Exploring emergency department providers’ uncertainty in neurological clinical reasoning

Angelica M. Lee; Kirsten R. Brown; Steven J. Durning; Sami A. Abuhamdeh

doi:10.1515/dx-2024-0184

Article

Exploring emergency department providers’ uncertainty in neurological clinical reasoning

Angelica M. Lee , Kirsten R. Brown , Steven J. Durning and Sami A. Abuhamdeh

Published/Copyright: March 18, 2025

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From the journal Diagnosis Volume 12 Issue 3

Abstract

Objectives

Diagnostic and management reasoning of neurological disorders may present unique challenges and uncertainty for clinicians, particularly in emergency department settings. This study aims to assess the level of uncertainty emergency department physicians experience when diagnosing neurological versus non-neurological conditions, and whether this uncertainty extends to the management of neurological conditions. Additionally, the study explores whether clinical experience is related to perceived diagnostic and/or management uncertainty.

Methods

Fifty-three emergency department physicians completed a survey measuring diagnostic uncertainty, management uncertainty, and associated anxiety. The survey included clinical vignettes depicting neurological and non-neurological cases, as well as items which assessed perceived diagnostic and management uncertainty across eight different specialties. Statistical analyses included paired samples t-test for comparing uncertainty between neurology and non-neurology cases and a general linear model to assess relationship between clinical experience and uncertainty.

Results

Emergency department physicians reported greater diagnostic uncertainty for neurological vignettes compared to non-neurological vignettes (Cohen’s d=1.37), as well as greater management uncertainty (Cohen’s d=1.41). They also reported greater anxiety when diagnosing neurological cases compared to non-neurological cases (Cohen’s d=1.33), as well as greater anxiety when managing them (Cohen’s d=0.69). Exploratory analyses indicated that with greater experience, management uncertainty of neurology cases decreased, while diagnostic uncertainty remained unchanged.

Conclusions

The results suggest unique diagnostic and management challenges posed by neurological cases in emergency departments, particularly for less experienced providers. Future research could focus on developing interventions to reduce diagnostic and management uncertainty in neurological conditions.

Keywords: clinical reasoning; diagnostic reasoning uncertainty; emergency medicine; management reasoning uncertainty; neurophobia; neurology

Corresponding author: Angelica M. Lee, Department of Neurology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, 20814, MD, USA, E-mail: angelica.lee@usush.edu

Research ethics: The Initial Review (ref# 968612) for your human subjects research protocol DBS.2024.662 entitled “Exploring Emergency Department Providers’ Uncertainty in Neurological Clinical Reasoning,” was reviewed and approved for execution on February 27, 2024 by Petrice Longenecker, PhD., Human Protection Administrator, as an EXEMPT protocol under the provision of 32CFR219.104(d)(2)(i). As such, this protocol does not require Institutional Review Board (IRB) review.
Informed consent: Implicit consent was obtained at the beginning of the questionnaire.
Author contributions: The questionnaire utilized implied consent. The first page provided information about the study, and participants’ decision to continue with the subsequent pages of the survey was considered as their consent to participate. All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Use of Large Language Models, AI and Machine Learning Tools: Angelica Lee used Grammarly.
Conflict of interest: The authors state no conflict of interest The opinions and assertions expressed herein are those of the authors and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense.
Research funding: None declared.
Data availability: Not applicable.

References

1. Bhise, V, Rajan, SS, Sittig, DF, Morgan, RO, Chaudhary, P, Singh, H. Defining and measuring diagnostic uncertainty in medicine: a systematic review. J Gen Intern Med 2018;33:103–15. https://doi.org/10.1007/s11606-017-4164-1.Search in Google Scholar PubMed PubMed Central

2. Santhosh, L, Chou, CL, Connor, DM. Diagnostic uncertainty: from education to communication. Diagnosis (Berlin, Germany) 2019;6:121–6. https://doi.org/10.1515/dx-2018-0088.Search in Google Scholar PubMed

3. Scott, IA, Doust, JA, Keijzers, GB, Wallis, KA. Coping with uncertainty in clinical practice: a narrative review. Med J Aust 2023;218:418–25. https://doi.org/10.5694/mja2.51925.Search in Google Scholar PubMed

