diagnostic uncertainty
I had an interaction on shift recently where I walked out of the room knowing the caregiver was less-than-satisfied with my conclusions. They were leaving not knowing exactly what was wrong, and that increased anxiety, despite my best efforts to reassure that everything seemed okay. This timely article discusses diagnostic uncertainty, how common it is in the PED, and how we as physicians best communicate it with the families.
What did they do? They provided surveys to physicians at a tertiary-care pediatric hospital after discharging a patient with an "acute respiratory illness." There were 220 patient encounters, with surveys completed by 60 different physicians. The primary outcome was the proportion of children discharged with diagnostic uncertainty as reported by the physician. Secondary outcomes evaluated how this uncertainty was communicated, whether or not physicians felt this was hard to convey, and what challenges they faced.
What did they find? Physicians reported diagnostic uncertainty in acute respiratory illness 31% of the time. Based on surveys, this uncertainty was communicated to the family 90% of the time, and was done so using terms like "maybe," "probably," and other similar terms. Other ways uncertainty was communicated was through a discussion of return precautions (59%), explaining the differential (56%), and describing the diagnoses that were ruled out (27%). About half of the physicians said it was challenging to communicate this uncertainty, mostly noting the increased anxiety for the family as a key challenge.
A 30% rate of diagnostic uncertainty is often cited in the adult ED literature as well. This is all based on what the physician thinks is "diagnostic uncertainty" so take it with a grain of salt ("could be rhino or adeno or..." vs "could be viral or bacterial"). Prior pediatric research shows that parents prefer to hear about the differential and return precautions over specifically saying "IDK."
Bottom line: Our most important job in the PED is to identify the patients with true medical emergencies. About 1/3 of patients will leave without a specific diagnosis, which is often frustrating for the parents. Discussions should focus on what we DO know (stable vital signs, other reassuring findings and the lack of concerning findings), a plan for home, and specific return precautions.
What did they do? They provided surveys to physicians at a tertiary-care pediatric hospital after discharging a patient with an "acute respiratory illness." There were 220 patient encounters, with surveys completed by 60 different physicians. The primary outcome was the proportion of children discharged with diagnostic uncertainty as reported by the physician. Secondary outcomes evaluated how this uncertainty was communicated, whether or not physicians felt this was hard to convey, and what challenges they faced.
What did they find? Physicians reported diagnostic uncertainty in acute respiratory illness 31% of the time. Based on surveys, this uncertainty was communicated to the family 90% of the time, and was done so using terms like "maybe," "probably," and other similar terms. Other ways uncertainty was communicated was through a discussion of return precautions (59%), explaining the differential (56%), and describing the diagnoses that were ruled out (27%). About half of the physicians said it was challenging to communicate this uncertainty, mostly noting the increased anxiety for the family as a key challenge.
A 30% rate of diagnostic uncertainty is often cited in the adult ED literature as well. This is all based on what the physician thinks is "diagnostic uncertainty" so take it with a grain of salt ("could be rhino or adeno or..." vs "could be viral or bacterial"). Prior pediatric research shows that parents prefer to hear about the differential and return precautions over specifically saying "IDK."
Bottom line: Our most important job in the PED is to identify the patients with true medical emergencies. About 1/3 of patients will leave without a specific diagnosis, which is often frustrating for the parents. Discussions should focus on what we DO know (stable vital signs, other reassuring findings and the lack of concerning findings), a plan for home, and specific return precautions.
