Examining the patterns of uncertainty across clinical reasoning tasks: effects of contextual factors on the clinical reasoning process

Abstract

<jats:title>Abstract</jats:title><jats:sec id="j_dx-2020-0019_abs_001_w2aab3b7b1b1b6b1aab1c11b2Aa"><jats:title>Objectives</jats:title><jats:p>Uncertainty is common in clinical reasoning given the dynamic processes required to come to a diagnosis. Though some uncertainty is expected during clinical encounters, it can have detrimental effects on clinical reasoning. Likewise, evidence has established the potentially detrimental effects of the presence of distracting contextual factors (i.e., factors other than case content needed to establish a diagnosis) in a clinical encounter on clinical reasoning. The purpose of this study was to examine how linguistic markers of uncertainty overlap with different clinical reasoning tasks and how distracting contextual factors might affect physicians’ clinical reasoning process.</jats:p></jats:sec><jats:sec id="j_dx-2020-0019_abs_002_w2aab3b7b1b1b6b1aab1c11b3Aa"><jats:title>Methods</jats:title><jats:p>In this descriptive exploratory study, physicians participated in a live or video recorded simulated clinical encounter depicting a patient with unstable angina with and without contextual factors. Transcribed think-aloud reflections were coded using Goldszmidt’s clinical reasoning task typology (26 tasks encompassing the domains of framing, diagnosis, management, and reflection) and then those coded categories were examined using linguistic markers of uncertainty (e.g., probably, possibly, etc.).</jats:p></jats:sec><jats:sec id="j_dx-2020-0019_abs_003_w2aab3b7b1b1b6b1aab1c11b4Aa"><jats:title>Results</jats:title><jats:p>Thirty physicians with varying levels of experience participated. Consistent with expectations, descriptive analysis revealed that physicians expressed more uncertainty in cases with distracting contextual factors compared to those without. Across the four domains of reasoning tasks, physicians expressed the most uncertainty in diagnosis and least in reflection.</jats:p></jats:sec><jats:sec id="j_dx-2020-0019_abs_004_w2aab3b7b1b1b6b1aab1c11b5Aa"><jats:title>Conclusions</jats:title><jats:p>These results highlight how linguistic markers of uncertainty can shed light on the role contextual factors might play in uncertainty which can lead to error and why it is essential to find ways of managing it.</jats:p></jats:sec>

How Physicians Manage Medical Uncertainty: A Qualitative Study and Conceptual Taxonomy

“…These theories emphasize how these interactions not only give rise to mental states such as uncertainty but also provide ways for individuals to regulate these states. 45,46…”

“…These theories emphasize how these interactions not only give rise to mental states such as uncertainty but also provide ways for individuals to regulate these states. 45,46 The taxonomy can thus assist efforts to understand and improve the management of medical uncertainty. It can help researchers to more systematically measure the effects of different uncertainty management strategies and to develop new theoretical understandings of uncertainty management as a broader psychological process.…”

Frequency of medical students' language expressing implicit uncertainty in simulated handovers

“…These findings are consistent with other research showing that more uncertainty is expressed during clinical reasoning inpatient cases where contextual distractions are present. 13,19 Physicians expressed the greatest uncertainty inpatient cases which contained contextual distractions that stemmed from either the patient (e.g., the complexity of presentation, English proficiency), the physician (e.g., fatigue, expertise, cognitive load), or the environment (e.g., length of consultation, the functionality of the electronic medical record). 13 In our study, we also found the highest number of statements expressing implicit uncertainty inpatient cases where contextual distractions arose from the patients' physical condition or misleading symptoms, i.e., patient 2 with iatrogenic opioid dependence, patient 3 with a history of unnecessary gallbladder removal, and patient 6 with vitamin B1 deficiency after gastric sleeve surgery.…”

Progress understanding diagnosis and diagnostic errors: thoughts at year 10

“…The studies by Abby Konapasky and colleagues provide illustrative examples [57], including an exploration of how contextual factors change the language of diagnosis [58], and how contextual factors change the likelihood of arriving at the correct diagnosis (the phenomenon of context specificity). A study by Divya Ramani and colleagues explores how uncertainty interacts with contextual factors in the clinical reasoning process [59]. Marcia Docherty and colleagues report their initial findings from observing senior ER residents [60].…”