“Unmasking” uncertainty, embracing it, and openly communicating about it could help alleviate anxiety and feelings of emotional exhaustion, detachment, and personal inadequacy

Understanding and Communicating Uncertainty in Achieving Diagnostic Excellence. Maria R. Dahm, Carmel Crock. JAMA, March 3, 2022. doi:10.1001/jama.2022.2141

Uncertainty pervades the diagnostic process. In health care, taxonomies of uncertainty have been developed to describe aspects such as personal (eg, individual knowledge gaps), scientific (eg, limits of biomedical knowledge), and probabilistic (eg, imprecise estimates of risk or prognosis) dimensions of uncertainty.1

When clinicians encounter diagnostic uncertainty, they often find themselves in an unfamiliar situation, without a clear method to proceed confidently, comfortably, and safely. Being unable to explain to patients what causes their symptoms may be perceived as a failure for all involved. When clinicians and patients dwell in diagnostic uncertainty, it can trigger feelings of concern and anxiety, may lead patients to mistrust clinicians’ competence, and could contribute to clinician burnout (feeling exhausted, disconnected, and personally inadequate), especially for early-career clinicians.2,3

Excellent diagnosticians should understand how uncertainty manifests. They should acknowledge and embrace uncertainty, and openly discuss it with other clinicians and patients to normalize its ubiquitous and inevitable part in the diagnostic process.4 Such a reimagining, focused on the inevitable and beneficial aspects of diagnostic uncertainty, relies on identifying how uncertainty is understood, managed, and communicated.

What Is Diagnostic Uncertainty, and for Whom?

Diagnosis is a complex and collaborative process that involves gathering, integrating, and interpreting information across the entire diagnostic team: clinicians (physicians, nurses, and allied health professionals), patients, and patients’ families and caregivers.5 All team members encounter different types of diagnostic uncertainty at different stages in the diagnostic process.3

From the clinicians’ perspective, diagnostic uncertainty has been defined as the “subjective perception of an inability to provide an accurate explanation of the patient’s health problem.”6 These subjective feelings are entangled in a multitude of factors and tensions surrounding the qualities deemed essential in clinicians, such as competence and confidence. The decisiveness with which clinicians make a diagnosis may be perceived as reflecting diagnostic expertise and clinical competence. Yet diagnostic excellence in the setting of uncertainty requires recognition and tolerance of uncertainty, cognitive flexibility, and willingness to engage with evolving information. It includes the ability to share clinical reasoning and communicate uncertainty to patients.3,4

Patients may experience uncertainty at any point along the diagnostic process and beyond. For patients, diagnostic uncertainty often begins before they present for health care, such as doubt about whether a persistent minor pain or occasional numbness warrants a clinical visit. Patients may have doubts about how long it will take to get answers, what their role is in the diagnostic process, whether a treatment is available, and whether they want a diagnosis if they already fear having a serious illness. They may have doubts about what a diagnosis means for their personal and professional life, their functional status, and quality of life.

Patients also encounter doubt when they perceive their valid symptoms are being dismissed. This is a common experience reported by patients, particularly those who experience other health disparities related to age, sex, race and ethnicity, or language background. For example, some women with myocardial ischemia may present with symptoms (such as back or abdominal pain or vomiting) that are not considered typical cardiac presentations, and may believe their symptoms are being dismissed. Some people might have doubts when a diagnosis does not match what they think is affecting them, or when family members, such as children and older adults who are unable to advocate for themselves, experience disease progression or adverse outcomes despite having been assigned a diagnostic label and associated treatments.

Managing Uncertainty Positively

“Unmasking”4 uncertainty, embracing it, and openly communicating about it could help alleviate anxiety and feelings of emotional exhaustion, detachment, and personal inadequacy associated with burnout and help clinicians “enjoy rather than dread the diagnostic process.”7 However, tolerating uncertainty rather than trying to reduce it to absolute certainty requires a major shift in the clinician’s mindset. Current medical education inadequately prepares early-career clinicians for feelings of failure associated with diagnostic uncertainty. Instead of upholding the illusion of certainty, medical education and professional development should provide a judgment-free opportunity for clinicians to openly and safely reflect, as well as be guided by and learn to live with the stress associated with diagnostic uncertainty.8

All clinicians across hierarchies and levels of experience need to openly acknowledge the realities of diagnostic uncertainty. The uncertainty surrounding diagnosis does need not be perceived as a threat to medical “authority,” expertise, or professionalism. On the contrary, clinicians who openly encourage and engage in discussions of uncertainty without blame or penalty model excellent diagnostic processes. Normalizing and promoting acceptance of uncertainty as integral to the diagnostic process thus should become routine within clinical care and medical education.8

The effects of explicitly acknowledging and managing uncertainty in the diagnostic process could be profound; doing so may help foster a safety culture in which all diagnostic team members can openly discuss, challenge, and collaborate to refine clinical reasoning. Diagnostic possibilities could be explored in self-reflection, and in interactions with colleagues and with patients.

