Chapter 14
The pragmatics of diagnostic uncertainty
A closer look at hedges and shared understanding in diagnostic statements
Diagnosis is a complex communicative and clinical task. This interdisciplinary study explores diagnostic statements, specifically uncertainty, combining perspectives from medicine and linguistics. We infer divergent understanding of uncertainty expressions between patients and clinicians, linking them to diagnostic errors and shared decision making.
We analysed 16 role-play scenarios, applying discourse analysis to identify diagnostic statements and analyse them for shared understanding and expressions of uncertainty.
Results showed that in interactions linked to diagnostic error, clinicians heavily relied on evidence and expressed uncertainty indirectly through hesitations, false starts, and lengthy introductory phrases. This suggests clinicians use evidence and phrases as ‘shields’ to signal their lack of commitment to the diagnosis. If these shields aren’t recognised as such, shared understanding may be at risk.
Article outline
- 1.Introduction
- 2.Methods
- 2.1Data collection and participants
- 3.Analysis and analytical frameworks
- 4.Findings
- 4.1Diagnosis and diagnostic statements
- 4.2Trust: Approachability features
- 4.3Shared understanding
- 4.3.1(Un)explained medical terminology
- 4.3.2Self-repairs
- 4.4Hedges and expressions of uncertainty
- 4.4.1Explicit expressions of uncertainty
- 4.4.2Hedges: Implicit expressions of uncertainty
- 5.Discussion
- 5.1Explicit expression of uncertainty or certainty?
- 5.2Implicit expressions of uncertainty and explicated evidence as shields against diagnostic uncertainty
- 5.3Hedges as markers of relational work or diagnostic uncertainty?
- 6.Concluding remarks
-
References
-
Appendix
References (66)
Adolphs, Svenja, Sarah Atkins, and Kevin Harvey
2007 “
Caught Between Professional Requirements and Interpersonal Needs: Vague Language in Healthcare Contexts.” In
Vague Language Explored, edited by
Joan Cutting, 62–78. London: Palgrave Macmillan UK.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
AVANT
2019 “
Diagnosis-related claims.” Accessed April.
[URL].
Bates, Joanna, and Rodney Andrew
2001 “
Untangling the Roots of Some IMGs’ Poor Academic Performance.”
Academic Medicine 76 (1): 43–46.
[URL].
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Beck, Rainer S., Rebecca Daughtridge, and Phillip D. Sloane
2002 “
Physician-Patient Communication in the Primary Care Office: A Systematic Review.”
Journal of the American Board of Family Medicine 15 (1): 25–38.
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Bhise, Viraj, Ashley N. D. Meyer, Shailaja Menon, Geeta Singhal, Richard L. Street, Traber D. Giardina, and Hardeep Singh
2018 “
Patient Perspectives on how Physicians Communicate Diagnostic Uncertainty: An Experimental Vignette Study.”
International Journal for Quality in Health Care 30 (1): 2–8.
[URL]![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Bhise, Viraj, Suja S. Rajan, Dean F. Sittig, Robert O. Morgan, Pooja Chaudhary, and Hardeep. Singh
2018 “
Defining and Measuring Diagnostic Uncertainty in Medicine: A Systematic Review.”
Journal of General Internal Medicine 33 (1): 103–115.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Blanch, Danielle C., Judith A. Hall, Debra L. Roter, and Richard M. Frankel
2009 “
Is it Good to Express Uncertainty to a Patient? Correlates and Consequences for Medical Students in a Standardized Patient Visit.”
Patient Education and Counseling 76 (3): 300–306.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Bureau of Infrastructure and Transport Research Economics
2020 “
Road Safety Statistics.”
[URL].
Caffi, Claudia
1999 “
On Mitigation.”
Journal of Pragmatics 31 (7): 881–909.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Caffi, Claudia
2007 Mitigation. Amsterdam: Elsevier.
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Carroll, Stacey M.
2019 “
Respecting and Empowering Vulnerable Populations: Contemporary Terminology.”
The Journal for Nurse Practitioners 15 (3): 228–231.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Connelly, Lynne M.
2016 “
Trustworthiness in Qualitative Research.”
