Drawing a line in the sand’: Physician diagnostic uncertainty in pediatric chronic pain

Background: Diagnostic uncertainty is the subjective perception of an inability to provide an accurate explanation of the patient’s health problem or that a label is missing or incorrect. While recently explored in youth with chronic pain and families, this is the first study to investigate diagnostic uncertainty from the perspectives of physicians. Methods: Individual, semi-structured interviews were conducted with sixteen pediatricians who assess and/or treat youth who experience complex chronic pain. Interviews explored pediatricians’ perceptions, beliefs, and confidence regarding the assessment and management of chronic pain in youth and how they manage uncertainty regarding the diagnosis. Interviews were analysed using inductive reflexive thematic analysis. Results: Analyses generated one prominent theme: ‘drawing a line in the sand’. Within this theme, physicians discussed uncertainty as inherent to their role treating youth with chronic pain. The metaphor of ‘drawing a line in the sand’ was used to describe a process of identifying a point at which physicians no longer sought a new diagnosis for the child’s pain or continued diagnostic investigations. This line was influenced by numerous factors, which are highlighted through four subthemes: physician training, experience, and mentorship; individual patient and family factors; perceived reassurance of diagnostic investigations; and the broader social context and implications. Conclusions: How physicians manage diagnostic uncertainty must be understood, as it is likely to critically impact how a diagnosis of chronic pain is communicated, the diagnostic investigations undertaken, the wait time to receiving a diagnosis, and ultimately youths’ pain experiences.