The role of communicating diagnostic uncertainty in the safety-netting process: insights from a vignette study

Why it matters

Although many clinicians practice safety-netting, a practice that’s been defined as, “information shared with a patient or carer, designed to help them identify the need to seek further medical help if their condition fails to improve,” what good practice looks like isn’t well-established. While NICE guidelines are available for use in specific circumstances and conditions like meningitis, guidelines aren’t commonly used.

Clinicians might use safety-netting when they aren’t sure about a diagnosis or the trajectory of a condition that’s been diagnosed. It’s intended to reduce potential harm by suggesting that if a patient notices new symptoms, or their existing symptoms don’t improve, they return to their doctor for further investigations. Although it’s recommended that doctors tell a patient about any diagnostic uncertainty when they are safety-netting, in practice this doesn’t always happen. It’s also not clear how, or why they communicate their uncertainty when they do.

We wanted to explore how and why doctors used safety-netting and showed hospital-based doctors working in internal medicine four vignettes depicting different clinical scenarios involving diagnostic uncertainty. After each one, an interviewer asked them what they would say to a ‘typical patient’ in this situation. We followed this up with a semi-structured interview which explored their reasons for communicating in the way they did. We examined both how and in particular why doctors chose to (not) communicate diagnostic uncertainty when they were safety-netting.

What we found

Focusing on secondary care in England, this study shows that doctors don’t often explicitly talk about diagnostic uncertainty to their patients as part of the safety-netting process, even if it’s recommended that they do so. There was also significant variation in how the doctors who took part in the study safety-netted.

While it was a widespread practice, safety-netting wasn’t universally used, and where it was used, clinicians each gave different levels of detail to patients about the symptoms they should be alert for, and what they should do if they arose or worsened.

Although many doctors thought that safety-netting was a valuable tool in managing diagnostic uncertainty, they didn’t discuss it explicitly, often choosing not to tell patients that they were unsure of their diagnosis. Most doctors said that they would recommend that patients return if their symptoms worsened or new ‘red flag’ symptoms developed, but they didn’t tell them that this was because there was a possibility of diagnostic error or uncertainty. Very few participants made it clear that they were uncertain about the working diagnosis although some alluded to the possibility of diagnostic error, saying that it was important for patients to return so they could be reassessed to make sure nothing had been ‘missed’.

Some participants thought that that if they told a patient they were uncertain about their diagnosis as part of safety-netting, it could cause them unnecessary anxiety, which was framed as potentially harmful to both the patient and the healthcare system (it could fuel unnecessary repeat presentations/investigations). Some participants, on the other hand, thought that it was equally important to mention serious but unlikely differential diagnoses (e.g. cancer) to encourage reattendance if their symptoms persisted or worsened.

It’s not clear whether communicating diagnostic uncertainty makes patients more likely to appropriately seek medical advice if their symptoms get worse, or if the anxiety that they might feel after being told about it should be viewed as harmful – or as a helpful tool for encouraging patients to take safety-netting advice seriously. However, the need to give patients enough information is even more important in acute secondary care settings where the doctor-patient relationship is transient – patients need to be empowered to make correct decision about when or if they need to reattend. This study emphasises the need for future research to find out what patients think and how different methods of safety-netting impact their health-seeking behaviours, to build an evidence base to inform best-practice safety-netting guidelines.