Summary
The study of clinical reasoning 3 is important not only for defining the nature of medical competence and skill but also for providing insight into human cognition in general. The diagnostic problems that are the focus of clinical reasoning are instances of the complex, practical problems that characterize the real world, problems in which solutions depend heavily upon experience and knowledge (Elstein, Kagan, Shulman, Jason, & Loupe, 1972). Medical problems are examples of “everyday reasoning” tasks, which are characterized by implicit premises; contextual embedding; multiple possible answers; and ambiguity about the “best” solution (Galotti 1989). Clinical reasoning has often been conceptualized as a categorization task — once the clinician has categorized the patient’s problem into a class of diseases, the problem is treated as solved (Custers, Regehr & Norman, 1996). However, in contrast with the categorization tasks examined in laboratory studies in psychology, medical diagnosis categorizations are pervaded by ambiguity in the presence and identification of features and a large number of possible alternatives that often do not form clearly separable options (Brooks, LeBlanc & Norman, 2000).
Thus clinical reasoning research is both a special case of cognitive research on reasoning and problem solving generally and a valuable contributor to our broader understanding of human cognition. This review will seek to provide an overview of a large body of research in clinical reasoning in medicine and provide linkages with the research literature outside of medicine to substantiate and clarify specific points. By necessity it cannot include all relevant studies or theoretical treatments; rather a representative sampling has been sought.
Clinical reasoning, clinical problem solving, and diagnostic problem solving are treated as essentially synonymous terms in this chapter.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
Preview
Unable to display preview. Download preview PDF.
References
Anderson-Levitt, K. M. (1986). Acquiring a cultural model: A case study of staff in workshops for mentallyretarded adults, Paper presented at the meeting of the American Anthropological Association.
Berliner, D. C. (1986). In pursuit of the expert pedagogue.Educational Researcher 15(7)5–13.
Beyth-Marom, R., & Fischhoff, B. (1983). Diagnosticity and pseudodiagnosticity.Journal of Personality and Social Psychology 451185–1195.
Bordage, G. (1994). Elaborated knowledge: a key to successful diagnostic thinking.Academic Medicine69, 883–885.
Bordage, G. (1999). Why did I miss the diagnosis? Some cognitive explanations and educational implications.Academic Medicine 74S138–S143.
Bordage, G.&Lemieux, M. (1991). Semantic structures and diagnostic thinking of experts and novices.Academic Medicine 66 S70-S72.
Bordage, G., & Zacks, R. (1984). The structure of medical knowledge in the memories of students and practitioners.Medical Education 18406–416.
Bordage, G., Connell, K. J., Chang, R. W., Gecht, M. R., & Sinacore, J. M. (1997). Assessing the semantic content of clinical case presentations: studies of reliability and concurrent validity.Academic Medicine72, S37–39.
Boreham, N. C. (1994). The dangerous practice of thinking.Medical Education 28172–179.
Boshuizen, H. P. A., & Schmidt, H. G. (1992). On the role of biomedical knowledge in clinical reasoning by experts, intermediates and novices.Cognitive Science 16153–184.
Bosk, C. L. (1980). Occupational rituals in patient management.New England Journal of Medicine 30371–76.
Bransford, J., Sherwood, R., Vye, N., & Reiser, J. (1986). Teaching thinking and problem solving: Research foundations.American Psychologist 411078–1089.
Brooks, L. R., LeBlanc, V. R., & Norman, G. R. (2000). On the difficulty of noticing obvious features in patient appearance.Psychological Science 11112–117.
Brooks, L. R., Norman, G. R., & Allen, S. W. (1991). Role of specific similarity in a medical diagnostic task.Journal of Experimental Psychology 120278–287.
Brown, A. (1987). Metacognition, executive control, self-regulation, and other more mysterious mechanisms. In F. E. Weinert & R. H. Kluwe (Eds.)Metacognition motivation and understandingHillsdale, NJ: Erlbaum.
Brown, J. S., Collins, A., & Duguid, P. (1989). Situated cognition and the culture of learning.Educational Researcher18(1), 32–42.
Chaiklin, S., & Lave, J. (1993).Understanding practice: Perspectives on activity and context.New York: Cambridge University Press.
