Diagnostic uncertainty: dichotomies are not the answer

Shinkins, Bethany; Perera, Rafael

doi:10.3399/bjgp13x664090

Cited by 16 publications

(16 citation statements)

References 10 publications

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“…It is unclear however whether such approaches have succeeded in reducing uncertainty [ 43 ]. Furthermore, even the apparent cognitive clarity of dichotomous, quantitative diagnostic tests, may do little to alleviate any diagnostic uncertainty in an environment as messy as primary care where much diagnostic information is lost, as disease prevalence is low and the accuracy of the test is poor [ 44 ].…”

Section: Discussionmentioning

confidence: 99%

Managing diagnostic uncertainty in primary care: a systematic critical review

et al. 2017

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BackgroundDiagnostic uncertainty is one of the largest contributory factors to the occurrence of diagnostic errors across most specialties in medicine and arguably uncertainty is greatest in primary care due to the undifferentiated symptoms primary care physicians are often presented with. Physicians can respond to diagnostic uncertainty in various ways through the interplay of a series of cognitive, emotional and ethical reactions. The consequences of such uncertainty however can impact negatively upon the primary care practitioner, their patients and the wider healthcare system. Understanding the nature of the existing empirical literature in relation to managing diagnostic uncertainty in primary medical care is a logical and necessary first step in order to understand what solutions are already available and/or to aid the development of any training or feedback aimed at better managing this uncertainty. This review is the first to characterize the existing empirical literature on managing diagnostic uncertainty in primary care.MethodsSixteen databases were systematically searched from inception to present with no restrictions. Hand searches of relevant websites and reference lists of included studies were also conducted. Two authors conducted abstract/article screening and data extraction. PRISMA guidelines were adhered to.ResultsTen studies met the inclusion criteria. A narrative and conceptual synthesis was undertaken under the premises of critical reviews. Results suggest that studies have focused on internal factors (traits, skills and strategies) associated with managing diagnostic uncertainty with only one external intervention identified. Cognitive factors ranged from the influences of epistemological viewpoints to practical approaches such as greater knowledge of the patient, utilizing resources to hand and using appropriate safety netting techniques. Emotional aspects of uncertainty management included clinicians embracing uncertainty and working with provisional diagnoses. Ethical aspects of uncertainty management centered on communicating diagnostic uncertainties with patients. Personality traits and characteristics influenced each of the three domains.ConclusionsThere is little empirical evidence on how uncertainty is managed in general practice. However we highlight how the extant literature can be conceptualised into cognitive, emotional and ethical aspects of uncertainty which may help clinicians be more aware of their own biases as well as provide a platform for future research.Trial registrationPROSPERO registration: CRD42015027555 Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-017-0650-0) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Managing diagnostic uncertainty in primary care: a systematic critical review

et al. 2017

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“…Several studies have found that moving away from the dichotomous division of quantitative test scales and identifying intermediate range(s) of test results gave a better understanding of the diagnostic accuracy potential of a test . We therefore suggest that in veterinary clinical practice, this approach—which clearly establishes the lower and upper thresholds—should facilitate clinical decisions.…”

Section: Discussionmentioning

confidence: 99%

Diagnostic potential of simplified methods for measuring glomerular filtration rate to detect chronic kidney disease in dogs

