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Duagnosis: Locating Clinical Uncertainty in the Diagnostic Framework.

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Title: Duagnosis: Locating Clinical Uncertainty in the Diagnostic Framework.
Authors: Hanaoka K; General Medicine Co-Creation Center, Kanazawa University Hospital, Kanazawa, Japan.; Kampo Clinical Center, Hiroshima University Hospital, Hiroshima, Japan., Miyamori D; Department of General Internal Medicine, Hiroshima University Hospital, Hiroshima, Japan., Ogawa-Ochiai K; Kampo Clinical Center, Hiroshima University Hospital, Hiroshima, Japan.
Source: Journal of evaluation in clinical practice [J Eval Clin Pract] 2026 Sep; Vol. 32 (6), pp. e70621.
Publication Type: Journal Article
Language: English
Journal Info: Publisher: Wiley-Blackwell Country of Publication: England NLM ID: 9609066 Publication Model: Print Cited Medium: Internet ISSN: 1365-2753 (Electronic) Linking ISSN: 13561294 NLM ISO Abbreviation: J Eval Clin Pract Subsets: MEDLINE
Imprint Name(s): Original Publication: Oxford, England : Wiley-Blackwell, c1995-
MeSH Terms: Clinical Reasoning* , Primary Health Care*, Humans ; Uncertainty ; Knowledge ; Philosophy, Medical ; Asia, Eastern
Abstract: Rationale, Aims and Objectives: Clinical reasoning research has predominantly operated within a single epistemological system. The prevailing response to clinical uncertainty in primary care has been to cultivate tolerance, embrace ambiguity, or learn to navigate it: each treats uncertainty as inherent to the encounter. We propose a complementary move. Much of what is called clinical uncertainty may be attributed less to the patient's condition than to the reach of the diagnostic framework through which the clinician reasons. We introduce the concept of duagnosis (dual + gnosis, 'knowing'): the clinical cognition in which two independent diagnostic systems are simultaneously activated within a single clinician's reasoning.
Methods: Conceptual analysis proceeding through concept definition, differentiation from neighbouring frameworks, development of the epistemological argument, and institutional comparison across East Asia. The analysis draws on clinical reasoning research, the philosophy of medicine, evidence on the care of persistent physical symptoms, and comparative scholarship on traditional medicine.
Results: The core contribution is epistemological: what one framework cannot formulate may resolve into a recognisable, actionable pattern in another, so that uncertainty is partly a property of the framework and not only of the patient. Duagnosis can be stated in two versions: a broad sense continuous with family medicine's plural readings of the patient, and a strict sense in which the criteria of evidence themselves change. An East Asian institutional comparison shows that Japan's unified medical licence locates diagnostic duality within individual clinician cognition for every physician, a capacity medical education has not cultivated.
Conclusion: Expanding the diagnostic repertoire, not merely tolerating uncertainty, can reduce the proportion of presentations for which no clinical formulation exists. Locating uncertainty partly in the reach of the framework, rather than in the patient, is a reframing that applies beyond any one health system, with implications for communication and referral.
(© 2026 The Author(s). Journal of Evaluation in Clinical Practice published by John Wiley & Sons Ltd.)
References: J Plast Reconstr Surg. 2026 Mar 26;5(Suppl):S1-S96. (PMID: 41982806)
BMJ. 2002 Dec 21;325(7378):1449-50. (PMID: 12493661)
Int J Clin Oncol. 2015 Aug;20(4):767-75. (PMID: 25627820)
