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Patient Perspectives on Communication of Diagnostic Uncertainty

Bhise V, Meyer A, Menon S, Singhal G, Street R, Giardina T, Singh H. Patient Perspectives on Communication of Diagnostic Uncertainty. Paper presented at: Diagnostic Error in Medicine Annual International Conference; 2016 Nov 7; Hollywood, CA.


Background: Communication of diagnostic uncertainty can negatively affect patient satisfaction, confidence in the physician, and patient adherence. However, given the prevalence of diagnostic error, we need to understand how to effectively communicate uncertainty to patients. We evaluated the effects of three different strategies for communicating diagnostic uncertainty on patient perceptions of physician competence and visit satisfaction. Methods: We used an experimental, vignette-based study design involving pediatric cases presented to a convenience sample of parents. We created 3 vignettes, each describing the same initial clinical scenario with a new pediatrician, followed by communication of diagnostic uncertainty to the parent by the pediatrician through one of 3 different strategies - (1) explicit expression of uncertainty ("not sure" about diagnosis), (2) implicit expression of uncertainty using broad differential diagnoses and (3) implicit expression of uncertainty using "most likely" diagnoses. In all 3 scenarios, the pediatrician subsequently reassured the parent and provided a plan of action. We used previous literature and input from patient advocates and experts to design our survey items and refined it after pilot-testing with 15 participants. We then recruited participants and randomly assigned them to one of the three vignettes. Study sample consisted of all parents participating in the patient and family advisor email listserv at a large pediatric academic center and a parent social-media group. Participants answered a 37-item web-based survey, consisting of subscales to measure perceived technical competence, trust, visit satisfaction, adherence to provider instructions, parent activation(parent PAM-10) and self-tolerance to uncertainty. Descriptive analyses were reported and ANOVA was used to compare differences between the three groups, followed by individual t-test comparisons. Results: Forty participants have thus far responded. In preliminary analyses, participants across the 3 groups were similar with respect to parent activation(PAM) levels, tolerance to uncertainty scores, parent age and child age. There were significant statistical differences in sub-scales for clinician competence, trust, visit satisfaction and patient adherence between the three groups. Direct expression of uncertainty was associated with lower perceived technical confidence in the provider(p = 0.01), less trust(p = 0.03), less visit satisfaction(p < 0.01), and lower patient adherence(p = 0.02) as compared to the other two groups where uncertainty communication was implicit. The latter two groups showed no differences. Conclusion: Our preliminary findings suggest that parents of pediatric patients prefer implicit expressions of diagnostic uncertainty using broad differential diagnoses or more likely diagnoses, over explicit expression. Strategies that clinicians can use to communicate diagnostic uncertainty while maintaining patient confidence still need to be defined.

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