Conceptualising diagnostic liminality: a qualitative exploration of the journey to heart failure diagnosis

Clare R Goyder; Clare J Taylor; Nikki Newhouse; Catherine Pope; FD Richard Hobbs; Lisa Hinton

doi:10.3399/BJGP.2025.0698

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Diagnostic liminality as a space for the effectual diagnostic approach
Masayuki Amano

Published on: 30 June 2026

Published on: (30 June 2026)
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Diagnostic liminality as a space for the effectual diagnostic approach
Masayuki Amano, GP, Minaminara General Medical Center, Japan
Goyder and colleagues have carved the concept of diagnostic liminality out of patients' journeys to a heart failure diagnosis.¹ Their key finding is that being given the disease label does not, on its own, release patients from this suspended state. Truth-telling and careful explanation, through sense-making, enable the escape. We want to carry this finding further.

Why is the label not enough? Because uncertainty is not one thing. Han and colleagues describe medical uncertainty as a subjective perception of ignorance, and sort it into three sources: ambiguity, complexity, and probability.² Meyer and colleagues, drawing on this taxonomy, describe how each behaves.³ Ambiguity yields to information collected or shared. Complexity yields to deeper understanding of what is driving it. Probability, the inability to foresee the future, cannot be reduced, only managed. Clinicians and patients, they note, experience it differently. The same moment is therefore not the same for each.

The disease label reduces one ambiguity: the absence of a name. But it does not resolve the patient's lived uncertainty. For the clinician, the label organises the case into a familiar category. For the patient, it opens a new complexity. Understanding does not arrive with the label. It has to be built.

Here the effectual diagnostic approach (EDA) offers a way forward.⁴ Understanding is hard to build alone. EDA places the patie...
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Goyder and colleagues have carved the concept of diagnostic liminality out of patients' journeys to a heart failure diagnosis.¹ Their key finding is that being given the disease label does not, on its own, release patients from this suspended state. Truth-telling and careful explanation, through sense-making, enable the escape. We want to carry this finding further.

Why is the label not enough? Because uncertainty is not one thing. Han and colleagues describe medical uncertainty as a subjective perception of ignorance, and sort it into three sources: ambiguity, complexity, and probability.² Meyer and colleagues, drawing on this taxonomy, describe how each behaves.³ Ambiguity yields to information collected or shared. Complexity yields to deeper understanding of what is driving it. Probability, the inability to foresee the future, cannot be reduced, only managed. Clinicians and patients, they note, experience it differently. The same moment is therefore not the same for each.

The disease label reduces one ambiguity: the absence of a name. But it does not resolve the patient's lived uncertainty. For the clinician, the label organises the case into a familiar category. For the patient, it opens a new complexity. Understanding does not arrive with the label. It has to be built.

Here the effectual diagnostic approach (EDA) offers a way forward.⁴ Understanding is hard to build alone. EDA places the patient at the origin and brings the clinician in as a partner. The clinician's familiarity with heart failure becomes a resource for the patient. Together they build the path ahead from the patient's life, values, resources, and relationships. Seen this way, truth-telling and sense-making divide the work. Truth-telling reduces ambiguity. Sense-making reduces complexity.

Goyder and colleagues write that clinicians should guide patients out of the airport lounge and fly them home.¹ We would carry this image one step further. After disease labelling, the destination may not be a home already on the map. Clinician and patient decide together where to go. EDA offers a way to walk that road when the future remains unforeseeable. How clinicians sustain this shared construction over time is the question Goyder and colleagues have opened.

References

1. Goyder CR, Taylor CJ, Newhouse N, Pope C, Hobbs FDR, Hinton L. Conceptualising diagnostic liminality: a qualitative exploration of the journey to heart failure diagnosis. Br J Gen Pract 2026;76(768):e534-e543.
2. Han PKJ, Klein WMP, Arora NK. Varieties of uncertainty in health care: a conceptual taxonomy. Med Decis Making 2011;31(6):828-838.
3. Meyer AND, Giardina TD, Khawaja L, Singh H. Patient and clinician experiences of uncertainty in the diagnostic process: current understanding and future directions. Patient Educ Couns 2021;104(11):2606-2615.
4. 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;15:8327-8332.
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Competing Interests: None declared.