Diagnostic uncertainty in physicians’ reasoning: a structured approach using BANI and GRACE2
-
Taro Shimizu
Abstract
Diagnostic uncertainty remains a persistent challenge in improving diagnostic practice, particularly for individual physicians. This paper applies the BANI (Brittle, Anxious, Nonlinear, Incomprehensible) framework to examine the nature of uncertainty encountered by physicians. Using clinical case examples, I demonstrate how BANI manifests in the diagnostic process and propose GRACE2, a six-element behavioral framework designed to support physicians in managing diagnostic uncertainty. GRACE2 integrates cognitive flexibility, adaptive reasoning, and empathic communication. Together with BANI, it offers a structured and actionable approach to enhancing physicians’ diagnostic decision-making, thereby contributing to the broader goal of improving diagnostic safety for patients.
-
Research ethics: Not applicable.
-
Informed consent: Not applicable.
-
Author contributions: The author has accepted responsibility for the entire content of this manuscript and approved its submission.
-
Use of Large Language Models, AI and Machine Learning Tools: None declared.
-
Conflict of interest: None declared.
-
Research funding: None.
-
Data availability: Not applicable.
References
1. Dahm, MR, Cattanach, W, Williams, M, Basseal, JM, Gleason, K, Crock, C. Communication of diagnostic uncertainty in primary care and its impact on patient experience: an integrative systematic review. J Gen Intern Med 2023;38:738–54. https://doi.org/10.1007/s11606-022-07768-y.Search in Google Scholar PubMed PubMed Central
2. Croskerry, P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003;78:775–80. https://doi.org/10.1097/00001888-200308000-00003.Search in Google Scholar PubMed
3. Shimizu, T, Graber, ML. An equation for excellence in clinical reasoning. Diagnosis (Berl) 2022;10:61–3. https://doi.org/10.1515/dx-2022-0060.Search in Google Scholar PubMed
4. Shimizu, T, Watanuki, S, Harada, Y, Kawamura, R, Amano, M, Isoda, S, et al.. Pioneering diagnosis in Asia: advancing clinical reasoning expertise through the lens of 3M. Diagnosis (Berl) 2025. https://doi.org/10.1515/dx-2024-0205. [Epub ahead of print.]Search in Google Scholar PubMed
5. Cascio, W, Aguinis, H. The BANI world: next steps for VUCA. Hum Resour Manag Rev 2021;31:100789.Search in Google Scholar
6. Graber, ML, Franklin, N, Gordon, R. Diagnostic error in internal medicine. Arch Intern Med 2005;165:1493–9. https://doi.org/10.1001/archinte.165.13.1493.Search in Google Scholar PubMed
7. Norman, G, Monteiro, S, Sherbino, J, Ilgen, JS, Schmidt, H, Mamede, S. The causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking. Acad Med 2017;92:23–30. https://doi.org/10.1097/acm.0000000000001421.Search in Google Scholar PubMed
8. White, RW, Horvitz, E. Cyberchondria: studies of the escalation of medical concerns in web search. ACM Trans Inf Syst 2009;27:23. https://doi.org/10.1145/1629096.1629101.Search in Google Scholar
9. Muse, K, McManus, F, Leung, C, Meghreblian, B, Williams, JM. Cyberchondriasis: fact or fiction? A preliminary examination of the relationship between health anxiety and searching for health information on the internet. J Anxiety Disord 2012;26:189–96. https://doi.org/10.1016/j.janxdis.2011.11.005.Search in Google Scholar PubMed