Evid Based Complement Alternat Med. 2013;2013:105413. (PMID: 24382975)
Evid Based Complement Alternat Med. 2011;2011:513842. (PMID: 21687585)
J Ayurveda Integr Med. 2025 Jul-Aug;16(4):101157. (PMID: 40582042)
Evid Based Complement Alternat Med. 2013;2013:658275. (PMID: 24191170)
Science. 1977 Apr 8;196(4286):129-36. (PMID: 847460)
Integr Med Res. 2021 Sep;10(3):100722. (PMID: 34136346)
J Eval Clin Pract. 2024 Jun;30(4):533-538. (PMID: 38300231)
BJGP Open. 2024 Jul 29;8(2):. (PMID: 38097267)
Korean J Med Educ. 2018 Dec;30(4):283-294. (PMID: 30522257)
Lancet. 2024 Jun 15;403(10444):2619-2629. (PMID: 38879261)
Integr Med Res. 2021 Sep;10(3):100685. (PMID: 33665088)
Evid Based Complement Alternat Med. 2011;2011:239659. (PMID: 21949669)
Front Pharmacol. 2022 Sep 02;13:971254. (PMID: 36120328)
J Altern Complement Med. 2021 Jul;27(7):613-616. (PMID: 33861620)
Ann Fam Med. 2009 Jul-Aug;7(4):293-9. (PMID: 19597165)
Jpn J Clin Oncol. 2015 Jul;45(7):650-6. (PMID: 25972515)
Cochrane Database Syst Rev. 2014 Sep 02;(9):CD000963. (PMID: 25180773)
J Eval Clin Pract. 2021 Apr;27(2):438-450. (PMID: 32573080)
Pract Neurol. 2016 Feb;16(1):7-17. (PMID: 26715762)
J Eval Clin Pract. 2024 Aug;30(5):788-796. (PMID: 38825755)
Fam Pract. 1986 Mar;3(1):24-30. (PMID: 3956899)
BMC Fam Pract. 2017 Feb 7;18(1):18. (PMID: 28173764)
BMC Complement Altern Med. 2012 Nov 02;12:207. (PMID: 23122050)
JAMA Netw Open. 2025 Nov 3;8(11):e2540897. (PMID: 41182768)
Front Pharmacol. 2021 Dec 20;12:751403. (PMID: 34987389)
Bull World Health Organ. 2025 Nov 1;103(11):715-721. (PMID: 41180270)
Acad Med. 2009 Aug;84(8):1022-8. (PMID: 19638766)
J Eval Clin Pract. 2024 Aug;30(5):741-748. (PMID: 37526287)
Geriatr Gerontol Int. 2017 Feb;17(2):211-218. (PMID: 26711658)
N Engl J Med. 2016 Nov 3;375(18):1713-1715. (PMID: 27806221)
Med Decis Making. 2011 Nov-Dec;31(6):828-38. (PMID: 22067431)
J Eval Clin Pract. 2015 Jun;21(3):357-64. (PMID: 25923823)
J Gen Intern Med. 2022 May;37(6):1415-1421. (PMID: 33904030)
Neurogastroenterol Motil. 2014 Jul;26(7):950-61. (PMID: 24766295)
Br J Gen Pract. 2017 Jun;67(659):244-245. (PMID: 28546389)
J Transl Med. 2008 Sep 09;6:48. (PMID: 18782426)
Evid Based Complement Alternat Med. 2014;2014:535146. (PMID: 24701241)
Br J Pain. 2015 May;9(2):109-14. (PMID: 26516565)
Tokai J Exp Clin Med. 2021 Jul 20;46(2):75-82. (PMID: 34216479)
Evid Based Complement Alternat Med. 2013;2013:576973. (PMID: 24550992)
Cochrane Database Syst Rev. 2020 Mar 25;3:CD012271. (PMID: 32212387)
J Alzheimers Dis. 2016 Sep 6;54(2):635-43. (PMID: 27497482)
J Eval Clin Pract. 2025 Mar;31(2):e14126. (PMID: 39291790)
J Eval Clin Pract. 2021 Jun;27(3):638-647. (PMID: 32939937)
Contributed Indexing: Keywords: clinical decision‐making; clinical reasoning; epistemology; medical pluralism; medicine, Kampo; medicine, traditional; uncertainty
Entry Date(s): Date Created: 20260925 Date Completed: 20260925 Latest Revision: 20260928
Update Code: 20260928
PubMed Central ID: PMC13613999
DOI: 10.1111/jep.70621
PMID: 42788636
Database: MEDLINE
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  Data: <searchLink fieldCode="AU" term="%22Hanaoka+K%22">Hanaoka K</searchLink>; General Medicine Co-Creation Center, Kanazawa University Hospital, Kanazawa, Japan.; Kampo Clinical Center, Hiroshima University Hospital, Hiroshima, Japan.<br /><searchLink fieldCode="AU" term="%22Miyamori+D%22">Miyamori D</searchLink>; Department of General Internal Medicine, Hiroshima University Hospital, Hiroshima, Japan.<br /><searchLink fieldCode="AU" term="%22Ogawa-Ochiai+K%22">Ogawa-Ochiai K</searchLink>; Kampo Clinical Center, Hiroshima University Hospital, Hiroshima, Japan.
