Defining and Measuring Diagnostic Uncertainty in Medicine: A Systematic Review

J Gen Intern Med. 2018 Jan;33(1):103-115. doi: 10.1007/s11606-017-4164-1. Epub 2017 Sep 21.


Background: Physicians routinely encounter diagnostic uncertainty in practice. Despite its impact on health care utilization, costs and error, measurement of diagnostic uncertainty is poorly understood. We conducted a systematic review to describe how diagnostic uncertainty is defined and measured in medical practice.

Methods: We searched OVID Medline and PsycINFO databases from inception until May 2017 using a combination of keywords and Medical Subject Headings (MeSH). Additional search strategies included manual review of references identified in the primary search, use of a topic-specific database (AHRQ-PSNet) and expert input. We specifically focused on articles that (1) defined diagnostic uncertainty; (2) conceptualized diagnostic uncertainty in terms of its sources, complexity of its attributes or strategies for managing it; or (3) attempted to measure diagnostic uncertainty.

Key results: We identified 123 articles for full review, none of which defined diagnostic uncertainty. Three attributes of diagnostic uncertainty were relevant for measurement: (1) it is a subjective perception experienced by the clinician; (2) it has the potential to impact diagnostic evaluation-for example, when inappropriately managed, it can lead to diagnostic delays; and (3) it is dynamic in nature, changing with time. Current methods for measuring diagnostic uncertainty in medical practice include: (1) asking clinicians about their perception of uncertainty (surveys and qualitative interviews), (2) evaluating the patient-clinician encounter (such as by reviews of medical records, transcripts of patient-clinician communication and observation), and (3) experimental techniques (patient vignette studies).

Conclusions: The term "diagnostic uncertainty" lacks a clear definition, and there is no comprehensive framework for its measurement in medical practice. Based on review findings, we propose that diagnostic uncertainty be defined as a "subjective perception of an inability to provide an accurate explanation of the patient's health problem." Methodological advancements in measuring diagnostic uncertainty can improve our understanding of diagnostic decision-making and inform interventions to reduce diagnostic errors and overuse of health care resources.

Keywords: definition; diagnostic process; diagnostic uncertainty; measurement; review.

Publication types

  • Research Support, U.S. Gov't, Non-P.H.S.
  • Research Support, U.S. Gov't, P.H.S.
  • Systematic Review

MeSH terms

  • Clinical Decision-Making* / methods
  • Delivery of Health Care / methods
  • Delivery of Health Care / standards*
  • Humans
  • Medicine / methods
  • Medicine / standards*
  • Uncertainty*