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Diagnosis (Berlin, Germany)
Mar 18, 2025;

Exploring emergency department providers' uncertainty in neurological clinical reasoning.

Angelica M Lee, Kirsten R Brown, Steven J Durning, Sami A Abuhamdeh
Author Information
  1. Angelica M Lee: Department of Neurology 1685 Uniformed Services University of the Health Sciences , Bethesda, MD, USA. ORCID
  2. Kirsten R Brown: Department of Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, MD, USA. ORCID
  3. Steven J Durning: Department of Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, MD, USA. ORCID
  4. Sami A Abuhamdeh: Department of Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, MD, USA. ORCID
PMID: 40091800 DOI: 10.1515/dx-2024-0184

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 neurology neurophobia

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 . [DOI: 10.1007/s11606-017-4164-1]
  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 . [DOI: 10.1515/dx-2018-0088]
  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 . [DOI: 10.5694/mja2.51925]
  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 . [DOI: 10.1111/jep.13756]
  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 . [DOI: 10.1111/acem.14297]
  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 . [DOI: 10.1016/j.radonc.2014.12.013]
  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 . [DOI: 10.1016/j.annemergmed.2019.10.015]
  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 . [DOI: 10.5811/westjem.2016.11.33191]
  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 . [DOI: 10.1097/acm.0b013e3182851b5b]
  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 . [DOI: 10.1097/acm.0000000000002902]
  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 . [DOI: 10.1515/dx-2022-0045]
  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 . [DOI: 10.1186/s12909-020-1990-3]
  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 . [DOI: 10.34197/ats-scholar.2020-0043ps]
  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 . [DOI: 10.1161/strokeaha.117.016979]
  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 . [DOI: 10.3402/meo.v21.32476]
  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 . [DOI: 10.15694/mep.2020.000003.1]
  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 . [DOI: 10.1001/archneur.1994.00540160018003]
  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 . [DOI: 10.1212/wnl.0000000000007369]
  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 . [DOI: 10.1186/s12909-017-1055-4]
  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 . [DOI: 10.1186/1472-6920-10-49]
  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 . [DOI: 10.1515/dx-2021-0125]
  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 . [DOI: 10.1186/s12883-020-01924-9]
  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 . [DOI: 10.1016/j.clineuro.2014.03.021]
  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 . [DOI: 10.1186/s12909-023-04812-1]
  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 . [DOI: 10.1186/s12875-017-0650-0]
  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 . [DOI: 10.1111/medu.13408]
  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 . [DOI: 10.1136/bmjqs-2018-008390]
  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 . [DOI: 10.3390/ijerph18189461]
  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 . [DOI: 10.22037/aaem.v11i1.1813]
  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 . [DOI: 10.1093/brain/123.4.665]
  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 . [DOI: 10.1001/jamaneurol.2022.4531]
  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 . [DOI: 10.1017/s0317167100008921]
  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 . [DOI: 10.1007/s00115-010-3020-x]
  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 . [DOI: 10.1212/ne9.0000000000200076]
  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 . [DOI: 10.33588/rn.7712.2023249]
  36. Dubosh, N, Edlow, J, Lefton, M, Pope, J. Types of diagnostic errors in neurological emergencies in the emergency department. Diagnosis 2014;2. https://doi.org/10.1515/dx-2014-0040 . [DOI: 10.1515/dx-2014-0040]
  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 . [DOI: 10.1007/s00415-021-10436-6]
  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 . [DOI: 10.1111/1742-6723.12135]
  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 . [DOI: 10.1186/1472-6920-13-2]
  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 . [DOI: 10.1002/aet2.10119]
  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 . [DOI: 10.1001/jamainternmed.2013.10081]
Journal Article

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