Pocar

Scarpa

Berrini

et al. 2019

Veterinary Internal Medicne

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Background Glomerular filtration rate (GFR) is the most sensitive indicator of initial renal function decline during chronic kidney disease (CKD), but conventional protocols for measuring GFR are labor‐intensive and stressful for the dog. Objectives To assess the diagnostic potential for detecting CKD with simplified GFR protocols based on iohexol plasma clearance. Animals Seventeen CKD‐positive and 23 CKD‐negative dogs of different breeds and sex. Methods Prospective nonrandomized study. Plasma iohexol was measured 5, 15, 60, 90, and 180 minutes after injection. Glomerular filtration rate was calculated using 5 samples (GFR5) or simplified protocols based on 1, 2, or 3 samples. The GFR5 and simplified GFR were compared by Bland‐Altmann and concordance correlation coefficient (CCC) analysis, and diagnostic accuracy for CKD by receiver operating characteristic curves. A gray zone for each protocol was bounded by the fourth quartile of the CKD‐positive population (lower cutoff) and the first quartile of the CKD‐negative population (upper cutoff). Results All simplified protocols gave reliable GFR measurements, comparable to reference GFR5 (CCC >0.92). Simplified protocols which included the 180‐minutes sampling granted the best GFR measure (CCC: 0.98), with strong diagnostic potential for CKD (area under the receiver operating characteristic curve ± SE: 0.98 ± 0.01). A double cutoff including a zone of CKD uncertainty guaranteed reliable diagnosis outside the gray area and identified borderline dogs inside it. Conclusions The simplified GFR protocols offer an accurate, hands‐on tool for CKD diagnosis in dogs. The gray zone might help decision‐making in the management of early kidney dysfunction.

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“…1 – 5 In addition to patient presentation, time constraints of the patient–clinician encounter, complexity of medical science and limitations of diagnostic tests all influence diagnostic decisions in the midst of uncertainty. 6 – 8 Described as analogous to looking for a “snowball in a blizzard,” diagnostic decision-making under uncertainty is challenging for clinicians and must be appropriately managed in medical practice. 1…”

Section: Introductionmentioning

confidence: 99%

Defining and Measuring Diagnostic Uncertainty in Medicine: A Systematic Review

et al. 2017

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BackgroundPhysicians routinely encounter diagnostic uncertainty in practice. Despite its impact on health care utilization, costs and error, measurement of diagnostic uncertainty is poorly understood. We conducted a systematic review to describe how diagnostic uncertainty is defined and measured in medical practice.MethodsWe searched OVID Medline and PsycINFO databases from inception until May 2017 using a combination of keywords and Medical Subject Headings (MeSH). Additional search strategies included manual review of references identified in the primary search, use of a topic-specific database (AHRQ-PSNet) and expert input. We specifically focused on articles that (1) defined diagnostic uncertainty; (2) conceptualized diagnostic uncertainty in terms of its sources, complexity of its attributes or strategies for managing it; or (3) attempted to measure diagnostic uncertainty.Key ResultsWe identified 123 articles for full review, none of which defined diagnostic uncertainty. Three attributes of diagnostic uncertainty were relevant for measurement: (1) it is a subjective perception experienced by the clinician; (2) it has the potential to impact diagnostic evaluation—for example, when inappropriately managed, it can lead to diagnostic delays; and (3) it is dynamic in nature, changing with time. Current methods for measuring diagnostic uncertainty in medical practice include: (1) asking clinicians about their perception of uncertainty (surveys and qualitative interviews), (2) evaluating the patient–clinician encounter (such as by reviews of medical records, transcripts of patient–clinician communication and observation), and (3) experimental techniques (patient vignette studies).ConclusionsThe term “diagnostic uncertainty” lacks a clear definition, and there is no comprehensive framework for its measurement in medical practice. Based on review findings, we propose that diagnostic uncertainty be defined as a “subjective perception of an inability to provide an accurate explanation of the patient’s health problem.” Methodological advancements in measuring diagnostic uncertainty can improve our understanding of diagnostic decision-making and inform interventions to reduce diagnostic errors and overuse of health care resources.Electronic supplementary materialThe online version of this article (10.1007/s11606-017-4164-1) contains supplementary material, which is available to authorized users.

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Diagnostic uncertainty: dichotomies are not the answer

Cited by 16 publications

References 10 publications

Managing diagnostic uncertainty in primary care: a systematic critical review

Managing diagnostic uncertainty in primary care: a systematic critical review

Diagnostic potential of simplified methods for measuring glomerular filtration rate to detect chronic kidney disease in dogs

Defining and Measuring Diagnostic Uncertainty in Medicine: A Systematic Review

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