The diagnostic certainty levels of junior clinicians: a retrospective cohort study

Background: Clinical decision-making is influenced by many factors, including clinicians’ perceptions of the certainty around what is the best course of action to pursue. Objective: To characterise the documentation of working diagnoses and the associated level of real-time certainty expressed by clinicians and to gauge patient opinion about the importance of research into clinician decision certainty. Method: This was a single-centre retrospective cohort study of non-consultant grade clinicians and their assessments of patients admitted from the emergency department between 01 March 2019 and 31 March 2019. De-identified electronic health record proformas were extracted that included the type of diagnosis documented and the certainty adjective used. Patient opinion was canvassed from a focus group. Results: During the study period, 850 clerking proformas were analysed; 420 presented a single diagnosis, while 430 presented multiple diagnoses. Of the 420 single diagnoses, 67 (16%) were documented as either a symptom or physical sign and 16 (4%) were laboratory-result-defined diagnoses. No uncertainty was expressed in 309 (74%) of the diagnoses. Of 430 multiple diagnoses, uncertainty was expressed in 346 (80%) compared to 84 (20%) in which no uncertainty was expressed. The patient focus group were unanimous in their support of this research. Conclusion: The documentation of working diagnoses is highly variable among non-consultant grade clinicians. In nearly three quarters of assessments with single diagnoses, no element of uncertainty was implied or quantified. More uncertainty was expressed in multiple diagnoses than single diagnoses. Implications: Increased standardisation of documentation will help future studies to better analyse and quantify diagnostic certainty in both single and multiple working diagnoses. This could lead to subsequent examination of their association with important process or clinical outcome measures

Forgone, but not forgotten: Toward a theory of forgone professional identities

Through an inductive, qualitative study, I developed a process model of how people deal with professional identities they have forgone by choice or constraint. I show that, when forgone professional identities are linked to unfulfilled values, people look for ways to enact them and retain them in the self-concept. I further identify three strategies that people use to enact foregone professional identities: (1) real enactment (i.e., enacting the forgone identity through real activities and social interactions either at work or during leisure time), (2) imagined enactment (i.e., enacting the forgone identity through imagined activities and interactions, either in an alternate present or in the future), and (3) vicarious enactment (i.e., enacting the forgone identity by observing and imagining close others enacting it and internalizing these experiences). These findings expand our conceptualization of professional identity beyond identities enacted through activities and interactions that are part of formal work roles, and illuminate the key role of imagination and vicarious experiences in identity construction and maintenance

Genomic epidemiology of SARS-CoV-2 in a UK university identifies dynamics of transmission

AbstractUnderstanding SARS-CoV-2 transmission in higher education settings is important to limit spread between students, and into at-risk populations. In this study, we sequenced 482 SARS-CoV-2 isolates from the University of Cambridge from 5 October to 6 December 2020. We perform a detailed phylogenetic comparison with 972 isolates from the surrounding community, complemented with epidemiological and contact tracing data, to determine transmission dynamics. We observe limited viral introductions into the university; the majority of student cases were linked to a single genetic cluster, likely following social gatherings at a venue outside the university. We identify considerable onward transmission associated with student accommodation and courses; this was effectively contained using local infection control measures and following a national lockdown. Transmission clusters were largely segregated within the university or the community. Our study highlights key determinants of SARS-CoV-2 transmission and effective interventions in a higher education setting that will inform public health policy during pandemics.</jats:p