Medsurg Nursing 25 (6): 435–436.
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Cooke, Georga
2012 “
A is for Aphorism. Is it True that ‘a Careful History Will Lead to the Diagnosis 80% of the Time’?"
Australian Family Physician 41: 534–534.
[URL].
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Crisp, Jackie, Clint Douglas, Geraldine Rebeiro, and Donna Waters
2016 Potter & Perry’s Fundamentals of Nursing – Australian Version. Amsterdam: Elsevier Health Sciences APAC.
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Dahm, Maria. R.
2011 “
Exploring Perception and Use of Everyday Language and Medical Terminology Among International Medical Graduates in a Medical ESP Course in Australia.”
English for Specific Purposes 30 (3): 186–197.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Dahm, Maria. R.
2012 “
Coming to Terms with Medical Terms – Exploring Insights from Native and Non-native English Speakers in Patient-Physician Communication.”
Hermes-Journal of Language and Communication in Business (49): 79–98.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Dahm, Maria. R.
2018 “
A Socio-Cognitive Investigation of English Medical Terminology: Dynamic Varieties of Meaning.”
Lexicography 4 (1): 81–103.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Dahm, Maria. R., William Cattanach, Maureen Williams, Jocelyne Basseal, Kelly Gleason, and Carmel Crock
2023 “
Communication of Diagnostic Uncertainty in Primary Care and its Impact on Patient Experience: An Integrative Systematic Review.”
Journal of General Internal Medicine 38:738–754.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Dahm, Maria. R., and Carmel Crock
2022a “
Diagnostic Statements: A Linguistic Analysis of how Clinicians Communicate Diagnosis.”
Diagnosis 9 (3):316–322.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Dahm, Maria. R., and Carmel Crock
2022b “
Understanding and Communicating Uncertainty in Achieving Diagnostic Excellence.”
JAMA Journal of the American Medical Association 327 (12): 1127–1128.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Dahm, Maria. R., Diana Slade, Bernadette Brady, Liza Goncharov, and Laura Chien
2022 “
Tracing Interpersonal Discursive Features in Australian Nursing Bedside Handovers: Approachability Features, Patient Engagement and Insights for ESP Training and Working with Internationally Trained Nurses.”
English for Specific Purposes 66: 17–32.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Dahm, Maria. R., Maureen Williams, and Carmel Crock
2022 “
‘More Than Words’-Interpersonal Communication, Cognitive Bias and Diagnostic Errors.”
Patient Education and Counseling 105 (1): 252–256.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Dahm, Maria. R., and Lynda Yates
2013 “
English for the Workplace: Doing Patient-Centred Care in Medical Communication.”
TESL Canada Journal 30 (Special Issue 7): 21–44.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Fraser, Bruce
2010 “
Pragmatic Competence: The Case of Hedging.” In
New Approaches to Hedging, edited by
Gunther Kaltenböck,
Wiltrud Mihatsch and
Stefan Schneider, 15–34. Bingley, UK:Emerald.
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Gleason, Kelly, and Maria R. Dahm
2022 “
How Patients Describe their Diagnosis Compared to Clinical Documentation.”
Diagnosis 9 (2): 250–254.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Goffman, Erving
1959 The Presentation of Self in Everyday Life. Garden City, NY: Doubleday.
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Gordon, Geoffrey H., Sandra K. Joos, and Jennifer Byrne
2000 “
Physician Expressions of Uncertainty During Patient Encounters.”
Patient Education and Counseling 40 (1): 59–65.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Graber, Mark L.
2013 “
The Incidence of Diagnostic Error in Medicine.”
BMJ Quality & Safety 22 (Suppl 2): ii21–ii27.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Graber, Mark L, Nancy Franklin, and Ruthanna Gordon
2005 “
Diagnostic Error in Internal Medicine.”
Archives of Internal Medicine 165 (13): 1493–1499.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Hall, Mark A., Elizabeth Dugan, Beiyao Zheng, and Aneil. K. Mishra
2001 “
Trust in Physicians and Medical Institutions: What is it, Can it Be Measured, and Does it Matter?”
