Communication of Diagnostic Uncertainty in Primary Care and Its Impact on Patient Experience: an Integrative Systematic Review

A qualitative study of people with Alzheimer's disease in a memory clinic considering lecanemab treatment

BackgroundPeople with Alzheimer's disease (AD) now have access to disease-modifying treatment with anti-amyloid monoclonal antibodies (mAbs). Their perception of risks and benefits and approach to treatment decisions remain unknown.ObjectiveWe aimed to understand how people with AD weigh the benefits and costs of anti amyloid mAbs and incorporate these into decisions about treatment.MethodsWe conducted semi-structured interviews with people with biomarker- or imaging-confirmed AD and mild or moderate cognitive impairment who were seen at memory care clinics and discussed lecanemab with a clinician. Interviews were recorded, transcribed, and deidentified. Thematic analysis identified themes and subthemes.ResultsAmong 22 participants (mean age 70, 8 [36%] women, 22 [100%] White), analysis revealed 3 major themes and associated subthemes: (1) People with AD sought and obtained information from different sources-advocacy organizations, the Internet, and clinicians; (2) Hopes, expected benefits, and the existential threat of dementia drove willingness and readiness to start lecanemab; (3) Individual traits, family factors, and degree of trust in expertise influenced how people balanced risks and benefits. Some would accept treatment at any cost; others carefully weighed risks and burdens, but were motivated by supportive families, insurance coverage, and trust in expertise; for a few, costs decidedly outweighed their personal benefits. People with AD desired more individualized information and to hear more from patients who took the medication.ConclusionsResults from this first qualitative study of people with AD considering treatment with anti-amyloid mAbs can inform clinician, health system and policy efforts to individualize decisions.

Coping With a Dead End by Relying on Your Own Compass: A Qualitative Study on Illness and Treatment Models in the Context of Fibromyalgia

Fibromyalgia lacks a coherent illness and treatment model, which includes a set of conceptual ideas shaping individuals' perceptions and understandings of pain, its causing and maintaining factors, and management strategies. Developing personalized illness models that can guide treatment plans and alleviate feelings of uncertainty is of crucial importance. This study investigates how individuals with fibromyalgia develop a personal illness and treatment model while navigating the current healthcare system and explore their experiences during this process. Semi-structured interviews were conducted with 15 cis women with fibromyalgia, which were analyzed using reflexive thematic analysis. The analysis produced two themes, each including two subthemes. The first theme encompassed the difficulty of developing a comprehensive illness model due to the biomedical perspective of the healthcare system; the second theme described the importance of participants (re)gaining ownership and agency over their pain management, by constructing their own illness and treatment model. Most women in this study got stuck in the biomedical healthcare web not being provided with a clear illness and treatment model. Consequently, most women gained ownership of this process by developing their personal illness and treatment model (self-empowerment). Conversely, a few women felt powerless and paralyzed. This study underscores the importance of promoting patient empowerment in chronic pain management. Agency is undervalued in the treatment of fibromyalgia and warrants more thorough examination. Increasing knowledge about agency could enhance treatment effectiveness.

Perceptions, approaches, and needs of Czech GPs in the management of patients with persistent somatic symptoms: the results of a nationwide cross-sectional survey

BACKGROUND

General practitioners (GPs) perceive patients with persistent somatic symptoms (PSS) as frustrating and difficult to manage. Patients commonly express dissatisfaction with the care they receive and often feel stigmatised and not taken seriously. Some Czech GPs use the option of extra psychosomatic education which focuses on better understanding and management of patients with PSS.

OBJECTIVES

To explore perceptions of Czech GPs, with and without additional psychosomatic training, regarding the care of patients with PSS, their beliefs, approaches in the management, and their organisational and educational needs.

METHODS

A nationwide cross-sectional survey study among Czech GPs exploring experiences, perceptions, and needs in managing patients with PSS was conducted. Statistical and qualitative approaches were performed to analyse the data.

RESULTS

A total of 152 GPs (37 with and 115 without additional psychosomatic training) participated in this survey (response rate 20,3%). GPs struggle with negative emotions, communication with patients, diagnostic uncertainty, patients' lack of understanding, the workload these patients generate, lack of specialized care, and other problems of the healthcare system. They call for more psychosomatic education and communication training. This should include theoretical explanatory models, Balint groups, and other kinds of supervision or peer groups. GPs with additional psychosomatic training feel more confident and competent caring for these patients, compared to GPs without such additional training (OR = 4.1; 95% CI = 1.85-9.11); p < 0.005). Furthermore, they view PSS patients as less burdensome (OR = 4.69; 2.11-10.4; p < 0.001).

