Understanding what helps or hinders effective communication during diagnosis in acute medical settings: an ethnographic study

Why it matters

Effective communication makes a difference to whether – and how – patients understand the diagnostic process. The diagnostic process can be thought of like a journey that both the patient and doctor take together, with communication being crucial in deciding how closely they travel on the journey.

Communication in acute medical settings can be especially challenging because of time pressure, a chaotic and noisy environment, frequent interruptions, brief interactions without an established doctor-patient relationship, and patients’ distress. Studies have shown that many patients leave acute care without fully understanding their diagnosis.

Research has found that when patients don’t understand their diagnosis or the reasons for follow-up, they are less likely to follow discharge instructions or seek necessary follow-up care. Miscommunication can also delay proper diagnosis, especially if patients don’t understand a doctor’s concerns about their symptoms or don’t realise that a diagnosis is still tentative.

There haven’t been many empirical studies involving the direct observation of how doctors and clinicians communicate with their patients during the diagnostic process. This ethnographic study involving interviews and observations across three acute care settings in the UK aimed to identify communicative practices that encouraged or discouraged shared understanding between patients and doctors. 

What we found

We found several practices which seemed to help, or hinder shared diagnostic understanding between patient and doctor, and have separated them into three themes:

• Communicating what has been understood from the medical record

What the doctor says when they first greet a patient really matters. A patient might not have seen anybody reading their notes, even if the doctor has seen them in advance, so starting a consultation with, “what seems to be the problem?” can lead to the patient thinking that the doctor hasn’t taken the time to read their notes. Starting with “I’ve read your notes, but could you tell me what’s going on your own words?” could show them that the doctor knows the background and wants to find out more from the patient’s perspective.

• Sharing the thought process and diagnostic reasoning

When doctors clearly explained what they were doing along with their reasons for doing so, patients were more able to understand what was happening to them and in some cases felt less worried. For example, a patient who was referred for a CT scan could be concerned that a doctor was worried that they were looking for a brain tumour when this wasn’t the case. If they were told the reasons for the referral, it could save them unnecessary anxiety.

• Closing the loop and discharge communication.

Patients can be frustrated if they feel that they don’t have an opportunity to talk to anyone about their test results or ongoing care before they are discharged. This could be because they are discharged by a different doctor to the one they originally saw. As a result, they may feel their care was disorganised and unfinished – and that they haven’t been able to ‘close the loop’.

We found that clear communication promoted better understanding about the diagnostic process and making sure that patients knew what had already been done and what was achievable in acute settings helped to increase patient satisfaction levels. Being honest when doctors were uncertain about a diagnosis was also welcomed and people appreciated when the doctors shared their thought processes. This confirms the findings of a recent video vignette study which explored patient communication preferences in hypothetical scenarios involving diagnostic uncertainty.

Written information can also be helpful in doctor-patient communication; several reviews have found that giving patients written and/or visual materials when they are discharged improves their recall of information. Providing patients with a brief written discharge information card can also help patients understand their diagnosis on discharge, which shows that the amount of information given to patients doesn’t have to be extensive or detailed to help them ‘close the loop’.

Overall, the study found that in UK acute secondary settings, giving people more information about the diagnostic process often led to better shared understanding between doctor and patient, which helped to minimise the confusion and dissatisfaction that can result from misaligned expectations or conclusions about the diagnosis.

We have made practical recommendations and suggested areas for further research to evaluate whether changes in communication may also affect patient outcomes.