Milbank Quartely 79 (4): 613–39, v.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Heritage, John, and Amanda McArthur
2019 “
The Diagnostic Moment: A Study in US Primary Care.”
Social Science & Medicine 228: 262–271.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Howes, Christine, Matt Purver, Rose McCabe, Patrick G. T. Healey, and Mary Lavelle
2012 “
Helping the Medicine Go Down: Repair and Adherence in Patient-Clinician Dialogues.” In
Proceedings of the 16th Workshop on the Semantics and Pragmatics of Dialogue, September 19–21, 2012, Paris, France, edited by
Sarah Brown-Schmidt,
Jonathan Ginzburg and
Staffan Larsson, 155–156.
Hsieh, Hsiu-Fang, and Sarah E. Shannon
2005 “
Three Approaches to Qualitative Content Analysis.”
Qualitative Health Research 15 (9): 1277–1288.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Jucker, Andreas H., Sara W. Smith, and Tanja Lüdge
2003 “
Interactive Aspects of Vagueness in Conversation.”
Journal of Pragmatics 35 (12): 1737–1769.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Jutel, Annemarie Goldstein
2014 Putting a Name to it: Diagnosis in Contemporary Society. Baltimore: JHU Press.
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Jutel, Annemarie Goldstein
2021 “
Uncertainty and the Inconvenient Facts of Diagnosis.”
Endeavour 45 (1–2): 100764.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Kärkkäinen, Elise
2010 “
Position and Scope of Epistemic Phrases in Planned and Unplanned American English.”, edited by
Gunther Kaltenböck,
Wiltrud Mihatsch and
Stefan Schneider, 203–236. Bingley, UK: Emerald.
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Kurtz, Suzanne M.
2002 “
Doctor-Patient Communication: Principles and Practices.”
Canadian Journal of Neurological Sciences 29 Suppl 2: S23–9.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Lakoff, George
1973 “
Hedges: A Study in Meaning Criteria and the Logic of Fuzzy Concepts.”
Journal of Philosophical Logic 2 (4): 458–508.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Levinson, Wendy
2011 “
Patient-Centred Communication: A Sophisticated Procedure.”
BMJ Quality & Safety 20 (10): 823–5.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Levinson, Wendy, Pamela Hudak, and Andrea C. Tricco
2013 “
A Systematic Review of Surgeon-Patient Communication: Strengths and Opportunities for Improvement.”
Patient Education and Counseling 93 (1): 3–17.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Lewicki, Roy J., Edward C. Tomlinson, and Nicole Gillespie
2006 “
Models of Interpersonal Trust Development: Theoretical Approaches, Empirical Evidence, and Future Directions.”
Journal of Management 32 (6): 991–1022.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Locher, Miriam A., and Sage L Graham
2010 Interpersonal Pragmatics Berlin: De Gruyter Mouton.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Majumdar, Basanti, J. S. Keystone, and Lori A. Cuttress
1999 “
Cultural Sensitivity Training Among Foreign Medical Graduates.”
Medical Education 33 (3): 177–84.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
McCabe, Rose, and Patrick G. T. Healey
2018 “
Miscommunication in Doctor – Patient Communication.”
Topics in Cognitive Science 10 (2): 409–424.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
McCabe, Rose, Patrick. G. T. Healey, Stefan Priebe, Mary Lavelle, David Dodwell, Richard Laugharne, Amelia Snell, and Stephen Bremner
2013 “
Shared Understanding in Psychiatrist-Patient Communication: Association with Treatment Adherence in Schizophrenia.”
Patient Education and Counseling 93 (1): 73–9.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Miao, Melissa, Maria R. Dahm, Julie Li, Judith Thomas, and Andrew Georgiou
2020 “
Managing Uncertainty During the Communication of Diagnostic Test Information between Patients and Clinicians in Australian Emergency Care.”
Qualiative Health Research 30 (8): 1287–1300.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Moran, Katinka, and Walid Jammal
2018 “
Avant Research Reveals Factors Underlying Diagnostic Error Claims.” Accessed February 2022.
[URL].