4. Brun, C, Zerhouni, O, Akinyemi, A, Houtin, L, Monvoisin, R, Pinsault, N. Impact of uncertainty intolerance on clinical reasoning: a scoping review of the 21st-century literature. J Eval Clin Pract 2023;29:539–53. https://doi.org/10.1111/jep.13756.Search in Google Scholar PubMed

5. Carpenter, CR, Bellolio, MF, Upadhye, S, Kline, JA. Navigating uncertainty with GRACE: society for Academic Emergency Medicine’s guidelines for reasonable and appropriate care in the emergency department. Acad Emerg Med 2021;28:821–5. https://doi.org/10.1111/acem.14297.Search in Google Scholar PubMed

6. Meldolesi, E, van Soest, J, Dinapoli, N, Dekker, A, Damiani, A, Gambacorta, MA, et al.. Medicine is a science of uncertainty and an art of probability (Sir W. Osler). Radiother Oncol 2015;114:132–4. https://doi.org/10.1016/j.radonc.2014.12.013.Search in Google Scholar PubMed

7. Platts-Mills, TF, Nagurney, JM, Melnick, ER. Tolerance of uncertainty and the practice of emergency medicine. Ann Emerg Med 2020;75:715–20. https://doi.org/10.1016/j.annemergmed.2019.10.015.Search in Google Scholar PubMed PubMed Central

8. Gruppen, LD. Clinical reasoning: defining it, teaching it, assessing it, studying it. West J Emerg Med 2017;18:4. https://doi.org/10.5811/westjem.2016.11.33191.Search in Google Scholar PubMed PubMed Central

9. Durning, SJ, Artino, JAR, Schuwirth, L, Van Der Vleuten, C. Clarifying assumptions to enhance our understanding and assessment of clinical reasoning. Acad Med 2013;88:442–8. https://doi.org/10.1097/acm.0b013e3182851b5b.Search in Google Scholar

10. Helou, MA, DiazGranados, D, Ryan, MS, Cyrus, JW. Uncertainty in decision making in medicine: a scoping review and thematic analysis of conceptual models. Acad Med 2020;95:157–65. https://doi.org/10.1097/acm.0000000000002902.Search in Google Scholar PubMed PubMed Central

11. Moulder, G, Harris, E, Santhosh, L. Teaching the science of uncertainty. Diagnosis 2023;10:13–8. https://doi.org/10.1515/dx-2022-0045.Search in Google Scholar PubMed

12. Gärtner, J, Berberat, PO, Kadmon, M, Harendza, S. Implicit expression of uncertainty – suggestion of an empirically derived framework. BMC Med Educ 2020;20:83. https://doi.org/10.1186/s12909-020-1990-3.Search in Google Scholar PubMed PubMed Central

13. Dunlop, M, Schwartzstein, RM. Reducing diagnostic error in the intensive care unit. Engaging uncertainty when teaching clinical reasoning. ATS Sch 2020;1:364–71. https://doi.org/10.34197/ats-scholar.2020-0043ps.Search in Google Scholar

14. Saber Tehrani, AS, Kattah, JC, Kerber, KA, Gold, DR, Zee, DS, Urrutia, VC, et al.. Diagnosing stroke in acute dizziness and vertigo: pitfalls and pearls. Stroke (1970) 2018;49:788–95. https://doi.org/10.1161/strokeaha.117.016979.Search in Google Scholar PubMed PubMed Central

15. Abushouk, AI, Duc, NM. Curing neurophobia in medical schools: evidence-based strategies. Med Educ Online 2016;21:32476. https://doi.org/10.3402/meo.v21.32476.Search in Google Scholar PubMed PubMed Central

16. Hernando-Requejo, V. Neurophobia: why, how much, consequences and solutions. MedEdPublish (2016) 2020;9:3. https://doi.org/10.15694/mep.2020.000003.1.Search in Google Scholar PubMed PubMed Central

17. Jozefowicz, RF. Neurophobia: the fear of neurology among medical students. Arch Neurol 1994;51:328–9. https://doi.org/10.1001/archneur.1994.00540160018003.Search in Google Scholar PubMed