CONCLUSIONS

GPs struggle with caring for patients with PSS. GPs with additional psychosomatic education indicate that they have more confidence and competence. Czech GPs call for more time and reimbursement when caring for patients with PSS, more psychosomatic training, better availability of specialized psychosomatic care, and better interdisciplinary cooperation.

The caring experience: Being a woman, mother and caregiver from patients diagnosed with mucopolysaccharidosis

INTRODUCTION

Rare or orphan diseases represent a challenge for the health system and the quality of life of patients and their families. In Colombia, mothers assume the main role of caregivers, facing physical, emotional, and financial challenges. This study aims to understand the experience of women who are mothers and caregivers of patients with Mucopolysaccharidosis in Colombia, and the variables associated with caregiver burden.

METHOD

A mixed study was conducted in which the Zarit Caregiver Overload Scale was applied to 48 female caregivers of children with Mucopolysaccharidosis, and they were given an individual structured interview.

RESULTS

The Zarit scale showed that 92% of the participants did not have overload. However, the interviews revealed a variety of negative emotions and feelings, such as loneliness, sadness, fear, and guilt. The women expressed an unfinished life project, with overloaded social roles and a constant permanent crisis. The main emotional resource and support wase faith in God. Tensions were found in the relational fabric with the child or patient, between overprotection and independence.

CONCLUSIONS

Understanding the experience of the caregivers of patients with MPS allowed unveiling the complex elements of caregiving through the three intertwined roles: being a woman, being a mother and being a caregiver. The use of religiosity as an indicator of physical and mental well-being confirms its benefit in the processes of coping with the difficulties related to the experience of diagnosis and treatment.

A Qualitative Study of People with Alzheimer's Disease in a Memory Clinic Considering Lecanemab Treatment

Background

People with Alzheimer's disease (AD) now have access to disease-modifying treatment with anti-amyloid monoclonal antibodies (mAbs). Their perception of risks and benefits and approach to treatment decisions remain unknown.

Objective

We aimed to understand how people with AD weigh the benefits and costs of anti-amyloid mAbs and incorporate these into decisions about treatment.

Methods

We conducted semi-structured interviews with people with biomarker- or imaging-confirmed AD and mild or moderate cognitive impairment who were seen at memory care clinics and discussed lecanemab with a clinician. Interviews were recorded, transcribed, and deidentified. Thematic analysis identified themes and subthemes.

Results

Among 22 participants (mean age 70, 8 [36%] women, 22 [100%] White), analysis revealed 3 major themes and associated subthemes: 1) People with AD sought and obtained information from different sources-advocacy organizations, the Internet, and clinicians; 2) Hopes, expected benefits, and the existential threat of dementia drove willingness and readiness to start lecanemab; 3) Individual traits, family factors, and degree of trust in expertise influenced how people balanced risks and benefits. Some would accept treatment at any cost; others carefully weighed risks and burdens, but were motivated by supportive families, insurance coverage, and trust in expertise; for a few, costs decidedly outweighed their personal benefits. People with AD desired more individualized information and to hear more from patients who took the medication.

Conclusion

Results from this first qualitative study of people with AD considering treatment with anti-amyloid mAbs can inform clinician, health system and policy efforts to individualize decisions.

Evaluating cognitive bias in clinical ethics supports: a scoping review

BACKGROUND

A variety of cognitive biases are known to compromise ethical deliberation and decision-making processes. However, little is known about their role in clinical ethics supports (CES).

METHODS

We searched five electronic databases (Pubmed, PsychINFO, the Web of Science, CINAHL, and Medline) to identify articles describing cognitive bias in the context of committees that deliberate on ethical issues concerning patients, at all levels of care. We charted the data from the retrieved articles including the authors and year of publication, title, CES reference, the reported cognitive bias, paper type, and approach.

RESULTS

Of an initial 572 records retrieved, we screened the titles and abstracts of 128 articles, and identified 58 articles for full review. Four articles were selected for inclusion. Two are empirical investigations of bias in two CES, and two are theoretical, conceptual papers that discuss cognitive bias during CES deliberations. Our main result first shows an overview of bias related to the working human environment and to information gathering that concerns different types of CES. Second, several determinants of cognitive bias were highlighted. Especially, stressful environments could be at risk of cognitive bias, whatever the clinical dilemma.

