John Goldie is a retired GP and medical educator.
Imagine a woman in her 50s comes in again with fatigue and joint pains. The notes describe her as a “…frequent attender, seeking reassurance.” Before she sits down, the frame is already in place — familiar, gravitational, quietly shaping what I expect to hear.
I realise, not entirely comfortably, that I have already decided what kind of consultation this will be.
But something doesn’t fit. Instead of moving briskly through the usual pattern, I pause and ask: “What feels important that we haven’t managed to cover in previous appointments?”
I realise, not entirely comfortably, that I have already decided what kind of consultation this will be.
The answer widens the frame. She describes escalating symptoms, a fear of not being believed, and a grief she has never voiced. What looked like reassurance-seeking reveals itself as misinterpreted suffering. Inflammatory illness remains possible. The story shifts because the frame shifts.
Moments like this are small and easily missed, yet they can change the trajectory of care. They show how interpretation can drift away from the patient — and how a single disconfirming question can pull it back.
Interpretive drift: the quiet hazard
General practice runs on interpretation. We make sense of patients’ accounts while managing time, uncertainty, and competing demands. Every consultation begins with a frame: the triage note, the receptionist’s summary, the memory of the last visit, the patient’s opening line.
These frames are necessary. They help us move quickly. But they also drift.
A label like “frequent attender” or “anxious” doesn’t just describe a patient — it shapes the consultation that follows. It changes the questions we ask, what we notice, and when we investigate. This happens quietly. We stop testing the frame and start working within it— a shift towards fast, intuitive reasoning that, while efficient, can leave assumptions unexamined.1
This is not simply cognitive. It is also relational and ethical. When drift occurs, the patient’s meaning is subtly reshaped to fit the frame already in place. For some patients — particularly those who feel unheard or easily dismissed — this becomes a form of harm.
A small discipline: epistemic clarity
To counter this, it is helpful to think in terms of a small, repeatable discipline: epistemic clarity. Not a new consultation model, but a micro-practice — something done in real time to keep interpretation close to the patient.
It has three parts.
- Hold the first frame lightly: Treat the inherited story as provisional. Notice its pull. If you can name the frame to yourself — “I’m assuming this is reassurance-seeking” — you are less likely to be captured by it.
- Test the fit collaboratively: Ask one disconfirming question. Make one assumption visible, “I may have got this wrong, but it sounds like…”
This is quick calibration — using epistemic humility to counter fast, intuitive judgement in a time-pressured setting.2 - Revise and proceed: Adjust the frame without defensiveness. Revision is routine clinical work. The consultation becomes a process of successive approximations, not a single early decision.
These steps take seconds, not minutes. But they can prevent the consultation from quietly narrowing around an untested assumption.
Why it matters
Diagnostic safety without extra burden: We often focus on cognitive bias and premature closure, but interpretive drift is more pervasive and less visible. A small discipline of checking and revising the frame can reduce error without adding complexity.
Relational justice in pressured systems
In systems shaped by triage and fragmented continuity, early framing carries more weight. Epistemic clarity helps protect patients from being misheard or prematurely categorised — particularly those at risk of epistemic injustice.3
Team-based framing
Naming the process makes it easier to share, teach, and refine.
Frames are not created in the consulting room alone. They begin at first contact. Developing a shared language of provisional frames and working understandings can help teams avoid fixing the story too early.
Teachability
This practice can be trained in small ways:
- generate one disconfirming question
- ask, “What did I assume?
- notice what surprised you
Naming the process makes it easier to share, teach, and refine.
A quiet safety practice
In general practice, the first diagnosis we make is often not a disease but a frame — a decision, usually unspoken, about what kind of problem this is and what kind of patient is in front of us.
Epistemic clarity is the discipline of revisiting that first diagnosis before it hardens.
In a ten-minute consultation, that small act of revision may be one of the most important safety practices in general practice.
References
- Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Educ. 2009;14(Suppl 1):27–35. DOI: 10.1007/s10459-009-9182-2
- Celi LA, Dorotic M, Dubin J, Nazarian N, Salarikia R. Epistemic humility for physicians and scientists. Lancet Reg Health Am. 2025;53: 101315. DOI: 10.1016/j.lana.2025.101315
- Kidd IJ, Carel H. Epistemic injustice in healthcare: a philosophical analysis. J Appl Philos. 2018;35(2):172–90. DOI: 10.1007/s11019-014-9560-2
Featured Photo by meriç tuna on Unsplash