18. Laurie, G, Carolyn, C, Justin, TJ, Charlene, EG, Veronica, S, Imran, A, et al.. Characteristics of graduating US allopathic medical students pursuing a career in neurology. Neurology 2019;92:e2051. https://doi.org/10.1212/wnl.0000000000007369.Search in Google Scholar PubMed

19. Shiels, L, Majmundar, P, Zywot, A, Sobotka, J, Lau, CSM, Jalonen, TO. Medical student attitudes and educational interventions to prevent neurophobia: a longitudinal study. BMC Med Educ 2017;17:225. https://doi.org/10.1186/s12909-017-1055-4.Search in Google Scholar PubMed PubMed Central

20. Zinchuk, AV, Flanagan, EP, Tubridy, NJ, Miller, WA, McCullough, LD. Attitudes of US medical trainees towards neurology education: “Neurophobia” - a global issue. BMC Med Educ 2010;10:49. https://doi.org/10.1186/1472-6920-10-49.Search in Google Scholar PubMed PubMed Central

21. Liberman, AL, Cheng, NT, Friedman, BW, Gerstein, MT, Moncrieffe, K, Labovitz, DL, et al.. Emergency medicine physicians’ perspectives on diagnostic accuracy in neurology: a qualitative study. Diagnosis (Berl) 2021;9:225–35. https://doi.org/10.1515/dx-2021-0125.Search in Google Scholar PubMed

22. Wang, J, Hu, X, Hu, Z, Sun, Z, Laureys, S, Di, H. The misdiagnosis of prolonged disorders of consciousness by a clinical consensus compared with repeated coma-recovery scale-revised assessment. BMC Neurol 2020;20:343. https://doi.org/10.1186/s12883-020-01924-9.Search in Google Scholar PubMed PubMed Central

23. McCarron, MO, Stevenson, M, Loftus, AM, McKeown, P. Neurophobia among general practice trainees: the evidence, perceived causes and solutions. Clin Neurol Neurosurg 2014;122:124–8. https://doi.org/10.1016/j.clineuro.2014.03.021.Search in Google Scholar PubMed

24. Han, F, Zhang, Y, Wang, P, Wu, D, Zhou, LX, Ni, J. Neurophobia among medical students and resident trainees in a tertiary comprehensive hospital in China. BMC Med Educ 2023;23:824. https://doi.org/10.1186/s12909-023-04812-1.Search in Google Scholar PubMed PubMed Central

25. Alam, R, Cheraghi-Sohi, S, Panagioti, M, Esmail, A, Campbell, S, Panagopoulou, E. Managing diagnostic uncertainty in primary care: a systematic critical review. BMC Fam Pract 2017;18:79. https://doi.org/10.1186/s12875-017-0650-0.Search in Google Scholar PubMed PubMed Central

26. Cooke, G, Tapley, A, Holliday, E, Morgan, S, Henderson, K, Ball, J, et al.. Responses to clinical uncertainty in Australian general practice trainees: a cross-sectional analysis. Med Educ 2017;51:1277–88. https://doi.org/10.1111/medu.13408.Search in Google Scholar PubMed

27. Lawton, R, Robinson, O, Harrison, R, Mason, S, Conner, M, Wilson, B. Are more experienced clinicians better able to tolerate uncertainty and manage risks? A vignette study of doctors in three NHS emergency departments in England. BMJ Qual Saf. 2019;28:382, https://doi.org/10.1136/bmjqs-2018-008390.Search in Google Scholar PubMed PubMed Central

28. Jung, YW, Ha, SO, Kim, JH, Yang, WS, Park, YS. Experience of a neuro-emergency expert in the emergency department during one year of the COVID-19 pandemic. Int J Environ Res Public Health 2021;18. https://doi.org/10.3390/ijerph18189461.Search in Google Scholar PubMed PubMed Central

29. Sheikh, HM, Osman Sidow, N, Gökgül, A, Ali Adam, B, Farah Osman, M, Hassan, MH, et al.. Pattern of neurological disorders among patients evaluated in the emergency department; cross-sectional study. Arch Acad Emerg Med 2023;11:e20. https://doi.org/10.22037/aaem.v11i1.1813.Search in Google Scholar PubMed PubMed Central

