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Systems and culture

Improving how differential diagnosis is made, communicated, and recorded in acute care


Diagnosis is an essential part of healthcare services. But the diagnostic process is complex, influenced by a number of practical, legal, and ethical issues.

This complexity begins when a patient first presents with symptoms. The doctor must start by considering a list of possible causes – known as “differential diagnosis” – while being careful not to eliminate any possibilities too early, which could lead to late or incorrect diagnosis. The doctor must also determine how to communicate these possible diagnoses to the patient while protecting them from unnecessary stress.

This presents a number of challenges, especially given the inherent uncertainty around diagnoses and their outcomes. And these challenges are magnified in acute care settings like emergency departments and medical units, where time is often limited and the stakes of a wrong diagnosis are high. There are also institutional factors to consider, like electronic health records that don’t allow for nuance in recording the uncertainty of a diagnosis, and legal requirements on how to inform patients about the risks of potential treatments.

Given these complexities, there is a surprising lack of clear professional guidance or legal requirements for what doctors should tell patients, what they should record, and in what circumstances. This is perhaps because the diagnostic process and the variations within in are still not well understood.

This project will take a closer look at how diagnosis is made, communicated, and recorded in acute care with the goal of improving the process for doctors and patients.


Our study will involve multiple workstreams, beginning with a literature review covering the ethical and philosophical influences on medical diagnosis.

The next phase will involve observing the diagnostic process in acute care settings and interviewing the healthcare practitioners, patients, and families that we observe. We will also interview policymakers, managers and lawyers about the broader considerations around diagnosis.

Two online vignette studies will specifically examine the communication of diagnostic uncertainty. One will involve clinicians (exploring what they typically communicate regarding diagnostic uncertainty and their reasons for this), and the other will involve patients (exploring the effects of communicating different levels of diagnostic uncertainty to them).

After an analysis of these observations and interviews, we will develop an ethically and legally grounded framework for making, communicating, and recording diagnosis.

Funding and ethics

This study is funded by the Health Foundation’s grant to The Healthcare Improvement Studies Institute (THIS Institute) and  the Wellcome Trust. It is independently led by THIS Institute . The study was reviewed by East of England – Essex Research Ethics Committee.

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