Charlin, B., Tardif, J., & Boshuizen, H. P. A. (2000). Scripts and medical diagnostic knowledge: Theory and applications for clinical reasoning instruction and research.Academic Medicine75, 182–190.
Chase, W. G., & Simon, H. A. (1973). Perception in chess.Cognitive Psychology 455–81.
Chi, M. T. H., Feltovich, P. J., & Glaser, R. (1981). Categorization and representation of physics problems by experts and novices.Cognitive Science 5121–152.
Chi, M. T. H., Glaser, R., & Rees, E. (1982). Expertise in problem solving. In R. J. Sternberg (Ed.)Advances in the psychology of human intelligence(Vol. 1, pp. 7–75). Hillsdale, NJ: Erlbaum.
Custers, E. J., Regehr, G., & Norman, G. R. (1996). Mental representations of medical diagnostic knowledge: a review.Academic Medicine71, S55–61.
De Jong, T., & Ferguson-Hessler, M. G. M. (1986). Cognitive structures of good and poor novice problem solvers in physics.Journal of Educational Psychology78(4), 279–288.
Dörner, D. (1983). Heuristics and cognition in complex systems. In R. Groner, M. Groner, & W. F. Bischof (Eds.)Methods and heuristics(pp. 89–107). Hillsdale, NJ: Erlbaum.
Elstein, A. S.&Bordage, G. S. (1979). Psychology of clinical reasoning. In G. S. Stone, F. Cohen, N. E.Adler&Associates (Eds.)Health psychology: A handbook(pp. 333–367). San Francisco: Jossey-Bass.
Elstein, A. S., Kagan, N., Shulman, L. S., Jason, H., & Loupe, M. J. (1972). Methods and theory in the study of medical inquiry.Journal of Medical Education 4785–92.
Elstein, A. S., Kleinmuntz, B., Rabinowitz, M., McAuley, R., Murakami, J., Heckerling, P. S., & Dod, J. M. (1993). Diagnostic reasoning for high-and low-domain knowledge clinicians: A reanalysis.Medical Decision Making 1321–29.
Elstein, A. S., Shulman, L. S., & Sprafka, S. A. (1978).Medical problem solving: An analysis of clinical reasoning.Cambridge, MA: Harvard University Press.
Elstein, A. S., Shulman, L. S., & Sprafka, S. A. (1990). Medical problem solving: A ten-year retrospective.Evaluation and the Health Professions 135–36.
Eva, K. W., Neville, A. J., & Norman, G. R. (1998). Exploring the etiology of content specificity: factors influencing analogic transfer and problem solving.Academic Medicine 73S1–S5.
Feltovich, P. J., & Barrows, H. S. (1984). Issues of generality in medical problem solving. In M. L. de Voider & H. G. Schmidt (Eds.)Tutorials in problem based learning: New directions in training for the health professions(pp. 128–142). Assen, Holland: Van Gorcum.
Feltovich, P. J., Spiro, R. J., & Coulson, R. L. (1989). The nature of conceptual understanding in biomedicine: The deep structure of complex ideas and the development of misconceptions. In D. A. Evans & V. L. Patel (Eds.)Cognitive science in medicine: Biomedical modeling(pp. 113–172). Cambridge, MA: Bradford.
Flavell, J. H. (1979). Metacognition and cognitive monitoring: A new area of cognitive-developmental inquiry.American Psychologist 34906–911.
Gale, J. (1982). Some cognitive components of the diagnostic thinking process.British Journal of Education Psychology 5264–76.
Galotti, K. M. (1989). Approaches to studying formal and everyday reasoning.Psychological Bulletin 105331–351.
Gettys, C. F., & Fisher, S. D. (1979). Hypothesis plausibility and hypothesis generation.Organizational Behavior and Human Performance 2493–110.
Gijselaers, W. H., & Arts, J. A. (2000). Effects of gender and mood on recall in expertise research. Paper presented at the American Educational Resarch Association, New Orleans.
Gilhooly, K. J. (1987). Mental modeling: A framework for the study of thinking. hi D. N. Perkins, J. Lochhead, & J. Bishop (Eds.)Thinking: The second international conference(pp. 19–32). Hillsdale, NJ: Erlbaum.
