Advances in Health Sciences Education

, Volume 2, Issue 2, pp 173–184 | Cite as

The Non-Analytical Basis of Clinical Reasoning

  • Geoffrey R. Norman
  • Lee R. Brooks

Abstract

This paper explores the assertion that much of clinical diagnostic thinking is based on the rapid and unconscious matching of the presenting problem to a similar, previously encountered, problem. This ‘non-analytic’ form of concept formation has been described in the psychology literature for over a decade. From this theory, we deduce and test several hypotheses: 1) Diagnosis is based in part on similarity to a particular previous example. In studies in dermatology, specific similarity accounts for about 30% of diagnosis. 2) When experts err, these errors are as likely as novices to occur on typical presentations. For residents, general practitioners and dermatologists, about 40% of errors were on typical slides. 3) Features are re-interpreted in light of diagnostic hypotheses. In radiology, attaching a standard positive history to the film bag increased the number of features seen on both normal and abnormal films by about 50%. 4) Experts cannot predict errors of other experts. In dermatology, experts predicted only 11–60% of errors committed by their colleagues. We conclude that amassing prior instances is an important component of expertise, and education should recognize this element.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Allen, S.W., Brooks, L.R., & Norman, G.R. (1992). Experimental stuidies of learning dermatological diagnosis: The impact of examples. Teaching and Learning in Medicine, 4, 35-44.CrossRefGoogle Scholar
  2. Barrows, H.S. Norman, G.R., Neufeld, V.R., & Feightner, J.W. (1982). The clinical reasoning process of randomly selected physicians in general medical practice. Clinical and Investigative Medicine, 5, 49-56.Google Scholar
  3. Baxt, W.G. (1991). Use of an artificial neural network for the diagnosis of acute myocardial infarction. Annals of Internal Medicine, 115, 843-848.Google Scholar
  4. Bordage, G., & Zacks, R. (1984). The structure of medical knowledge in the memories of medical students and general practitioners: Categories and prototypes. Medical Education, 18, 406-416.CrossRefGoogle Scholar
  5. Brooks, L.R. (1987). Decentralized control of categorization: The role of prior processing episodes. In U. Neisser (ed.), Concepts and conceptual development: Ecological and intellectual factors in categorization. Cambridge: Cambridge University Press, 141-174.Google Scholar
  6. Brooks, L.R., Allen, S.W., & Norman, G.R. (1991). Role of specific similarity in a medical diagnostic task. Journal of Experimental Psychology: General, 120, 278-287.CrossRefGoogle Scholar
  7. Clancey, W. (1988). Ac1quiring, representing, and evaluating a competence model of medical diagnosis. In M. Chi, R. Glaser & M. Farr (eds.) The nature of expertise (pp. 343-418). Hillsdale, N.J., Laurence Erlbaum.Google Scholar
  8. Dreyfus, H., & Dreyfus, S. (1984). Mindless Machines. The Sciences. New York Academy of Sciences, 18-22.Google Scholar
  9. Fischoff, B., & Beyth-Marom, R. (1983). Hypothesis evaluation from a Bayesian perspective. Psychological Review, 90, 239-260.CrossRefGoogle Scholar
  10. Guppy, K.H., Detrano, R., Abbassi, N., Janosi, A., Sandhu, S., & Froelicher, V. (1989). The Reliability of Probability Analysis in the Prediction of Coronary Artery Disease in Two Hospitals. Medical Decision Making, 9, 181-189.Google Scholar
  11. Hassebrock, F., & Pretula, M. (1990). Autobiographical memory in medical problem solving. Paper presented at the American Educational Research Association annual meeting, Boston MA.Google Scholar
  12. Jacoby, L.L., Baker, J.G., & Brooks, L.R. (1989). The Priority of the Specific: Episodic Effects in Picture Identification. Journal of Experimental Psychology: Learning, Memory & Cognition, 15, 275-281.CrossRefGoogle Scholar
  13. Kahnemann, D., & Miller, D.T. (1986). Norm theory: Comparing reality to its alternatives. Psychological Review, 93, 136-153.CrossRefGoogle Scholar
  14. Needham, D.R., & Begg, I.R. (1991). Problem oriented training promotes spontaneous analogical transfer: Memory oriented training promotes memory for training. Memory and Cognition, 19, 543-557.Google Scholar
  15. Norman, G.R. (1992). Expertise in visual diagnosis: A review of the literature. Academic Medicine, 67(supp), S78-S83.CrossRefGoogle Scholar
  16. Norman, G.R., Brooks, L.R., & Allen, S.W. (1989a). Recall by expert medical practitioners as a record of processing attention. Journal of Experimental Psychology: Learning, Memory & Cognition, 15, 1166-1174.CrossRefGoogle Scholar
  17. Norman, G.R., Brooks, L.R., Rosenthal, D., Allen, S.W., & Muzzin, L.J. (1989b). The development of expertise in dermatology. Archives of Dermatology, 125, 1063-1068.CrossRefGoogle Scholar
  18. Norman, G.R., Brooks, L.R., Coblentz, C.K., & Babcook, C.J. (1992). The correlation of feature identification and category judgments in diagnostic radiology. Memory and Cognition, 20, 344-355.Google Scholar
  19. Rosch, E.H., & Mervis, C.B. (1975). Family resemblances: Studies in the internal structure of categories. Cognitive Psychology, 7, 573-605.CrossRefGoogle Scholar
  20. Swanson, D.B., Feltovich, P.E., & Johnson, P. (1977). Psychological analysis of physician expertise: Implications for the design of decision support systems. Proceedings of the Second World Conference on Medical Information Systems (Medinfo '77). D.B. Shires and H. Wolf (eds.) Amsterdam, North Holland, pp. 161-164.Google Scholar
  21. Waldrop, M.M. (1989). Humanity 2, Computers 0. Science, 246, 572-573.Google Scholar
  22. Weinstein, M.D., Fineberg, H.U., & Elstein, A.S. et al. (1980). Clinical Decision Analysis. Philadelphia, PA: W.B. Saunders.Google Scholar
  23. Wigton, R.S. (1988). Use of linear models to analyze physicians' decisions. Medical Decision Making, 8, 241-252.Google Scholar
  24. Van Rossum, H.J.M., & Bender, W.W. (1990a). What can be learned from a boy with appendicitis? Persistent effects of a case presentation on the diagnostic judgement of family doctors. Paper presented at the fourth Ottawa conference, Ottawa, ON.Google Scholar
  25. Van Rossum, H.J.M., Bender, W.W., & Meinders, E.E. (1990b). The effect of reading a case in a medical journal on diagnostic judgement of practising physicians. Paper presented at the Fourth Ottawa conference, Ottawa, ON.Google Scholar

Copyright information

© Kluwer Academic Publishers 1997

Authors and Affiliations

  • Geoffrey R. Norman
    • 1
  • Lee R. Brooks
    • 1
  1. 1.Health Science CenterMcMaster UniversityHamiltonCanada

Personalised recommendations