TL;DR — What to Say When You Don’t Have an Answer
The mindset shift: When treating patients with acute complaints, especially in the ED or urgent care, your job isn’t to diagnose everything. It’s to determine whether something dangerous is happening right now. Those are different goals, and they don’t always produce the same outcome.
What to say: “My job today was to rule out the big, bad, scary things. And I can tell you that’s not what’s going on here.” Then tell them what you specifically ruled out, what you think is most likely, and what symptoms should bring them back.
When this comes up most: Abdominal pain, chest pain, headache, dizziness. These are the complaints where the right outcome is ruling out the bad stuff and reassuring the patient, even when a definitive diagnosis isn’t available.
What to build: Comfort with uncertainty. You aren’t always going to have the answers. Come to terms with that sooner rather than later.
I spent the early part of my PA career in the emergency room, and “abdominal pain” was the chief complaint that frustrated me the most (eh, besides maybe “weakness”). Not because it was the most complicated, but because I could ask all the right questions, order every test known to man and still walk back in the room with no definitive answers for the patient. I ruled out appendicitis, obstruction, cancer, perfs, I checked what needed to be checked, and then I had to explain that I couldn’t tell them exactly what was causing their pain.
That’s a hard conversation to have, especially when you’re new, because it feels like you’ve failed them. You went to school for years, did the rotations, learned all the differentials and tests to order and how to interpret them, and now someone is looking at you expecting a diagnosis and you don’t have one. My initial instinct was to fill the silence with something that sounds more certain than it actually is, or to just rush through the discharge process so I didn’t have to have an uncomfortable conversation.
But neither of those is the right move. And understanding why takes a shift in how you think about what your job actually is.
What School Doesn’t Teach You
Medical education is built around diagnosis. You learn to work up a complaint, narrow the differential, and land on a conclusion. What programs don’t spend much time on is what to do when the workup is complete and the conclusion is “this isn’t immediately life-threatening, but I can’t tell you exactly what it is.”
In urgent care and emergency medicine, that outcome is actually a legitimate clinical result. A patient came in because they were scared something serious was happening. Your job was to find out if it was. When the answer is no, and you can explain why you know that, you’ve done your job. You won’t be able to give every patient a diagnosis, but you DO owe them a thorough, honest evaluation and a clear explanation of where things stand.
The shift is understanding that diagnosis and safe disposition are two different things. They often come together, but sometimes they don’t, and in this setting especially, knowing how to navigate that gap is one of the more important skills you’ll develop.
The Line That Changed How I Handled It
At some point, I landed on a line I used consistently: “My job today was to rule out the big, bad, scary things, and I can tell you that’s not what’s going on here. I know it can be frustrating to not have an answer, but let’s go over what I do know.”
It’s not a script. It’s just an honest description of what actually happened, and it does something important. It gives the patient a framework for understanding the visit that isn’t “my provider didn’t figure out what’s wrong with me.” It tells them what you did, why it matters that you did it, and why they can go home feeling reasonably okay about that.
From there, the conversation depends on the situation. For abdominal pain where everything is reassuring, I’d add what I specifically ruled out and why that mattered, what I thought was most likely even if I wasn’t certain, and what symptoms would bring them back. “This is most consistent with a GI bug or muscle strain, but if your pain gets significantly worse, if you develop a fever, or if anything new comes up, I want you to come back or go to the ER.” That’s a real, human conversation, and patients respond to it differently than they respond to a vague “everything looks fine, follow up with your PCP” with no explanation of what “fine” actually means.
The specificity is what makes the difference. Telling someone you’re not concerned about appendicitis based on their exam and labs lands completely differently than telling them everything looks okay. One shows your reasoning while the other sounds like you’re trying to get them out the door.
What Clinical Uncertainty Actually Looks Like
New providers tend to confuse not having a definitive diagnosis with not being a good clinician, and the two genuinely aren’t the same thing. Some presentations don’t resolve into a clean answer in a single visit. Abdominal pain is one of the more common examples, but chest pain in a young low-risk patient can be another, and headache and dizziness both show up on that list regularly. You can do thorough, careful workups on all of those and the patient can still leave without a confirmed diagnosis. That’s okay if you’ve thought clearly about and documented what needs to be ruled out and done it.
What actually matters is whether you asked the right questions and considered what could seriously harm this person. Did you address the red flags and does your documentation reflect your reasoning? If yes, then walking out of that room without a perfect answer doesn’t mean you’re a bad provider. It’s just the reality of practicing in the real world with real humans who don’t present like textbooks.
I will say, the thing most worth paying attention to is your gut. When their exam doesn’t fit their story, when something in the presentation is nagging at you and you can’t explain why, that’s worth sitting with for a few extra minutes. But that’s a different feeling from not having a clean label at the end of a visit where nothing concerning turned up.
The providers who worried me in practice weren’t the ones willing to admit that they were uncertain, it was the ones who dismissed patients’ concerns or rushed through a workup or punted the responsibility to the PCP. That’s where things get missed and patient care suffers, and patients can feel it.
Saying “I can tell you what this isn’t, and I feel good about that, but I can’t tell you exactly what it is right now” isn’t a sign of weakness. It’s an honest description of a legitimate situation, and most patients, when you explain your reasoning, will receive it that way.
Honesty and humility go a long way in medicine. Try to remember this the next time you have a patient staring at you waiting for an answer you don’t have.