Skip to main content
Log in

Competing Conceptions of Diagnostic Reasoning – Is There a Way Out?

  • Published:
Theoretical Medicine and Bioethics Aims and scope Submit manuscript

Abstract

Diagnostic errors are more frequently a result of the clinician's failure to combine medical knowledge adequately than of data inaccuracy. Diagnostic reasoning studies are valuable to understand and improve diagnostic reasoning. However, most diagnostic reasoning studies are characterized by some limitations which make these studies seem more simple than diagnostic reasoning in real life situations actually is. These limitations are connected both to the failure to acknowledge components of knowledge used in clinical practice as well as to acknowledge the physician-patient relationship's influence on clinical knowledge and on the reasoning process itself. In addition the modes of reasoning described in these studies frequently is oversimplified. In this paper three simplistic and competing models of diagnostic reasoning are analyzed and criticized, followed by an evaluation of two alternative models proposing a combined view.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

REFERENCES

  1. Mabeck CE, Kragstrup J. Is variation a quality in general practice? Scand J Prim Health Care 1993; 11Suppl 1: 32-5.

    Google Scholar 

  2. Eddy DM: Variations in physician practice: The role of uncertainty. In Dowie J and Elstein A, eds. Professional judgment. A reader in clinical decision making. Cambridge: Cambridge Univ Press, 1988: 45-59.

    Google Scholar 

  3. Kalf AJH, Spruijt-Metz D. Variation in diagnoses: Influence of specialists' training on selecting and ranking relevant infomation in geriatric case vignettes. Soc Sci Med 1996; 42: 705-12.

    Google Scholar 

  4. Koren LM. The reliability of clinical methods, data and judgments. NEJM 1975; Okt 2.: 695-701.

    Google Scholar 

  5. Ridderikhoff J. Problem-solving in general practice. Theor Med 1993; 14: 343-63.

    Google Scholar 

  6. Schøn DA. The reflective practitioner. How professionals think in action. Cambridge: Basic Books, 1983.

    Google Scholar 

  7. Timka T, Arborelius E. The GP's dilemmas: A study of knowledge need and use during health care consultations. Meth Inform Med 1990; 29: 23-9.

    Google Scholar 

  8. Hobus PPM, Schmidt HG, Boshuizen HPA, Patel VL. Contextual factors in the activation of first diagnostic hypothese: Expert-novice differences. Med Ed 1987; 21: 471-6.

    Google Scholar 

  9. Førde R, Malterud K. Components of clinical knowledge which indicate need for intervention in pregnancy. Scand J Prim Health Care 1992; 10: 272-6.

    Google Scholar 

  10. Hughes D. Everyday and medical knowledge in categorizing patients. In Dingwell R, Heath C, Reid M and Stacey M, eds. Health care and health knowledge. London: Croom Helm Ltd, 1977: 127-40.

    Google Scholar 

  11. Barrows HS, Tamblyn RM. Problem-based learning. An approach to medical education. NY: Springer Publ Comp, 1980.

    Google Scholar 

  12. Friedman HS. Nonverbal communication between patients and medical practitioners. J Soc Issues 1979; 35: 82-99.

    Google Scholar 

  13. Bugental DE, Kaswan JW, Love LR. Perception of contradictory meanings conveyed by verbal and nonverbal channels. J Pers Soc Psych 1970; 16: 647-55.

    Google Scholar 

  14. Helman CG. Culture, health and illness. Oxford: Butterworth-Heinemann Ltd, 1993.

    Google Scholar 

  15. Siegman AW. Paraverbal correlates of stress: Implications for stress identification and management. In Goldberger L and Breznitz S., eds. Handbook of stress. Theoretical and clinical aspects. NY: The Free Press, 1993: 274-99.

    Google Scholar 

  16. Stein HF. The psychodynamics of medical practice. Unconscious factors in patient care. Berkely/Los Angeles/London: University of California Press, 1985.

    Google Scholar 

  17. Zinn WM. Doctors have feelings too. JAMA 1988; 259: 3296-8.

    Google Scholar 

  18. Sober E. The art and science of clinical judgment: An informational approach. In Engelhardt HT, Spicker SF, Towers B., eds. Clinical judgment: A critical appraisal. Dordrecht/Boston/London: Reidel Publishing Comp, 1979: 29-44.

