{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T12:00:01Z","timestamp":1790769601470,"version":"4.1.0"},"reference-count":40,"publisher":"Ubiquity Press, Ltd.","issue":"1","license":[{"start":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T00:00:00Z","timestamp":1790726400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Perspect Med Educ"],"abstract":"<jats:p>Purpose: Practice variation across physicians is commonly attributed to idiosyncratic tendencies. What factors contribute to physicians\u2019 practice variation in the disposition of children with asthma exacerbation? How do metrics demonstrating variation impact physicians and learners?\nMethods: In this social constructivist qualitative study, we interviewed 11 Pediatric Emergency Medicine attendings, purposively sampling across a spectrum of acute asthma exacerbation admission rates. Participants reflected on their recent care of patients with asthma, how they assess patients, and how they determine disposition. They were shown a de-identified funnel plot demonstrating disposition rates across the physician group and reflected on the 1) quality of the metric and 2) impact on practice. We used reflexive thematic analysis to describe patterns across the data that addressed the study\u2019s research questions.\nResults: Participants cited factors at the patient, caregiver, clinical care team, clinical environment, and personal practice levels that might result in variation. Participants framed the ability to weigh these sometimes competing factors as a reflection of patient-centered care. But when presented with a group-level data display, participants were surprised by the variation, valued seeing how they practiced compared to peers, and sometimes expressed a willingness to alter their practices to be \u201cnearer the mean.\u201d\nConclusions: Some variation in care may be driven by physician adaptive expertise, which is not fully captured through metric-driven nomothetic data. Though metrics are fundamental to understanding practice patterns, decontextualized aggregations of data may risk minimizing, or even framing as deviant, the expertise exercised by physicians when they weigh multiple factors in decision-making.<\/jats:p>","DOI":"10.5334\/pme.2887","type":"journal-article","created":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T11:28:11Z","timestamp":1790767691000},"page":"1028-1038","source":"Crossref","is-referenced-by-count":0,"title":["Pediatric Emergency Care Variation: Might Normothetic Data Undermine Adaptive Expertise?"],"prefix":"10.5334","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7147-1289","authenticated-orcid":false,"given":"Laura F.","family":"Sartori","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4888-8857","authenticated-orcid":false,"given":"Bjorn K.","family":"Watsjold","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3159-517X","authenticated-orcid":false,"given":"Katherine","family":"Wu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lanelle","family":"Quzack","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4590-6570","authenticated-orcid":false,"given":"Jonathan S.","family":"Ilgen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9414-0201","authenticated-orcid":false,"given":"Joseph J.","family":"Zorc","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1412-4341","authenticated-orcid":false,"given":"Lara","family":"Varpio","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"3285","published-online":{"date-parts":[[2026,9,30]]},"reference":[{"issue":"1","key":"key20260930112807_B1","article-title":"Variations in pediatric emergency medicine physician practices for intravenous fluid management in children with sickle cell disease and vaso-occlusive pain: A single institution experience","volume":"65","year":"2018","journal-title":"Pediatr Blood Cancer"},{"issue":"2","key":"key20260930112807_B2","doi-asserted-by":"crossref","first-page":"153","DOI":"10.1001\/jamainternmed.2024.6925","article-title":"Variation in Emergency Department Physician Admitting Practices and Subsequent Mortality","volume":"185","year":"2025","journal-title":"JAMA Intern Med"},{"key":"key20260930112807_B3","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1016\/j.thromres.2017.09.026","article-title":"Identifying the factors influencing practice variation in thrombosis medicine: A qualitative content analysis of published practice-pattern surveys","volume":"159","year":"2017","journal-title":"Thromb Res"},{"issue":"5","key":"key20260930112807_B4","doi-asserted-by":"crossref","first-page":"561","DOI":"10.5811\/westjem.2016.7.30832","article-title":"Wide Variability in Emergency Physician Admission Rates: A Target to Reduce Costs Without Compromising Quality","volume":"17","year":"2016","journal-title":"West J Emerg Med"},{"issue":"2","key":"key20260930112807_B5","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1377\/hlthaff.2020.00670","article-title":"Variation In Emergency Department Admission Rates Among Medicare Patients: Does The