Table 5:

Individual Patient Factors Sub-themes and Illustrative Quotes

PATIENT
Knowledge about his/her own condition/health literacy	“…it’s the way the physicians talk to the patient because sometimes they don’t understand that this patient [doesn’t] understand all our medical terms. So most of the time, you have to break it down …how bad it is or how not bad it is. So two years ago, they found a stone on my husband’s neck, a salivary gland, but it was simple, probably just small enough, and they didn’t even talk to him about the CT scan. They [said] We’ll send an ENT to touch base with you. But it’s a guy that doesn’t know anything about medical [things]. He’s an IT guy. An African-American-guy- they hate surgery. Surgery is like the last thing, except if [they’re] dying. That’s when you’re gonna operate . So they called him, and it’s like, Oh, well you have a referral for ENT. Can we see you? But at the back of his mind, he’s like, This is not a big deal. I’m not showing up. You’re just gonna wanna talk to me again.” (FG3)
Cognitive challenges that prohibit clear history	“….patients who are cognitively impaired. Those are very difficult to get a clear history and to pinpoint exactly what is going on. So that would be a patient that has dementia, for example. They may not be aware of it, but you can’t get much information from them. Like this patient’s not moving the arm; and if they can’t tell you how they were yesterday, then that can sometimes create a challenge in terms of diagnostic delays.” (FG9)
Narrative skills-good historian	“So, if the patient is a poor historian obviously, you will miss things, and it happens many times. On the fourth or fifth day, we find out that, Oh patient’s taking this medication, but three people- pharmacy asked, nursing asked, provider asked. The patient never admitted, I’m taking this medication. And suddenly, in the morning, patient said, Oh I forgot to tell you…so I think being a poor historian also kind of doesn’t help, I mean it is a cause of delays.” (FG8) “And I think, like we mentioned before, too, like - people will say various symptoms. They’ll say this symptom to this group and this symptom to this one. Or they won’t mention this because, Oh I didn’t think that was important. Well that really was a big important part of that diagnosis” (FG6)
Language	“But I think language is a huge deal. I think language barriers and care are a huge deal. I think even working through interpreters is just not the same, and I think that’s a big hindrance a lot of times [to accurate and timely diagnosis]. I don’t have a great fix for it other than directly speaking the language.” (FG1 )
Culture	“I think there’s some cultures that are very timid about telling you their symptoms. That’s always painful. … It just takes a lot longer. There are some cultures you walk in the room, and you get their whole life story in 30 seconds, and then there are others that you have to ask repeated questions to get to actually what you need to know [to make the diagnosis].” (FG9) “One provider explained: “I can tell a family is reserved because they are in fear of that bias …They’ve heard that, historically, they might get treated differently because of their race …so sometimes, it’ll take longer to develop that trust with them and that understanding” (FG10)
Medical complexity or atypical presentation	“The medical complexity of some of the patients that we see here…probably leads to some diagnostic error, delay, …and that’s just a product of how sick they are.” (FG5) “diagnostic reasoning isn’t necessarily a black and white process, right? I mean - not everybody drops into a clean bucket, and we spend a lot of time communicating back and forth diagnostic uncertainty and the things that we think [are] going on. I mean, frequently, when the patient comes in critically ill, we’ll empirically cover several different diagnoses until we let the dust settle and the patient differentiates themselves.” (FG1)
Family- interfering	“Difficult families, too, get in the way…especially when two or three of ‘em think different things” (FG11) “family sometimes can be a barrier, to getting things done. Again they’re bargaining or they’re questioning why we’re doing things. And then you have to go back and explain things…(causing a) delay” (FG3)
Behavioral issues	“I was thinking that like on my floor, personally, we have a lot of behavioral patients. And so a lot of times, they misinform the providers with things or nursing with things that maybe aren’t even true or just they are false or just different things.”(FG4) “I think they’re [clinicians] likely to fall back on a, Well they’ve done this. This is their behavior. This is what- This is their “norm,” and so I think a lot of things can like get missed in that circumstance.”(FG4)
Acuity of condition	“…one thing that would prevent a problem/diagnosis from getting identified is a multitude of problems and the hierarchy of the problems. And where day two, this is considered a low-level problem, but it was never addressed. So now on day four, it leapfrogged a couple other ones, so it’s now a higher problem. Like if we didn’t address hypovolemia on day two, and we just let it slide, and we just said, Oh the patient’s gotta drink cause their gut’s working; but on day four, well now, they got put into A-fib. So that smaller problem exacerbated and propelled itself to a larger problem…So I guess it would be the acuity of the problem list can interfere with addressing a diagnosis.” (FG8)