Physician Perspectives on Diagnostic Uncertainty in Radiographic Imaging Reports for Pulmonary Embolism: A Qualitative Study - 08/12/25

Doi : 10.1016/j.annemergmed.2025.10.008

Lauren M. Westafer, DO, MS ^a,^b,^⁎ , Patrick Walsh, DO, MS ^b, Ron Helderman, MD ^c, Natalie Strokes, DO, MPH ^a,^b, Colin F. Greineder, MD, PhD ^d, Geoffrey D. Barnes, MD, MSc ^e, David R. Vinson, MD ^f,^g, William B. Stubblefield, MD, MPH ^h
^a Department of Department of Healthcare Delivery and Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
^b Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
^c Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX
^d Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
^e Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Medical School, Ann Arbor, MI
^f Division of Research, Kaiser Permanente Northern California, Pleasanton, CA
^g Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA
^h Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN

^∗Corresponding Author.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Monday 08 December 2025

Abstract

Study objectives

To explore physicians’ interpretation and decisionmaking when encountering computed tomographic pulmonary angiogram (CTPA) reports communicating diagnostic uncertainty about the presence of pulmonary embolism (PE).

Methods

We conducted semistructured interviews from February 1 to June 3, 2024 among purposively sampled emergency medicine and hospital medicine physicians in the United States. Interviews were recorded, transcribed, and analyzed in an iterative process using reflexive thematic analysis.

Results

We analyzed interviews from 25 emergency physicians and 17 hospitalists. The median age was 41 years and 33% identified as women. Participants were diverse in practice setting and years of practice. Central themes included a lack of organized approach to diagnostic uncertainty, a perception that empiric anticoagulation would represent “erring on the side of caution,” a tendency to defer additional testing and ascertainment of diagnostic certainty to downstream decision makers, and a disinclination to engage in repeat testing due to time pressures and local culture. Although many participants expressed support for the general idea of standardized communication of diagnostic uncertainty, most resisted its quantification in the context of CTPA reports. Many voiced concern that quantification of uncertainty left them without a clear course of action.

Conclusion

Although diagnostic uncertainty regarding the presence of PE is commonly encountered in CTPA reports, most physicians report a lack of an organized approach to this scenario, often defaulting to empiric anticoagulation and deferring additional diagnostic testing. Future efforts are needed to develop data-driven guidance for encountering diagnostic uncertainty in radiographic imaging reports for PE.

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Keywords : Pulmonary embolism, Diagnostic uncertainty, Qualitative methods, Emergency medicine

Plan

Introduction

Background

Importance

Goals of This Investigation

Methods

Study Design and Setting

Selection of Participants

Data Collection

Results

Perspectives on Further Evaluation and Protocols

Limitations

Discussion

	Please see page XX for the Editor’s Capsule Summary of this article.
	Supervising editor: Nicholas M. Mohr, MD, MS. Specific detailed information about possible conflict of interest for individual editors is available at editors .
	Author contributions : LMW and WBS conceived the study. LMW and WBS designed the study. LMW, WBS, DRV, NS, and RH were involved in data collection. All authors were involved in data analysis. LMW drafted the manuscript, and all authors contributed substantially to its revision. LMW takes responsibility for the paper as a whole.
	Data sharing statement : Partial or complete datasets and data dictionary are available from publication on request to Dr. Westafer at email lauren.westafer@baystatehealth.org to investigators who provide an IRB letter of approval.
	All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
	Fundingandsupport: By Annals’ policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/ ). The project described was supported by the National Heart, Lung and Blood Institute through grant 5K23H155895 (LMW). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The authors have declared that no competing interests exist.
	Presentation information: Presented at the Society for Academic Emergency Medicine conference, Philadelphia, PA, May 2025.