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Zhang C. A Literature Study of Medical Simulations for Non-Technical Skills Training in Emergency Medicine: Twenty Years of Progress, an Integrated Research Framework, and Future Research Avenues. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4487. [PMID: 36901496 PMCID: PMC10002261 DOI: 10.3390/ijerph20054487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/26/2023] [Accepted: 03/01/2023] [Indexed: 06/18/2023]
Abstract
Medical simulations have led to extensive developments in emergency medicine. Apart from the growing number of applications and research efforts in patient safety, few studies have focused on modalities, research methods, and professions via a synthesis of simulation studies with a focus on non-technical skills training. Intersections between medical simulation, non-technical skills training, and emergency medicine merit a synthesis of progress over the first two decades of the 21st century. Drawing on research from the Web of Science Core Collection's Science Citation Index Expanded and Social Science Citation Index editions, results showed that medical simulations were found to be effective, practical, and highly motivating. More importantly, simulation-based education should be a teaching approach, and many simulations are utilised to substitute high-risk, rare, and complex circumstances in technical or situational simulations. (1) Publications were grouped by specific categories of non-technical skills, teamwork, communication, diagnosis, resuscitation, airway management, anaesthesia, simulation, and medical education. (2) Although mixed-method and quantitative approaches were prominent during the time period, further exploration of qualitative data would greatly contribute to the interpretation of experience. (3) High-fidelity dummy was the most suitable instrument, but the tendency of simulators without explicitly stating the vendor selection calls for a standardised training process. The literature study concludes with a ring model as the integrated framework of presently known best practices and a broad range of underexplored research areas to be investigated in detail.
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Affiliation(s)
- Cevin Zhang
- School of Media and Design, Beijing Technology and Business University, Sunlight South Road 1, Beijing 102488, China
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Rising KL, Cameron KA, Salzman DH, Papanagnou D, Doty AMB, Piserchia K, Leiby BE, Shimada A, McGaghie WC, Powell RE, Klein MR, Zhang XC, Vozenilek J, McCarthy DM. Communicating Diagnostic Uncertainty at Emergency Department Discharge: A Simulation-Based Mastery Learning Randomized Trial. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:384-393. [PMID: 36205492 DOI: 10.1097/acm.0000000000004993] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
PURPOSE There are no standardized approaches for communicating with patients discharged from the emergency department with diagnostic uncertainty. This trial tested efficacy of the Uncertainty Communication Education Module, a simulation-based mastery learning curriculum designed to establish competency in communicating diagnostic uncertainty. METHOD Resident physicians at 2 sites participated in a 2-arm waitlist randomized controlled trial from September 2019 to June 2020. After baseline (T1) assessment of all participants via a standardized patient encounter using the Uncertainty Communication Checklist (UCC), immediate access physicians received training in the Uncertainty Communication Education Module, which included immediate feedback, online educational modules, a smartphone-based application, and telehealth deliberate practice with standardized patients. All physicians were retested 16-19 weeks later (T2) via in-person standardized patient encounters; delayed access physicians then received the intervention. A final test of all physicians occurred 11-15 weeks after T2 (T3). The primary outcome measured the percentage of physicians in the immediate versus delayed access groups meeting or exceeding the UCC minimum passing standard at T2. RESULTS Overall, 109 physicians were randomized, with mean age 29 years (range 25-46). The majority were male (n = 69, 63%), non-Hispanic/Latino (n = 99, 91%), and White (n = 78, 72%). At T2, when only immediate access participants had received the curriculum, immediate access physicians demonstrated increased mastery (n = 29, 52.7%) compared with delayed access physicians (n = 2, 3.7%, P < .001; estimated adjusted odds ratio of mastery for the immediate access participants, 31.1 [95% CI, 6.8-143.1]). There were no significant differences when adjusting for training site or stage of training. CONCLUSIONS The Uncertainty Communication Education Module significantly increased mastery in communicating diagnostic uncertainty at the first postintervention test among emergency physicians in standardized patient encounters. Further work should assess the impact of clinical implementation of these communication skills.
