By Stacey Kusterbeck
Patients likely expect to leave the emergency department (ED) with a definite understanding of what is wrong. Yet many ED patients are discharged or admitted with an uncertain diagnosis.
“Uncertainty is common in the diagnostic process. Communicating uncertainty to patients is important but complex,” says Kelly Gleason, RN, PhD, an assistant professor at Johns Hopkins School of Nursing.
Gleason and colleagues conducted a study to learn about how patients perceived diagnostic uncertainty. Of 1,116 patients surveyed, 106 (10%) reported uncertainty in their diagnosis in the ED or urgent care setting. Of the patients who reported uncertainty, 73% identified poor communication as a factor.1 “While uncertainty is often present in the diagnostic process, how it is communicated varies widely,” Gleason says. One patient stated, “The follow-up appointment with my primary care doctor showed the real issue was different from what the ER team thought.”
Only 10% of the patients said that healthcare providers were transparent about the uncertainty of their diagnosis. One stated, “They were not able to determine exactly what was causing my problem. They admitted it and gave me a couple of doctors to follow up with.”
“When there is uncertainty, communicating to the patient why there is uncertainty, what you have ruled out, what you are unable to rule out, and what next steps are to determine the cause goes a long way,” Gleason says.
Excluding straightforward injury and minor illness cases, there is not a definitive diagnosis in possibly most ED cases at the point of discharge or admission, according to Alan Lembitz, MD, chief medical officer at Copic, a Denver-based medical professional liability insurance provider.
Often, the correct diagnosis is determined only after the patient leaves the ED — either during the hospitalization or after the patient is discharged. While ED providers are aware of how common diagnostic uncertainty is, patients probably expect to leave the ED with a definite diagnosis. “That is a big disconnect,” Lembitz notes.
ED providers are obligated to rule out specific life-threatening conditions. Once they have done so, the patient might be discharged without knowing the final diagnosis. “In the liability world, the big issues are neurological, chest pain, and acute surgical abdomen. Those are the areas where, oftentimes, patients are leaving without a definitive diagnosis,” Lembitz explains.
Typically, EDs do a good job of ruling out myocardial infarction in chest pain patients and can tell patients if they are at low risk for a heart attack soon. However, those patients still may have coronary artery disease that goes undetected during the ED visit. “We really aren’t studying them and giving them follow-up, and we don’t know what their exact coronary anatomy is and what their ultimate long-term risks are,” Lembitz says. The same is true for neurological conditions. “In neurology, it’s probably even more problematic, in that a lot of the diagnoses are nonspecific,” Lembitz notes.
ED providers are not likely to miss acute anterior circulation events. However, posterior circulation and brain stem events can present with nonspecific dizziness or vertigo, subtle cognitive dysfunction, or confusion, headache, and/or diffuse weakness. “You can’t definitively image every presentation that has some of those features. Many common conditions that are not serious can mimic the truly serious,” Lembitz explains.
Lembitz has reviewed multiple liability claims involving patients who presented to the ED before the correct diagnosis was apparent. A common fact pattern in the lawsuits is a patient visiting an ED within the first two or three hours of the onset of abdominal pain. The patient’s labs and imaging all came back normal, and vital signs were either normal or slightly abnormal. The patient went home from the ED, falsely reassured, and the condition evolved. “In 24 to 36 hours, the person is septic and the labs are terrible,” Lembitz says. “Patients who looked OK during the initial ED visit may return to the ED with a surgical abdomen, have a poor outcome, and sue for malpractice.”
The ED providers must testify at their deposition, or in front of a jury, that at the time of the ED visit, it was not yet possible to make the correct diagnosis. To prevent poor outcomes that can result in litigation, Lembitz says that admitting the patient for ED observation or very close-term follow-up with re-exams in 12 to 24 hours is a good approach. The problem is that EDs often will discharge the patients with instructions to follow up with primary care, but the patients often cannot get an appointment on short notice. Patients do not know where to go for follow-up and end up with a poor outcome. “It is a high-liability area,” Lembitz underscores.
Good communication with patients at the point of discharge can mitigate some of these risks. Written discharge instructions are generally clear on the need for close follow-up. In Lembitz’s experience, what is missing is that the patient goes home without understanding that there is diagnostic uncertainty. “I think you could reduce emergency medicine lawsuits enormously by targeting this specific area because it really is about the patient having appropriate expectations,” Lembitz explains. “Just because we ruled out the dangerous stuff, it doesn’t mean you don’t have something else.”
Emergency physicians (EPs) often delegate discharges and simply ask the nursing staff to “sign the patient out.” “That’s a missed opportunity for the physician to sit with the patient and family — it doesn’t take more than two or three minutes — and close the loop with the after-visit summary,” Lembitz says.
Many patients with abdominal pain, early serious infections, chest pain, or an acute neurological finding do not quite meet the criteria for hospital admission at the time of the ED visit. Most of those patients do well after the ED discharge, but some experience poor outcomes. “Those are the cases that turn into malpractice claims. I don’t see successful abdominal patients that do just fine. The cases I do see are the ones where we did miss things, there’s a misdiagnosis, and there’s an adverse outcome and a lawsuit,” Lembitz says.
It is important for ED providers to adequately address the issue that the patient is concerned about. “There’s a disconnect between what the patient hears and what you have said. But there is also a disconnect between the chief concern and the chief complaint. The chief concern is what the patient thinks it is, and sometimes they are right,” Lembitz says. If the patient’s chief concern turns out to be correct, and the ED providers missed it, those malpractice cases are difficult to defend. The patient can testify that they told the ED nurse they were worried about a perforated bowel and got sent home — and were admitted two days later for a perforated bowel.
The ED chart can help with the defense of a malpractice claim involving diagnostic uncertainty. “If you look at most liability carriers, about 75% to 80% of filed claims are dismissed without indemnity at some point. And 20% to 25% are either settled or in some fashion, the patient has an indemnity payment made to them. That tells me we can defend most cases with good documenting,” Lembitz says.
Yet even the best documentation showing solid medical decision-making does not shield the EP from a lawsuit for failure to diagnose. “The chart doesn’t protect you from the unhappy patient who had different expectations and didn’t understand what you were doing. They are still going to file litigation that will make you miserable,” Lembitz says. Even if the malpractice claim is successfully defended, it is still not a process any EP would want to endure.
“Maybe we’ve done a disservice in the risk management world,” Lembitz suggests. “People are spending so much time documenting, which is done outside the view of the patient. We have this idea that everybody is going to see and read the documentation. But most patients don’t see the documentation, even with portals.”
While good documentation is essential, it also is important for EPs to practice good communication while the patient is still in the ED. EPs can do this by clearly stating that there is diagnostic uncertainty at the point of discharge and by giving patients a chance to reiterate their concerns.
“Spending time at the after-visit, with a little bit of communication, goes a long way,” Lembitz emphasizes. “The outcomes would be better — and the expectations would also be more appropriate.”
REFERENCE
- DeGennaro AP, Gonzalez N, Peterson S, Gleason KT. How do patients and care partners describe diagnostic uncertainty in an emergency department or urgent care setting? Diagnosis (Berl) 2023;Sep 26. doi: 10.1515/dx-2023-0085. [Online ahead of print].
Patients likely expect to leave the emergency department with a definite understanding of what is wrong. Yet many patients are discharged or admitted with an uncertain diagnosis.
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