Diagnostic Certainty Affects ED Patients’ Satisfaction
ED patients are more satisfied if they leave with a certain diagnosis, according to the authors a recent study.1
“This study was motivated by a lack of clear understanding of what factors drive patient experience and satisfaction during their emergency department visit,” says Peter B. Smulowitz, MD, MPH, the study’s lead author.
Smulowitz and colleagues surveyed 148 patients at a single academic tertiary care ED with a chief complaint of abdominal pain, back pain, chest pain, or headache. All were in the process of discharge from the ED. The patients rated how strongly they agreed with these statements: “I am sure about exactly what is wrong,” “My doctors know exactly what is wrong,” and “I am satisfied with the quality of care I received in the ED.”
Researchers were somewhat surprised to learn that patient diagnostic certainty was such an important driver of satisfaction, regardless of the number or types of tests performed in the ED.
“In other words, just doing more tests didn’t help address satisfaction,” says Smulowitz, chief medical officer at Milford (MA) Regional Medical Center.
The findings suggest the goal of an ED visit is different for patients than it is for EPs. “Physicians in the ED are looking to rule out life threats, while it appears patients may be seeking certainty. If there is such a disconnect here, then perhaps we should rethink how we actually measure and report on patient satisfaction,” Smulowitz offers.
Just remaining mindful that patients are looking for certainty is important for EPs. This does not mean ordering more tests or procedures; instead, take the time to explain any diagnostic uncertainty that may exist even after an ED evaluation.
“Diagnostic certainty is often not possible in the ED. The ED setting is for ruling out emergencies requiring urgent care,” says Kelly Gleason, RN, PhD, an assistant professor at Johns Hopkins School of Nursing.
Many ED patients need further testing to establish a diagnosis. “When a health problem is found not to require urgent treatment, it is often for the best that it is resolved in an outpatient setting,” Gleason notes.
A patient receives pain relief for severe chronic back pain in the ED, but the EP recommends follow-up care in an outpatient setting. Since the patient expects to leave with a diagnosis, the EP must explain why there is uncertainty. “This is the right way to go in the event where a certain diagnosis cannot be established,” Gleason says.
EPs should take time to explain why they do not believe the patient is experiencing a medical emergency and why it is not possible to establish a definitive diagnosis. They also should note that to reach a conclusive diagnosis, follow-up in an outpatient setting is necessary. Finally, EPs should explain the reasons why they believe it is safe to discharge the patient.
“This is preferable to giving a patient a diagnosis when there is any uncertainty around the diagnosis,” Gleason says.
Some EPs give a diagnosis of “upper respiratory viral syndrome” to patients who present with cough and no symptoms of a bacterial illness. That may satisfy patients momentarily, but honesty is better in the long run. “Have some trust in your patient’s ability to reason and understand,” Gleason offers. “The worst thing you can do is not be transparent with the patient.”
EDs deal with uncertainty continually, even in critically ill patients. “We often admit and discharge patients with no confirmed or certain diagnosis,” says Martin Huecker, MD, FACEP, FAAEM, associate professor and research director in the department of emergency medicine at the University of Louisville. With many medical conditions, no lab or radiologic tests exist to confirm the diagnosis. “This leaves a so-called ‘clinical diagnosis,’ or even more nebulous, a ‘diagnosis of exclusion,’” Huecker says. These practices can reduce risks for patients with diagnostic uncertainty:
- Engage in shared decision-making as to whether a patient will be discharged or admitted. “Document that the patient completely understands and can even recite back the areas of uncertainty,” Huecker suggests.
- Identify specific reasons to return to the ED and importance of close follow-up with primary care.
- Explain the differential diagnosis list to patients so they understand the possible causes of their symptoms and the subsequent need for further testing or treatment. “We sometimes go over what diagnoses we are considering and why they are more or less probable,” Huecker notes. This may be a hard sell for patients who came to the ED looking for a diagnosis. “But often that’s the only answer we can give, that we have ruled out the life-threatening diagnoses, and here are the alternate diagnoses that remain that could be confirmed or ruled out by physicians in an outpatient setting,” Huecker says.
- Document the rationale for discharge in the medical decision-making portion of the chart so others can understand the EP’s thought processes. There always is the potential for liability in “uncertain diagnosis” cases. In the ED, the focus is on ruling out any life-threatening causes of the patient’s symptoms. “But some patients present early in the disease process, and some tests can be limited in these cases,” Huecker says.
Appendicitis can be missed on the CT scan of patients who arrive early in the disease process, in the first few hours that they experience pain. “Another situation can involve intermittent symptoms and intermittent diagnostic inclusion,” Huecker observes. For instance, patients can experience ovarian torsion that is intermittent in nature. This can be missed on ultrasound if the patient is not symptomatic at the time.
A misdiagnosis, lack of diagnosis, or delayed diagnosis does not necessarily demonstrate negligence. “Skilled physicians exercising reasonable care are not usually found negligent,” says Danielle M. Trostorff, Esq., a health law specialist at Degan, Blanchard & Nash in New Orleans. Trostorff has seen these factors determine the outcome of malpractice claims if a patient is discharged with an incorrect diagnosis (or none at all):
- Whether the patient was harmed by improper medical treatment, delayed treatment, or no treatment.
- Whether the patient’s condition worsened because the EP failed to diagnose the condition.
- Whether the patient failed to follow up as instructed, or delayed in doing so. “The delay may relieve an ER physician of negligence,” Trostorff says. If follow-up care does lead to a definitive diagnosis, but the intervening delay did not harm the patient, “then the lack of a diagnosis at the time of discharge from the ER would not support a negligence claim,” Trostorff adds.2
- Hagerty SF, Burke RC, Isbell LM, et al. Patient perceptions of diagnostic certainty at discharge and patient satisfaction in the ED. Acad Emerg Med 2021; Apr 8. doi: 10.1111/acem.14262. [Online ahead of print].
- Malbrough v. Rodgers, 290 So. 3d. 204 (LA. 3rd Cir. Court of Appeal 2020).
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