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EXPLAINING DIAGNOSTIC UNCERTAINTY
Mr Kastagir attended his local emergency department with chest pain. Local data on prevalence suggests that the pretest probability of a patient with suspected cardiac chest pain having an acute coronary syndrome is approximately 25%.1 His physician is also aware that after serious disease has been excluded, the precise cause of the symptoms can often remain unclear.
When a clinician sees a patient with an unclear presentation, 2 of the most important questions are (1) What is the exact diagnosis? (“What is the cause of my chest pain, doctor?”), and (2) What is the risk to the patient from the most potentially harmful differential diagnoses? (“Am I going to die from a heart attack?”)
Both questions are important. However, clinicians and patients emphasise these questions differently. For example, patients may want to know the cause for their chest pain, while clinicians focus on the inclusion or exclusion of serious cardiac disease. If the clinician feels serious disease has been ruled out and tells the patient, the latter may still feel dissatisfied and worried because the cause of the pain has not been discovered.
Explaining our uncertainty about diagnosis can be difficult, especially if having a causal “label” is important to the patient. Chest pain is a common acute presenting complaint in the emergency department. In our hospital, most patients presenting to the emergency department with acute chest pain are admitted,1 and, whether admitted or discharged, approximately 75% of patients are given the final diagnosis of “non-specific chest pain.” For attending clinicians, …