Diagnostic uncertainty and clinical decision-making strategies

Uncertainty and the inconvenient facts of diagnosis

One common contemporary usage of the term "diagnostic uncertainty" is to refer to cases for which a diagnosis is not, or cannot, be applied to the presenting case. This is a paradoxical usage, as the absence of diagnosis is often as close to a certainty as can be a human judgement. What makes this sociologically interesting is that it represents an "epistemic defence," or a means of accounting for a failure of medicine's explanatory system. This system is based on diagnosis, or the classification of individual complaints into recognizable diagnostic categories. Diagnosis is pivotal to medicine's epistemic setting, for it purports to explain illness via diagnosis, and yet is not always able to do so. This essay reviews this paradoxical use, and juxtaposes it to historical explanations for non-diagnosable illnesses. It demonstrates how representing non-diagnosis as uncertainty protects the epistemic setting by positioning the failure to locate a diagnosis in the individual, rather than in the medical paradigm.

The clinical utility of routine spinal radiographs by chiropractors: a rapid review of the literature

Introduction

When indicated by signs or symptoms of potentially serious underlying pathology (red flags), chiropractors can use radiographs to inform their diagnosis. In the absence of red flags, the clinical utility of routine or repeat radiographs to assess the structure and function of the spine is controversial.

Objectives

To determine the diagnostic and therapeutic utility of routine or repeat radiographs (in the absence of red flags) of the cervical, thoracic or lumbar spine for the functional or structural evaluation of the spine. Investigate whether functional or structural findings on repeat radiographs are valid markers of clinically meaningful outcomes. The research objectives required that we determine the validity, diagnostic accuracy and reliability of radiographs for the structural and functional evaluation of the spine.

Evidence review

We searched MEDLINE, CINAHL, and Index to Chiropractic Literature from inception to November 25, 2019. We used rapid review methodology recommended by the World Health Organization. Eligible studies (cross-sectional, case-control, cohort, randomized controlled trials, diagnostic and reliability) were critically appraised. Studies of acceptable quality were included in our synthesis. The lead author extracted data and a second reviewer independently validated the data extraction. We conducted a qualitative synthesis of the evidence.

Findings

We identified 959 citations, screened 176 full text articles and critically appraised 23. No relevant studies assessed the clinical utility of routine or repeat radiographs (in the absence of red flags) of the cervical, thoracic or lumbar spine for the functional or structural evaluation of the spine. No studies investigated whether functional or structural findings on repeat radiographs are valid markers of clinically meaningful outcomes. Nine low risk of bias studies investigated the validity (n = 2) and reliability (n = 8) of routine or repeat radiographs. These studies provide no evidence of clinical utility.

Conclusion

We found no evidence that the use of routine or repeat radiographs to assess the function or structure of the spine, in the absence of red flags, improves clinical outcomes and benefits patients. Given the inherent risks of ionizing radiation, we recommend that chiropractors do not use radiographs for the routine and repeat evaluation of the structure and function of the spine.

Drawing a line in the sand: affect and testimony in autism assessment teams in the UK

Diagnosis of autism in the UK is generally made within a multidisciplinary team setting and is primarily based on observation and clinical interview. We examined how clinicians diagnose autism in practice by observing post-assessment meetings in specialist autism teams. Eighteen meetings across four teams based in the south of England and covering 88 cases were audio-recorded, transcribed and analysed using thematic analysis. We drew out two themes, related to the way in which clinicians expressed their specialist disciplinary knowledge to come to diagnostic consensus: Feeling Autism in the Encounter; and Evaluating Testimonies of Non-present Actors. We show how clinicians produce objective accounts through their situated practices and perform diagnosis as an act of interpretation, affect and evaluation to meet the institutional demands of the diagnostic setting. Our study contributes to our understanding of how diagnosis is accomplished in practice.