30. MacDonald, BK, Cockerell, OC, Sander, JW, Shorvon, SD. The incidence and lifetime prevalence of neurological disorders in a prospective community-based study in the UK. Brain 2000;123:665–76. https://doi.org/10.1093/brain/123.4.665.Search in Google Scholar PubMed

31. Liberman, AL, Prabhakaran, S, Zhang, C, Kamel, H. Prevalence of neurological complaints in US emergency departments, 2016-2019. JAMA Neurol 2023;80:213–5. https://doi.org/10.1001/jamaneurol.2022.4531.Search in Google Scholar PubMed PubMed Central

32. Moeller, JJ, Kurniawan, J, Gubitz, GJ, Ross, JA, Bhan, V. Diagnostic accuracy of neurological problems in the emergency department. Can J Neurol Sci 2008;35:335–41. https://doi.org/10.1017/s0317167100008921.Search in Google Scholar PubMed

33. Royl, G, Ploner, CJ, Möckel, M, Leithner, C. [Neurological chief complaints in an emergency room]. Nervenarzt 2010;81:1226–30. https://doi.org/10.1007/s00115-010-3020-x.Search in Google Scholar PubMed

34. Arthur, NR, Tarsis, SS, Márcio, CRM, Diego, SS, Brenda, HBK, Serginara, CFPS, et al.. Education research: monitoring and tracking neurophobia. Neurology: Education 2023;2:e200076. https://doi.org/10.1212/ne9.0000000000200076.Search in Google Scholar

35. Saldaña-Inda, I, Cisneros-Gimeno, AI, Lambea-Gil, A. Neurophobia among resident physicians in the emergency service. Rev Neurol 2023;77:285–91. https://doi.org/10.33588/rn.7712.2023249.Search in Google Scholar PubMed PubMed Central

36. Dubosh, N, Edlow, J, Lefton, M, Pope, J. Types of diagnostic errors in neurological emergencies in the emergency department. Diagnosis 2015;2:21–8. https://doi.org/10.1515/dx-2014-0040.Search in Google Scholar PubMed

37. Walzl, D, Solomon, AJ, Stone, J. Functional neurological disorder and multiple sclerosis: a systematic review of misdiagnosis and clinical overlap. J Neurol 2022;269:654–63. https://doi.org/10.1007/s00415-021-10436-6.Search in Google Scholar PubMed PubMed Central

38. Arora, M, Asha, S, Chinnappa, J, Diwan, AD. Review article: burnout in emergency medicine physicians. Emerg Med Australas 2013;25:491–5. https://doi.org/10.1111/1742-6723.12135.Search in Google Scholar PubMed

39. Cooke, GP, Doust, JA, Steele, MC. A survey of resilience, burnout, and tolerance of uncertainty in Australian general practice registrars. BMC Med Educ 2013;13:2. https://doi.org/10.1186/1472-6920-13-2.Search in Google Scholar PubMed PubMed Central

40. Omron, R, Kotwal, S, Garibaldi, BT, Newman‐Toker, DE, Promes, S. The diagnostic performance feedback “calibration gap”: why clinical experience alone is not enough to prevent serious diagnostic errors. AEM Educ Train 2018;2:339–42. https://doi.org/10.1002/aet2.10119.Search in Google Scholar PubMed PubMed Central

41. Meyer, AN, Payne, VL, Meeks, DW, Rao, R, Singh, H. Physicians’ diagnostic accuracy, confidence, and resource requests: a vignette study. JAMA Intern Med 2013;173:1952–8. https://doi.org/10.1001/jamainternmed.2013.10081.Search in Google Scholar PubMed

Supplementary Material

This article contains supplementary material (https://doi.org/10.1515/dx-2024-0184).

Received: 2024-11-08

Accepted: 2025-02-06

Published Online: 2025-03-18

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Keywords for this article

clinical reasoning; diagnostic reasoning uncertainty; emergency medicine; management reasoning uncertainty; neurophobia; neurology