Real time self-rating of decision certainty by clinicians: A systematic review

Abstract

Background We sought to establish to what extent decision certainty has been measured in real time and whether high or low levels of certainty correlate with clinical outcomes. Methods Our pre-specified study protocol is published on PROSPERO, CRD42019128112. We identified prospective studies from Medline, Embase and PsycINFO up to February 2019 that measured real time self-rating of the certainty of a medical decision by a clinician. Findings Nine studies were included and all were generally at high risk of bias. Only one study assessed long-term clinical outcomes: patients rated with high diagnostic uncertainty for heart failure had longer length of stay, increased mortality and higher readmission rates at 1 year than those rated with diagnostic certainty. One other study demonstrated the danger of extreme diagnostic confidence – 7% of cases (24/341) labelled as having either 0% or 100% diagnostic likelihood of heart failure were made in error. Conclusions The literature on real time self-rated certainty of clinician decisions is sparse and only relates to diagnostic decisions. Further prospective research with a view to generating hypotheses for testable interventions that can better calibrate clinician certainty with accuracy of decision making could be valuable in reducing diagnostic error and improving outcomes.