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Uncertainty Communication Toolkit

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Why did we create this toolkit? At least 37% of patients treated in the emergency department (ED) are discharged without a definitive diagnosis, thus leaving the encounter with diagnostic uncertainty.1 A national survey of medical trainees found that 99% of trainees had experienced challenges discharging patients with diagnostic uncertainty, and 51% wanted formal communication training regarding uncertainty.2 In response to this need, we developed this toolkit to provide healthcare providers with a standardized approach to establish competency in communication of diagnostic uncertainty.  

How did we create this toolkit? The materials included in this toolkit were created through an AHRQ-funded study, “Promoting safe care transitions: Simulation-based mastery learning to improve communication in times of diagnostic uncertainty.” The toolkit components were developed with input from patients as well as an international panel of experts in in healthcare communication, diagnostic uncertainty, simulation and education. 

Funding information: This project was supported by grant R18HS025651 from the Agency for Healthcare Research and Quality (AHRQ). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

1Wen L, Espinola J, Mosowsky J, Camargo C. Do Emergency Department Patients Receive a Pathological Diagnosis? A Nationally-Representative Sample. West J Emerg Med. 2015;16(1):50-54.

2Rising KL, Papanagnou D, McCarthy D, Gentsch A, Powell R. Emergency medicine resident perceptions about the need for increased training in communicating diagnostic uncertainty. Cureus. 2018;10(1).

Components of the toolkit were developed with input from researchers at Thomas Jefferson University and Northwestern University, as well as members of an expert panel composed of patients and experts in patient communication, education, health literacy, diagnostic uncertainty, and simulation. Roles at the time this work was conducted were as follows:

Jefferson Team

Kristin Rising, MD MSHP
Principal Investigator, Jefferson
Jefferson Emergency medicine physician; clinical and health services researcher

Mandy Doty, MS
Research Coordinator

Dimitrios Papanagnou, MD MPH EdD
Co-Investigator
Jefferson Emergency medicine physician; medical educator; Director of the Jefferson In Situ Simulation Training Program.

Rhea Powell, MD MPH
Co-Investigator
Primary care physician and researcher

Northwestern University Team

Danielle McCarthy, MD MS
Site-Priciple Investigator
Emergency medicine physician; health services researcher

Kenzie Cameron, PhD MPH
Co-Investigator, NU
Research professor; health services researcher

 

William McGaghie, PhD
Co-Investigator
Medical education researcher

Kate Piserchia
Research coordinator

David Salzman, MD MEd,/b>
Co-Investigator
Emergency medicine physician; medical educator; Director of Simulation for Undergraduate Medical Studies

Expert Panel
Kirsten Engel, MD; Erik Hess, MD MS Annemarie Jutel, RN BPhED(Hons) PhD; Juanita Lavalais; Larry Loebell, MA, MFA; Zachary Meisel, MD MPH MSHP; Erica Shelton, MD, MPH, MHS, FACEP; John Vozenliek, MD; Gail Weingarten; Michael Wolf, PhD MPH

Additional Collaborators
Jessica Diebold; Matt Klein, MD; Ben Leiby, PhD; Ayako Shimado, MS; Tony Zhang, MD

Acknowledgements
Thank you to the 2019-2020 Emergency Medicine residents and residency leadership of both universities and standardized patients who participated in the trial associated with this work.

 

 

This toolkit was developed with funding from the Agency for Healthcare Research and Quality (AHRQ). There is no cost to use the materials included in this toolkit. However, if you are considering using any part of this curriculum, please provide your name and email. This information is helpful for us to be able to track the extent of use of this curriculum and its potential impact.

For questions about using this curriculum, feedback, or any other thoughts, please contact Dr. Kristin Rising.

This toolkit was developed with funding from the Agency for Healthcare Research and Quality (AHRQ). There is no cost to use the materials included in this toolkit. However, if you are considering using any part of this curriculum, please provide your name and email. This information is helpful for us to be able to track the extent of use of this curriculum and its potential impact.

