Communicating Diagnostic Uncertainty at Emergency Department Discharge: A Simulation-Based Mastery Learning Randomized Trial

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.

Testing a Novel Deliberate Practice Intervention to Improve Diagnostic Reasoning in Trauma Triage

“…These results confirm those of previous studies, which demonstrated the ability of deliberate practice to facilitate the acquisition of expertise in medicine, across domains as varied as communication in the emergency department or intensive care unit, resuscitation, and surgery. [32][33][34][35][36] Efficacy: compliance with clinical practice guidelines for the triage of patients with trauma…”

“…These results confirm those of previous studies, which demonstrated the ability of deliberate practice to facilitate the acquisition of expertise in medicine, across domains as varied as communication in the emergency department or intensive care unit, resuscitation, and surgery. 32 , 33 , 34 , 35 , 36 For example, a meta-analytic comparative review of the literature on skill acquisition in procedural domains (eg, laparoscopic surgery) identified a correlation between the use of deliberate practice and positive outcomes ( r = 0.71). 32 Our study expands on these results by focusing on diagnostic reasoning and targeting the performance of physicians in practice rather than medical trainees.…”

Time to reimagine diagnosis in the acute care setting

“…Rather than framing this as a deficiency in clinical skills and something that should never been acknowledged, diagnostic uncertainty of varying degrees should be normalized as an expected occurrence during emergency care 4 . Education and training through the use of validated instruments to scaffold provider conversations with their patients, for example, through the uncertainty communication checklist, has been demonstrated to increase mastery in physicians successfully communicating diagnostic uncertainty to ED patients 5 …”

“…4 Education and training through the use of validated instruments to scaffold provider conversations with their patients, for example, through the uncertainty communication checklist, has been demonstrated to increase mastery in physicians successfully communicating diagnostic uncertainty to ED patients. 5 In conclusion, the AHRQ report should not be read as an indictment of EM providers but, rather, raise awareness about the need for more effective solutions to address diagnostic error in this unique and high-risk clinical environment that provides acute and unscheduled care. The resulting controversy is best met with a redoubling of efforts and increased support for research examining how we can more effectively identify and reduce diagnostic error across all health care settings and mitigate the associated waste and patient harm.…”