Delivering a diagnosis

A learner explains a diagnosis to an SP.
[Girolamo Mercuriali via wikimedia]

When learners try to give me a diagnosis, I often feel unsatisfied because the explanation is missing one or more key components that will help my understanding.

When I go to the doctor I want to know these things in this order:

• How has this conclusion been reached? Without a summary of findings or history, I have less ability to relate the diagnosis to my chief complaint. Transparency allows me to trust the diagnosis when it comes.

• What is it? The diagnosis should include the medical term and the layman term if there is one. For instance, if the diagnosis is "Non-Hodgkins Disease" or a "lymphoma," I may not understand the learner is telling me I have cancer. If it is a serious diagnosis, I ask learners to leave a beat at this point so I have a chance to process it before continuing with the other parts.

• What does the patient know about it? After the diagnosis has been named and I know how the doctor has reached that conclusion, it is very effective if the student-doctor opens up the conversation with, "What do you know about [X]?" This allows the patient to lead the conversation and it gives the opportunity for the student-doctor to clear up any misunderstandings or praise the patient for their knowledge.

• How serious is it? Regardless of the diagnosis, there is always a range of outcomes and consequences. I will likely leap to the worst-case scenario unless I know what the range is. My perception may also change based on any previous experiences I've had (directly or indirectly) with the diagnosis. If I'm not going to die immediately, hearing, "X% of people with this diagnosis have Y happen to them" is really helpful. This is especially true if I am hearing the results of a screening test as opposed to a true diagnosis. 

• How long will this affect me? Knowing whether the diagnosis will affect me for three days or three years shapes my ability to understand the scope and impact of the diagnosis. Sometimes learners tell me they will "treat" my condition for a period of time: when I hear this, as a patient I think they mean they will cure it. So I want learners to be clear whether this is a treatment meant to prolong my life, or whether my condition is something that will resolve after treatment.

• What's the next step? And equally importantly, what's my next step? Even if my next step is "wait until the test results come back in 2-3 days," I still know what to do.

Plain language, reassurance, validation, empathy, teach back, collaboration, etc. are good tools to use within this framework, too, but they can't be used to replace one of these steps.

For example:

"Based on your coughing & fever, and those sounds I heard in your lungs, I think you probably have pneumonia, which is a lung infection that causes fluid to build up in your lungs. You're young and healthy so I'm not too concerned right now, but I'm glad you came in so we can treat it before it gets worse. Fortunately, it will probably get better in a couple of weeks after we begin treatment. I'm going to recommend a chest X-ray and a test of what you're coughing up so we know for sure it's pneumonia and so we know what kinds of medications to give you. How does that sound?"

Learners are of course welcome to elaborate on these points if the patient indicates they want more information or clarity. Otherwise, each of these steps should be no more than 1-2 sentences each.