As we discussed before, making a diagnosis is challenging and stressful. The goal is to be perfect and to do it quickly. These two rarely go together. These challenges introduce a burden and stress that can lead to burnout, most seen as emotional exhaustion and depersonalization.
But perhaps the solution is to accept that diagnostic uncertainty is unavoidable. To that end, Rahul et al. have completed an excellent review of the topic along with some guidelines.
Alam Rahul, Cheraghi-Sohi Sudeh, Panagioti Maria, Esmail Aneez, Campbell Stephen, Panagopoulou Efharis. Managing diagnostic uncertainty in primary care: a systematic critical review. BMC Fam Pract. August 7, 2017;18. doi:10.1186/s12875-017-0650-0.
First, consider ways to decrease the burden of diagnostic uncertainty.
- Further discussion with a patient regarding errors or concerns about the proper diagnosis
- Integrating primary care clinical guidelines
- Differential diagnosis tools
- Laboratory tests and consultations
Each of these different means to address uncertainty and diagnosis incurs a different cost of eliminating uncertainty.
- Free of cost, but takes time
- Builds rapport
- Decreases anxiety and anger from the patient which may, in the end, cost you much more time
Primary Care Clinical Guidelines
- Free of cost, but takes time
- In the process, you develop a more standardized practice based on best practice
- Knowledge gained can be applied to future work and incur time savings and decreased stress/anxiety
Differential Diagnosis Tools and Artificial Intelligence
- The cost is probably not yours, but learning them will take some time.
- EHR has not lived up to its potential to be a vast collector of data, but could potentially become an advisor to assess the potential accuracy or inaccuracy of a diagnosis.
- Tools come with a variety of utility and are fallible.
- Varying tools can harm process and increase uncertainty.
- Sometimes provides an excessive expansion of diagnosis options or options inconsistent with what physician believes is correct
- Essential to assess the accuracy of the tool and for the user to establish confidence and trust in the tool
Laboratory tests and consultations
- Most expensive for the system
- Subject to all the problems of differential diagnosis tools in terms of actually increasing uncertainty and stress
- Used mostly by practitioners with the highest levels of anxiety
- Physicians less comfortable with uncertainty are more likely to order tests and consultations, whereas the other approaches may be more cost-effective.
- Tests and consultations are an essential part of medical practice, but they will not eliminate all diagnostic uncertainty
- Use laboratory tests and consultations with confidence that they will help, not to counter fear that you are wrong
So, enhancing skills to cope with uncertainty may reduce the cost of care, decrease complications due to unnecessary tests, and actually improve accuracy. Make it a goal to improve your strategy to manage diagnostic uncertainty and release yourself from the burden that the diagnosis must be correct.
The review article provides ideas, but little regarding research guidance. Only one of the interventions in the article targeted the challenge of determining whether decreasing or managing the uncertainty related to diagnosis results in decreased stress. Unfortunately, it did not show an impact.
Simulation is an excellent means to test out and develop strategies, as well as an effective way to address the stress of diagnostic uncertainty by practicing dealing with uncertainty. Patients can be interviewed, standardized protocols can be followed, and consultations pursued. Exploring a simulation can provide insight into the upside and downside of patient communication, guidelines, screening tools, differential diagnosis tools, consultation, and laboratory tests.
To that end, we have developed the Clinical Encounters Platform and broader ecosystem to create and complete cases that assist in this process. The platform makes it easy to produce cases to improve clinical skills including diagnosis. Currently, the emphasis is mostly on improving and assessing success with the cognitive challenge of diagnosis, a clear source of stress. But the platform can also help investigate areas of diagnostic uncertainty and their impact on burnout.