A randomized experimental study to assess the effect of language on medical students’ anxiety due to uncertainty
-
Arabella L. Simpkin
,
Zachary Murphy
Abstract
Background
Communication and handoff failures are common causes of diagnostic errors in hospital. Human quest for certainty can increase the likelihood of premature closure in decision-making, the most common phenomenon in misdiagnosis. Little research exists on whether language choice in handoffs affects physicians’ sense of uncertainty.
Methods
Medical students from a large US medical school were randomized to receive one of four language variations describing a presumed diagnosis in hypothetical handoffs from emergency department (ED) to inpatient ward. The control language arm used the word ‘diagnosis’; experimental arms replaced this word with either ‘hypothesis’, ‘probability of 60%’, or ‘working diagnosis’ with a short differential. Outcome measures were students’ anxiety due to uncertainty (range 5–30; higher scores indicating higher stress from uncertainty) and clinical uncertainty about the ED provider’s presumed diagnosis.
Results
Mean anxiety due to uncertainty was significantly higher in subjects receiving the ‘hypothesis’ language arm compared to those receiving the control ‘diagnosis’ language [19.2 (4.6) vs. 15.5 (3.4); p<0.008]. Differences between subjects who received the probability language [17.2 (5.8) vs. 15.5 (3.4); p=0.26] and ‘working diagnosis’ language [16 (5) vs. 15.5 (3.4); p=0.69] were not statistically significant. There was no difference in items assessing clinical uncertainty after each scenario.
Conclusions
The word ‘hypothesis’ increased anxiety due to uncertainty compared to the word ‘diagnosis’, but did not change assessments of clinical uncertainty. Further research is needed to assess how use of language in clinical handoffs may influence perceptions and anxiety related to uncertainty and whether optimal language can be identified that leads to recognition of uncertainty without maladaptive stress or anxiety due to uncertainty.
Appendix
Items to assess certainty about ED provider’s presumed diagnosis
Six-point Likert scale: Strongly disagree (1); Moderately disagree (2); Slightly disagree (3); Slightly agree (4); Moderately agree (5); Strongly agree (6).
| 1. | I am confident that I know what is going on with this patienta |
| 2. | I think the admitting diagnosis for this patient is incorrect |
| 3. | The patient should be told that we are not sure what is going on |
| 4. | More tests are needed to understand what is going on with this patient |
| 5. | Getting the input of a specialist will be important to care for this patient |
aReverse-scored.
Items to assess anxiety due to uncertainty [subscale from the Physician’s Reaction to Uncertainty scale [17]]
Six-point Likert scale: Strongly disagree (1); Moderately disagree (2); Slightly disagree (3); Slightly agree (4); Moderately agree (5); Strongly agree (6).
| 1. | I usually feel anxious when I am not sure of a diagnosis |
| 2. | I find the uncertainty involved in patient care disconcerting |
| 3. | Uncertainty in patient care makes me uneasy |
| 4. | I am quite comfortable with the uncertainty in patient carea |
| 5. | The uncertainty of patient care often troubles me |
aReverse-scored.
Author contributions: Arabella L. Simpkin and Katrina A. Armstrong conceptualized and designed the study, and designed the data collection instruments. Arabella L. Simpkin and Zachary Murphy coordinated and supervised collection of data from participants. All authors carried out data analysis, and were responsible for drafting the manuscript, critical revision for important intellectual content, and final approval of the manuscript. Arabella L. Simpkin is the guarantor for the study. Arabella L. Simpkin affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained. All authors had full access to all the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.
