Medical problem-solving: a critique of the literature

Descriptive studies of clinical reasoning have been based primarily on an information-processing paradigm that has entailed microscopic analyses of the verbal behavior of small numbers of persons confronted with the task of making a diagnosis of a patient with symptoms of acute illness. From these studies, researchers have generally concluded: that medical problem-solving is an hypothetico-deductive process and that performance is not generalizable across problems. The author of the present paper argues that this narrow approach casts serious doubt on the validity of the conclusions and leaves unilluminated a large portion of the cognitive process involved in decisions about patient care. On the other hand, prescriptive, decision-analysis studies of medical problem-solving have generally been based on sophisticated decision theory that involves calculation and manipulation of complex probability and utility values in order to arrive at optimal decisions that will maximize patient benefits. While these prescriptive studies offer a methodology for improving clinical judgment, that methodology may not be one which decision-makers find attractive or feasible to employ.