Language in clinical reasoning: using and learning the language of collective clinical decision making

Abstract

The aim of the research presented in this thesis was to come to a deeper understanding of clinical decision making from within the interpretive paradigm. The project draws on ideas from a number of schools of thought which have the common emphasis that the interpretive use of language is at the core of all human activity. This research project studied settings where health professionals and medical students engage in clinical decision making in groups. Settings included medical students participating in problem-based learning tutorials and a team of health professionals working in a multidisciplinary clinic. An underlying assumption of this project was that in such group settings, where health professionals are required to articulate their clinical reasoning for each other, the individuals involved are likely to have insights that could reveal the nature of clinical decision making. Another important assumption of this research is that human activities, such as clinical reasoning, take place in cultural contexts, are mediated by language and other symbol systems, and can be best understood when investigated in their historical development. Data were gathered by interviews of medical students and health professionals working in the two settings, and by non-participant observation. Data analysis and interpretation revealed that clinical decision making is primarily a social and linguistic skill, acquired by participating in communities of practice called health professions. These communities of practice have their own subculture including the language game called clinical decision making which includes an interpretive repertoire of specific language tools and skills. New participants to the profession must come to embody these skills under the guidance of more capable members of the profession, and do so by working through many cases. The interpretive repertoire that health professionals need to master includes skills with words, categories, metaphors, heuristics, narratives, rituals, rhetoric, and hermeneutics. All these skills need to be coordinated, both in constructing a diagnosis and management plan and in communicating clinical decisions to other people, in a manner that can be judged as intelligible, legitimate, persuasive, and carrying the moral authority for subsequent action.