CONCLUSIONS

Whether a need for a better taxonomy of cognitive bias in CES is highlighted, a proposal is made to focus on individual, group, institutional and professional biases that can be present during clinical ethics deliberation. However, future studies need to focus on an ecological evaluation of CES deliberations, in order to better-characterize cognitive biases and to study how they impact the quality of ethical decision-making. This information would be useful in considering countermeasures to ensure that deliberation is as unbiased as possible, and allow the most appropriate ethical decision to emerge in response to the dilemma at hand.

Beyond pathology: Patient experiences of laparoscopy for persistent pelvic pain with no identifiable cause found

BACKGROUND

Laparoscopy has often been considered a core part of the workup for pelvic pain. However, many of these laparoscopies find no pathology.

AIMS

To evaluate the experiences of patients following laparoscopy for pelvic pain when there is no diagnosis found.

MATERIALS AND METHODS

This descriptive qualitative study reviewed patients who underwent a diagnostic laparoscopy for persistent pelvic pain with no pathology found. Participants completed a written questionnaire and an in-depth semi-structured interview. Interview data were thematically analysed.

RESULTS

Fifteen patients were interviewed with a median age of 30 years. Six themes were identified: desire for a diagnosis, hope as a coping strategy, inadequate communication, having 'next steps' of management offered, mental health impacts, and system issues. Participants wanted a diagnosis to help understand their condition, to enable connection with others, and believed that clinicians viewed pain with a diagnosis more seriously. Participants who were confident preoperatively that laparoscopy would lead to a diagnosis reported this contributing to poorer postoperative mental health. Participants discussed diagnoses not listed in the medical records, which provided hope for future management options. Participants reported worse mental health following the laparoscopy.

CONCLUSION

This study provides insight into the experiences of patients following a laparoscopy without an identifiable diagnosis. It highlights the importance of pre- and postoperative counselling, including discussing the potential for no findings at laparoscopy; the language used around other potential diagnoses; and the value in considering a patient's pre-existing mental health. The findings of this study are relevant for all clinicians counselling people with persistent pelvic pain where endometriosis is suspected.

Evaluation of natural history communication and shared decision making for self-limiting conditions: Analysis of UK primary care consultations

OBJECTIVE

To analyse communication about the natural course of self-limiting illnesses, as part of shared decision-making (SDM), in general practice consultations.

METHODS

Natural history communication and SDM (using Observing Patient Involvement in Decision-Making (OPTION-12) and Assessing Communication about Evidence and Patient Preferences (ACEPP) items) were rated by two raters using transcripts from the UK 'One in a Million' database.

RESULTS

Of 55 eligible consultations, a 'wait and see' option was mentioned in 27 consultations (49 %), using varying terminology, with a general recovery timeframe provided in 21. Mean OPTION-12 score (of 100) was 25.2 (SD=7.4), indicating a low level of SDM. Mean ACEPP score (out of 5) was 1.2 (SD=0.5), indicating minimal communication about the options' benefits and harms. Recovery likelihood was quantified in only two consultations, while harms were quantified in none.

CONCLUSION

Communication about the natural history of self-limiting illnesses was generally limited. The 'wait and see' approach, along with its benefits and harms, was typically not explicitly presented as an option for patients to consider.

PRACTICE IMPLICATIONS

Improving clinicians' awareness of the importance of and skills for communicating the natural history of self-limiting illnesses, as part of SDM, may facilitate informed decision-making in managing these conditions.

Communicating safety-netting information in primary care physiotherapy consultations for people with low back pain

BACKGROUND

Safety-netting involves communicating information to patients about diagnostic uncertainty, the likely time-course of their condition and how to appropriately seek help from a healthcare professional if their condition persists or worsens. Little is known about how physiotherapists communicate safety-netting information to people with low back pain (LBP).

OBJECTIVES

This research aimed to use a Safety-Netting Coding Tool (SaNCoT) to explore how physiotherapists communicate safety-netting information to people with LBP.

METHODS

The SaNCoT was used to conduct a secondary analysis of audio-recordings and transcripts from 79 primary care physiotherapy consultations (41 initial and 38 follow-up) involving 12 physiotherapists and 41 patients with LBP in Southern England. Quantitative data from the SaNCoT were analysed descriptively.

FINDINGS

The study found evidence of diagnostic uncertainty in 53 (67%) appointments and no examples of physiotherapists providing patients with specific information about their condition time-course. Eight patients were given safety-netting advice, but most (57.9%, n = 11) episodes of safety-netting advice did not include specific signs and symptoms for patients to monitor. Potential missed opportunities for safety-netting advice were identified in 19 appointments (24.1%) which tended to relate to the patient's associated leg symptoms but also included possible serious pathology.

