Clinical reasoning in the real world is mediated by bounded rationality: implications for diagnostic clinical practice guidelines.
BACKGROUND
Little is known about the reasoning mechanisms used by physicians in decision-making and how this compares to diagnostic clinical practice guidelines. We explored the clinical reasoning process in a real life environment.


METHODS
This is a qualitative study evaluating transcriptions of sixteen physicians' reasoning during appointments with patients, clinical discussions between specialists, and personal interviews with physicians affiliated to a hospital in Brazil.


RESULTS
FOUR MAIN THEMES WERE IDENTIFIED: simple and robust heuristics, extensive use of social environment rationality, attempts to prove diagnostic and therapeutic hypothesis while refuting potential contradictions using positive test strategy, and reaching the saturation point. Physicians constantly attempted to prove their initial hypothesis while trying to refute any contradictions. While social environment rationality was the main factor in the determination of all steps of the clinical reasoning process, factors such as referral letters and number of contradictions associated with the initial hypothesis had influence on physicians' confidence and determination of the threshold to reach a final decision.


CONCLUSIONS
Physicians rely on simple heuristics associated with environmental factors. This model allows for robustness, simplicity, and cognitive energy saving. Since this model does not fit into current diagnostic clinical practice guidelines, we make some propositions to help its integration.
Bonilauri Ferreira
Ana Paula Ribeiro
AP
Univille, Joinville, Brazil.
Ferreira
Rodrigo Fernando
RF
Rajgor
Dimple
D
Shah
Jatin
J
Menezes
Andrea
A
Pietrobon
Ricardo
R
D001938:Brazil; D015510:Clinical Medicine / Q000379:methods* / Q000592:standards; D003071:Cognition; D003657:Decision Making; D003933:Diagnosis; D017410:Practice Guidelines as Topic; D012931:Social Environment