Diagnosis is almost certainly the most difficult challenge in that it demands a high level of accuracy and is both time and cost constrained. The aspects of diagnostic challenge can be broken down into three challenges:
- Cognitive: In addition to scientific and data analysis challenge, one must consider the financial costs associated with the process of making a diagnosis. This concern is especially important in an era of increasingly expensive tests, insurance requirements, and the risk of cost to the patient. The article also points out the difference between the approaches of intuition or pattern-recognition versus more scientific fact-based decisions. A full discussion of different strategies toward diagnosis requires review of the literature on gist versus verbatim memory and is outside this discussion – we will include it later.
- Emotional: The diagnosis may have disturbing ramifications for the patient or their family. Also, the diagnosis can in conflict with previous diagnoses, as well as the current provider. A missed diagnosis leads to stress and self-doubt. There is a scale to assess the anxiety related to uncertainty. It is helpful to look at the personality factors related to making a diagnosis and resolution of anxiety related to the uncertainty of diagnosis. It appears that communication skills also key to more accurate diagnosis and the reduction of anxiety
- Ethical: The Hippocratic Oath paper discusses the potential conflict between this common oath as it conceived and implemented in today’s practice of medicine. That is, the struggle with the need to put the patient’s needs first versus the need to address economic models with a movement toward more corporate based healthcare delivery.
These challenges introduce a burden and stress that can lead to burnout, most seen as emotional exhaustion and depersonalization. In fact, these categories are an excellent way to conceptualize other factors that contribute to burnout.
The management of diagnostic uncertainty is an important topic in its own right. A goal of improved management of diagnostic uncertainty is to release the physician from the burden that the diagnosis must be correct.
- 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.
There are several different aspects of addressing uncertainty and diagnosis and there are differences in the cost of eliminating uncertainty:
- The most efficient process may be to discuss further with a patient regarding errors or concerns about the proper diagnosis.
- The utilization of primary care clinical guidelines may be an efficient process.
- Artificial intelligence can assist in the resolution of this conflict. Although the EHR has not lived up to its potential to be a vast collection of data, it could potentially become such an advisor to assess the potential accuracy or inaccuracy of a diagnosis. Differential diagnosis tools, unfortunately, come with a variety of utility and are certainly fallible. Varying differential diagnosis tools can harm this process and increase uncertainty if they provide an excessive expansion of the options or if they choose an option with certainty that’s inconsistent with what the physician believes is correct. It is essential to assess the accuracy of the tool and for the user to establish confidence and trust in the tool.
- The least efficient process would be the use of laboratory tests and consultations. This is seen in those with the highest levels of anxiety. Physicians that are less comfortable with uncertainty are more likely to order tests and consultations, whereas the other approaches may be more cost-effective. So, enhancing skills to cope with uncertainty may decrease the cost of care, decrease complications due to unnecessary tests, and actually improve accuracy.
Only one of the interventions in the article was actually targeting the challenge of decreasing the uncertainty related to diagnosis. Unfortunately, it did not show an impact. In contrast, simulation is an excellent means to address this stress, practice dealing with uncertainty, and to improve success. On a simulation, laboratory tests and their effectiveness can be explored. Standardized protocols can be followed and consultations pursued.
To that end, we have created 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 associated with the cognitive challenge of diagnosis, a clear source of stress of challenge. But the platform can also help investigate areas of diagnostic uncertainty and their impact on burnout.
The simulation can provide experiences that mirror the conflict between the Hippocratic oath (or its equivalent) and the practice of medicine. In the simulation, we can identify ethically challenging situations where the process of care limits the ability to act in the patient’s best interest due to reimbursement, time constraints, insurance requirements, hospital expectations, or other financial-based requirements. We can both assess if a conflict exists and offer means to resolve the conflict or simply to acknowledge it.
You can read more about the Clinical Encounters platform at its website.