10. Djulbegovic, M, Elqayam, S. Many faces of rationality: implications of the great rationality debate for clinical decision-making. J Eval Clin Pract 2017;23:915–22. https://doi.org/10.1111/jep.12788.Search in Google Scholar PubMed PubMed Central
11. Wallace, EJC, Liberman, AL. Diagnostic challenges in outpatient stroke: stroke chameleons and atypical stroke syndromes. Neuropsychiatric Dis Treat 2021;17:1469–80. https://doi.org/10.2147/ndt.s275750.Search in Google Scholar PubMed PubMed Central
12. Harada, Y, Otaka, Y, Katsukura, S, Shimizu, T. Prevalence of atypical presentations among outpatients and associations with diagnostic error. Diagnosis (Berl) 2023;11:40–8. https://doi.org/10.1515/dx-2023-0060.Search in Google Scholar PubMed
13. Shimizu, T. Physician’s prism: illuminating history with structured expertise. Diagnosis (Berl) 2025. https://doi.org/10.1515/dx-2025-0003. [Epub ahead of print.].Search in Google Scholar PubMed
14. Rousseaux, M, Sève, A, Vallet, M, Pasquier, F, Maowiak-Cordoliani, MA. An analysis of communication in conversation in patients with dementia. Neuropsychologia 2010;48:3884–90. https://doi.org/10.1016/j.neuropsychologia.2010.09.026.Search in Google Scholar PubMed
15. Mewes, R. Recent developments on psychological factors in medically unexplained symptoms and somatoform disorders. Front Public Health 2022;10:1033203. https://doi.org/10.3389/fpubh.2022.1033203.Search in Google Scholar PubMed PubMed Central
16. Kurlansik, SL, Maffei, MS. Somatic symptom disorder. Am Fam Physician 2016;93:49–54.Search in Google Scholar
17. Henningsen, P, Zipfel, S, Herzog, W. Management of functional somatic syndromes. Lancet 2007;369:946–55. https://doi.org/10.1016/s0140-6736-07-60159-7.Search in Google Scholar
18. Paas, F, Renkl, A, Sweller, J. Cognitive load theory and instructional design: recent developments. Educ Psychol 2003;38:1–4. https://doi.org/10.1207/s15326985ep3801_1.Search in Google Scholar
19. Kurvers, RHJM, Herzog, SM, Hertwig, R, Krause, J, Carney, PA, Bogart, A, et al.. Boosting medical diagnostics by pooling independent judgments. J Med Internet Res 2016;18:e79.10.1073/pnas.1601827113Search in Google Scholar PubMed PubMed Central
20. Boyle, JG, Walters, MR, Jamieson, S, Durning, SJ. Distributed cognition: theoretical insights and practical applications to health professions education: AMEE guide no. 159. Med Teach 2023;45:1323–33. https://doi.org/10.1080/0142159x.2023.2190479.Search in Google Scholar
21. Salas, E, Sims, DE, Burke, CS. Is there a “big five” in teamwork? Small Group Res 2005;36:555–99. https://doi.org/10.1177/1046496405277134.Search in Google Scholar
22. Smith, KM, Valenta, AL. Safety I to safety II: a paradigm shift or more work as imagined? Comment on “false dawns and new horizons in patient safety research and practice.” Int J Health Pol Manag 2018;7:671–3. https://doi.org/10.15171/ijhpm.2018.24.Search in Google Scholar PubMed PubMed Central
23. Smith, MW, Davis Giardina, T, Murphy, DR, Laxmisan, A, Singh, H. Resilient actions in the diagnostic process and system performance. BMJ Qual Saf 2013;22:1006–13. https://doi.org/10.1136/bmjqs-2012-001661.Search in Google Scholar PubMed PubMed Central
24. Teece, DJ, Peteraf, MA, Leih, S. Dynamic capabilities and organizational agility: risk, uncertainty, and strategy in the innovation economy. Calif Manag Rev 2016;58:13–35. https://doi.org/10.1525/cmr.2016.58.4.13.Search in Google Scholar
25. Croskerry, P. Adaptive expertise in medical decision making. Med Teach 2018;40:803–8. https://doi.org/10.1080/0142159x.2018.1484898.Search in Google Scholar PubMed
