Elsevier

Mayo Clinic Proceedings

Volume 82, Issue 11, November 2007, Pages 1319-1328
Mayo Clinic Proceedings

ORIGINAL ARTICLE
Overreliance on Symptom Quality in Diagnosing Dizziness: Results of a Multicenter Survey of Emergency Physicians

https://doi.org/10.4065/82.11.1319Get rights and content

OBJECTIVE

To assess emergency physicians' diagnostic approach to the patient with dizziness, using a multicenter quantitative survey.

PARTICIPANTS AND METHODS

We anonymously surveyed attending and resident emergency physicians at 17 academic-affiliated emergency departments with an Internet-based survey (September 1, 2006, to November 3, 2006). The survey respondents ranked the relative importance of symptom quality, timing, triggers, and associated symptoms and indicated their agreement with 20 statements about diagnostic assessment of dizziness (Likert scale). We used logistic regression to assess the impact of “symptom quality ranked first” on odds of agreement with diagnostic statements; we then stratified responses by academic rank.

RESULTS

Of the 505 individuals surveyed, 415 responded for an overall response rate of 82%. A total of 93% (95% confidence interval [CI], 90%-95%) agreed that determining type of dizziness is very important, and 64% (95% CI, 60%-69%) ranked symptom quality as the most important diagnostic feature. In a multivariate model, those ranking quality first (particularly resident physicians) more often reported high-risk reasoning that might predispose patients to misdiagnosis (eg, in a patient with persistent, continuous dizziness, who could have a cerebellar stroke, resident physicians reported feeling reassured that a normal head computed tomogram indicates that the patient can safely go home) (odds ratio, 6.74; 95% CI, 2.05-22.19).

CONCLUSION

Physicians report taking a quality-of-symptoms approach to the diagnosis of dizziness in patients in the emergency department. Those relying heavily on this approach may be predisposed to high-risk downstream diagnostic reasoning. Other clinical features (eg, timing, triggers, associated symptoms) appear relatively undervalued. Educational initiatives merit consideration.

Section snippets

PARTICIPANTS AND METHODS

We conducted a multicenter, anonymous, Web-based survey of EPs from September 1, 2006, to November 3, 2006. The study was developed and implemented at Johns Hopkins University, in collaboration with the Emergency Medicine Network (www.emnet-usa.org). The survey was approved by the human subjects committees at all participating institutions, with consent waived.

All EM resident and attending EPs at 17 hospitals affiliated with 5 academic centers (New York-Presbyterian—The University Hospital of

RESULTS

Of the 505 individuals surveyed, 415 responded for an overall response rate of 82%. Of these 415 respondents, 389 (94%) completed all survey questions. Of the 415 responders, 200 were randomly assigned to survey version A and 215 to version B. Completion rates for versions A and B were not significantly different (91% vs 96%, respectively; P=.36). The median survey duration, including demographic questions, was 5.3 minutes (interquartile range, 4.1-7.3 minutes). The breakdown of demographic

DISCUSSION

Our survey results demonstrate that the quality-of-symptoms approach to dizziness (1) is the dominant diagnostic paradigm in the ED, (2) drives physician thinking and self-reported behaviors at multiple levels, and (3) could be contributing to risky clinical reasoning in the diagnostic assessment of dizziness. These findings are important because recent evidence indicates that the quality-of-symptoms approach appears flawed4 and critical misdiagnosis of dizziness in patients in the ED may be

CONCLUSION

Despite its potential limitations, our study presents strong evidence that the quality-of-symptoms approach is the dominant paradigm for diagnosing acute dizziness among patients in the ED. Furthermore, it suggests that this approach may be displacing alternative diagnostic models, such as those emphasizing other symptom dimensions (eg, timing, triggers, and associated symptoms) to guide diagnostic reasoning. Finally, we have shown significant interindividual variability in physician

Acknowledgments

We thank Elizabeth Elliott, ScD, of the Johns Hopkins Bloomberg School of Public Health for her invaluable help with the survey design and Adam Stubblefield, PhD, of the Department of Computer Science for his help in developing the Web portal to randomly assign participants to the different survey versions.

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  • Cited by (0)

    This work was presented in poster form at the American College of Emergency Physicians 2007 Annual Meeting; October 8, 2007; Seattle, WA.

    1

    This research was supported principally by the University of California, San Francisco Dean's Summer Fellowship Program (V.A.S.) and by the National Institutes of Health National Center for Research Resources K23 RR17324-01, “Building a New Model for Diagnosis of ED Dizzy Patients” (D.E.N.-T.).

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