Uncertainty pervades the diagnostic process. In health care, taxonomies of uncertainty have been developed to describe aspects such as personal (eg, individual knowledge gaps), scientific (eg, limits of biomedical knowledge), and probabilistic (eg, imprecise estimates of risk or prognosis) dimensions of uncertainty.¹

 

When clinicians encounter diagnostic uncertainty, they often find themselves in an unfamiliar situation, without a clear method to proceed confidently, comfortably, and safely. Being unable to explain to patients what causes their symptoms may be perceived as a failure for all involved. When clinicians and patients dwell in diagnostic uncertainty, it can trigger feelings of concern and anxiety, may lead patients to mistrust clinicians’ competence, and could contribute to clinician burnout (feeling exhausted, disconnected, and personally inadequate), especially for early-career clinicians.^2,3

 

Excellent diagnosticians should understand how uncertainty manifests. They should acknowledge and embrace uncertainty, and openly discuss it with other clinicians and patients to normalize its ubiquitous and inevitable part in the diagnostic process.⁴ Such a reimagining, focused on the inevitable and beneficial aspects of diagnostic uncertainty, relies on identifying how uncertainty is understood, managed, and communicated.

 

 

Diagnosis is a complex and collaborative process that involves gathering, integrating, and interpreting information across the entire diagnostic team: clinicians (physicians, nurses, and allied health professionals), patients, and patients’ families and caregivers.⁵ All team members encounter different types of diagnostic uncertainty at different stages in the diagnostic process.³

 

From the clinicians’ perspective, diagnostic uncertainty has been defined as the “subjective perception of an inability to provide an accurate explanation of the patient’s health problem.”⁶ These subjective feelings are entangled in a multitude of factors and tensions surrounding the qualities deemed essential in clinicians, such as competence and confidence. The decisiveness with which clinicians make a diagnosis may be perceived as reflecting diagnostic expertise and clinical competence. Yet diagnostic excellence in the setting of uncertainty requires recognition and tolerance of uncertainty, cognitive flexibility, and willingness to engage with evolving information. It includes the ability to share clinical reasoning and communicate uncertainty to patients.^3,4

 

Patients may experience uncertainty at any point along the diagnostic process and beyond. For patients, diagnostic uncertainty often begins before they present for health care, such as doubt about whether a persistent minor pain or occasional numbness warrants a clinical visit. Patients may have doubts about how long it will take to get answers, what their role is in the diagnostic process, whether a treatment is available, and whether they want a diagnosis if they already fear having a serious illness. They may have doubts about what a diagnosis means for their personal and professional life, their functional status, and quality of life.

 

Patients also encounter doubt when they perceive their valid symptoms are being dismissed. This is a common experience reported by patients, particularly those who experience other health disparities related to age, sex, race and ethnicity, or language background. For example, some women with myocardial ischemia may present with symptoms (such as back or abdominal pain or vomiting) that are not considered typical cardiac presentations, and may believe their symptoms are being dismissed. Some people might have doubts when a diagnosis does not match what they think is affecting them, or when family members, such as children and older adults who are unable to advocate for themselves, experience disease progression or adverse outcomes despite having been assigned a diagnostic label and associated treatments.