Research funding: None declared.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
References
1. Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, GallivanT, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. J Am Med Assoc 1995;274:35–43.10.1001/jama.274.1.35Search in Google Scholar
2. Saber Tehrani AS, Lee H, Mathews SC, Shore A, Makary MA, Pronovost PJ, et al. 25-Year summary of US malpractice claims for diagnostic errors 1986-2010: an analysis from the National Practitioner Data Bank. BMJ Qual Saf 2013;22: 672–80.10.1136/bmjqs-2012-001550Search in Google Scholar PubMed
3. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med 2005;165:1493–9.10.1001/archinte.165.13.1493Search in Google Scholar PubMed
4. Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008;121:S2–23.10.1016/j.amjmed.2008.01.001Search in Google Scholar PubMed
5. Burroughs TE, Waterman AD, Gallagher TH, Waterman B, Adams D, Jeffe DB, et al. Patient concerns about medical errors in emergency departments. Acad Emerg Med 2005;12:57–64.10.1197/j.aem.2004.08.052Search in Google Scholar PubMed
6. Croskerry P, Sinclair D. Emergency medicine: a practice prone to error? CJEM 2001;3:271–6.10.1017/S1481803500005765Search in Google Scholar PubMed
7. Lambe KA, O’Reilly G, Kelly BD, Curristan S. Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. BMJ Qual Saf 2016;25:808–20.10.1136/bmjqs-2015-004417Search in Google Scholar PubMed
8. Tversky AK. The framing of decisions and the psychology of choice. Science 1981;211:453–8.10.1126/science.7455683Search in Google Scholar PubMed
9. Simpkin AL, Schwartzstein RM. Tolerating uncertainty – the next medical revolution? N Engl J Med 2016;375:1713–5.10.1056/NEJMp1606402Search in Google Scholar PubMed
10. Politi MC, Han PK, Col NF. Communicating the uncertainty of harms and benefits of medical interventions. Med Decis Making 2007;27:681–95.10.1177/0272989X07307270Search in Google Scholar PubMed
11. Kahneman D, Tversky A. Prospect theory: an analysis of decision making under risk. Econometica 1979;6:621–30.10.21236/ADA045771Search in Google Scholar
12. Kahneman D, Tversky A. The psychology of preferences. Scientific American 1982;246:160–73.10.1038/scientificamerican0182-160Search in Google Scholar
13. Pelletier LG. Persuasive communication and proenvironmental behaviors: how message tailoring and message framing can improve the integration of behaviours through self-determined motivations. Can Pscyhoo 2008;49:210–7.10.1037/a0012755Search in Google Scholar
14. Eva KW, Wood TJ, Riddle J, Touchie C, Bordage G. How clinical features are presented matters to weaker diagnosticians. Med Educ 2010;44:775–85.10.1111/j.1365-2923.2010.03705.xSearch in Google Scholar
15. Croskerry P, Abbass AA, Wu AW. How doctors feel: affective issues in patients’ safety. Lancet 2008;372:1205–6.10.1016/S0140-6736(08)61500-7Search in Google Scholar
16. Gerrity MS, DeVellis RF, Earp JA. Physicians’ reactions to uncertainty in patient care. A new measure and new insights. Med Care 1990;28:724–36.10.1097/00005650-199008000-00005Search in Google Scholar PubMed
17. Gerrity MS WK, DeVellis RF, Dittus RS. Physicians’ reactions to uncertainty: refining the constructs and scales. Motiv Emot 1995;19:175–91.10.1007/BF02250510Search in Google Scholar
18. Coutts L, Rogers J. Predictors of student self-assessment accuracy during a clinical performance exam: comparisons between over-estimators and under-estimators of SP-evaluated performance. Acad Med 1999;74:S128–30.10.1097/00001888-199910000-00062Search in Google Scholar PubMed
19. Simpkin AL, Khan A, West DC, Garcia BM, Sectish TC, Spector ND, et al. Stress from uncertainty and resilience among depressed and burned out residents: a cross-sectional study. Acad Pediatr 2018;18:698–704.10.1016/j.acap.2018.03.002Search in Google Scholar PubMed
20. Hillen MA, Gutheil CM, Strout TD, Smets EM, Han PK. Tolerance of uncertainty: conceptual analysis, integrative model, and implications for healthcare. Soc Sci Med 2017;180:62–75.10.1016/j.socscimed.2017.03.024Search in Google Scholar PubMed
21. The Pediatrics Milestone Project. A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Pediatrics. 2017 [cited 2017. Available from: https://acgme.org/Portals/0/PDFs/Milestones/PediatricsMilestones.pdf.Search in Google Scholar
22. General Medical Council: Outcomes for Graduates 2018 [Available from: https://www.gmc-uk.org/-/media/documents/dc11326-outcomes-for-graduates-2018_pdf-75040796.pdf.Search in Google Scholar
23. Ahmed H, Naik G, Willoughby H, Edwards AG. Communicating risk. Br Med J 2012;344:e3996.10.1136/bmj.e3996Search in Google Scholar PubMed
24. Evans L, Trotter DR. Epistemology and uncertainty in primary care: an exploratory study. Fam Med 2009;41:319–26.Search in Google Scholar
25. Logan RL, Scott PJ. Uncertainty in clinical practice: implications for quality and costs of health care. Lancet 1996;347:595–8.10.1016/S0140-6736(96)91284-2Search in Google Scholar
26. Jensen PM, Trollope-Kumar K, Waters H, Everson J. Building physician resilience. Can Fam Physician 2008;54:722–9.Search in Google Scholar
27. Zwack J, Schweitzer J. If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Acad Med 2013;88:382–9.10.1097/ACM.0b013e318281696bSearch in Google Scholar PubMed
28. Mathot KJ, Wright J, Kempenaers B, Dingemanse NJ. Adaptive strategies for managing uncertainty may explain personality-related differences in behavioural plasticity. Oikos 2012;121:1009–20.10.1111/j.1600-0706.2012.20339.xSearch in Google Scholar
Article note
This work was conducted at Harvard Medical School, Boston, MA.
