title: Examining the Influence of Context and Professional Culture on Clinical Reasoning Through Rhetorical-Narrative Analysis.
abstract: According to the dual process model of reasoning, physicians make diagnostic decisions using two mental systems: System 1, which is rapid, unconscious, and intuitive, and System 2, which is slow, rational, and analytical. Currently, little is known about physicians' use of System 1 or intuitive reasoning in practice. In a qualitative study of clinical reasoning, physicians were asked to tell stories about times when they used intuitive reasoning while working up an acutely unwell patient, and we combine socio-narratology and rhetorical theory to analyze physicians' stories. Our analysis reveals that in describing their work, physicians draw on two competing narrative structures: one that is aligned with an evidence-based medicine approach valuing System 2 and one that is aligned with cooperative decision making involving others in the clinical environment valuing System 1. Our findings support an understanding of clinical reasoning as distributed, contextual, and influenced by professional culture.
authors.affiliation: 1 McMaster University, Hamilton, Ontario, Canada.
authors.forename: Amanda
authors.initials: A
authors.lastname: Peters
authors.affiliation: 1 McMaster University, Hamilton, Ontario, Canada.
authors.forename: Meredith
authors.initials: M
authors.lastname: Vanstone
authors.affiliation: 1 McMaster University, Hamilton, Ontario, Canada.
authors.forename: Sandra
authors.initials: S
authors.lastname: Monteiro
authors.affiliation: 1 McMaster University, Hamilton, Ontario, Canada.
authors.forename: Geoff
authors.initials: G
authors.lastname: Norman
authors.affiliation: 1 McMaster University, Hamilton, Ontario, Canada.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Sherbino
authors.affiliation: 1 McMaster University, Hamilton, Ontario, Canada.
authors.forename: Matthew
authors.initials: M
authors.lastname: Sibbald
mesh_terms: D000328:Adult; D003657:Decision Making; D019317:Evidence-Based Medicine / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D033262:Narration; D010820:Physicians / Q000523:psychology*; D011340:Problem Solving; D011369:Professional-Patient Relations; D036301:Qualitative Research
keywords: Ontario, Canada; clinical reasoning; evidence-based medicine; medical education; professional culture; qualitative research; rhetorical theory; socio-narratology