I read with interest the JAMA Viewpoint article on diagnostic excellence by Dahm & Crock (2022). As a medical educator, I recalled the many preceptorials I’ve had with students, leading them through differential diagnoses and the complex process of ruling in and ruling out. Are we teaching the students enough about diagnostic uncertainty, or waxing lyrical about the proverbial clinical eye too much?
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.Dahm MR, Crock C. Understanding and Communicating Uncertainty in Achieving Diagnostic Excellence. JAMA. Published online March 03, 2022. doi:10.1001/jama.2022.2141
As a clinician, I’ve found myself admitting to the patient, “I don’t know,” before referring to another specialist for opinion and co-management. Sometimes I tell my patients, hindi na po kaya ng powers ko, kaya papapuntahin kita sa eksperto sa [insert specialty here]. Though patients invariably smile, it’s also often followed by a nervous question, Dok, bakit po, malala na po ba? Certainly, we need to think about how we communicate uncertainty to our patients.
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.Dahm MR, Crock C. Understanding and Communicating Uncertainty in Achieving Diagnostic Excellence. JAMA. Published online March 03, 2022. doi:10.1001/jama.2022.2141
As an internal medicine resident, I was taught to specify the reason for referral. I find this to be helpful even now, as it makes clear not only to the patient but also to the specialist I’m referring to, what I’m uncertain about, and specifically what I need help with. For example, I might refer to a cardiologist, a patient I’ve treated for hyperthyroidism who continues to have palpitations. I explain to my patient that usually we would expect the palpitations to become infrequent or even disappear when the thyroid hormone levels become normal. That she continues to have palpitations is something we need to investigate further, hence the referral.
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.Dahm MR, Crock C. Understanding and Communicating Uncertainty in Achieving Diagnostic Excellence. JAMA. Published online March 03, 2022. doi:10.1001/jama.2022.2141
On Twitter, fellow internists had a good laugh watching the video of @DGlaucomflecken on How to Speak Internal Medicine. The video really shows how internists hedge all the time. Rovi, a radiologist also weighed in on the language they use in reports.
Join us tonight, 9 pm Manila time at the #HealthXPH tweet chat. Let’s talk about communicating uncertainty to patients.
T1. As a healthcare professional, how did you learn about diagnostic uncertainty when you were in training?
T2. As a healthcare professional, what are the words/phrases you use to communicate uncertainty? As a patient, what words/phrases do you often hear when doctors are expressing uncertainty?
T3. As a healthcare professional, how uncomfortable are you when communicating uncertainty? How can you address this discomfort? As a patient, how do you feel when doctors say they are unsure or do not know?