Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia.
Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia.
Hum Reprod. 2020 Mar 27;35(3):660-668. doi: 10.1093/humrep/deaa005.
What are clinicians' views about the diagnosis of polycystic ovary syndrome (PCOS), and how do they handle any complexities and uncertainties in practice?
Clinicians have to navigate many areas of complexity and uncertainty regarding the diagnosis of PCOS, related to the diagnostic criteria, limitations in current evidence and misconceptions surrounding diagnosis, and expressed concern about the risk and consequences of both under- and overdiagnosis.
PCOS is a complex, heterogeneous condition with many areas of uncertainty, raising concerns about both underdiagnosis and overdiagnosis. Quantitative studies with clinicians have found considerable variation in diagnostic criteria used and care provided, as well as a lack of awareness around the breadth of PCOS features and poor uptake of recommended screening for metabolic complications. Clinicians' views about the uncertainties and complexities of diagnosing PCOS have not been explored.
STUDY DESIGN, SIZE, DURATION: Semi-structured telephone interviews were conducted with clinicians from September 2017 to July 2018 to explore their perceptions about the diagnosis of PCOS, including how they handle any complexities and uncertainties in practice.
PARTICIPANTS/MATERIALS, SETTING, METHODS: A group of 36 clinicians (15 general practitioners, 10 gynaecologists and 11 endocrinologists) currently practicing in Australia, were recruited through advertising via professional organisations, contacting a random sample of endocrine and gynaecology teams across Australia and snowballing. Transcribed audio-recordings were analysed thematically using Framework analysis.
Clinicians expressed a range of uncertainties and complexities regarding the diagnosis of PCOS, which were organised into three areas: (i) establishing diagnosis (e.g. lack of standardisation regarding diagnostic cut-offs, risk of misdiagnosis), (ii) factors influencing the diagnostic process (e.g. awareness of limitations in evidence and consideration of the benefits and harms) and (iii) strategies for handling challenges and uncertainties (e.g. using caution and communication of uncertainties). Clinicians also varied in their concerns regarding under- and overdiagnosis. Overall, most felt the diagnosis was beneficial for women provided that it was the correct diagnosis and time was taken to assess patient expectations and dispel misconceptions, particularly concerning fertility.
LIMITATIONS, REASONS FOR CAUTION: There is possible selection bias, as clinicians who are more knowledgeable about PCOS may have been more likely to participate. Clinicians' views may also differ in other countries.
These findings underscore the vital need to first consider PCOS a diagnosis of exclusion and use caution before giving a diagnosis in order to reduce misdiagnosis, as suggested by clinicians in our study. Until there is greater standardisation of diagnostic criteria, more transparent conversations with women may help them understand the uncertainties surrounding the criteria and limitations in the evidence. Additionally, clinicians emphasised the importance of education and reassurance to minimise the potential harmful impact of the diagnosis and improve patient-centred outcomes.
STUDY FUNDING/COMPETING INTEREST(S): The study was funded by the University of Sydney Lifespan Research Network and an NHMRC Program Grant (APP1113532). T.C. is supported by an Australian Government Research Training Program (RTP) Scholarship and a Sydney Medical School Foundation Scholarship, from the The University of Sydney, Australia. B.W.M. reports consultancy for ObsEva, Merck, Merck KGaA and Guerbet. No further competing interests exist.
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临床医生如何看待多囊卵巢综合征（PCOS）的诊断，以及他们在实践中如何处理任何复杂性和不确定性？
临床医生在诊断 PCOS 方面必须应对许多复杂和不确定的问题，这些问题涉及到诊断标准、当前证据的局限性以及围绕诊断的误解，同时还对过度诊断和漏诊的风险和后果表示担忧。
PCOS 是一种复杂、异质的疾病，存在许多不确定性，这引发了人们对过度诊断和漏诊的担忧。对临床医生进行的定量研究发现，他们在使用的诊断标准和提供的护理方面存在很大差异，而且对 PCOS 特征的广泛性以及对代谢并发症筛查的推荐接受程度也缺乏认识。临床医生对诊断 PCOS 的不确定性和复杂性的看法尚未得到探讨。
研究设计、规模、持续时间：2017 年 9 月至 2018 年 7 月期间，通过电话对澳大利亚的 36 名临床医生（15 名全科医生、10 名妇科医生和 11 名内分泌医生）进行了半结构化访谈，以探讨他们对 PCOS 诊断的看法，包括他们在实践中如何处理任何复杂性和不确定性。
参与者/材料、设置、方法：通过专业组织的广告、联系澳大利亚各地内分泌和妇科团队的随机样本以及滚雪球的方式，招募了目前在澳大利亚执业的一组 36 名临床医生（15 名全科医生、10 名妇科医生和 11 名内分泌医生）。转录的音频记录使用框架分析进行了主题分析。
临床医生对 PCOS 的诊断表示出一系列的不确定性和复杂性，这些问题可以分为三个方面：（i）建立诊断（例如，缺乏关于诊断截止值的标准化，误诊的风险），（ii）影响诊断过程的因素（例如，对证据局限性的认识以及对益处和危害的考虑），（iii）处理挑战和不确定性的策略（例如，谨慎使用和沟通不确定性）。临床医生对过度诊断和漏诊的担忧也各不相同。总的来说，大多数人认为只要诊断正确，并且有时间评估患者的期望并消除误解，特别是关于生育能力的误解，那么诊断对女性是有益的。
局限性、谨慎的原因：可能存在选择偏差，因为对 PCOS 了解更多的临床医生可能更有可能参与。在其他国家，临床医生的观点也可能有所不同。
这些发现强调了首先考虑将 PCOS 作为排除性诊断的必要性，并在做出诊断之前谨慎行事，以减少误诊，正如我们研究中的临床医生所建议的那样。在诊断标准更加标准化之前，与女性进行更透明的对话可能有助于她们理解标准的不确定性和证据的局限性。此外，临床医生强调了教育和保证的重要性，以尽量减少诊断的潜在有害影响，并改善以患者为中心的结果。
研究资助/利益冲突：该研究由悉尼大学寿命研究网络和澳大利亚 NHMRC 计划资助（APP1113532）。TC 得到澳大利亚政府研究培训计划（RTP）奖学金和悉尼医学院基金会奖学金的支持，来自澳大利亚悉尼大学。BWm 报告说，他为 ObsEva、默克、默克 KGaA 和 Guerbet 提供咨询服务。没有其他利益冲突。
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