Gilhooly, K. J. (1990). Cognitive psychology and medical diagnosis.Applied Cognitive Psychology 4261–272.
Gott, S. P. (1988). Apprenticeship instruction for real-world tasks: The coordination of procedures, mental models, and strategies. In E. Z. Rothkopf (Ed.)Review of research in education(Vol. 15, pp. 97–169). Washington, DC: American Educational Research Association.
Greeno, J. G. (1976). Indefinite goals in well-structured problems.Psychological Review 83(6)479–491.
Groen, G. J., & Patel, V. L. (1991). A view from medicine. In M. U. Smith (Ed.)Toward a unified theory of problem solving: Views from the content domains(pp. 35–44). Hillsdale, NJ: Erlbaum.
Gruppen, L. D. (1997). Implications of cognitive research for ambulatory care education.Academic Medicine 72 117-120.
Gruppen, L. D., Wolf, F. M., & Billi, J. E. (1987). Gathering vs. use of probabilistic information as causes of biased diagnostic decisions. Paper presented at the Proceedings of the American Statistical Association: Social Statistics Section.
Harkness, A. R., DeBono, K. G., & Borgida, E. (1985). Personal involvement and strategies for making contingency judgments. A stake in the dating game makes a difference.Journal of Personality and Social Psychology 4922–32.
Hassebrock, F., Bullemer, P., & Johnson, P. E. (1988). When less is more: Selective memory of problem-solving experts. Paper presented at the American Educational Research Association.
Hatala, R., Norman, G. R., & Brooks, L. R. (1999). Influence of a single example on subsequent electrocardiogram interpretation.Teaching and Learning in Medicine 11110–117.
Hebb, D. O. (1949).The organization of behavior.New York: John Wiley & Sons.
Henle, M. (1955). Some effects of motivational processes on cognition.Psychological Review 62423–452.
Hobus, P. P. M., Boshuizen, H. P. A., & Schmidt, H. G. (1991). Expert-novice differences in the role of contextual factors in early medical diagnosis. Paper presented at the American Educational Research Association, Chicago, April.
Hobus, P. P. M., Schmidt, H. G., Boshuizen, H. P. A., & Patel, V. L. (1987). Contextual factors in the activation of first diagnostic hypotheses: Expert-novice differences.Medical Education 21471–476.
Homa, D., Sterling, S., & Treppel, L. (1981). Limitations of exemplar-based generalization and the abstraction of categorical information.Journal of Experimental Psychology: Human Learning and Memory7, 419–439.
Isen, A. M., & Daubman, K. A. (1984). The influence of affect on categorization.Journal of Personality and Social Psychology 471206–1217.
Isen, A. M., Means, B., Patrick, R., & Nowicki, G. (1982). Some factors influencing decision-making strategy and risk taking. In M. S. Clark & S. T. Fiske (Eds.)Affect and cognition: The seventeenth annual Carnegie symposium on cognition(pp. 243–261). Hillsdale, NJ: Erlbaum.
Isen, A. M., Rosenzweig, A. S., & Young, M. J. (1991). The influence of positive affect on clinical problem solving.Medical Decision Making 11221–227.
Jeffries, R., Turner, A., Poison, P. G., & Atwood, M. E. (1981). The processes involved in designing software. In J. R. Anderson (Ed.)Cognitive skills and their acquisition(pp. 255–284). Hillsdale, NJ: Erlbaum.
Johnson, P. E., Durán, A. S., Hassebrock, F., Moller, J., Prietula, M., Feltovich, P. J., & Swanson, D. B. (1981). Expertise and error in diagnostic reasoning.Cognitive Science 5235–283.
Jolly, B., Coles, C., Norman, G., & Stalenhoef, B. (1984). The generalisability of knowledge and the assessment of clinical performance. Paper presented at the Directions in clinical assessment, Cambridge, England, July 1.
Joseph, G.-M., & Patel, V. (1990). Domain knowledge and hypothesis generation in diagnostic reasoning.Medical Decision Making 1031–46.
Kaplan, S. (1977). Participation in the design process. In D. Stokols (Ed.)Perspectives on environment and behavior: Theory research and applications(pp. 221–234). New York: Plenum.