    Google Scholar 

  19. Hornby AS. Oxford advanced learner's dictionary of current English. London: Oxford Univ Press, 1974.

    Google Scholar 

  20. Måseide P. Analytical aspects of clinical reasoning: A discussion of models for medical problem solving. Social organization of doctor-patient communication. In Fisher S and Todd AD, eds. Doctor-patient communication. Wash: The Center for Applied Linguistics, 1983: 241-65.

    Google Scholar 

  21. Vanderpool HY, Weiss GB. Patient truthfulness: A test of models of the physician-patient relationship. J Med Phil 1984; 9: 353-72.

    Google Scholar 

  22. Eisenberg JM. Sociologic influences on decision-making by clinicians. Ann Int Med 1979; 90: 957-64.

    Google Scholar 

  23. Quill TE. Recognizing and adjusting to barriers in doctor-patient communication. Ann Int Med 1989; 11: 51-7.

    Google Scholar 

  24. Elstein AS, Shulman LS, Sprafka SA. Medical problem solving. An analysis of clinical reasoning. Cambridge and London: Harvard Univ Press, 1978.

    Google Scholar 

  25. Clark JA, Potter DA, McKinlay JB. Bringing social structure back into clinical decision making. Soc Sci Med 1991; 32: 853-66.

    Google Scholar 

  26. Shiber A, Maoz B, Antonovsky Aa, Antonovsky H. Detection of emotional problems in the primary care clinic. Fam Pract 1990; 7: 195-200.

    Google Scholar 

  27. Barrows HS, Feltoviz PJ. The clinical reasoning process. Med Educ 1987; 21: 86-91.

    Google Scholar 

  28. McGuire CH. Medical problem-solving: A critique of the literature. J Med Educ 1985; 60: 587-95.

    Google Scholar 

  29. Barosi G, Magnani L, Stefanelli M. Medical diagnostic reasoning: Epistemological modeling as a strategy for design of computer-based consultation programs. Theor Med 1993; 14: 43-55.

    Google Scholar 

  30. Ridderikhoff J. Medical problem-solving: An exploration of strategies. Med Educ 1991; 25: 196-207.

    Google Scholar 

  31. Ridderikhoff J. Methods in medicine. A descriptive study of physicians' behaviour. Dordrecht/Boston/London: Kluwer Academic Publishers, 1989.

    Google Scholar 

  32. Sacket DL, Haynes RB, Tugwell P. Clinical epidemiology. A basic science for clinical medicine. Boston/Toronto: Little, Brown and Company, 1985.

    Google Scholar 

  33. Groen GJ, Patel VL. Medical problem-solving: some questionable assumptions. Med Educ 1985; 19: 95-100.

    Google Scholar 

  34. Barrows HS, Norman GR, Neufeld VR, Feightner JW. The clinical reasoning of randomly selected physicians in general medical practice. Clinical & Investigative Med 1982; 5: 49-55.

    Google Scholar 

  35. Hamm RM. Clinical intuition and clinical analysis: expertise and the cognitive continuum. In Dowie J and Elstein A, eds. Professional judgment. A reader in clinical decision making. Cambridge: Cambridge Univ Press, 1988: 78-105.

    Google Scholar 

  36. Rabinowitz S, Herz M, Granek M, Lehmann S, Pincus C, Maoz B. The doctor and his feelings: A course for residents in family medicine. Fam Pract 1989; 6: 199-202.

    Google Scholar 

  37. Waitzkin H. Doctor-patient communication. Clinical implications of social scientific research. JAMA 1984; 252: 2441-6.

    Google Scholar 

  38. Wassermann RC. Systematic analysis of clincian-patient interactions: A critique of recent approaches with suggestions for future research. Med Care 1983; 11: 279-93.

    Google Scholar 

  39. Balla JI. Logical thinking and the diagnostic process. Meth Inform Med 1980; 19: 88-92.

    Google Scholar 

  40. Maguire P. Can communication skills be taught? Br J Hosp Med 1990; 43: 215-6.

    Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Rights and permissions

Reprints and permissions

About this article

Cite this article

Førde, R. Competing Conceptions of Diagnostic Reasoning – Is There a Way Out?. Theor Med Bioeth 19, 59–72 (1998). https://doi.org/10.1023/A:1009978315185

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1023/A:1009978315185

Navigation