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Affiliation(s)
- Kristin L Rising
- K.L. Rising is professor and director of acute care transitions, Department of Emergency Medicine, Sidney Kimmel Medical College, professor of nursing, College of Nursing, and director, Center for Connected Care, Thomas Jefferson University, Philadelphia, Pennsylvania; ORCID: https://orcid.org/0000-0003-3882-4956
| | - Kenzie A Cameron
- K.A. Cameron is professor, Division of General Internal Medicine, Department of Medicine, and Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois; ORCID: https://orcid.org/0000-0002-3535-6459
| | - David H Salzman
- D.H. Salzman is associate professor, Department of Emergency Medicine and Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois; ORCID: https://orcid.org/0000-0001-5090-3433
| | - Dimitrios Papanagnou
- D. Papanagnou is professor and vice chair for education, Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania; ORCID: https://orcid.org/0000-0003-3682-8371
| | - Amanda M B Doty
- A.M.B. Doty is research coordinator, Center for Connected Care, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Katherine Piserchia
- K. Piserchia is clinical research coordinator, Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Benjamin E Leiby
- B.E. Leiby is professor and director, Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania; ORCID: https://orcid.org/0000-0003-0761-8383
| | - Ayako Shimada
- A. Shimada is statistician, Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania; ORCID: https://orcid/org/0000-0002-9941-7660
| | - William C McGaghie
- W.C. McGaghie is professor, Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois; ORCID: https://orcid.org/0000-0003-1672-0398
| | - Rhea E Powell
- R.E. Powell is associate professor, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania; ORCID: https://orcid.org/0000-0002-4157-3070
| | - Matthew R Klein
- M.R. Klein is assistant professor, Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; ORCID: https://orcid.org/0000-0001-7888-6372
| | - Xiao Chi Zhang
- X.C. Zhang is assistant professor, Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - John Vozenilek
- J. Vozenilek is vice president and chief medical officer, innovation and digital health, Jump Trading Simulation and Education Center, OSF Healthcare, Peoria, Illinois, clinical professor, Department of Emergency Medicine, University of Illinois College of Medicine, Peoria, Illinois, and clinical professor, Department of Bioengineering, University of Illinois Grainger College of Engineering, Urbana, Illinois; ORCID: https://orcid.org/0000-0001-7955-4089
| | - Danielle M McCarthy
- D.M. McCarthy is associate professor, Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; ORCID: https://orcid.org/0000-0002-9038-2852
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Moulder G, Harris E, Santhosh L. Teaching the science of uncertainty. Diagnosis (Berl) 2023; 10:13-18. [PMID: 36087299 DOI: 10.1515/dx-2022-0045] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/16/2022] [Indexed: 11/15/2022]
Abstract
As we increasingly acknowledge the ubiquitous nature of uncertainty in clinical practice (Meyer AN, Giardina TD, Khawaja L, Singh H. Patient and clinician experiences of uncertainty in the diagnostic process: current understanding and future directions. Patient Educ Counsel 2021;104:2606-15; Han PK, Klein WM, Arora NK. Varieties of uncertainty in health care: a conceptual taxonomy. Med Decis Making 2011;31:828-38) and strive to better define this entity (Lee C, Hall K, Anakin M, Pinnock R. Towards a new understanding of uncertainty in medical education. J Eval Clin Pract 2020; Bhise V, Rajan SS, Sittig DF, Morgan RO, Chaudhary P, Singh H. Defining and measuring diagnostic uncertainty in medicine: a systematic review. J Gen Intern Med 2018;33:103-15), as educators we should also design, implement, and evaluate curricula addressing clinical uncertainty. Although frequently encountered, uncertainty is often implicitly referred to rather than explicitly discussed (Gärtner J, Berberat PO, Kadmon M, Harendza S. Implicit expression of uncertainty - suggestion of an empirically derived framework. BMC Med Educ 2020;20:83). Increasing explicit discussion of - and comfort with -uncertainty has the potential to improve diagnostic reasoning and accuracy and improve patient care (Dunlop M, Schwartzstein RM. Reducing diagnostic error in the intensive care unit. Engaging. Uncertainty when teaching clinical reasoning. Scholar;1:364-71). Discussion of both diagnostic and prognostic uncertainty with patients is central to shared decision-making in many contexts as well, (Simpkin AL, Armstrong KA. Communicating uncertainty: a narrative review and framework for future research. J Gen Intern Med 2019;34:2586-91) from the outpatient setting to the inpatient setting, and from undergraduate medical education (UME) trainees to graduate medical education (GME) trainees. In this article, we will explore the current status of how the science of uncertainty is taught from the UME curriculum to the GME curriculum, and describe strategies how uncertainty can be explicitly discussed for all levels of trainees.