©2019 Walter de Gruyter GmbH, Berlin/Boston
Articles in the same Issue
- Frontmatter
- Editorial
- The Model List of Essential In Vitro Diagnostics: nuisance or opportunity?
- Reviews
- Skeletal myopathies as a non-cardiac cause of elevations of cardiac troponin concentrations
- Histo-genomics: digital pathology at the forefront of precision medicine
- Opinion Papers
- Patients as diagnostic collaborators: sharing visit notes to promote accuracy and safety
- Understanding the “philosophy” of laboratory hemostasis
- Original Articles
- Serious misdiagnosis-related harms in malpractice claims: The “Big Three” – vascular events, infections, and cancers
- Electronic health records, communication, and data sharing: challenges and opportunities for improving the diagnostic process
- Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error
- Experienced physician descriptions of intuition in clinical reasoning: a typology
- A randomized experimental study to assess the effect of language on medical students’ anxiety due to uncertainty
- Development and application of a PCR-HRM molecular diagnostic method of SNPs linked with TNF inhibitor efficacy
- Acute rejection in kidney transplantation and the evaluation of associated polymorphisms (SNPs): the importance of sample size
- Letter to the Editor
- Physically damaged second victims by diagnostic delay in pulmonary tuberculosis of hospitalized patients. Cognitive errors with urgent need for prevention
- The physical examination, including point of care technology, is an important part of the diagnostic process and should be included in educational interventions to improve clinical reasoning
- Case Reports
- Case reports of diagnostic error: liposarcoma mistaken for hematoma in an obese female with concurrent ipsilateral thrombosis on rivaroxaban
- Macro-CK type 2 in metastatic prostate cancer
Articles in the same Issue
- Frontmatter
- Editorial
- The Model List of Essential In Vitro Diagnostics: nuisance or opportunity?
- Reviews
- Skeletal myopathies as a non-cardiac cause of elevations of cardiac troponin concentrations
- Histo-genomics: digital pathology at the forefront of precision medicine
- Opinion Papers
- Patients as diagnostic collaborators: sharing visit notes to promote accuracy and safety
- Understanding the “philosophy” of laboratory hemostasis
- Original Articles
- Serious misdiagnosis-related harms in malpractice claims: The “Big Three” – vascular events, infections, and cancers
- Electronic health records, communication, and data sharing: challenges and opportunities for improving the diagnostic process
- Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error
- Experienced physician descriptions of intuition in clinical reasoning: a typology
- A randomized experimental study to assess the effect of language on medical students’ anxiety due to uncertainty
- Development and application of a PCR-HRM molecular diagnostic method of SNPs linked with TNF inhibitor efficacy
- Acute rejection in kidney transplantation and the evaluation of associated polymorphisms (SNPs): the importance of sample size
- Letter to the Editor
- Physically damaged second victims by diagnostic delay in pulmonary tuberculosis of hospitalized patients. Cognitive errors with urgent need for prevention
- The physical examination, including point of care technology, is an important part of the diagnostic process and should be included in educational interventions to improve clinical reasoning
- Case Reports
- Case reports of diagnostic error: liposarcoma mistaken for hematoma in an obese female with concurrent ipsilateral thrombosis on rivaroxaban
- Macro-CK type 2 in metastatic prostate cancer
