case we’ve seen before … and you know this feeling like it’s gonna nag us forever if we don’t get it. (ID34) On the physical exam I’m gonna look to see if he has any swelling in his calves or anything going … but even if he doesn’t … he’s at high risk, we’re gonna have to go after that, and the only way to go after that is a CT PE study, which we can get done. (ID22) I don’t find that rules are going to be overly helpful if you’re clinical gestalt from talking to someone is sufficient enough to have you concerned to order a study. For me personally, whether or not her Wells score is 2 or 5 is not gonna change how I actually work up. (ID12) I wouldn’t, umm, wouldn’t use Wells, I would just go straight to imaging, so CT chest just because his risk is much higher, umm and then investigation is done. (ID23) If your clinical suspicion thinks that PE is likely, then that trumps all of that scores. (ID13) I guess one of the challenges with clinical decision rules is sometimes you really want to do something although technically they don’t fit in the clinical decision rule so you will have to wrestle with yourself. Are you going to let your clinical decisions trump the decision rule? (ID21) |
Subjective reasoning and cognitive bias |
| The answer is actually he is excluded. He is overtly excluded [from having the Wells score applied]. He’s had a previous PE which is a point, but he has a known disease like is Factor V Leiden. He is just out, like he is completely out on all of those derivation studies, he is not even included. (ID22) You know your mother, grandmother didn’t look at a recipe card to make your favourite dishes by memory right? She gave it to you and you wrote it down, you do it a few times and you do it often enough, you stop looking at the recipe card. You’d also tinker with the recipe card to add a little butter or mint or something, you tinker with it a little bit to make it suit you better. (ID38) Would probably be doing the d-dimer just for completion’s sake to say that I’ve done it, sometimes I just kinda, it just shows that it’s being done, um, but you know, I’ve already made the decision that I’m going to need to do a CT. (ID11) “t wasn’t a tough decision. It wouldn’t matter what the Wells criteria said I would have gone to it [CT] anyways. (ID27) |
Clinical decision rules are used mainly to rule out PE |
| So, I suspect that I’m far more likely to use them [clinical decision rules] when in the back of my head I say oh yeah, for sure this patient is PERC negative so I’m gonna put it on the chart. (ID12) If you think it’s like low probability (not no probability), and you, just before you [discharge them] saying this isn’t anything, you have to be negative for the PERC rule. (ID63) |