Diagnostic uncertainty in primary care: what is known about its communication, and what are the associated ethical issues?

BACKGROUND: Diagnostic uncertainty (DU) in primary care is ubiquitous, yet no review has specifically examined its communication, or the associated ethical issues. OBJECTIVES: To identify what is known about the communication of DU in primary care and the associated ethical issues. METHODS: Systematic review, critical interpretive synthesis and ethical analysis of primary research published worldwide. Medline, Embase, Web of Science and SCOPUS were searched for papers from 1988 to 2020 relating to primary care AND diagnostic uncertainty AND [ethics OR behaviours OR communication]. Critical interpretive synthesis and ethical analysis were applied to data extracted. RESULTS: Sixteen papers met inclusion criteria. Although DU is inherent in primary care, its communication is often limited. Evidence on the effects of communicating DU to patients is mixed; research on patient perspectives of DU is lacking. The empirical literature is significantly limited by inconsistencies in how DU is defined and measured. No primary ethical analysis was identified; secondary analysis of the included papers identified ethical issues relating to maintaining patient autonomy in the face of clinical uncertainty, a gap in considering the direct effects of (not) communicating DU on patients, and considerations regarding over-investigation and justice. CONCLUSIONS: This review highlights significant gaps in the literature: there is a need for explicit ethical and patient-centred empirical analyses on the effects of communicating DU, and research directly examining patient preferences for this communication. Consensus on how DU should be defined, and greater research into tools for its measurement, would help to strengthen the empirical evidence base.

The National Institute of Standards and Technology's Impact on Fire Safety Standards.

The authors document the role of the National Institute for Standards and Technology (NIST) in the initial adoption of smoke alarms, ongoing changes to smoke alarm performance requirements, and ongoing research on wildfire safety in the wildland urban interface. They also provide econometric estimates of the social and economic impact of the fire safety standards that NIST helped develop.

Understanding the Economic Benefit Associated with Research and Services at the National Institute for Occupational Safety and Health: An Approach and Three Case Studies.

The National Institute for Occupational Safety and Health (NIOSH) asked the RAND Corporation to develop an approach, reported here, for estimating the economic benefit of NIOSH research, using three case studies. The cases provide concrete illustrations of the ways in which NIOSH research could affect worker health and safety practices and outcomes, as well as some initial estimates of the economic benefit associated with those impacts. The authors selected the case studies to illustrate variation in types of NIOSH research and in intended users. The first case study examines research to develop, test, and support implementation of engineering control measures to limit exposure to silica among road construction workers. This case study offers an example of NIOSH's intervention and surveillance research and provision of technical assistance. The second case study involves two NIOSH studies that strengthened the evidence base about the linkage between firefighting activities and increased risk of certain cancers among firefighters. This case study provides an example of etiological and exposure surveillance research, coupled with an intervention study. The third case study involves a NIOSH evaluation of the effectiveness of Ohio's Safety Intervention Grant Program in reducing the prevalence and costs of workplace injuries. This case study illustrates intervention research targeting government organizations. The first and second case studies led to the development of control technologies, and all three case studies involved dissemination and stakeholder engagement efforts that promoted the adoption of risk-reducing technologies and practices.