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Official Journal of the Society to Improve Diagnosis in Medicine (SIDM)

Editor-in-Chief: Graber, Mark L. / Plebani, Mario

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A randomized experimental study to assess the effect of language on medical students’ anxiety due to uncertainty

Arabella L. Simpkin
  • Corresponding author
  • Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
  • Harvard Medical School, Boston, MA, USA
  • Department of Pharmacology, University of Oxford, Oxford, UK, Phone: +1-347-556-3358
  • Email
  • Other articles by this author:
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/ Zachary Murphy / Katrina A. Armstrong
Published Online: 2019-02-12 | DOI: https://doi.org/10.1515/dx-2018-0050



Communication and handoff failures are common causes of diagnostic errors in hospital. Human quest for certainty can increase the likelihood of premature closure in decision-making, the most common phenomenon in misdiagnosis. Little research exists on whether language choice in handoffs affects physicians’ sense of uncertainty.


Medical students from a large US medical school were randomized to receive one of four language variations describing a presumed diagnosis in hypothetical handoffs from emergency department (ED) to inpatient ward. The control language arm used the word ‘diagnosis’; experimental arms replaced this word with either ‘hypothesis’, ‘probability of 60%’, or ‘working diagnosis’ with a short differential. Outcome measures were students’ anxiety due to uncertainty (range 5–30; higher scores indicating higher stress from uncertainty) and clinical uncertainty about the ED provider’s presumed diagnosis.


Mean anxiety due to uncertainty was significantly higher in subjects receiving the ‘hypothesis’ language arm compared to those receiving the control ‘diagnosis’ language [19.2 (4.6) vs. 15.5 (3.4); p<0.008]. Differences between subjects who received the probability language [17.2 (5.8) vs. 15.5 (3.4); p=0.26] and ‘working diagnosis’ language [16 (5) vs. 15.5 (3.4); p=0.69] were not statistically significant. There was no difference in items assessing clinical uncertainty after each scenario.


The word ‘hypothesis’ increased anxiety due to uncertainty compared to the word ‘diagnosis’, but did not change assessments of clinical uncertainty. Further research is needed to assess how use of language in clinical handoffs may influence perceptions and anxiety related to uncertainty and whether optimal language can be identified that leads to recognition of uncertainty without maladaptive stress or anxiety due to uncertainty.

Keywords: communication; clinical reasoning; decision-making; medical education; premature closure


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About the article

Received: 2018-07-12

Accepted: 2019-01-08

Published Online: 2019-02-12

Author contributions: Arabella L. Simpkin and Katrina A. Armstrong conceptualized and designed the study, and designed the data collection instruments. Arabella L. Simpkin and Zachary Murphy coordinated and supervised collection of data from participants. All authors carried out data analysis, and were responsible for drafting the manuscript, critical revision for important intellectual content, and final approval of the manuscript. Arabella L. Simpkin is the guarantor for the study. Arabella L. Simpkin affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained. All authors had full access to all the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

Research funding: None declared.

Employment or leadership: None declared.

Honorarium: None declared.

Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

Citation Information: Diagnosis, 20180050, ISSN (Online) 2194-802X, ISSN (Print) 2194-8011, DOI: https://doi.org/10.1515/dx-2018-0050.

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