CONCLUSION

The SaNCoT was successfully used to measure safety-netting communication within physiotherapy consultations and found missed opportunities for providing clear safety-netting advice. Physiotherapists can use the findings to reflect on how they can provide clear safety-netting information to patients with LBP to effectively support patients to self-manage and help them seek appropriate care if their condition deteriorates.

Addressing diagnostic uncertainty and excellence in emergency care-from multicountry policy analysis to communication practice in Australian emergency departments: a multimethod study protocol

INTRODUCTION

Communication failings may compromise the diagnostic process and pose a risk to quality of care and patient safety. With a focus on emergency care settings, this project aims to examine the critical role and impact of communication in the diagnostic process, including in diagnosis-related health and research policy, and diagnostic patient-clinician interactions in emergency departments (EDs).

METHODS AND ANALYSIS

This project uses a qualitatively driven multimethod design integrating findings from two research studies to gain a comprehensive understanding of the impact of context and communication on diagnostic excellence from diverse perspectives. Study 1 will map the diagnostic policy and practice landscape in Australia, New Zealand and the USA through qualitative expert interviews and policy analysis. Study 2 will investigate the communication of uncertainty in diagnostic interactions through a qualitative ethnography of two metropolitan Australian ED sites incorporating observations, field notes, video-recorded interactions, semistructured interviews and written medical documentation, including linguistic analysis of recorded diagnostic interactions and written documentation. This study will also feature a description of clinician, patient and carer perspectives on, and involvement in, interpersonal diagnostic interactions and will provide crucial new insights into the impact of communicating diagnostic uncertainty for these groups. Project-spanning patient and stakeholder involvement strategies will build research capacity among healthcare consumers via educational workshops, engage with community stakeholders in analysis and build consensus among stakeholders.

ETHICS AND DISSEMINATION

The project has received ethical approvals from the Human Research Ethics Committee at ACT Health, Northern Sydney Local Health District and the Australian National University. Findings will be disseminated to academic peers, clinicians and healthcare consumers, health policy-makers and the general public, using local and international academic and consumer channels (journals, evidence briefs and conferences) and outreach activities (workshops and seminars).

Diagnostic Discordance, Uncertainty, and Treatment Ambiguity in Community-Acquired Pneumonia : A National Cohort Study of 115 U.S. Veterans Affairs Hospitals

BACKGROUND

Evidence-based practice in community-acquired pneumonia often assumes an accurate initial diagnosis.

OBJECTIVE

To examine the evolution of pneumonia diagnoses among patients hospitalized from the emergency department (ED).

DESIGN

Retrospective nationwide cohort.

SETTING

118 U.S. Veterans Affairs medical centers.

PATIENTS

Aged 18 years or older and hospitalized from the ED between 1 January 2015 and 31 January 2022.

MEASUREMENTS

Discordances between initial pneumonia diagnosis, discharge diagnosis, and radiographic diagnosis identified by natural language processing of clinician text, diagnostic coding, and antimicrobial treatment. Expressions of uncertainty in clinical notes, patient illness severity, treatments, and outcomes were compared.

RESULTS

Among 2 383 899 hospitalizations, 13.3% received an initial or discharge diagnosis and treatment of pneumonia: 9.1% received an initial diagnosis and 10.0% received a discharge diagnosis. Discordances between initial and discharge occurred in 57%. Among patients discharged with a pneumonia diagnosis and positive initial chest image, 33% lacked an initial diagnosis. Among patients diagnosed initially, 36% lacked a discharge diagnosis and 21% lacked positive initial chest imaging. Uncertainty was frequently expressed in clinical notes (58% in ED; 48% at discharge); 27% received diuretics, 36% received corticosteroids, and 10% received antibiotics, corticosteroids, and diuretics within 24 hours. Patients with discordant diagnoses had greater uncertainty and received more additional treatments, but only patients lacking an initial pneumonia diagnosis had higher 30-day mortality than concordant patients (14.4% [95% CI, 14.1% to 14.7%] vs. 10.6% [CI, 10.4% to 10.7%]). Patients with diagnostic discordance were more likely to present to high-complexity facilities with high ED patient load and inpatient census.

LIMITATION

Retrospective analysis; did not examine causal relationships.

CONCLUSION

More than half of all patients hospitalized and treated for pneumonia had discordant diagnoses from initial presentation to discharge. Treatments for other diagnoses and expressions of uncertainty were common. These findings highlight the need to recognize diagnostic uncertainty and treatment ambiguity in research and practice of pneumonia-related care.