  1. Rising KL, Powell RE, Cameron KA, Salzman DH, Papanagnou D, Doty AMB, Latimer L, Piserchia K, McGaghie WC, McCarthy DM. Development of the Uncertainty Communication Checklist: A Patient-Centered Approach to Patient Discharge From the Emergency Department. Acad Med. 2020 Jul;95(7):1026-1034. doi: 10.1097/ACM.0000000000003231. PMID: 32101919; PMCID: PMC7302334.
  2. Papanagnou D, Klein MR, Zhang XC, Cameron KA, Doty A, McCarthy DM, Rising KL, Salzman DH. Developing standardized patient-based cases for communication training: lessons learned from training residents to communicate diagnostic uncertainty. Adv Simul (Lond). 2021 Jul 22;6(1):26. doi: 10.1186/s41077-021-00176-y. PMID: 34294153; PMCID: PMC8296470.
  3. Poluch M, Feingold-Link J, Ankam N, Kilpatrick J, Cameron K, Chandra S, Doty A, Klein M, McCarthy D, Rising K, Salzman D, Ziring D, Papanagnou D. I Don't Have a Diagnosis for You: Preparing Medical Students to Communicate Diagnostic Uncertainty in the Emergency Department. MedEdPORTAL. 2022 Feb 4;18:11218. doi: 10.15766/mep_2374-8265.11218. PMID: 35178469; PMCID: PMC8814030.
  4. McCarthy DM, Formella KT, Ou EZ, Vozenilek JA, Cameron KA, Salzman DH, Doty AM, Piserchia K, Papanagnou D, Rising KL. There's an app for that: Teaching residents to communicate diagnostic uncertainty through a mobile gaming application. Patient Educ Couns. 2022 Jun;105(6):1463-1469. doi: 10.1016/j.pec.2021.09.038. Epub 2021 Oct 5. PMID: 34674922; PMCID: PMC9109131.
  5. Doty AM, Rising KL, Hsiao T, Amadio G, Gentsch AT, Salcedo VJ, McElwee I, Cameron KA, Salzman DH, Papanagnou D, McCarthy DM. "Unfortunately, I don't have an answer for you": How resident physicians communicate diagnostic uncertainty to patients during emergency department discharge. Patient Educ Couns. 2022 Jul;105(7):2053-2057. doi: 10.1016/j.pec.2021.12.002. Epub 2021 Dec 9. PMID: 35168855; PMCID: PMC9177889.
  6. Rising KL, Cameron KA, Salzman DH, Papanagnou D, Doty AMB, Piserchia K, Leiby BE, Shimada A, McGaghie WC, Powell RE, Klein MR, Zhang XC, Vozenilek J, McCarthy DM. Communicating Diagnostic Uncertainty at Emergency Department Discharge: A Simulation-Based Mastery Learning Randomized Trial. Acad Med. 2023 Mar 1;98(3):384-393. doi: 10.1097/ACM.0000000000004993. Epub 2022 Oct 4. PMID: 36205492.
  7. McCarthy DM, Powell RE, Cameron KA, Salzman DH, Papanagnou D, Doty AM, Leiby BE, Piserchia K, Klein MR, Zhang XC, McGaghie WC, Rising KL. Simulation-based mastery learning compared to standard education for discussing diagnostic uncertainty with patients in the emergency department: a randomized controlled trial. BMC Med Educ. 2020 Feb 19;20(1):49. doi: 10.1186/s12909-020-1926-y. PMID: 32070353; PMCID: PMC7029572.
  8. Salzman DH, Rising KL, Cameron KA, Powell RE, Papanagnou D, Doty A, Piserchia K, Latimer L, McGaghie WC, McCarthy DM. Setting a Minimum Passing Standard for the Uncertainty Communication Checklist Through Patient and Physician Engagement. J Grad Med Educ. 2020 Feb;12(1):58-65. doi: 10.4300/JGME-D-19-00483.1. PMID: 32089795; PMCID: PMC7012525.
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