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.
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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.
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.
Baxt, W.G. (1991). Use of an artificial neural network for the diagnosis of acute myocardial infarction. Annals of Internal Medicine, 115, 843-848.
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.
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.
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.
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.
Dreyfus, H., & Dreyfus, S. (1984). Mindless Machines. The Sciences. New York Academy of Sciences, 18-22.
Fischoff, B., & Beyth-Marom, R. (1983). Hypothesis evaluation from a Bayesian perspective. Psychological Review, 90, 239-260.
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.
Hassebrock, F., & Pretula, M. (1990). Autobiographical memory in medical problem solving. Paper presented at the American Educational Research Association annual meeting, Boston MA.
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.
Kahnemann, D., & Miller, D.T. (1986). Norm theory: Comparing reality to its alternatives. Psychological Review, 93, 136-153.
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.
Norman, G.R. (1992). Expertise in visual diagnosis: A review of the literature. Academic Medicine, 67(supp), S78-S83.
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.
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.
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.
Rosch, E.H., & Mervis, C.B. (1975). Family resemblances: Studies in the internal structure of categories. Cognitive Psychology, 7, 573-605.
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.
Waldrop, M.M. (1989). Humanity 2, Computers 0. Science, 246, 572-573.
Weinstein, M.D., Fineberg, H.U., & Elstein, A.S. et al. (1980). Clinical Decision Analysis. Philadelphia, PA: W.B. Saunders.
Wigton, R.S. (1988). Use of linear models to analyze physicians' decisions. Medical Decision Making, 8, 241-252.
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.
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.
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Norman, G.R., Brooks, L.R. The Non-Analytical Basis of Clinical Reasoning. Adv Health Sci Educ Theory Pract 2, 173–184 (1997). https://doi.org/10.1023/A:1009784330364
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DOI: https://doi.org/10.1023/A:1009784330364