PRIMARY FUNDING SOURCE

The Gordon and Betty Moore Foundation.

How is diagnostic uncertainty communicated and managed in real world primary care settings?

BACKGROUND

Managing diagnostic uncertainty is a major challenge in primary care due to factors such as the absence of definitive tests, variable symptom presentations and disease evolution. Maintaining patient trust during a period of investigative uncertainty, whilst minimising scope for diagnostic error is a challenge. Mismanagement can lead to diagnostic errors, treatment delays, and suboptimal patient outcomes.

OBJECTIVE

Our aim was to explore how UK primary care physicians (GPs) address and communicate diagnostic uncertainty in practice.

DESIGN

This qualitative study used video and audio-recordings. Verbatim transcripts were coded with a modified, validated tool to capture GPs' actions and communication in primary care consultations that included diagnostic uncertainty. The tool includes items relating to advice regarding new symptoms or symptom deterioration (sometimes called 'safety netting'). Video data was analysed to identify GP and patient body postures during and after the delivery of the management plan.

PARTICIPANTS

All patient participants had a consultation with a GP, were over the age of 50 and had (1) at least one new presenting problem or (2) one persistent problem that was undiagnosed.

APPROACH

Data collection occurred in GP-patient consultations during 2017-2018 across 7 practices in UK during 2017-2018.

KEY RESULTS

GPs used various management strategies to address diagnostic uncertainty, including (1) symptom monitoring without treatment, (2) prescribed treatment with symptom monitoring, and (3) addressing risks that could arise from administrative tasks. GPs did not make management plans for potential treatment side effects. Specificity of uncertainty management plans varied among GPs, with only some offering detailed actions and timescales. The transfer of responsibility for the management plan to patients was usually delivered rather than negotiated, with most patients confirming acceptance before concluding the discussion.

CONCLUSIONS

We offer guidance to healthcare professionals, improving awareness of using and communicating management plans for diagnostic uncertainty.

Identifying Facilitators and Inhibitors of Shared Understanding: An Ethnography of Diagnosis Communication in Acute Medical Settings

BACKGROUND AND AIMS

Communication is important in determining how patients understand the diagnostic process. Empirical studies involving direct observation of communication within diagnostic processes are relatively limited. This ethnographic study aimed to identify communicative practices facilitating or inhibiting shared understanding between patients and doctors in UK acute secondary care settings.

METHODS

Data were collected in acute medical sectors of three English hospitals. Researchers observed doctors as they assessed patients; semistructured interviews were undertaken with doctors and patients directly afterwards. Patients were also interviewed 2-4 weeks later. Case studies of individual encounters (consisting of these interviews and observational notes) were created, and were cross-examined by an interdisciplinary team to identify divergence and convergence between doctors' and patients' narratives. These data were analysed thematically.

RESULTS

We conducted 228 h of observation, 24 doctor interviews, 32 patient interviews and 15 patient follow-up interviews. Doctors varied in their communication. Patient diagnostic understanding was sometimes misaligned with that of their doctors; interviews revealed that they often made incorrect assumptions to make sense of the fragmented information received. Thematic analysis identified communicative practices that seemed to facilitate, or inhibit, shared diagnostic understanding between patient and doctor, revealing three themes: (1) communicating what has been understood from the medical record, (2) sharing the thought process and diagnostic reasoning and (3) closing the loop and discharge communication. Shared understanding was best fostered by clear communication about the diagnostic process, what had already been done and what was achievable in acute settings. Written information presents an underutilised tool in such communication.

CONCLUSIONS

In UK acute secondary settings, the provision of more information about the diagnostic process often fostered shared understanding between doctor and patient, helping to minimise the confusion and dissatisfaction that can result from misaligned expectations or conclusions about the diagnosis, and the uncertainty therein.

PATIENT/PUBLIC CONTRIBUTION

A patient and public involvement group (of a range of ages and backgrounds) was consulted. They contributed to the design of the protocol, including the timing of interviews, the acceptability of a follow-up telephone interview, the development of the interview guides and the participant information sheets.

Surgeons Have an Implicit Preference for Specific Disease Over Nonspecific Illness

BACKGROUND

Many symptoms are not associated with a specific, measurable pathophysiology. Such nonspecific illnesses may carry relative social stigma that biases humans in favor of specific diseases. Such a bias could lead musculoskeletal surgeons to diagnose a specific disease in the absence of a specific, measurable pathology, resulting in potential overdiagnosis and overtreatment.

