When patients come to the emergency department (ED), they’re seeking a solution for their symptoms and answers to their questions. However, about a third of all patients leave the ED without a diagnosis because their treatment team cannot specifically identify their acute health condition during their visit. These patients will instead be discharged with a “symptom-based” diagnosis.
Navigating Uncertainty in Medicine
How two emergency medicine professors are implementing communication training to improve patient outcomes.
“For many patients, leaving without a concrete diagnosis is frustrating, and they may feel unheard and undertreated if their provider doesn’t help them understand this outcome,” says Dr. Kristin Rising, director of the Jefferson Center for Connected Care and professor of emergency medicine at Sidney Kimmel Medical College.
Unfortunately, patients who leave without a diagnosis often return to the ED with the same issue or go somewhere else and get repeat care. “More than anything, we’ve found that patients wanted more information at the time of their discharge,” Dr. Rising says. “Many patients come back for a second ED visit within a short time because they had what we call an ongoing ‘intolerable level of uncertainty’ about their condition.”
For Dr. Rising, this highlighted a need to teach clinicians how to accept uncertainty as a regular part of clinical practice—and effectively communicate it to patients.
Research partners Drs. Dimitrios Papanagnou and Kristin Rising work to teach med students and physicians how to accept uncertainty as a regular part of clinical practice—and effectively communicate it to patients.
Her research partner, Dr. Dimitrios Papanagnou, senior associate dean for faculty development and professor of emergency medicine, acknowledged this concept wasn’t unique to ED-based care and implemented a curriculum at Sidney Kimmel Medical College to train students in diagnostic uncertainty from the start of their education.
“Medical school has historically trained students in certainty, teaching them there’s always a certain diagnosis, a right way to take action,” explains Dr. Papanagnou, who recently earned the AAMC’s Alpha Omega Alpha Robert J. Glaser Distinguished Teacher Award. “But when they start working in the clinical environment, they realize there’s a lot of gray area and struggle with that cognitive dissonance. Our goal is to help our students and clinicians acknowledge that discomfort, recognize it as a normal part of the treatment process, and provide tools they need to effectively communicate with patients and ultimately build trust in the healthcare system.”
Dr. Papanagnou adds, “At this point, we’re seeing emergency medicine trainees who’ve already had years of training in diagnostic uncertainty. They’ve practiced it, but now they’re working full time in the hospital and need further support to carry out what they’ve learned in real time.”
Tackling Uncertainty in the Moment
Drs. Rising and Papanagnou are collaborating to implement their work into educational and clinical practice settings. With support from the American Board of Internal Medicine Foundation, Dr. Papanagnou will lead a multidisciplinary team to create a comprehensive library of existing resources for communicating uncertainty in clinical settings. His team will develop additional training and assessment materials, as well as implementation guidelines for clinical locations.
Our goal is to help our students and clinicians acknowledge that discomfort, recognize it as a normal part of the treatment process, and provide tools they need to effectively communicate with patients and ultimately build trust in the healthcare system.
Funded by the Agency for Healthcare Research and Quality, Dr. Rising and her team will integrate their communication approach to diagnostic uncertainty into routine ED discharge practices. To do this, they will build a system of automated alerts and protocols into the hospital’s electronic medical records (EMR) to prompt clinicians to take action when discharging a patient with diagnostic uncertainty.
These alerts will remind treatment teams of the support and tools they have to validate patient symptoms, ask focused questions and outline next steps post-discharge.
“EMR-based alerts already exist within the hospital’s EMRs to help clinicians tailor treatment plans,” Dr. Rising says. “Our ‘uncertainty protocol’ will work similarly—whenever an emergency medicine clinician enters a symptom-based diagnosis into the discharge section, an alert will trigger a series of actions, including a note in the discharge paperwork, an inbox message to the patient’s primary care provider if they’re within the system, and a prompt for the clinician to employ our uncertainty communication checklist.”
Nuance in language is so important. Even making small changes in the way we speak—like substituting the word ‘life-threatening’ for ‘serious’—can make a huge difference for patients.
The communication checklist provides specific language clinicians can use when speaking to patients about their uncertainty, she says. “Nuance in language is so important. Even making small changes in the way we speak—like substituting the word ‘life-threatening’ for ‘serious’—can make a huge difference for patients.”
Once these education- and workplace-based approaches are implemented, Drs. Rising and Papanagnou will run a trial period to measure patient discharge outcomes.
“Our goal is to reframe clinicians’ minds around how they talk to patients regarding diagnostic uncertainty,” Dr. Rising says. “Dr. Papanagnou’s curriculum has been immensely important in priming med students for the challenges of communicating uncertainty in the clinical environment. We now plan to focus on just-in-time, in-the-moment training to help guide these conversations and help our clinicians not only accept uncertainty into their everyday practice but be better partners in their patients’ health journeys.”