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Affiliation(s)
- Glenn Moulder
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Emily Harris
- Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Lekshmi Santhosh
- Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
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Sivanathan M, Yanguez Franco L, Joshi S, Micallef J, Button D, Dubrowski A. Development of Simple and Advanced Adult Proximal Tibia Simulators for a Decentralized Simulation-Based Education Model to Teach Paramedics-in-Training the Intraosseous Infusion Procedure. Cureus 2022; 14:e30929. [DOI: 10.7759/cureus.30929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
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Doty AM, Rising KL, Hsiao T, Amadio G, Gentsch AT, Salcedo VJ, McElwee I, Cameron KA, Salzman DH, Papanagnou D, McCarthy DM. "Unfortunately, I don't have an answer for you": How resident physicians communicate diagnostic uncertainty to patients during emergency department discharge. PATIENT EDUCATION AND COUNSELING 2022; 105:2053-2057. [PMID: 35168855 PMCID: PMC9177889 DOI: 10.1016/j.pec.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/24/2021] [Accepted: 12/05/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To describe how emergency medicine resident physicians discuss diagnostic uncertainty during a simulated ED discharge discussion. METHODS A secondary content analysis of simulated clinical encounter audiotapes completed by emergency medicine residents across two sites. RESULTS When discussing lack of diagnosis, residents explained the evaluation revealed no cause for symptoms, noted concerning diagnoses that were excluded, and acknowledged both symptoms and patients' feelings. Residents used explicit and implicit language to discuss diagnostic uncertainty with similar frequency. Almost half of the residents discussed the ED role as focused on emergent illness to give patients context for their uncertain diagnoses. However, 28% of residents in this study did not discuss diagnostic uncertainty in any form. All residents provided reassurance. CONCLUSION Residents use a range of approaches to discuss diagnostic uncertainty with patients at the time of a simulated ED discharge, with some residents omitting discussion of uncertainty entirely. PRACTICE IMPLICATIONS These findings represent the current state of communication, which needs improvement. These findings do not immediately transfer to clinical practice recommendations, but rather support a need for both further study and development of formal communication training on this topic.
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Affiliation(s)
- Amanda Mb Doty
- Center for Connected Care, Thomas Jefferson University, Philadelphia, USA.
| | - Kristin L Rising
- Center for Connected Care, Thomas Jefferson University, Philadelphia, USA; Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, USA
| | - TingAnn Hsiao
- Center for Connected Care, Thomas Jefferson University, Philadelphia, USA
| | - Grace Amadio
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, USA
| | | | - Venise J Salcedo
- Center for Connected Care, Thomas Jefferson University, Philadelphia, USA
| | - Ian McElwee
- Center for Connected Care, Thomas Jefferson University, Philadelphia, USA
| | - Kenzie A Cameron
- Department of Medicine, Northwestern University, Chicago, USA; Research Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, USA
| | - David H Salzman
- Department of Medical Education, Feinberg School of Medicine, Northwestern University, Chicago, USA; Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Dimitrios Papanagnou
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, USA
| | - Danielle M McCarthy
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, USA
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McCarthy DM, Formella KT, Ou EZ, Vozenilek JA, Cameron KA, Salzman DH, Doty AM, Piserchia K, Papanagnou D, Rising KL. There's an app for that: Teaching residents to communicate diagnostic uncertainty through a mobile gaming application. PATIENT EDUCATION AND COUNSELING 2022; 105:1463-1469. [PMID: 34674922 PMCID: PMC9109131 DOI: 10.1016/j.pec.2021.09.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 09/17/2021] [Accepted: 09/27/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Clear communication is integral to good clinical care; however, communication training is cost and time intensive. Mobile applications (apps) may provide a useful adjunct to traditional simulation skills training. OBJECTIVE To evaluate (1) use of an app for teaching communication skills about diagnostic uncertainty, (2) feedback on app use, and (3) the association between use and skill mastery. PATIENT INVOLVEMENT The app under study is designed to improve doctor-patient communication. METHODS The study was a planned sub-analysis of a randomized controlled waitlist trial with emergency medicine resident physicians randomized to receive immediate or delayed access to an educational curriculum focused on diagnostic uncertainty. The curriculum included a web-based interactive module and the app. Metrics describing participants' use of the app, feedback on use, and association of use and achieving mastery in communicating diagnostic uncertainty are reported. Differences between groups utilizing the app were analyzed using Chi-squared test; logistic regression assessed the association between app use and achieving mastery of the communication skill. RESULTS Among 109 participants completing the trial, only 34 (31.2%) used the app. Most participants engaged with the app on one occasion for a median of 50 min (IQR 31, 87). Senior residents were more likely to use the app than junior residents (41.3% vs 23.8%, p=0.05). Overall reviews were positive; 76% reported the app helped them learn. There was no significant association between app use and achieving mastery of the communication skill in the trial [OR 2.1, 95% CI (0.91-4.84)]. DISCUSSION Despite positive reviews of app use, overall use was low and there was no association with achieving mastery. PRACTICAL VALUE Offering an app as an auxiliary training opportunity may be beneficial to some residents, but shouldn't be planned for use as a primary didactic modality unless there is evidence for effectiveness and use is mandated. AVAILABILITY OF DATA AND MATERIALS The datasets generated and/or analyzed during the current study are not publicly available since some data may be identifiable but are available from the corresponding author on reasonable request.