QUESTIONS/PURPOSES

(1) What factors are associated with surgeon implicit preference for specific disease over nonspecific illness? (2) What factors are associated with surgeon explicit preference for specific disease over nonspecific illness? (3) Is there a relationship between surgeon implicit and explicit preferences for specific disease over nonspecific illness?

METHODS

One hundred three members of the Science of Variation Group participated in a survey-based experiment that included an Implicit Associations Test (IAT) to assess implicit preferences for specific, measurable musculoskeletal pathophysiology (specific disease) compared with symptoms that are not associated with a specific, measurable pathophysiology (nonspecific illness), and a set of four simple, face valid numerical ratings of explicit preferences. The Science of Variation Group is an international collaborative of mostly United States and European (85% [88 of 103] in this study), mostly academic (83% [85 of 103]), and mostly fracture and upper extremity surgeons (83% [86 of 103]), among whom approximately 200 surgeons complete at least one survey per year. The human themes addressed in this study are likely relatively consistent across these variations. Although concerns have been raised about the validity and utility of the IAT, we believe this was the right tool, given that the timed delays in association that form the basis of the measurement likely represent bias and social stigma regarding nonspecific illness. Both measures were scaled from -150, which represents a preference for nonspecific illness, to 150, which represents a preference for specific disease. The magnitude of associations can be assessed relative to the standard deviation or interquartile range. We used multivariable linear regression to identify surgeon factors associated with surgeon implicit and explicit preference for specific disease or nonspecific illness. We measured the relationship between surgeon implicit and explicit preferences for specific disease or nonspecific illness using Spearman correlation.

RESULTS

Overall, there was a notable implicit bias in favor of specific diseases over nonspecific illness (median [IQR] 70 [54 to 88]; considered notable because the mean value is above zero [neutral] by more than twice the magnitude of the IQR), with a modestly greater association in the hand and wrist subspecialty. We found no clinically important explicit preference between specific disease and nonspecific illness (median 8 [-15 to 37]; p = 0.02). There was no correlation between explicit preference and implicit bias regarding specific disease and nonspecific illness (Spearman correlation coefficient -0.13; p = 0.20).

CONCLUSION

Given that our study found an implicit bias among musculoskeletal specialists toward specific diseases over nonspecific illness, future research might address the degree to which this bias may account, in part, for patterns of use of low-yield diagnostic testing and the use of diagnostic labels that imply specific pathophysiology when none is detectable.

CLINICAL RELEVANCE

Patients and clinicians might limit overtesting, overdiagnosis, and overtreatment by anticipating an implicit preference for a specific disease and intentionally anchoring on nonspecific illness until a specific pathophysiology accounting for symptoms is identified, and also by using nonspecific illness descriptions until objective, verifiable pathophysiology is identified.

How do we explain painful non-traumatic knee conditions to adolescents? A multiple-method study to develop credible explanations

BACKGROUND

Perceived diagnostic uncertainty can leave adolescents confused about their condition and impede their ability to understand "what's wrong with me". Our aim is to develop credible explanations about the condition for adolescents suffering from non-traumatic knee pain.

METHODS

This multiple-method study integrated findings from two systematic literature searches of qualitative and quantitative studies, an Argumentative Delphi with international experts (n = 16) and think-aloud interviews with adolescents (n = 16). Experts provided feedback with arguments on how to communicate credible explanations to meet adolescents' needs; we analysed feedback using thematic analysis. The explanations were tailored based on the adolescent end-users' input.

RESULTS

We screened 3239 titles/abstracts and included 16 papers exploring diagnostic uncertainty from adolescents' and parents' perspectives. Five themes were generated: (1) understanding causes and contributors to the pain experience, (2) feeling stigmatized for having an invisible condition, (3) having a name for pain, (4) controllability of pain, and (5) worried about something being missed. The Argumentative Delphi identified the following themes: (1) multidimensional perspective, (2) tailored to adolescents, (3) validation and reassurance, and (4) careful wording. Merging findings from the systematic search and the Delphi developed three essential domains to address in credible explanations: "What is non-traumatic knee pain and what does it mean?", "What is causing my knee pain?" and "How do I manage my knee pain?"

CONCLUSIONS

Six credible explanations for the six most common diagnoses of non-traumatic knee pain were developed. We identified three domains to consider when tailoring credible explanations to adolescents experiencing non-traumatic knee pain.

