Close Encounters of the Diagnostic Kind: Improving Provider–Patient Communication During the Diagnostic Process
Laura M. Cascella, MA
The model of the diagnostic team, proposed in the Institute of Medicine’s (IOM’s) pivotal report Improving Diagnosis in Health Care, relies strongly on close collaboration with patients/families as part of the diagnostic process. In its recommendation for implementing a team approach, the IOM notes “Health care professionals and organizations are responsible for creating environments in which patients and their families can learn about and engage in the diagnostic process and provide feedback about their experience.”1
Yet, even with this growing emphasis on patient engagement and collaboration, communication failures continue to be a top risk factor in diagnostic errors. Ten years of MedPro Group closed claims data show that communication issues are the second most common contributing factor in diagnosis-related malpractice claims, occurring in 33 percent of these cases — and these issues have remained persistent over the years.2
Because diagnosis is a complex process that involves various interactions between providers and patients/families, many opportunities for miscommunication can occur. One noted area that is prone to these lapses is the provider–patient encounter. A JAMA study that focused on the types and origins of diagnostic errors in primary care found that more than 75 percent of the process breakdowns that led to diagnostic errors involved the provider–patient encounter.3 What goes wrong during these interactions? It’s not always clear, but various factors can play a role, such as:
- Ongoing distractions and interruptions in the care setting.
- Discomfort on the part of patients in reporting their symptoms or medical histories.
- Circumstances in which providers prematurely cut off patients while they’re talking. Studies have suggested that doctors will interrupt or redirect patients within the first 18–30 seconds of telling their stories.
- Situations in which patients/families feel that healthcare providers are devaluing their views or failing to understand their perspectives.
- Circumstances in which patients/families do not understand or fully comprehend health or treatment information.
These issues, alone or in combination, can lead to communication breakdowns, problems with data collection and synthesis, patient dissatisfaction, and — ultimately — diagnostic mistakes.
Tackling provider–patient communication issues can be tricky due to the somewhat nebulous nature of these problems. However, practitioners can employ various techniques and strategies to enhance interactions, build better partnerships, and engage patients/families in the diagnostic process. For example, providers can:
- Allow adequate time for dialogue, and repeat important information to confirm their understanding of a patient’s reason for visiting, concerns, and point of view.
- Make an effort to allow the patient to fully voice his/her concerns without interruption.
- Determine what the patient hopes to achieve as a result of the visit.
- Sit, rather than stand, while taking the patient’s history or reviewing clinical information.
- Ask open-ended questions to generate more thorough information. For example, “So, you’re having pain?” becomes “Can you tell me more about your pain?”
- Encourage questions and open dialogue. Ask whether the patient has questions or would like to offer any more information before the appointment concludes.
- Discuss health and treatment information using layman’s terms, and provide plain language patient educational materials.
- Use eye contact in face-to-face conversations. Eye contact is particularly important when using electronic health records, which might seem to depersonalize the patient encounter.
- Consider body language and how the patient might perceive it. For example, fidgeting or constantly looking at a computer screen might be construed as dismissive. Certain facial expressions might be considered judgmental, which may cause the patient to withhold information.
Although these strategies will not eliminate the potential for miscommunication, they might help providers (a) improve processes for gathering information, (b) build patient trust, and (c) reinforce a culture of safety — critical elements for improving the diagnostic process, reducing the risk of errors, and preventing liability claims.
Healthcare providers also can use patient-friendly tools and resources to help patients/ families become more active partners in the diagnostic team. Two examples of patient-friendly resources are the National Patient Safety Foundation’s Checklist for Getting the Right Diagnosis and Kaiser Permanente’s Smart Partners About Your Health. Adapted versions of both of these resources are available through the IOM’s Improving Diagnosis in Health Care: Resources for Patients, Families, and Health Care Professionals.
1National Academies of Sciences, Engineering, and Medicine. (2015). Improving diagnosis in health care. Washington, DC: The National Academies Press.
2MedPro Group closed claims data, 2007–2016.
3Singh, H., Giardina, T. D., Meyer, A. N., Forjuoh, S. N., Reis, M. D., & Thomas, E. J. (2013, March 25). Types and origins of diagnostic errors in primary care settings. JAMA Internal Medicine, 173(6), 418–425.
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