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  Data: Rationale, Aims and Objectives: Clinical reasoning research has predominantly operated within a single epistemological system. The prevailing response to clinical uncertainty in primary care has been to cultivate tolerance, embrace ambiguity, or learn to navigate it: each treats uncertainty as inherent to the encounter. We propose a complementary move. Much of what is called clinical uncertainty may be attributed less to the patient's condition than to the reach of the diagnostic framework through which the clinician reasons. We introduce the concept of duagnosis (dual + gnosis, 'knowing'): the clinical cognition in which two independent diagnostic systems are simultaneously activated within a single clinician's reasoning.<br />Methods: Conceptual analysis proceeding through concept definition, differentiation from neighbouring frameworks, development of the epistemological argument, and institutional comparison across East Asia. The analysis draws on clinical reasoning research, the philosophy of medicine, evidence on the care of persistent physical symptoms, and comparative scholarship on traditional medicine.<br />Results: The core contribution is epistemological: what one framework cannot formulate may resolve into a recognisable, actionable pattern in another, so that uncertainty is partly a property of the framework and not only of the patient. Duagnosis can be stated in two versions: a broad sense continuous with family medicine's plural readings of the patient, and a strict sense in which the criteria of evidence themselves change. An East Asian institutional comparison shows that Japan's unified medical licence locates diagnostic duality within individual clinician cognition for every physician, a capacity medical education has not cultivated.<br />Conclusion: Expanding the diagnostic repertoire, not merely tolerating uncertainty, can reduce the proportion of presentations for which no clinical formulation exists. Locating uncertainty partly in the reach of the framework, rather than in the patient, is a reframing that applies beyond any one health system, with implications for communication and referral.<br /> (© 2026 The Author(s). Journal of Evaluation in Clinical Practice published by John Wiley & Sons Ltd.)
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  Data: J Plast Reconstr Surg. 2026 Mar 26;5(Suppl):S1-S96. (PMID: <searchLink fieldCode="PM" term="%2241982806%22">41982806)</searchLink><br />BMJ. 2002 Dec 21;325(7378):1449-50. (PMID: <searchLink fieldCode="PM" term="%2212493661%22">12493661)</searchLink><br />Int J Clin Oncol. 2015 Aug;20(4):767-75. (PMID: <searchLink fieldCode="PM" term="%2225627820%22">25627820)</searchLink><br />Evid Based Complement Alternat Med. 2013;2013:105413. (PMID: <searchLink fieldCode="PM" term="%2224382975%22">24382975)</searchLink><br />Evid Based Complement Alternat Med. 2011;2011:513842. (PMID: <searchLink fieldCode="PM" term="%2221687585%22">21687585)</searchLink><br />J Ayurveda Integr Med. 2025 Jul-Aug;16(4):101157. (PMID: <searchLink fieldCode="PM" term="%2240582042%22">40582042)</searchLink><br />Evid Based Complement Alternat Med. 2013;2013:658275. (PMID: <searchLink fieldCode="PM" term="%2224191170%22">24191170)</searchLink><br />Science. 1977 Apr 8;196(4286):129-36. (PMID: <searchLink fieldCode="PM" term="%22847460%22">847460)</searchLink><br />Integr Med Res. 2021 Sep;10(3):100722. (PMID: <searchLink fieldCode="PM" term="%2234136346%22">34136346)</searchLink><br />J Eval Clin Pract. 2024 Jun;30(4):533-538. (PMID: <searchLink fieldCode="PM" term="%2238300231%22">38300231)</searchLink><br />BJGP Open. 2024 Jul 29;8(2):. (PMID: <searchLink fieldCode="PM" term="%2238097267%22">38097267)</searchLink><br />Korean J Med Educ. 2018 Dec;30(4):283-294. (PMID: <searchLink fieldCode="PM" term="%2230522257%22">30522257)</searchLink><br />Lancet. 2024 Jun 15;403(10444):2619-2629. (PMID: <searchLink fieldCode="PM" term="%2238879261%22">38879261)</searchLink><br />Integr Med Res. 2021 Sep;10(3):100685. (PMID: <searchLink fieldCode="PM" term="%2233665088%22">33665088)</searchLink><br />Evid Based Complement Alternat Med. 2011;2011:239659. (PMID: <searchLink fieldCode="PM" term="%2221949669%22">21949669)</searchLink><br />Front Pharmacol. 