SIGNIFICANCE

This study provides credible explanations for the six most common diagnoses of non-traumatic knee pain. Additionally, we identified three key domains that may need to be addressed to reduce diagnostic uncertainty in adolescents suffering from pain complaints. Based on our findings, we believe that clinicians will benefit from exploring adolescents' own perceptions of why they experience pain and perceived management strategies, as this information might capture important clinical information when managing these young individuals.

Perceptions of Uncertainty in Medical Care Among Non-medical Professionals and Nurses in Japan: A Cross-Sectional Internet-Based Preliminary Survey

BACKGROUND

Medical care is impacted by uncertainty caused by various factors. The uncertainty that exists in medical care can cause patient distrust and lead to conflict. This study compared the tolerance of uncertainty in medical care between non-medical professionals and nurses.

METHODS

We conducted a cross-sectional Internet-based survey. Participants included 2,100 individuals (600 nurses and 1,500 non-medical professionals; aged ≥ 20 years) from different parts of Japan. Of these, we excluded 70 participants who were classified as non-medical professionals but were registered nurses. Finally, we analyzed data from 2,030 participants (600 nurses and 1,430 non-medical professionals). Three registered nurses and nursing researchers developed an original questionnaire on tolerance of uncertainty in medical care. Data regarding participants' characteristics (age, sex, education level, marital status, having children, population size of the residential area, medical care usage, and occupation) were obtained. We performed a one-way analysis of variance (ANOVA) to compare the data between non-medical professionals and nurses. Additionally, we employed a multiple regression model to investigate factors related to tolerance of uncertainty in medical care scores.

RESULTS

A significant portion of participants (36.7%) were aged 40-50 years (n = 745). Most were women (n = 1,210, 59.6%), and a considerable percentage were medical care users (n = 1,309, 64.5%). Non-medical professionals were less tolerant of uncertainty than nurses, and uncertainty scores were associated with medical care usage, occupation, and population size of the residential area.

CONCLUSIONS

Our findings revealed variations in perceptions of uncertainty in medical care between non-medical professionals and medical care providers. To mitigate conflicts related to medical issues, medical care providers should enhance non-medical professionals' education regarding perceptions of uncertainty in medical care.

How and why do doctors communicate diagnostic uncertainty: An experimental vignette study

BACKGROUND

Diagnostic uncertainty is common, but its communication to patients is under-explored. This study aimed to (1) characterise variation in doctors' communication of diagnostic uncertainty and (2) explore why variation occurred.

METHODS

Four written vignettes of clinical scenarios involving diagnostic uncertainty were developed. Doctors were recruited from five hospitals until theoretical saturation was reached (n = 36). Participants read vignettes in a randomised order, and were asked to discuss the diagnosis/plan with an online interviewer, as they would with a 'typical patient'. Semi-structured interviews explored reasons for communication choices. Interview transcripts were coded; quantitative and qualitative (thematic) analyses were undertaken.

RESULTS

There was marked variation in doctors' communication: in their discussion about differential diagnoses, their reference to the level of uncertainty in diagnoses/investigations and their acknowledgement of diagnostic uncertainty when safety-netting. Implicit expressions of uncertainty were more common than explicit. Participants expressed both different communication goals (including reducing patient anxiety, building trust, empowering patients and protecting against diagnostic errors) and different perspectives on how to achieve these goals. Training in diagnostic uncertainty communication is rare, but many felt it would be useful.

CONCLUSIONS

Significant variation in diagnostic uncertainty communication exists, even in a controlled setting. Differing communication goals-often grounded in conflicting ethical principles, for example, respect for autonomy versus nonmaleficence-and differing ideas on how to prioritise and achieve them may underlie this. The variation in communication behaviours observed has important implications for patient safety and health inequalities. Patient-focused research is required to guide practice.

PATIENT OR PUBLIC CONTRIBUTION

In the design stage of the study, two patient and public involvement groups (consisting of members of the public of a range of ages and backgrounds) were consulted to gain an understanding of patient perspectives on the concept of communicating diagnostic uncertainty. Their feedback informed the formulations of the research questions and the choice of vignettes used.

How do patients and care partners describe diagnostic uncertainty in an emergency department or urgent care setting?

OBJECTIVES

Little is known about how patients perceive diagnostic uncertainty. We sought to understand how patients and care partners perceive uncertainty in an emergency or urgent care setting, where making a final diagnosis is often not possible.

METHODS

We administered a survey to a nationally representative panel on patient-reported diagnostic excellence in an emergency department or urgent care setting. The survey included items specific to perceived diagnostic excellence, visit characteristics, and demographics. We analyzed responses to two open-ended questions among those who reported uncertainty in the explanation they were given. Themes were identified using an inductive approach, and compared by whether respondents agreed or disagreed the explanation they were given was true.

