Improving Diagnosis in Health Care

Resources to Facilitate Communication Between Patients and Clinicians September 22, 2015

The 2015 report Improving Diagnosis in Health Care says that patients and their loved ones should be central members of the diagnostic team; they provide vital input that informs diagnosis and decisions about the path of care. Yet for a variety of reasons, patients may not be effectively engaged in the diagnostic process. For example, some patients may fear asserting themselves and coming across as “difficult,” because they are concerned that may influence the quality of care they receive. Some may lack familiarity with or adequate access to the health care system. Cultural and language barriers also can be significant challenges to full participation in the diagnostic process. Even if a patient speaks the same language as his or her clinicians, there can be communication challenges if the patient has limited health literacy or if clinicians use unfamiliar medical terminology.

Watch these videos to hear three people’s experiences with diagnosis and how communication affected their outcomes, and scroll down to view additional information and resources listed in the report.

Patients and Their Families Are Essential Members of the Diagnostic Team

Effective communication and collaboration among all members of the diagnostic team are essential to improve health care and outcomes and to reduce the risk of diagnostic error. Although there are a number of challenges to patient engagement in the diagnostic process, a critical step is for health care professionals and organizations to create environments in which patients and their families can learn about the diagnostic process and feel comfortable participating in this process. A number of patients, health care professionals, and organizations have developed information and resources to help patients learn about and engage in the diagnostic process. The report features two examples of resources—one by the National Patient Safety Foundation and Society to Improve Diagnosis in Medicine, and the other by Kaiser Permanente—designed to help patients get the right diagnosis. Scroll down to view them or download the PDF here.

Checklist for Getting the Right Diagnosis

Adapted from the National Patient Safety Foundation and the Society to Improve Diagnosis in Medicine*

Tell Your Story Well: Be clear, complete, and accurate when you tell your clinician about your illness.

  • Be Clear–Take some time to think about when your symptoms started, what made your symptoms better or worse, or if your symptoms were related to taking medications, eating a meal, exercising, or a certain time of day.
  • Be Complete–Try to remember all of the important information about your illness. Write down some notes and bring them with you. A family member may be able to help you with this
  • Be Accurate–Sometimes you may see multiple clinicians during a medical appointment. Make sure your clinicians hear the same story regarding your illness.

Be a Good Historian

  • Remember what treatments you have tried in the past, if they helped, and what, if any, side effects you experienced.
  • Think about how your illness has progressed over time.
  • Think about your family’s medical history and if you may be at risk for similar illnesses.

Keep Good Records

  • Keep your own records of test results, referrals, and hospital admissions.
  • Keep an accurate list of your medications.
  • Bring your medication list with you when you see your clinician or pharmacist.

Be an Informed Consumer

  • Learn about your illness by looking at reliable sources on the Internet or visit a local library.
  • Learn about the tests or procedures you are having done.
  • Learn about your medications:
    • Know the names of your medications (both generic and brand names). For example: Tylenol (brand name) and acetaminophen (generic name)
    • Know what the medication is for
    • Know the amount (dose) you need to take
    • Know the time(s) you need to take it during the day
    • Know the side effects to watch for and report to your clinician
    • Know if the medication interacts with any food or drugs

Take Charge of Managing Your Health

  • When meeting with your clinician, use the Ask Me 3 brochure, Good Questions for Getting the Right Diagnosis:
    • What could be causing my problem?
    • What else could it be?
    • When will I get my test results, and what should I do to follow up?
  • If you have more than one clinician, make sure each clinician knows what the other person is thinking and planning.
  • Make sure each clinician knows all of your test results, medications, or other treatments.
  • Be informed and involved in decisions about your health.

Know Your Test Results

  • Make sure both you and your clinician get the results from any tests that are done.
  • Don’t assume that no news is good news; call and check on your test results.
  • Ask what the test results mean and what needs to be done next.

Follow Up

  • Ask when you need to make another appointment (follow up) with your clinician once you start treatment.
  • Ask what to expect from the treatment or what it will do for you.
  • Ask what you need to do if you get new symptoms or start to feel worse.

Make Sure It Is the Right Diagnosis

  • Sometimes your diagnosis is the most “likely” thing that is wrong, but it may not be the “right” diagnosis.
  • Don’t be afraid to ask “What else could this be?”
  • Encourage your clinicians to think about other possible reasons for your illness.

Record Your Health Information and Monitor Your Progress

  • Track your health information and share it with your health care team in a structured format.a
a. One available resource is SIDM’s patient toolkit.

Adapted and reprinted, with permission, from the National Patient Safety Foundation and the Society to Improve Diagnosis in Medicine (2014). Ask Me 3 is a registered trademark of Pfizer Inc and is licensed to the National Patient Safety Foundation. 

Smart Partners About Your Health

Adapted from Kaiser Permanente*

Before your visit, think about… 

  • What you want to talk about during your visit
    What symptoms are you having? How long have you had them? Do they go away? Have you tried any home treatments? If so, what?
  • Inviting someone to go with you 
    Bringing someone to your appointment can help you to answer questions and give your clinician information. 
  • Write down your questions or some words that will help remind you 
    What concerns do you have about your symptoms? What concerns are most important to you?
  • Be prepared
    Be prepared to go over your medications, vitamins, and supplements. Make sure you mention any changes that you have made.

During your visit…

  • Confirm with your clinician why you are there
  • Your symptoms
    When did your symptoms start?
    Do they go away?
    Where are they located?
    How do they affect your daily activities?
  • Share what home treatments you have tried
    Did they help or make your symptoms worse?
  • Share your worries about your symptoms
  • Share what you think might be going on

Your diagnosis: consider asking the clinician…

• What else could it be?
• Do all my symptoms match your diagnosis?
• Could there be more than one thing going on? 

At the end of your visit…

  • Make sure you understand what you need to do next
    Repeat your treatment plan and the information you received from your clinician. If you don’t understand, ask your clinician to explain any words or ideas that are confusing. Talk about things that you feel might keep you from following the treatment plan. Talk about other treatment plans or options.
  • Be sure to ask for your after-visit summary 
  • Follow all your clinician’s instructions or let them know if you can’t

Copyright 2012 by Kaiser Permanente. Adapted and reprinted with permission.

*These checklists do not necessarily reflect committee consensus or the views of the National Academies of Sciences, Engineering, and Medicine but rather represent examples of ways that health care professionals and organizations can provide patients with opportunities to learn about the diagnostic process and become more actively involved in their health care.