Physician Matter?","volume":"40","year":"2021","journal-title":"Health Aff (Millwood)"},{"issue":"4","key":"key20260930112807_B6","doi-asserted-by":"crossref","first-page":"474","DOI":"10.1016\/j.annemergmed.2021.03.020","article-title":"Variation in Rates of Hospital Admission from the Emergency Department Among Medicare Patients at the Regional, Hospital, and Physician Levels","volume":"78","year":"2021","journal-title":"Ann Emerg Med"},{"issue":"8","key":"key20260930112807_B7","doi-asserted-by":"crossref","first-page":"874","DOI":"10.1111\/acem.70020","article-title":"Clinician-level variation in admission practices for common conditions in Veteran Affairs emergency departments","volume":"32","year":"2025","journal-title":"Acad Emerg Med Off J Soc Acad Emerg Med"},{"issue":"6","key":"key20260930112807_B8","doi-asserted-by":"crossref","first-page":"638","DOI":"10.1016\/j.annemergmed.2013.01.016","article-title":"Emergency department physician-level and hospital-level variation in admission rates","volume":"61","year":"2013","journal-title":"Ann Emerg Med"},{"issue":"9","key":"key20260930112807_B9","article-title":"Analysis of Consistency in Emergency Department Physician Variation in Propensity for Admission Across Patient Sociodemographic Groups","volume":"4","year":"2021","journal-title":"JAMA Netw Open"},{"issue":"6","key":"key20260930112807_B10","first-page":"E857","article-title":"Variations in Epidural Steroid Injection Practice Patterns by Pain Medicine Physicians in the United States","volume":"25","year":"2022","journal-title":"Pain Physician"},{"issue":"3","key":"key20260930112807_B11","doi-asserted-by":"crossref","first-page":"765","DOI":"10.1007\/s11060-025-05085-y","article-title":"Practice variations in indication, timing and outcome of Multiple Myeloma patients undergoing surgery for vertebral lesions \u2013 results from the European M2Spine study group","volume":"174","year":"2025","journal-title":"J Neurooncol"},{"issue":"2","key":"key20260930112807_B12","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1542\/peds.2012-2830","article-title":"Variation and Trends in ED Use of Radiographs for Asthma, Bronchiolitis, and Croup in Children","volume":"132","year":"2013","journal-title":"Pediatrics"},{"issue":"12","key":"key20260930112807_B13","first-page":"902","article-title":"Physician Practice Variation in the Pediatric Emergency Department and Its Impact on Resource Use and Quality of Care: Pediatr Emerg Care","volume":"26","year":"2010"},{"issue":"2","key":"key20260930112807_B14","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1542\/peds.2013-0179","article-title":"Variation in Emergency Department Diagnostic Testing and Disposition Outcomes in Pneumonia","volume":"132","year":"2013","journal-title":"Pediatrics"},{"issue":"3","key":"key20260930112807_B15","doi-asserted-by":"crossref","first-page":"170","DOI":"10.1111\/wvn.12492","article-title":"Audit and Feedback: An Evidence-Based Practice Literature Review of Nursing Report Cards","volume":"18","year":"2021","journal-title":"Worldviews Evid Based Nurs"},{"issue":"2","key":"key20260930112807_B16","article-title":"Provider Reactions to Opioid-Prescribing Report Cards","volume":"28","year":"2022","journal-title":"J Public Health Manag Pract"},{"issue":"3","key":"key20260930112807_B17","doi-asserted-by":"crossref","first-page":"e670","DOI":"10.1542\/peds.2014-2363","article-title":"Impact of Physician Scorecards on Emergency Department Resource Use, Quality, and Efficiency","volume":"136","year":"2015","journal-title":"Pediatrics"},{"issue":"11","key":"key20260930112807_B18","doi-asserted-by":"crossref","first-page":"901","DOI":"10.1542\/hpeds.2025-008440","article-title":"Audit and Feedback on Pediatric Emergency Department Performance Measures: A Stepped-Wedge Trial","volume":"15","year":"2025","journal-title":"Hosp Pediatr"},{"issue":"5","key":"key20260930112807_B19","doi-asserted-by":"crossref","first-page":"429","DOI":"10.1016\/j.cct.2010.05.007","article-title":"Development and implementation of a performance measure tool in an academic pediatric research network","volume":"31","year":"2010","journal-title":"Contemp Clin Trials"},{"issue":"3","key":"key20260930112807_B20","doi-asserted-by":"crossref","first-page":"539","DOI":"10.1542\/peds.2014-1278","article-title":"Variation in emergency department admission rates in US children\u2019s hospitals","volume":"134","year":"2014","journal-title":"Pediatrics"},{"issue":"6","key":"key20260930112807_B21","article-title":"Variation in hospital admission from the emergency department for children with cancer: A Pediatric Health Information System study","volume":"67","year":"2020","journal-title":"Pediatr Blood Cancer"},{"issue":"4","key":"key20260930112807_B22","article-title":"Differences in admission rates of children with bronchiolitis by pediatric and general emergency departments","volume":"110","year":"2002","journal-title":"Pediatrics"},{"issue":"2","key":"key20260930112807_B23","doi-asserted-by":"crossref","first-page":"166","DOI":"10.1111\/acem.12857","article-title":"Practice