Communication of Diagnostic Uncertainty in Primary Care and Its Impact on Patient Experience: an Integrative Systematic Review

Abstract

Background Diagnostic uncertainty is a pervasive issue in primary care where patients often present with non-specific symptoms early in the disease process. Knowledge about how clinicians communicate diagnostic uncertainty to patients is crucial to prevent associated diagnostic errors. Yet, in-depth research on the interpersonal communication of diagnostic uncertainty has been limited. We conducted an integrative systematic literature review (PROSPERO CRD42020197624, unfunded) to investigate how primary care doctors communicate diagnostic uncertainty in interactions with patients and how patients experience their care in the face of uncertainty. Methods We searched MEDLINE, PsycINFO, and Linguistics and Language Behaviour Abstracts (LLBA) from inception to December 2021 for MeSH and keywords related to ‘communication’, ’diagnosis’, ‘uncertainty’ and ‘primary care’ environments and stakeholders (patients and doctors), and conducted additional handsearching. We included empirical primary care studies published in English on spoken communication of diagnostic uncertainty by doctors to patients. We assessed risk of bias with the QATSDD quality assessment tool and conducted thematic and content analysis to synthesise the results. Results Inclusion criteria were met for 19 out of 1281 studies. Doctors used two main communication strategies to manage diagnostic uncertainty: (1) patient-centred communication strategies (e.g. use of empathy), and (2) diagnostic reasoning strategies (e.g. excluding serious diagnoses). Linguistically, diagnostic uncertainty was either disclosed explicitly or implicitly through diverse lexical and syntactical constructions, or not communicated (omission). Patients’ experiences of care in response to the diverse communicative and linguistic strategies were mixed. Patient-centred approaches were generally regarded positively by patients. Discussion Despite a small number of included studies, this is the first review to systematically catalogue the diverse communication and linguistic strategies to express diagnostic uncertainty in primary care. Health professionals should be aware of the diverse strategies used to express diagnostic uncertainty in practice and the value of combining patient-centred approaches with diagnostic reasoning strategies.

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“…70 Box 5 provides a structured approach to communicating uncertainty to patients based on findings from recent reviews. [71][72][73][74] However, successfully enacting this approach requires both clinicians and patients to be free of time pressures, distractions and competing priorities.…”

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“…Uncertainty may have a cascading effect of higher anxiety, pain catastrophizing, fear of pain and lower acceptance of self-management recommendations [30,46,62]. The diagnostic process has a high impact on how the diagnosis of CMP is communicated and understood by clinicians, adolescents, and parents [11,43,46,48]. Adolescents and parents often report that they do not understand explanations given by clinicians, why some tests are (or are not) conducted, or the diagnostic label itself [23,43,46].…”

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