Jacques Tardif

Scripts and Medical Diagnostic Knowledge: Theory and Applications for Clinical Reasoning Instruction and Research

Medical diagnosis is a categorization task that allows physicians to make predictions about features of clinical situations and to determine appropriate course of action. The script concept, which first arose in cognitive psychology, provides a theoretical framework to explain how medical diagnostic knowledge can be structured for diagnostic problem solving. The main characteristics of the script concept are pre-stored knowledge, values acceptable or not acceptable for each illness attribute, and default values. Scripts are networks of knowledge adapted to goals of clinical tasks. The authors describe how scripts are used in diagnostic tasks, how the script concept fits within the clinical reasoning literature, how it contrasts with competing theories of clinical reasoning, how educators can help students build and refine scripts, and how scripts can be used to assess clinical competence.

An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory

Abstract Context. Clinical reasoning plays a major role in the ability of doctors to make diagnoses and decisions. It is considered as the physicians most critical competence, and has been widely studied by physicians, educationalists, psychologists and sociologists. Since the 1970s, many theories about clinical reasoning in medicine have been put forward. Purpose. This paper aims at exploring a comprehensive approach: the “dual-process theory”, a model developed by cognitive psychologists over the last few years. Discussion. After 40 years of sometimes contradictory studies on clinical reasoning, the dual-process theory gives us many answers on how doctors think while making diagnoses and decisions. It highlights the importance of physicians’ intuition and the high level of interaction between analytical and non-analytical processes. However, it has not received much attention in the medical education literature. The implications of dual-process models of reasoning in terms of medical education will be discussed.

Insights into emergency physicians' minds in the seconds before and into a patient encounter.

Clinical reasoning is a core competency in medical practice. No study has explored clinical reasoning occurring before a clinical encounter, when physicians obtain preliminary information about the patient, and during the first seconds of the observation phase. This paper aims to understand what happens in emergency physicians’ minds when they acquire initial information about a patient, and when they first meet a patient. The authors carried out in-depth interviews based on the video recordings of emergency situations filmed in an “own-point-of-view-perspective”. 15 expert emergency physicians were interviewed between 2011 and 2012. Researchers analysed data using an interpretive approach based on thematic analysis and constant comparison. Almost all participants used a few critical pieces of information to generate hypotheses even before they actually met the patient. Pre-encounter hypotheses played a key role in the ensuing encounter by directing initial data gathering. Initial data, collected within the first few seconds of the encounter, included the patient’s position on the stretcher, the way they had been prepared, their facial expression, their breathing, and their skin colour. Physicians also rapidly appraised the seriousness of the patient’s overall condition, which determined their initial goals, i.e. initiating emergency treatment or pursuing the diagnostic investigation. The study brings new insights on what happens at the very beginning of the encounter between emergency physicians and patients. The results obtained from an innovative methodological approach open avenues for the development of clinical reasoning in learners.

Do emergency physicians trust their patients

The primary focus of research on the physician-patient relationship has been on patients’ trust in their physicians. In this study, we explored physicians’ trust in their patients. We held semi-structured interviews with expert emergency physicians concerning a patient they had just been managing. The physicians had been equipped with a head-mounted micro camera to film the encounter from an “own point of view perspective”. The footage was used to stimulate recall during the interviews. Several participants made judgments on the reliability of their patients’ accounts from the very beginning of the encounter. If accounts were not deemed reliable, participants implemented a variety of specific strategies in pursuing their history taking, i.e. checking for consistency by asking the same question at several points in the interview, cross-referencing information, questioning third-parties, examining the patient record, and systematically collecting data held to be objective. Our study raises the question of the influence of labeling patients as “reliable” or “unreliable” on their subsequent treatment in the emergency department. Further work is necessary to examine the accuracy of these judgments, the underlying cognitive processes (i.e. analytic versus intuitive) and their influence on decision-making.

Optometrists' clinical reasoning made explicit: a qualitative study.

Purpose Because the clinical reasoning processes engaged in by practicing optometrists have not previous been investigated, until now, there has been no way of knowing whether models of clinical reasoning from other health professions can be transposed to optometry. The purpose of this study has therefore been twofold: making explicit the clinical reasoning processes of optometrists at both the “competent” and “expert” levels and comparing these processes to highlight the characteristics of clinical reasoning expertise. Methods Four competent-level optometrists and four expert-level optometrists participated in this qualitative study. Each optometrist performed a complete optometric examination on a preselected patient. Each of these examinations was recorded on a DVD video and followed by a feedback session, also captured on a DVD video. The feedback session was conducted using techniques inspired by a form of interview called the “explicitation interview,” aiming to describe optometrists’ mental actions and the time sequence of these actions throughout the examination. Results The results indicate that optometrists’ clinical reasoning is patient centered and includes both analytical and nonanalytical modes of reasoning. When compared with a competent-level optometrist, an expert-level optometrist is more patient centered, formulates an earlier mental representation of the patient’s clinical situation (including diagnosis formulation), plans examinations more thoroughly, is able to analyze and reflect during cognitively demanding tasks, and draws up his or her care management plan throughout the entire examination. Conclusions The verbalization of optometrists’ clinical reasoning processes represents a first step toward a better understanding of this competency. The impact of this research on optometric education is discussed. The results open doors to further research in the field, for example, toward defining the stages of clinical reasoning development among optometry students and professionals.