2022 Sep 02;13:971254. (PMID: <searchLink fieldCode="PM" term="%2236120328%22">36120328)</searchLink><br />J Altern Complement Med. 2021 Jul;27(7):613-616. (PMID: <searchLink fieldCode="PM" term="%2233861620%22">33861620)</searchLink><br />Ann Fam Med. 2009 Jul-Aug;7(4):293-9. (PMID: <searchLink fieldCode="PM" term="%2219597165%22">19597165)</searchLink><br />Jpn J Clin Oncol. 2015 Jul;45(7):650-6. (PMID: <searchLink fieldCode="PM" term="%2225972515%22">25972515)</searchLink><br />Cochrane Database Syst Rev. 2014 Sep 02;(9):CD000963. (PMID: <searchLink fieldCode="PM" term="%2225180773%22">25180773)</searchLink><br />J Eval Clin Pract. 2021 Apr;27(2):438-450. (PMID: <searchLink fieldCode="PM" term="%2232573080%22">32573080)</searchLink><br />Pract Neurol. 2016 Feb;16(1):7-17. (PMID: <searchLink fieldCode="PM" term="%2226715762%22">26715762)</searchLink><br />J Eval Clin Pract. 2024 Aug;30(5):788-796. (PMID: <searchLink fieldCode="PM" term="%2238825755%22">38825755)</searchLink><br />Fam Pract. 1986 Mar;3(1):24-30. (PMID: <searchLink fieldCode="PM" term="%223956899%22">3956899)</searchLink><br />BMC Fam Pract. 2017 Feb 7;18(1):18. (PMID: <searchLink fieldCode="PM" term="%2228173764%22">28173764)</searchLink><br />BMC Complement Altern Med. 2012 Nov 02;12:207. (PMID: <searchLink fieldCode="PM" term="%2223122050%22">23122050)</searchLink><br />JAMA Netw Open. 2025 Nov 3;8(11):e2540897. (PMID: <searchLink fieldCode="PM" term="%2241182768%22">41182768)</searchLink><br />Front Pharmacol. 2021 Dec 20;12:751403. (PMID: <searchLink fieldCode="PM" term="%2234987389%22">34987389)</searchLink><br />Bull World Health Organ. 2025 Nov 1;103(11):715-721. (PMID: <searchLink fieldCode="PM" term="%2241180270%22">41180270)</searchLink><br />Acad Med. 2009 Aug;84(8):1022-8. (PMID: <searchLink fieldCode="PM" term="%2219638766%22">19638766)</searchLink><br />J Eval Clin Pract. 2024 Aug;30(5):741-748. (PMID: <searchLink fieldCode="PM" term="%2237526287%22">37526287)</searchLink><br />Geriatr Gerontol Int. 2017 Feb;17(2):211-218. (PMID: <searchLink fieldCode="PM" term="%2226711658%22">26711658)</searchLink><br />N Engl J Med. 2016 Nov 3;375(18):1713-1715. (PMID: <searchLink fieldCode="PM" term="%2227806221%22">27806221)</searchLink><br />Med Decis Making. 2011 Nov-Dec;31(6):828-38. (PMID: <searchLink fieldCode="PM" term="%2222067431%22">22067431)</searchLink><br />J Eval Clin Pract. 2015 Jun;21(3):357-64. (PMID: <searchLink fieldCode="PM" term="%2225923823%22">25923823)</searchLink><br />J Gen Intern Med. 2022 May;37(6):1415-1421. (PMID: <searchLink fieldCode="PM" term="%2233904030%22">33904030)</searchLink><br />Neurogastroenterol Motil. 2014 Jul;26(7):950-61. (PMID: <searchLink fieldCode="PM" term="%2224766295%22">24766295)</searchLink><br />Br J Gen Pract. 2017 Jun;67(659):244-245. (PMID: <searchLink fieldCode="PM" term="%2228546389%22">28546389)</searchLink><br />J Transl Med. 2008 Sep 09;6:48. (PMID: <searchLink fieldCode="PM" term="%2218782426%22">18782426)</searchLink><br />Evid Based Complement Alternat Med. 2014;2014:535146. (PMID: <searchLink fieldCode="PM" term="%2224701241%22">24701241)</searchLink><br />Br J Pain. 2015 May;9(2):109-14. (PMID: <searchLink fieldCode="PM" term="%2226516565%22">26516565)</searchLink><br />Tokai J Exp Clin Med. 2021 Jul 20;46(2):75-82. (PMID: <searchLink fieldCode="PM" term="%2234216479%22">34216479)</searchLink><br />Evid Based Complement Alternat Med. 2013;2013:576973. (PMID: <searchLink fieldCode="PM" term="%2224550992%22">24550992)</searchLink><br />Cochrane Database Syst Rev. 2020 Mar 25;3:CD012271. (PMID: <searchLink fieldCode="PM" term="%2232212387%22">32212387)</searchLink><br />J Alzheimers Dis. 2016 Sep 6;54(2):635-43. (PMID: <searchLink fieldCode="PM" term="%2227497482%22">27497482)</searchLink><br />J Eval Clin Pract. 2025 Mar;31(2):e14126. (PMID: <searchLink fieldCode="PM" term="%2239291790%22">39291790)</searchLink><br />J Eval Clin Pract. 2021 Jun;27(3):638-647. (PMID: <searchLink fieldCode="PM" term="%2232939937%22">32939937)</searchLink>
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