Kassirer, J. P., & Gorry, G. A. (1978). Clinical problem solving: A behavioral analysis.Annals of Internal Medicine 89245–255.
Keren, G. (1984). On the importance of identifying the correct “problem space”.Cognition 16121–128.
Klayman, J.&Brown, K. (1993). Debias the environment instead of the judge: an alternative approach to reducing error in diagnostic (and other) judgment.Cognition 4997–122.
Koedinger, K. R.&Anderson, J. R. (1990). Abstract planning and perceptual chunks - elements of expertise in geometry.Cognitive Science 14 511–550.
Lave, J. (1988).Cognition in practice.Cambridge, MA: Cambridge University Press.
Mandler, G. (1975). Memory storage and retrieval: Some limits on the reach of attention and consciousness.In P. M. A. Rabbitt & S. Dornic (Eds.)Attention and performance V(pp. 499–516). New York: Pergamon.
Mann, K. (1999). Motivation in medical education: How theory can inform our practice.Academic Medicine 74237–239.
Markus, H., & Zajonc, R. B. (1985). The cognitive perspective in social psychology. In G. Lindzey & E.Aronson (Eds.)Handbook of social psychology(3rd ed., pp. 137–230). Reading, MA: Addison-Wesley.
Murphy, G. L. (1991). Parts in object concepts: Experiments with artificial categories.Memory and Cognition 19423–438.
Norman, G. R., Brooks, L. R., Coblentz, C. L., & Babcock, C. J. (1992). The correlation of feature identification and category judgments in diagnostic radiology.Memory and Cognition 20344–355.
Norman, G. R., Rosenthal, D., Brooks, L. R., Allen, S. W., & Muzzin, L. J. (1989). The development of expertise in dermatology.Archives of Dermatology 1251063–1068.
Patel, V. L., Evans, D. A., & Groen, G. J. (1989). Biomedical knowledge and clinical reasoning. In D. A. Evans & V. L. Patel (Eds.)Cognitive science in medicine: Biomedical modeling(pp. 53–112). Cambridge, MA: Bradford.
Patel, V. L., Groen, G. J., & Norman, G. R. (1993). Reasoning and instruction in medical curricula.Cognition and Instruction 10335–378.
Patel, V. L., Kaufman, D. R., & Magder, S. A. (1996). The acquisition of medical expertise in complex dynamic environments. In K. A. Ericsson (Ed.)The road to excellence(pp. 127–166). Rahwah, NJ: Lawrence Erlbaum.
Patel, V. L., Kong, H. P., & Mark, V. C. (1984). Role of prior knowledge in comprehension of medical information by medical students and physicians.Proceedings of the 23rd Annual Conference on Research in Medical Education 23127–132.
Pople, H. E., Jr. (1982). Heuristic methods for imposing structure on ill-structured problems: The structuring of medical diagnostics. In P. Szolovits (Ed.)Artificial intelligence in medicine(pp. 119–190). Boulder, CO: Westview.
Posner, M. I. (1986). Empirical studies of prototypes. In C. Craig (Ed.)Noun classes and categorization(pp. 53–61). Philadelphia: John Benjamins.
Pressley, M. (1994). Embracing the complexity of individual differences in cognition: Studying good information processing and how it might develop.Learning and Individual Differences 6259–284.
Regehr, G., & Norman, G., R. (1996). Issues in cognitive psychology: Implications for professional education.Academic Medicine71, 988–1001.
Rogoff, B., & Lave, J. (1984).Everyday cognition: Its development in social context.Cambridge, MA: Harvard University Press.
Rosch, E., Mervis, C. B., Gray, W. D., Johnson, D. M.&Boyes-Braem, P. (1976). Basic objects in natural categories.Cognitive Psychology 8382–439.
Schank, R. C., & Abelson, R. P. (1977). Scripts, plans, goals, and understanding: An inquiry into human knowledge and structures. Hillsdale, NJ: Erlbaum.
Schmidt, H. G., & Boshuizen, H. P. A. (1992). Encapsulation of biomedical knowledge. In D. A. Evans & V. L. Patel (Eds.)Advanced models of cognition for medical training and practice(pp. 265–282). New York: Springer-Verlag.
