From: Managing diagnostic uncertainty in primary care: a systematic critical review
Author Year Country | Study type | Specialty or condition/clinician grade or experience | Setting/ recruitment/ Sample size (n) | Uncertainty assessment | Uncertainty Resource | Uncertainty type Cognitive (C) Emotional (E) Ethical (ETH) | Results |
---|---|---|---|---|---|---|---|
Griffiths 2005 UK [13] | Qualitative study | Hormone replacement therapy, bone densitometry and breast screening/Practice nurses, general practitioners, consultants, specialist registrars, specialist nurse, radiographer | 7 general practices, 3 secondary care clinics (n = 25) | Constant comparative analysis of audio recorded transcripts | Strategies health professionals use | Utilizing safety netting techniques (C) Communicating uncertainty to patients (Eth) Accepting uncertainty (E) | Three key strategies were identified: 1) Focus on certainty for now and this test; 2) providing a coherent account of the medical evidence for the risks and benefits (blurring the uncertainty); and 3) acknowledging inherent uncertainty of medical evidence and negotiating a provisional decision. |
Hewson 1996 USA [32] | Process evaluation | Primary and secondary care/a range of clinical experiences (1st year residents to faculty physicians) | Primary and secondary care. 10 tapes of 9 physicians interacting with 4 standardized patient cases in phase one. 19 faculty physicians rating the strategies in phase two. | Clinicians reasoning and strategic medical management was rated using the “Medical checklist, Clinical Reasoning Skills Rating Scale, Interpersonal Skills Rating Scale & Strategic Medical Management Checklist”. | Identification and frequency of strategies used by clinicians when faced with uncertainty | Behaviour patterns when clinicians are faced with diagnostic uncertainty (C) Patient communication and involvement with uncertainty (Eth). | Nine important strategies were identified: 1) defining the context of diagnosis and explaining symptoms; 2) eliminating alternative diagnoses; 3) describing the prognosis; 4) negotiating problems; 5) negotiating the plan of action; 6) keeping diagnostic options open; 7) cautious not to miss potential diagnoses; 8) appropriate time limited safety netting and 9) appropriate contingency planning. |
Seaburn 2005 USA [33] | Observational study with 2 unannounced SP visits (thematic analysis) | Family practice / internists and family physicians | Community based primary care in a metropolitan area (n = 23); n = 46 interviews (the application of 7 codes from thematic analyses led to potentially >46 types of responses). | NA | NA | Greater knowledge about patient’s life circumstances (C) Physician responses to ambiguous symptom presentations by patients (Eth) | Primary care physicians respond to ambiguity by either ignoring the ambiguity and becoming more directive (UC) or, less often, by acknowledging the ambiguity and attempting to explore symptoms and patient concerns in more detail (HP). |
Sommers 2007 USA [34] | Intervention evaluation-thematic and frequency analysis | Primary care physicians/NS | Primary care (n = 14 practice sites, 98 clinicians with 118 patient cases) | Practice-based learning in small groups | Intervention “Practice Inquiry” | Not knowing enough about the patient and managing clinician-patient boundaries, expectations and trust (C + Eth) Using gut feelings (E) | Of the 30 sites approached between 2002 and 2005, 14 held introductory meetings and by summer 2006, 98 clinicians from 11 sites continued to hold regular Practice Inquiry group meetings suggesting the feasibility and acceptability of the intervention to clinicians. |