National Academies of Science Engineering & Medicine (NASEM)
2015 Improving Diagnosis in Health Care. Washington DC: NASEM.
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Newman-Toker, David E., Adam C. Schaffer, C. Winnie Yu-Moe, Najlla Nassery, Ali S. Saber Tehrani, Gwendolyn D. Clemens, Zheyu Wang, Yuxin Zhu, Mehdi Fanai, and Dana Siegal
2019 “
Serious Misdiagnosis-related Harms in Malpractice Claims: The “Big Three” – Vascular events, Infections, and Cancers.”
Diagnosis 6 (3): 227–240.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
O’Grady, Catherine
2011 “
Teaching the Communication of Empathy in Patient-Centred Medicine.” In
English Language and the Medical Profession: Instructing and Assessing the Communication Skills of International Physicians, edited by
B. Hoekje and
S. Tipton, 43–72. Bingley, UK: Emerald.
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
O’Grady, Catherine, Maria R. Dahm, Peter Roger, and Lynda Yates
2014 “
Trust, Talk and the Dictaphone: Tracing the Discursive Accomplishment of Trust in a Surgical Consultation.”
Discourse & Society 25 (1): 65–83.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Ong, Lucille M. L., Johanna C. J. M. de Haes, Aloysia M. Hoos, and Frits B. Lammes
1995 “
Doctor-patient Communication: A Review of the Literature.”
Social Science & Medicine 40 (7): 903–918.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Parsons, Talcott
1975 “
The Sick Role and the Role of the Physician Reconsidered.”
The Milbank Memorial Fund Quarterly. Health and Society: 257–278.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Peräkylä, Anssi
2006 “
Communicating and Responding to Diagnosis.” In
Communication in Medical Care: Interaction between Primary Care Physicians and Patients, edited by
D. W. Maynard and
J. Heritage, 214–247. Cambridge: Cambridge University Press.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Prince, Ellen F., Joel Frader, and Charles Bosk
1982 “
On hedging in physician-physician discourse.”
Linguistics and the Professions 8 (1): 83–97.
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Rousseau, Denise M., Sim B. Sitkin, Ronald S. Burt, and Colin Camerer
1998 “
Not so Different After All: A Cross-Discipline View of Trust.”
Academy of Management Review 23 (3): 393–404.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Scott, Ian A, and Carmel Crock
2020 “
Diagnostic Error: Incidence, Impacts, Causes and Preventive Strategies.”
Medical Journal of Australia 213 (7): 302–305.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Simpkin, Arabella L., and Richard M. Schwartzstein
2016 “
Tolerating Uncertainty-The Next Medical Revolution?”
New England Journal of Medicine 375 (18): 1713–1715.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Singh, Hardeep, Traber Davis Giardina, Ashley N. D. Meyer, Samuel N. Forjuoh, Michael D. Reis, and Eric J. Thomas
2013 “
Types and Origins of Diagnostic Errors in Primary Care Settings.”
JAMA Internal Medicine 173 (6): 418–425.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Smulowitz, Peter
2020 “
The Illusion of Perfection.”
BMJ Quality & Safety 29 (4): 345–347.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Spencer-Oatey, Helen
2002 “
Managing Rapport in Talk: Using Rapport Sensitive Incidents to Explore the Motivational Concerns Underlying the Management of Relations.”
Journal of Pragmatics 34 (5): 529–545.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Stewart, Moira, Judith Belle Brown, W Wayne Weston, Ian R McWhinney, Carol L McWilliam, and Thomas R Freeman
2013 Patient-Centered Medicine: Transforming the Clinical Method. 3rd ed. Boca Raton: CRC press.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Wachter, Robert M.
2010 “
Why Diagnostic Errors Don’t Get Any Respect – And What Can Be Done About Them.”
Health Affairs 29 (9): 1605–1610.
![DOI logo](https://benjamins.com/logos/doi-logo.svg)
![Google Scholar](https://benjamins.com/logos/google-scholar.svg)
Cited by (1)
Cited by 1 other publications
This list is based on CrossRef data as of 5 july 2024. Please note that it may not be complete. Sources presented here have been supplied by the respective publishers.
Any errors therein should be reported to them.