Schmidt, H. G., & Boshuizen, H. P. A. (1993a). On acquiring expertise in medicine.Educational Psychology Review5, 1–17.
Schmidt, H. G., & Boshuizen, H. P. A. (1993b). On the origin of intermediate effects in clinical case recall.Memory and Cognition 21338–351.
Schmidt, H. G., & Norman, G. R. (1989).A stage theory on the development of expertise in medicineAmerican Educational Research Association.
Schmidt, H. G., Boshuizen, H. P. A., & Hohus, P. P. M. (1988). Transitory stages in the development of medical expertise: The “intermediate effect” in clinical case representation studies. InProceedings of the Cognitive Science Society Meeting(pp. 139–145). Hillsdale, NJ: Lawrence Erlbaum.
Schmidt, H. G., Norman, G. R., & Boshuizen, H. P. A. (1990). A cognitive perspective on medical expertise: Theory and implications.Academic Medicine65, 611–621.
Schön, D. A. (1987).Educating the reflective practitioner: Toward a new design for teaching and learning in the professions.San Francisco: Jossey-Bass.
Scribner, S. (1986). Thinking in action: Some characteristics of practical thought. In R. J. Sternberg & R. K. Wagner (Eds.)Practical intelligence: Origins of competence in the everyday world(pp. 13–30). Cambridge: Cambridge University Press.
Smith, E. E., & Medin, D. L. (1981).Categories and concepts.Cambridge, MA: Harvard University Press.
Sternberg, R. J. (1985). Review of Meichembaum, Burland, Gruson and Cameron’s “Metacognitive assessment.”. In S. R. Yussen (Ed.)The growth of reflection in childrenNew York: Academic Press.
Swanson, D. B. (1987). A measurement framework for performance-based tests. In I. Hart & R. Harden (Eds.)Further development in assessing clinical competence(pp. 13–45). Montreal: Can-Heal Publications.
Szolovits, P., & Pauker, S. G. (1984). Categorical and probabilistic reasoning in medical diagnosis. In W. J. Clancey & E. H. Shortliffe (Eds.)Readings in medical artificial intelligence: The first decade(pp. 210–240). Reading, MA: Addison-Wesley.
Teigen, K. H. (1988). The language of uncertainty.Acta Psychologica 6827–38.
Tobias, S. (1994). Interest, prior knowledge, and learning.Review of Educational Research 6437–54.
Van de Wiel, M. W. J., Boshuizen, H. P. A., Schmidt, H. G., & Schaper, N. C. (1999). The explanation of clinical concepts by expert physicians, clerks, and advanced students.Teaching and Learning in Medicine 11 153–163.
Vanderbilt, T. C. A. (1990). Anchored instruction and its relationship to situated cognition.Educational Researcher19(6), 2–10.
Voss, J. F., Tyler, S. W., & Yengo, L. A. (1983). Individual differences in the solving of social science problems. In R. Dillon & R. Schmeck (Eds.)Individual differences in cognition(Vol. 1, pp. 205–232). New York: Academic Press.
Voytovich, A. E., & Rippey, R. M. (1982). Knowledge, realism, and diagnostic reasoning in a physical diagnosis course.Journal of Medical Education 57461–467.
Voytovich, A. E., Rippey, R. M., & Suffredini, A. (1985). Premature conclusions in diagnostic reasoning.Journal of Medical Education 60302–307.
Author information
Authors and Affiliations
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2002 Springer Science+Business Media Dordrecht
About this chapter
Cite this chapter
Gruppen, L.D., Frohna, A.Z. (2002). Clinical Reasoning. In: Norman, G.R., et al. International Handbook of Research in Medical Education. Springer International Handbooks of Education, vol 7. Springer, Dordrecht. https://doi.org/10.1007/978-94-010-0462-6_8
Download citation
DOI: https://doi.org/10.1007/978-94-010-0462-6_8
Published:
Publisher Name: Springer, Dordrecht
Print ISBN: 978-94-010-3904-8
Online ISBN: 978-94-010-0462-6
eBook Packages: Springer Book Archive