Affective Aspects of Clinical Reasoning: Their Importance in Assessment of Behavioral Diagnoses in Medical Patients

Abstract

Physicians' expectations of patients' behavior are de facto aspects of clinical reasoning. Yet, for the most part, these aspects are not included in the modern paradigm of clinical decision making, which presumes that physicians should decide only on a normative probabilistic logic. If diagnostic cues are equivocal, physicians are more likely to be affected by the doctor-patient encounter from which they derive their expectations about patients' compliance. Affective aspects of clinical reasoning are particularly important in evaluation of behavioral diagnoses which are often equivocal. Physicians' reasoning about patients' compliance with diagnostic testing and medical treatment was studied by questionnaires completed at the end of the office visits. The physicians' expectations of testing compliance were associated with a high percent of significant medical problems, more severe illness, younger patients, and junior resident staff. The expectation of non-compliance with treatment was associated with a lower percent of significant medical problems, discomfort in talking to the patient, and a behavioral diagnosis. Physicians were more comfortable talking to sicker patients who had significant medical problems. We conclude that physicians expect patients to behave pragmatically, complying with testing and treatment if their problems are serious and treatable. When physicians are uncomfortable with patients because the patients have problems which are deemed less medically significant, more equivocal, or because of the patients' personalities, physicians are more likely to expect that the patient will not take treatment.