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Affiliation(s)
- Danielle M McCarthy
- Department of Emergency Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
| | - Kyle T Formella
- Jump Trading Simulation and Education Center, OSF Healthcare, Peoria, IL, USA.
| | - Eric Z Ou
- Jump Trading Simulation and Education Center, OSF Healthcare, Peoria, IL, USA.
| | - John A Vozenilek
- Jump Trading Simulation and Education Center, OSF Healthcare, Peoria, IL, USA; Department of Emergency Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL, USA; Department of BioEngineering, University of Illinois Grainger College of Engineering Urbana, IL, USA.
| | - Kenzie A Cameron
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University, Chicago, IL, USA; Department of Medical Education, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
| | - David H Salzman
- Department of Emergency Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA; Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University, Chicago, IL, USA.
| | - Amanda Mb Doty
- Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA; Center for Connected Care, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA.
| | - Katherine Piserchia
- Department of Emergency Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
| | - Dimitrios Papanagnou
- Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA.
| | - Kristin L Rising
- Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA; Center for Connected Care, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA.
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Nord GA, Doty AMB, Monick AJ, McCarthy DM, Casten RJ, Aldeen AZ, Nawrocki PS, Rising KL. Emergency Medicine Clinician Experiences Addressing Uncertainty in First-Trimester Bleeding. J Patient Exp 2022; 9:23743735221140698. [DOI: 10.1177/23743735221140698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The purpose of this work is to understand Emergency Department (ED) clinicians’ experiences in communicating uncertainty about first-trimester bleeding (FTB) and their need for training on this topic. This cross-sectional study surveyed a national sample of attending physicians and advanced practice providers (APPs). The survey included quantitative and qualitative questions about communicating with patients presenting with FTB. These questions assessed clinicians’ frequency encountering challenges, comfort, training, prior experience, and interest in training on the topic. Of 402 respondents, 54% reported that they encountered challenges at least sometimes when discussing FTB with patients where the pregnancy outcome is uncertain. While the majority (84%) were at least somewhat prepared for these conversations from their training, which commonly addressed the diagnostic approach to this scenario, 39% strongly or moderately agreed that they could benefit from training on the topic. Because the majority of ED clinicians identified at least sometimes encountering challenges communicating with pregnant patients about FTB, our study indicates a need exists for more training in this skill.
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Affiliation(s)
- Garrison A Nord
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Amanda MB Doty
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Andrew J Monick
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Danielle M McCarthy
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Robin J Casten
- Department of Psychiatry, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Philip S Nawrocki
- US Acute Care Solutions, Canton, OH, USA
- Department of Emergency Medicine, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Kristin L Rising
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- College of Nursing, Thomas Jefferson University, Philadelphia, PA, USA
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Meyer AND, Giardina TD, Khawaja L, Singh H. Patient and clinician experiences of uncertainty in the diagnostic process: Current understanding and future directions. PATIENT EDUCATION AND COUNSELING 2021; 104:2606-2615. [PMID: 34312032 DOI: 10.1016/j.pec.2021.07.028] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Uncertainty occurs throughout the diagnostic process and must be managed to facilitate accurate and timely diagnoses and treatments. Better characterization of uncertainty can inform strategies to manage it more effectively in clinical practice. We provide a comprehensive overview of current literature on diagnosis-related uncertainty describing (1) where patients and clinicians experience uncertainty within the diagnostic process, (2) how uncertainty affects the diagnostic process, (3) roots of uncertainty related to probability/risk, ambiguity, or complexity, and (4) strategies to manage uncertainty. DISCUSSION Each diagnostic process step involves uncertainty, including patient engagement with the healthcare system; information gathering, interpretation, and integration; formulating working diagnoses; and communicating diagnoses to patients. General management strategies include acknowledging uncertainty, obtaining more contextual information from patients (e.g., gathering occupations and family histories), creating diagnostic safety nets (e.g., informing patients what red flags to look for), engaging in worst case/best case scenario planning, and communicating diagnostic uncertainty to patients, families, and colleagues. Potential strategies tailored to various aspects of diagnostic uncertainty are also outlined. CONCLUSION Scientific knowledge on diagnostic uncertainty, while previously elusive, is now becoming more clearly defined. Next steps include research to evaluate relationships between management and communication of diagnostic uncertainty and improved patient outcomes.
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Affiliation(s)
- Ashley N D Meyer
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, 2002 Holcombe Boulevard (152), Houston, TX 77030, USA; Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
| | - Traber D Giardina
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, 2002 Holcombe Boulevard (152), Houston, TX 77030, USA; Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
| | - Lubna Khawaja
- Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, 2002 Holcombe Boulevard (152), Houston, TX 77030, USA; Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
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