Pattern Variation in the Care of Children With Acute Asthma","volume":"23","year":"2016","journal-title":"Acad Emerg Med"},{"issue":"6","key":"key20260930112807_B24","doi-asserted-by":"crossref","first-page":"305","DOI":"10.1542\/hpeds.2017-0085","article-title":"Ohio Pediatric Asthma Repository: Opportunities to Revise Care Practices to Decrease Time to Physiologic Readiness for Discharge","volume":"8","year":"2018","journal-title":"Hosp Pediatr"},{"key":"key20260930112807_B25","unstructured":"CDC 2019 National Asthma Data. https:\/\/www.cdc.gov\/asthma\/most_recent_national_asthma_data.htm"},{"key":"key20260930112807_B26","unstructured":"Children\u2019s Hospital of Philadelphia Emergency Department Clinical Pathway for Evaluation\/Treatment of Children with Asthma. https:\/\/www.chop.edu\/clinical-pathway\/asthma-emergent-care-clinical-pathway"},{"key":"key20260930112807_B27","unstructured":"Guidelines for the Diagnosis and Management of Asthma 2007 (EPR-3) | NHLBI, NIH. December 3, 2020. Accessed November 10, 2025. https:\/\/www.nhlbi.nih.gov\/health-topics\/guidelines-for-diagnosis-management-of-asthma"},{"key":"key20260930112807_B28","unstructured":"2020 Focused Updates to the Asthma Management Guidelines | NHLBI, NIH. December 3, 2020. Accessed November 10, 2025. https:\/\/www.nhlbi.nih.gov\/health-topics\/asthma-management-guidelines-2020-updates"},{"key":"key20260930112807_B29","volume-title":"Social Construction in Context","year":"2001"},{"key":"key20260930112807_B30","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1007\/978-3-031-13942-0_2","volume-title":"Supporting Research in Counselling and Psychotherapy : Qualitative, Quantitative, and Mixed Methods Research","year":"2022"},{"key":"key20260930112807_B31","volume-title":"The Blackwell Encyclopedia of Sociology","year":"2015"},{"issue":"5","key":"key20260930112807_B32","first-page":"1292","article-title":"Expanding Qualitative Research Interviewing Strategies: Zoom Video Communications","volume":"25","year":"2020","journal-title":"Qual Rep"},{"issue":"13","key":"key20260930112807_B33","doi-asserted-by":"crossref","first-page":"1753","DOI":"10.1177\/1049732315617444","article-title":"Sample Size in Qualitative Interview Studies: Guided by Information Power","volume":"26","year":"2016","journal-title":"Qual Health Res"},{"issue":"7","key":"key20260930112807_B34","doi-asserted-by":"crossref","first-page":"989","DOI":"10.1097\/ACM.0000000000003075","article-title":"The Distinctions Between Theory, Theoretical Framework, and Conceptual Framework","volume":"95","year":"2020","journal-title":"Acad Med J Assoc Am Med Coll"},{"key":"key20260930112807_B35","first-page":"262","volume-title":"Child Development and Education in Japan","year":"1986"},{"issue":"3","key":"key20260930112807_B36","doi-asserted-by":"crossref","first-page":"674","DOI":"10.1111\/jep.12905","article-title":"Developing the experts we need: Fostering adaptive expertise through education","volume":"24","year":"2018","journal-title":"J Eval Clin Pract"},{"issue":"8","key":"key20260930112807_B37","doi-asserted-by":"crossref","first-page":"865","DOI":"10.1080\/0142159X.2021.1931081","article-title":"Reframing faculty development practice and research through the lens of adaptive expertise","volume":"43","year":"2021","journal-title":"Med Teach"},{"issue":"7","key":"key20260930112807_B38","first-page":"559","article-title":"Training Future Family Physicians to Become Master Adaptive Learners","volume":"53","year":"2021","journal-title":"Fam Med"},{"issue":"5","key":"key20260930112807_B39","first-page":"321","article-title":"Defining the specialist generalist: The imperative for adaptive expertise in family medicine","volume":"67","year":"2021","journal-title":"Can Fam Physician Med Fam Can"},{"issue":"1","key":"key20260930112807_B40","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1177\/0959354398081001","article-title":"History and natural science","volume":"8","year":"1998","journal-title":"Theory Psychol"}],"container-title":["Perspectives on Medical Education"],"original-title":[],"link":[{"URL":"https:\/\/pmejournal.org\/articles\/2887\/files\/6abcf21e5552e.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/pmejournal.org\/articles\/2887\/files\/6abcf235b5cde.xml","content-type":"text\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/pmejournal.org\/articles\/2887\/files\/6abcf25ce53c3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/pmejournal.org\/articles\/2887\/files\/6abcf21e5552e.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T11:30:53Z","timestamp":1790767853000},"score":1,"resource":{"primary":{"URL":"https:\/\/pmejournal.org\/articles\/10.5334\/pme.2887"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,30]]},"references-count":40,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,1,20]]}},"URL":"https:\/\/doi.org\/10.5334\/pme.2887","relation":{},"ISSN":["2212-277X"],"issn-type":[{"value":"2212-277X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,30]]}}}