26. Patterson, ES, Su, G, Sarkar, U. Reducing delays to diagnosis in ambulatory care settings: a macrocognition perspective. Appl Ergon 2020;82:102965. https://doi.org/10.1016/j.apergo.2019.102965.Search in Google Scholar PubMed PubMed Central
27. Mylopoulos, M, Regehr, G. Cognitive metaphors of expertise and knowledge: prospects and limitations for medical education. Med Educ 2007;41:1159–65. https://doi.org/10.1111/j.1365-2923.2007.02912.x.Search in Google Scholar PubMed
28. Taylor, MJ, McNicholas, C, Nicolay, C, Darzi, A, Bell, D, Reed, JE. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf 2014;23:290–8. https://doi.org/10.1136/bmjqs-2013-001862.Search in Google Scholar PubMed PubMed Central
29. Prakash, S, Sladek, RM, Schuwirth, L. Interventions to improve diagnostic decision making: a systematic review and meta-analysis on reflective strategies. Med Teach 2019;41:517–24. https://doi.org/10.1080/0142159x.2018.1497786.Search in Google Scholar
30. Royce, CS, Hayes, MM, Schwartzstein, RM. Teaching critical thinking: a case for instruction in cognitive biases to reduce diagnostic errors and improve patient safety. Acad Med 2019;94:187–94. https://doi.org/10.1097/acm.0000000000002518.Search in Google Scholar
31. Kotwal, S, Howell, M, Zwaan, L, Wright, SM. Exploring clinical lessons learned by experienced hospitalists from diagnostic errors and successes. J Gen Intern Med 2024;39:1386–92. https://doi.org/10.1007/s11606-024-08625-w.Search in Google Scholar PubMed PubMed Central
32. Sarasvathy, SD. Causation and effectuation: toward a theoretical shift from economic inevitability to entrepreneurial contingency. Acad Manag Rev 2001;26:243–63. https://doi.org/10.2307/259121.Search in Google Scholar
33. Amano, M, Harada, Y, Shimizu, T. Effectual diagnostic approach: a new strategy to achieve diagnostic excellence in high diagnostic uncertainty. Int J Gen Med 2022;15:8327–32. https://doi.org/10.2147/ijgm.s389691.Search in Google Scholar PubMed PubMed Central
34. Sacco, AY, Self, QR, Worswick, EL, Couperus, CJ, Kolli, SS, Muñoz, SA, et al.. Patients’ perspectives of diagnostic error: a qualitative study. J Patient Saf 2021;17:e1759–64. https://doi.org/10.1097/pts.0000000000000642.Search in Google Scholar PubMed
35. Singh, H, Upadhyay, DK, Torretti, D. Developing health care organizations that pursue learning and exploration of diagnostic excellence: an action plan. Acad Med 2020;95:1172–8. https://doi.org/10.1097/acm.0000000000003062.Search in Google Scholar PubMed PubMed Central
36. Yokose, M, Harada, Y, Shimizu, T. The reply. Am J Med 2020;133:e328. https://doi.org/10.1016/j.amjmed.2020.02.011.Search in Google Scholar PubMed
37. Shimizu, T, Tokuda, Y. System 3 diagnostic process: the lateral approach. J Gen Intern Med 2013;5:873–4. https://doi.org/10.2147/ijgm.s36859.Search in Google Scholar PubMed PubMed Central
38. Zwaan, L. Cognitive bias in large language models: implications for research and practice. NEJM AI 2024;1:1. https://doi.org/10.1056/aie2400961.Search in Google Scholar
39. Dunn, TL, Gaspar, C, McLean, D, Koehler, DJ, Risko, EF. Distributed metacognition. Technol Mind Behav 2021;2:1–10. https://doi.org/10.1037/tmb0000039.Search in Google Scholar
40. Brown, T. Design thinking. Harv Bus Rev 2009;86:84–92.10.3724/SP.J.1187.2009.04086Search in Google Scholar
© 2025 Walter de Gruyter GmbH, Berlin/Boston
