Research Article: Sensitivity for multimorbidity: The role of diagnostic uncertainty of physicians when evaluating multimorbid video case-based vignettes

Date Published: April 10, 2019

Publisher: Public Library of Science

Author(s): Daniel Hausmann, Vera Kiesel, Lukas Zimmerli, Narcisa Schlatter, Amandine von Gunten, Nadine Wattinger, Thomas Rosemann, Agustin Martínez Molina.


Multimorbidity can be defined as the co-occurrence of two or more chronic medical conditions in one person. Within the diagnostic process, accurately detecting a multimorbid disease pattern still poses a major challenge for most physicians, and is known as a source of diagnostic uncertainty.

We investigated, how sensitive, confident, and accurate physicians are in diagnosing multimorbid versus monomorbid patients.

We created eight video case-based vignettes, which differed in type of morbidity (multimorbid versus monomorbid), field of medical specialization (somatic versus mental), and relatedness of underlying diseases (causally related versus unrelated). In total, 74 physicians (GPs, residents in an emergency department and psychiatrists) watched three to five randomly allocated video cases and had to generate suspected diagnoses at the end of each of three video sequences. Additionally, participating physicians rated subjective confidence for all mentioned diagnoses and for three sequences per case with the help of confidence profiles.

Altogether, physicians made a large number of accurate diagnoses (69%). Nevertheless, the overall number of underdiagnosed multimorbid cases (misses) was significantly higher (71%) than over-diagnosed monomorbid cases (false alarms) (7%).

According to Signal Detection Theory, GPs and psychiatrists both showed lower detection performance for medical cases that lay beyond their own field of specialization. Remarkably, residents show the highest sensitivity for multimorbid cases with an approximately identically detection performance d’ slightly over 1 for both field of medical specialization (somatic and mental). Furthermore, higher uncertainty in diagnosing multimorbid cases is related to lower confidence especially at the beginning of a diagnostic process, as well as to unrelated and therefore probably rare disease pattern. Several limitations of the study and the video case-based vignettes are described within the discussion section.

Physicians have to be sensitized for multimorbidity even more, and have to be taught in the prevalence of existing disease combinations. Communicating uncertainty with other specialists could be helpful when faced with a sometimes “fuzzy” pattern of symptoms.

Partial Text

The encouraging fact that life expectancy of people increased over the last few decades is strongly associated with cumulative medical issues [1]. A high and increasing incidence of multimorbidity is closely linked to ageing and growing populations of elderly people in the context of demographic change [2–5]. Multimorbidity can be defined as the co-occurrence of two or more chronic medical conditions in one person [6]. Nevertheless definitions are characterized by a high heterogeneity [7], but meanwhile mostly distinguished from the concept of comorbidity [4,8]. For instance, impacts of multimorbidity are found in a reduced quality of life of affected persons, the need for enhanced interdisciplinary collaboration among physicians, and increased financial burden for health care systems [9–13]. Despite its high prevalence rates and substantial effects on patients, physicians and health care systems, medical research is still focused on diagnosis and treatment of single diseases [14]. Knowing that multimorbidity is highly relevant in our present and future society, we raised the research question of how well physicians can handle multimorbid medical cases. Consequently, this article focuses on how sensitive, confident, and accurate physicians are in diagnosing multimorbid patients.

In summary, 74 physicians performed a total of 269 medical cases, from which 98 were monomorbid and 171 were multimorbid. Of 1027 reported diagnoses in total, physicians mentioned 1 to 10 suspected diagnoses per person and case over the three video sequences (M = 3.82; SD = 1.79) (see also S3 File).

Even though the prevalence of multimorbid medical cases is increasing steadily, less is known about how accurate, confident and sensitive physicians are when diagnosing multimorbid patients. Our experimental study design with eight video case-based vignettes revealed some specific factors that make diagnosing multimorbid medical cases challenging for physicians. First of all, GPs and psychiatrists showed worse detection performance for cases that did not fully fall into their own medical field of specialization, as for example for mixed multimorbid cases (somatic and mental) [30–32]. Second, especially at the beginning of the diagnostic process, GPs and psychiatrists are significantly less certain about accurate suspected diagnoses, when confronted with a multimorbid patient. And third, physicians express significantly less certainty, if two underlying diseases were unrelated [33].

Multimorbidity continues to represent a major challenge within the diagnostic process. Our study revealed that detecting and diagnosing multimorbid medical cases seems to be that the less related the underlying diseases are, the more difficult detection and diagnosis are for physicians. Therefore, it is beneficial if future investigations explore and describe the incidence and relatedness of disease combinations and teach this knowledge to physicians. Finally, communicating about the uncertainty of suspected diagnoses with other specialists could help in further exploring and not missing a multimorbid disease pattern within patients.




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