The patient narrative distortion index (PNDI): a framework to detect narrative loss as a hidden driver of diagnostic error

Background Patient narratives are foundational to diagnosis, yet clinicians frequently and unintentionally distort, minimize, or reinterpret these narratives during clinical encounters. These distortions – termed patient narrative distortion – are unmeasured contributors to diagnostic error [G.D. Schiff, O. Hasan, S. Kim, R. Abrams, K. Cosby, B.L. Lambert et al., Diagnostic error in medicine: analysis of 583 physician-reported errors, Arch Intern Med 169 (2009) 1881–1887; P. Croskerry, The importance of cognitive errors in diagnosis and strategies to minimize them, Acad Med 78 (2003) 775–780; H. Singh, A.N.D. Meyer, E.J. Thomas, The frequency of diagnostic errors in outpatient care, BMJ Qual Saf 23 (2014) 727–731; and M.L. Graber, N. Franklin, R. Gordon, Diagnostic error in internal medicine, Arch Intern Med 165 (2005) 1493–1499], emotional harm [J. Conway, F. Federico, K. Stewart, M.J. Campbell, Respectful Management of Serious Clinical Adverse Events, IHI Innovation Series White Paper, IHI, Cambridge, MA, 2011], and inequity [E.N. Chapman, A. Kaatz, M. Carnes, Physicians and implicit bias: how it affects clinical decision making, Acad Med 88 (2013) 354–360; and M. Marmot, R.G. Wilkinson (Eds.), Social Determinants of Health, 2nd ed., Oxford University Press, Oxford, 2005]. No existing safety tool captures the fidelity with which clinicians preserve patient stories [T. Greenhalgh, B. Hurwitz (Eds.), Narrative Based Medicine: Dialogue and Discourse in Clinical Practice, BMJ Books, London, 1998; and W. Levinson, D.L. Roter, J.P. Mullooly, V.T. Dull, R.M. Frankel, Physician-patient communication: the relationship with malpractice claims, JAMA 277 (1997) 553–559]. The stages at which narrative distortion emerges are illustrated in Figure 1. The objective of this article was to define patient narrative distortion as a measurable construct, develop a five-domain taxonomy, propose a scoring system (PNDI), and outline a workflow and validation strategy for clinical use. Methods We conducted iterative conceptual modeling and structured synthesis of the diagnostic-safety and narrative-medicine literatures [G.D. Schiff, O. Hasan, S. Kim, R. Abrams, K. Cosby, B.L. Lambert et al., Diagnostic error in medicine: analysis of 583 physician-reported errors, Arch Intern Med 169 (2009) 1881–1887; P. Croskerry, The importance of cognitive errors in diagnosis and strategies to minimize them, Acad Med 78 (2003) 775–780; H. Singh, A.N.D. Meyer, E.J. Thomas, The frequency of diagnostic errors in outpatient care, BMJ Qual Saf 23 (2014) 727–731; and M.L. Graber, N. Franklin, R. Gordon, Diagnostic error in internal medicine, Arch Intern Med 165 (2005) 1493–1499] to identify core distortion modes, develop domain definitions, item-level anchors, and scoring thresholds. We propose a multi-phase validation plan including content validity, inter-rater reliability, construct validity, criterion validity, and responsiveness. Results The PNDI taxonomy includes five domains: Narrative Completeness Distortion, Meaning Substitution Distortion, Salience Distortion, Context Stripping Distortion, and Bias-Driven Distortion [E.N. Chapman, A. Kaatz, M. Carnes, Physicians and implicit bias: how it affects clinical decision making, Acad Med 88 (2013) 354–360]. Each domain includes 0–3 severity anchors and real-world clinical examples. The total PNDI score ranges from 0–15, with interpretation bands for narrative integrity and safety risk. Encounter-level, unit-level, and organizational-level workflows for implementation are outlined. The five-domain PNDI taxonomy is shown in Figure 2. Conclusions PNDI operationalizes narrative integrity as a measurable dimension of diagnostic safety [The Joint Commission, National Patient Safety Goals: Improving Diagnosis in Health Care 2024–2026, The Joint Commission, Oakbrook Terrace, IL, 2024]. It provides clinicians, educators, and safety teams with a practical tool to detect narrative loss, reduce diagnostic error [G.D. Schiff, O. Hasan, S. Kim, R. Abrams, K. Cosby, B.L. Lambert et al., Diagnostic error in medicine: analysis of 583 physician-reported errors, Arch Intern Med 169 (2009) 1881–1887; P. Croskerry, The importance of cognitive errors in diagnosis and strategies to minimize them, Acad Med 78 (2003) 775–780; H. Singh, A.N.D. Meyer, E.J. Thomas, The frequency of diagnostic errors in outpatient care, BMJ Qual Saf 23 (2014) 727–731; and M.L. Graber, N. Franklin, R. Gordon, Diagnostic error in internal medicine, Arch Intern Med 165 (2005) 1493–1499], and strengthen patient trust [W. Levinson, D.L. Roter, J.P. Mullooly, V.T. Dull, R.M. Frankel, Physician-patient communication: the relationship with malpractice claims, JAMA 277 (1997) 553–559].