Communicating Uncertainty

Effective communication about uncertainty across the entire diagnostic team is essential to avoid diagnostic error and patient harm.9

Diagnostic error has been defined as a failure to find an accurate and timely explanation for a health problem or failure to communicate that explanation to the patient.5 This definition should be expanded to include failure to communicate uncertainty explicitly, given its pervasiveness, as a potent contributor to diagnostic error.3 When clinicians do not disclose their doubts, patients may leave the clinical encounter feeling reassured yet remain unaware of their clinician’s uncertainty. When medical notes in electronic medical records (EMRs) present diagnoses as certainties, the diagnostic team may miss other diagnostic possibilities. Instead, EMRs should embed differential diagnosis and language expressing uncertainty (such as “possible viral conjunctivitis”) into documentation.

Probabilistic reasoning is often used to articulate uncertainty. Probabilistic (or bayesian) reasoning is a useful method to reduce cognitive biases when information is assessed during the diagnostic process,5 yet it is underused or even misunderstood in routine medical practice. Applying bayesian reasoning principles could lead clinicians to adjust their thinking and revise disease probabilities as they gather more information, thereby potentially avoiding diagnostic errors (eg, considering the frequency of disease processes in the immediate population to avoid base-rate neglect: the tendency to overemphasize information specific to an individual).5 Most clinicians apply probabilistic reasoning unconsciously, but bringing these skills and related language to interactions could be one way to explicitly communicate uncertainty.

How people understand language commonly associated with uncertainty and probability (eg, “occasionally,” “rarely”), including in radiology or pathology reports (eg, “highly suspicious for,” “suggestive of”), could differ between speaker/sender and hearer/receiver and may lead to ambiguity regarding diagnostic certainty. Clinicians also communicate uncertainty via implicit communication strategies that patients may not identify as expressions of uncertainty. For the clinician, “I’d like to follow-up with you next week” may signal they are unsure of a diagnosis and are adopting a watchful, waiting approach. For the patient, it may seem like an ordinary follow-up appointment without any indication of uncertainty.

Key Points for Diagnostic Excellence

.  Diagnostic uncertainty should be shared explicitly with patients. Failure to communicate uncertainty contributes to diagnostic error.

.  Understanding diagnostic uncertainty can be enriched by incorporating perspectives from medicine, social sciences, and humanities.

.  Diagnostic uncertainty should be reimagined as positive and routinely embraced in clinical care and education.

.  Explicitly acknowledging, managing, and communicating uncertainty promotes a robust diagnostic safety culture.

Clinical practice would benefit from evidence-based recommendations on how to best communicate uncertainty in diagnostic encounters. For example, linguistic analysis of video-recorded diagnostic interactions can help identify the language structures clinicians use when expressing diagnostic uncertainty. Diagnostic excellence should be informed by broadening the current understanding of diagnostic uncertainty beyond medical realms to include linguistic, communication, humanistic, sociological, and patient-centered perspectives to better understand and describe the nuance of the diagnostic process and uncertainty.

Diagnosis as a Relational, Communicative Process

Diagnosis is “a relational process, with each party (lay and medical) confronting illness with different explanations, understandings, values, and beliefs.”10 Managing patient anxiety surrounding uncertainty in diagnosis requires open interpersonal communication to increase patients’ awareness of the nature of diagnosis as a process rather than an isolated event. Clinicians could build rapport and trust and manage expectations by listening to patients, clearly communicating steps along the diagnostic process, and sharing their own uncertainty.

Patients’ expectations change as they gain a more transparent understanding of the complex and often complicated pathway to diagnosis. Clinicians can build safety nets by alerting patients about their uncertainty, discussing red-flag symptoms, and codeveloping plans of when and where patients should seek additional or urgent help.3 Open communication between clinicians and patients could also provide avenues for feedback on diagnostic performance, essential to calibrate clinicians’ diagnostic abilities.5

To effectively manage the complexity and challenges of the diagnostic process, clinicians and patients need to find approaches to address uncertainty. Acknowledging, embracing, and communicating uncertainty opens diagnostic possibilities and a way toward achieving diagnostic excellence.