Using "Own-Point-of-View" Video and Stimulated Recall to Reveal Physician Thought Processes: A Methodology Paper

Video methods used in medicine have been described as the "gold standard" because they show events as they occurred and with a level of detail unattainable when events are reconstructed using other methods. In stimulated recall, video or pictures during interviews prompt discussion about participants' thoughts or feelings when images were captured. Coupled with video, stimulated recall can deepen researchers' understanding of a participant's thinking at the time. However, conducting video-based stimulated recall interviews with participants is poorly described in the literature because of word count limits in today's journals. In this paper we describe how we used video with stimulated recall interviews to learn how the diagnostic process evolves for emergency physicians.

We used the theory of distributed cognition to describe how information processing develops over time and occurs across physicians, the technologies used, and social organization. We conducted a qualitative study, collecting data in pediatric and adult emergency departments (ED) of an academic Level I trauma center. Participants wore head-mounted video cameras for two hours while providing care to ED patients and revealed their thinking throughout the diagnostic process in subsequent stimulated recall interviews. We reviewed video recordings to identify situations related to the diagnostic process or to one of the concepts in distributed cognition. We identified short video clips from each session to display during interviews and prepared accompanying questions. Stimulated-recall interviews were conducted using video conferencing technology, audio recorded, transcribed, and verified for accuracy. We used content analysis to analyze results.

Eleven attending physicians from February 2022-May 2023 (five from the pediatric ED and six from the adult ED) interacted with 52 patients over a total of 24.4 hours on video. We obtained patients' permission to film encounters before a participating physician provided care, wearing the head-mounted camera. We conducted individual stimulated recall interviews (mean 53 minutes, range 33-63 minutes) with all 11 physicians, which uncovered perspectives beyond what was revealed on film. For example, the complexity of cognition resides in patients as well as physicians. Thus, physicians must exert great effort to elicit the patient story and make a likely diagnosis in the chaotic, noisy environment of the ED.

Using innovative methods to uncover emergency physicians' cognitive processes has the potential to advance our understanding in other settings. This methodology brings awareness to how one's thoughts can become visible and, thus, amenable to reflection and change.