RESULTS

Of the 1,116 respondents, 106 (10 %) reported that the care team was not certain in the explanation of their health problem. Five themes were identified in the open-ended responses: poor communication (73 %), uncertainty made transparent (10 %), incorrect information provided (9 %), inadequate testing equipment (4 %), and unable to determine (4 %). Of the respondents who reported uncertainty, 21 % (n=22/106) reported the explanation of their problem given was not true.

CONCLUSIONS

The findings of this analysis suggest that the majority of patients and their care partners do not equate uncertainty with a wrong explanation of their health problem, and that poor communication was the most commonly cited reason for perceived uncertainty.

Improving general practice management of patients with chronic musculoskeletal pain: Interdisciplinarity, coherence, and concerns

OBJECTIVES

Management of patients with chronic musculoskeletal pain (CMP) remains a challenge in general practice. The general practitioner (GP) often experiences diagnostic uncertainty despite frequently referring patients with CMP to specialized departments. Therefore, it remains imperative to gain insights on how to optimize and reframe the current setup for the management of patients with CMP. The objective was to explore GP's perspectives on the challenges, needs, and visions for improving the management of patients with CMP.

METHODS

A qualitative study with co-design using the future workshop approach. Eight GPs participated in the future workshop (five females). Insights and visions emerged from the GP's discussions and sharing of their experiences in managing patients with CMP. The audio-recorded data were subjected to thematic text analysis.

RESULTS

The thematic analysis revealed four main themes, including (1) challenges with current pain management, (2) barriers to pain management, (3) the need for a biopsychosocial perspective, and (4) solutions and visions. All challenges are related to the complexity and diagnostic uncertainty for this patient population. GPs experienced that the patients' biomedical understanding of their pain was a barrier for management and underlined the need for a biopsychosocial approach when managing the patients. The GPs described taking on the role of coordinators for their patients with CMP but could feel ill-equipped to handle diagnostic uncertainty. An interdisciplinary unit was recommended as a possible solution to introduce a biopsychosocial approach for the examination, diagnosis, and management of the patient's CMP.

CONCLUSIONS

The complexity and diagnostic uncertainty of patients with CMP warrants a revision of the current setup. Establishing an interdisciplinary unit using a biopsychosocial approach was recommended as an option to improve the current management for patients with CMP.

Understanding diagnostic conversations in clinical practice: A systematic review

OBJECTIVE

Summarize frameworks to understand diagnostic conversations and assessments of diagnostic conversations in practice.

METHODS

We systematically searched MEDLINE, Scopus, Cochrane, and other databases from inception to July 2022 for reports of diagnostic conversations. Two authors independently reviewed studies for eligibility, assessed methodological quality with the mixed methods appraisal tool and extracted information related to study characteristics, frameworks and components evaluated in assessments of diagnostic conversations and results.

RESULTS

Eight studies were included. One study reported an empiric framework of diagnostic conversations that included the following components: identifying the problem that requires diagnosis, obtaining information, and delivering the diagnosis and treatment plan. Thematic analyses highlighted communication between patients and clinicians as central in diagnostic conversations as it allows a) patient's presentation of their symptoms which guide subsequent diagnostic steps, b) negotiation of the significance of the patient's symptoms through conversation and c) introducing and resolving diagnostic uncertainty.

CONCLUSION

Despite the importance of diagnostic conversation only one empiric framework described its components. Additionally, limited available evidence suggests patients can have an important role in the diagnostic process that expands beyond patients as an information source.

PRACTICE IMPLICATIONS

Patients should be included as active partners in co-development of diagnostic plans of care.

Improving the safety and effectiveness of urgent and emergency care

Delays and waiting in urgent and emergency care (UEC) services are causing avoidable harm to patients and affecting staff morale. Patients are often having a poor experience of using UEC services, increasing stress and anxiety for both their families and themselves, delaying their recovery. Despite the constraints of available permanent staffing, funding and competing NHS priorities, changes along the whole UEC pathway in and out of hospital, admitted and non-admitted pathways need to be made safe, timely and accessible, to provide clinically appropriate care for patients. Changes in clinician behaviour, culture, and training toward the management and sharing of clinical risk differently along the whole UEC pathway are also required. Modifying operational processes with a focus on patients in different UEC settings will improve productivity, flow and the patient experience. There is a need to do things differently rather than continuing as we are and expecting a different result to unlock the perennial UEC crisis.