Anatomy of diagnosis in a clinical encounter: how clinicians discuss uncertainty with patients

Maram Khazen, Erin E. Sullivan, Jason Ramos, Maria Mirica, Mark Linzer, Gordon D. Schiff, Andrew P. J. Olson

Research output: Contribution to journalArticlepeer-review

12 Scopus citations


Background: Studies consider the clinical encounter as linear, comprising six phases (opening, problem presentation, history-taking, physical examination, diagnosis, treatment and closing). This study utilizes formal conversation analysis to explore patient-physician interactions and understanding diagnostic utterances during these phases. Methods: This study is a qualitative sub-analysis that explores how the diagnosis process, along with diagnostic uncertainty, are addressed during 28 urgent care visits. We analyzed physicians’ hypothesis-generation process by focusing on: location of diagnostic utterances during the encounter; whether certain/uncertain diagnostic utterances were revised throughout the encounter; and how physicians tested their hypothesis-generation and managed uncertainty. We recruited 7 primary care physicians (PCPs) and their 28 patients from Brigham and Women’s Hospital (BWH) in 3 urgent care settings. Encounters were audiotaped, transcribed, and coded using NVivo12 qualitative data analysis software. Data were analyzed inductively and deductively, using formal content and conversation analysis. Results: We identified 62 diagnostic communication utterances in 12 different clinical situations. In most (24/28, 86%) encounters, the diagnosis process was initiated before the diagnosis phase (57% during history taking and 64% during physical examination). In 17 encounters (61%), a distinct diagnosis phase was not observed. Findings show that the diagnosis process is nonlinear in two ways. First, nonlinearity was observed when diagnostic utterances occurred throughout the encounter, with the six encounter phases overlapping, integrating elements of one phase with another. Second, nonlinearity was noted with respect to the resolution of diagnostic uncertainty, with physicians acknowledging uncertainty when explaining their diagnostic reasoning, even during brief encounters. Conclusions: Diagnosis is often more interactive and nonlinear, and expressions of diagnostic assessments can occur at any point during an encounter, allowing more flexible and potentially more patient-centered communication. These findings are relevant for physicians’ training programs and helping clinicians improve their communication skills in managing uncertain diagnoses.

Original languageEnglish (US)
Article number153
JournalBMC Primary Care
Issue number1
StatePublished - Dec 1 2022

Bibliographical note

Funding Information:
Dr. Olson is supported by the Alliance for Academic Internal Medicine, CRICO (Harvard Risk Management Foundation), and the Gordon and Betty Moore Foundation for work focused on improving diagnostic safety. Dr. Schiff acknowledges the support of the Gordon and Betty Moore Foundation and CRICO (Harvard Risk Management Foundation) for diagnostic safety work. Dr. Linzer is supported by CRICO (Harvard Risk Management Foundation) for diagnostic safety work as a consultant. Dr. Khazen is supported by a post-doctorate fellowship by the Israeli Council of Higher Education.

Funding Information:
The authors declare that there are no competing interests. Dr. Linzer declares support through his place of employment (Hennepin Healthcare) by the American Medical Association (AMA), American College of Physicians (ACP), the Optum Office for Provider Advancement (OPA), Essentia Health Systems, Gillette Children’s Hospital, the Institute for Healthcare Improvement (IHI), and the American Board of Internal Medicine Foundation (ABIMF) for burnout prevention research, projects, and training. He is also supported for scholarly work by the NIH and the US Federal Agency for Healthcare Quality and Research.

Publisher Copyright:
© 2022, The Author(s).

PubMed: MeSH publication types

  • Journal Article
  • Research Support, Non-U.S. Gov't


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