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Emergency medicine is a varied and exciting specialty in which the aim is not always to confirm a diagnosis but to be safe and appropriate in your management of potential diagnoses. Medical and nursing staff are therefore taught risk stratification of the presenting signs and symptoms they see. For example, generally it is far more important that the severity of respiratory distress is recognised, rather than its underlying cause. A correct diagnosis of bronchiolitis is irrelevant if you have missed the fact that the child is peri-arrest due to hypoxia and respiratory fatigue.
In their qualitative study of junior doctors’ decision-making Bowen et al1 explore how experience impacts on decision-making in the ED. They focus on breathing difficulty in under 5-year-olds but their work is relevant to many conditions. Not unexpectedly junior doctors and nurses rely on guidelines and admission criteria and are generally risk adverse. Feeling safe is important to them2 but as you become more experienced, ‘intuition’, however that might be defined, plays a more prominent role. It is surprising how little we concentrate on the process of making a diagnosis during training. Different diagnostic approaches have been identified3 between junior doctors and we are increasingly realising how gut feeling impacts on decision-making.4 ,5 How guidelines might interact with experience and gut feeling has yet to be completely delineated but clearly in some cases guidelines trump gut feeling and vice versa. The ROLMA matrices6 are 2×2 tables to aid visualisation and understanding of how evidence-based …
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