Guarding Against Fixation, Leaning on Stories: Cognitive Expertise in the Emergency Department

Introduction

In a previous post, we wrote about two competing approaches for enhancing performance: error reduction versus enhancing expertise. For decades, researchers in the Naturalistic Decision Making community have used observation and interview techniques to examine the power of the second approach by documenting how skilled practitioners use their intuition in challenging situations to see things that novices may miss. Recent research from our team has highlighted the various facets of expertise involved in making diagnoses in the emergency department (ED). In contrast with other research communities, which choose to examine failures and diagnostic errors, our team used cognitive interviewing and observation to uncover the techniques and strategies ED clinicians use to make successful diagnoses. 

The Power of Stories for Sensemaking

Our journal article describes how our research team (including researchers from the Johns Hopkins School of Medicine and the University of South Florida) documented six areas of expertise that ED clinicians rely on to efficiently diagnose patients. Through interviews with 43 practitioners with experience in three unique EDs, we explored how practitioners handled challenging diagnoses in their careers. 

When it came to making sense of complex diagnoses, practitioners in the majority of cases we analyzed (63.3%) discussed how they used a story to connect a patient’s symptoms to a possible diagnosis. Additionally, clinicians often generated a working diagnosis within moments of seeing a patient. This strategy was in contrast with a more rigid process of listing all possible diagnoses and ruling them in or out (which we found was present in only 30% of the cases we examined). We see these findings as strong support for an approach to diagnosis that is aligned with the Recognition-Primed Decision model rather than weighing multiple options analytically, ED practitioners tended to “recognize” a plausible story, which then led them to gather additional data to confirm or refine their hypothesis.

Our interviews also showed that clinicians do not simply take stock of a patient’s symptoms in order to compare them with symptoms associated with a diagnosis, but instead construct narratives which help them determine possible causality and the trajectory of a patient’s illness. This forward-looking process is consistent with mental simulation, another component of RPD that explains how experts use data to predict future states.

Combatting Fixation

As part of this effort, our team was also interested in how ED practitioners addressed fixation during the diagnostic process. In much of the extant literature, researchers have highlighted premature fixation as a major cause of diagnostic error. In an ED context, fixation could mean prematurely locking onto one finding, story, or diagnosis, which can have serious, sometimes deadly, consequences for patients. Some examples include a distracting injury overshadowing subtle but life-threatening conditions, or a family member’s explanation (“it’s always a UTI”) leading to missed cardiac problems. We found that ED practitioners with experience worry about fixation because of scars from past mistakes and often employ safeguards against it. One strategy frequently discussed was that practitioners often wanted to make sense of data themselves, without input from others (e.g., “I never want to be told an EKG is ‘normal’; I look at it fresh”). 

Expertise in the Emergency Department

Expertise in the ED is vital because the diagnostic process occurs under conditions of extreme time pressure, uncertainty, and high stakes. This study identified six aspects of expertise—technical, perceptual, organizational, teamwork, emotional, and sensemaking—that together describe how clinicians recognize, interpret, and respond to patient problems.

Technical expertise provides clinicians with rich mental models of how diseases unfold, enabling them to anticipate complications, tailor treatments, and avoid premature closure. 

Perceptual expertise allows them to notice subtle cues such as skin color, breathing sounds, or patient movement, which distinguish a critical condition from a stable one. Without these perceptual discriminations, early warning signs may be missed.

Organizational expertise ensures clinicians can navigate the complex web of hospital resources, policies, and interdepartmental processes to secure timely imaging, consults, or transfers. 

In parallel, teamwork expertise is essential, both with colleagues and with patients and their families. High-quality communication fosters trust, secures compliance with care and allows rapid coordination among constantly shifting teams.

Emotional expertise supports self-awareness, helping providers recognize doubt or unease as signals to revisit assumptions, which helps ED practitioners guard against fixation. 

Finally, sensemaking expertise—especially story building, anticipation, and anomaly detection—enables clinicians to integrate fragmented data into coherent narratives, often more effectively than purely analytical hypothesis testing.

Together, these aspects of expertise highlight that accurate diagnosis in the ED is not only about procedural skill but about cognitive adaptability, interpersonal acuity, and system fluency. Emphasizing these dimensions in training and feedback systems could improve patient safety and accelerate the development of novice clinicians. By shifting focus from error cataloging to expertise cultivation, healthcare systems can better prepare professionals to manage the realities of emergency care.

Conclusion

Our article challenges traditional approaches to understanding ED practitioner performance by examining areas of expertise instead of documenting ways clinicians can make diagnostic errors. The skills and strategies we highlighted in this overview provide a clear example of how NDM concepts play out in real-world contexts. 

By valuing expertise as much as error, we can better support clinicians and improve diagnostic safety.