Before the First Test Is Ordered: How Framing Shapes Diagnosis
Long before a doctor meets a patient, a story has already begun.
It might start as a triage line—“young anxious woman with chest pain.”
It might come through in a referral—“frequent flyer with abdo pain.”
It might be embedded in a past note—“opioid-seeking,” “non-compliant,” “known to psych.”
By the time the clinician enters the room, that story is already doing cognitive work.
This is the framing effect: the well-described psychological phenomenon in which the way information is presented changes how it is interpreted, even when the underlying facts are the same. In medicine, framing shapes what diagnoses feel likely, which tests feel necessary, and how seriously symptoms are taken—often without anyone being aware it is happening [1].
What the Framing Effect Is
The framing effect was first formally described by Tversky and Kahneman, who showed that identical information leads to different decisions depending on how it is worded or contextualised [1]. When applied to diagnosis, this means that the same patient can be placed on entirely different diagnostic trajectories simply because of how their case is described.
“Chest pain in a young woman” evokes a different cognitive pathway to
“chest pain in an anxious young woman,” even though nothing about the underlying physiology has changed.
Once a frame is set, clinicians do not just interpret information differently—they notice different information. Early framing influences what questions are asked, which findings stand out, and how ambiguous results are interpreted [2].
How Framing Works in the Brain
Human cognition is predictive. The brain continuously generates hypotheses about what it is seeing and then tests incoming information against those expectations. This makes perception fast and efficient—but it also means that the first story we hear becomes the lens through which we interpret everything else [3].
In clinical reasoning, the initial frame acts as a cognitive anchor. It shapes attention, memory retrieval, and pattern recognition. Data that fits the frame feels salient and convincing; data that contradicts it feels like noise or inconvenience. This is not deliberate. It is how the brain minimises uncertainty and cognitive load [2,3].
Where Frames Come From
In modern healthcare, clinicians rarely encounter patients in a narrative vacuum. Frames are inherited from:
triage notes
ambulance handovers
referral letters
handover meetings
problem lists
past documentation
diagnostic labels
Each layer adds interpretive weight. Over time, provisional hypotheses harden into apparent facts. A patient becomes not someone with pain, but “the chronic pain patient.” Not someone in distress, but “the anxious one.” The system slowly teaches everyone how to see them.
When Framing Meets Identity
This is where framing stops being merely cognitive and becomes ethical.
Decades of research show that demographic labels—gender, race, mental health history, disability, socioeconomic status—alter how clinicians interpret symptoms and risk. These effects occur even when clinicians consciously reject prejudice [4].
Women presenting with chest pain are less likely to be investigated aggressively and more likely to have their symptoms attributed to anxiety, despite having equivalent or higher mortality when acute coronary syndromes are missed [5,6].
First Nations, Black, and other racialised patients are systematically undertreated for pain and more likely to have their symptoms minimised or psychologised, even when presenting with the same conditions as white patients [7,8].
Patients with mental illness or substance use disorders are more likely to have new physical symptoms attributed to behavioural or psychiatric causes, a phenomenon sometimes referred to as diagnostic overshadowing [9].
These are not simply social problems. They are framing problems.
Once a patient is framed as anxious, difficult, drug-seeking, or unreliable, the diagnostic lens shifts. The same symptom now means something different.
The Burden of Suspicion
Minority patients often enter the healthcare system already framed in ways that invite doubt rather than curiosity. Their symptoms are more likely to be questioned, contextualised away, or treated as secondary to their identity.
This produces a double cognitive burden. Not only do they have to be sick; they have to be sick in a way that escapes the frame that precedes them.
The result is well-documented disparities in time to diagnosis, adequacy of pain relief, escalation of care, and ultimately outcomes [6–9].
How Framing Becomes Self-Reinforcing
Once a frame is set, it becomes remarkably difficult to dislodge.
Subsequent clinicians read previous notes before seeing the patient. Language becomes more definitive. Alternative explanations are explored less. Discordant findings are explained away. The story becomes more convincing not because it is correct, but because it is coherent.
This is how bias becomes institutional rather than individual.
When Framing Replaces Curiosity
Framing quietly transforms open-ended clinical exploration into hypothesis-testing. Instead of asking, “What is happening to this person?”, we begin asking, “How does this fit the story I was given?”
Once that shift occurs, diagnostic breadth narrows. Important clues can be missed not because they were invisible, but because they did not belong.
How to Interrupt the Frame
The goal is not to eliminate framing—that would be impossible. The goal is to become aware of it.
Small changes matter. Reading the patient’s story before reading their labels. Re-phrasing the case in neutral terms. Asking how the presentation would be interpreted if the demographic descriptors were removed. Seeking the patient’s narrative before inheriting the system’s.
These are not bureaucratic exercises. They are acts of cognitive and moral hygiene.
Language Is a Clinical Tool
Every word we write and read shapes what is seen.
“Anxious young woman”
“First Nations man”
“Frequent flyer"
“Drug seeker”
"Poor historian"
These are not neutral descriptors. They are frames. And frames shape fate.
A Final Reflection
Before we examine a patient, before we order a test, before we make a decision, we are already responding to a story.
The question is not whether we use frames. It is whether we notice them.
References
Tversky A, Kahneman D. The framing of decisions and the psychology of choice. Science. 1981.
https://science.sciencemag.org/content/211/4481/453(opens in a new tab)Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine. 2003.
https://journals.lww.com/academicmedicine/Abstract/2003/08000/The_Importance_of_Cognitive_Errors_in_Diagnosis.3.aspx(opens in a new tab)Kahneman D. Thinking, Fast and Slow. Farrar, Straus and Giroux, 2011.
Green AR et al. Implicit bias among physicians and its prediction of thrombolysis decisions for Black and White patients. J Gen Intern Med. 2007.
https://link.springer.com/article/10.1007/s11606-007-0258-5(opens in a new tab)Mosca L et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women. Circulation. 2011.
https://www.ahajournals.org/doi/10.1161/CIR.0b013e31820faaf8(opens in a new tab)Mehta LS et al. Acute myocardial infarction in women: A scientific statement from the American Heart Association. Circulation. 2016.
https://www.ahajournals.org/doi/10.1161/CIR.0000000000000351(opens in a new tab)Hoffman KM et al. Racial bias in pain assessment and treatment recommendations. Proc Natl Acad Sci USA. 2016.
https://www.pnas.org/doi/10.1073/pnas.1516047113(opens in a new tab)Lee P et al. Racial and ethnic disparities in pain management in US emergency departments: Meta-analysis and systematic review. Am J Emerg Med. 2019 Sep;37(9):1770-1777 https://pubmed.ncbi.nlm.nih.gov/31186154/(opens in a new tab)
Jones S et al. Diagnostic overshadowing: Worse physical health care for people with mental illness. Acta Psychiatr Scand. 2008.
https://onlinelibrary.wiley.com/doi/10.1111/j.1600-0447.2008.01211.x