The role of patient involvement in the diagnostic process in internal medicine: a cognitive approach.

Much cognitive and clinical research has addressed clinical reasoning, pointing out that physicians often have difficulties in following a linear course when making accurate diagnoses. Some authors suspect that physicians make mistakes because they unknowingly fail to observe the laws of formal logic and that their reasoning becomes influenced by contextual factors. In this paper, we introduce some basic principles of the cognitive approach to medical decision making and we describe the cognitive balanced model. Then we discuss the relationship between construction of mental models, cognitive biases and patient involvement by the use of a clinical vignette. Medical decisions may be considered fundamentally biased since the use of judgment heuristics and a combination of cognitive-related and system-related factors limit physicians' rationality. While traditional understanding of clinical reasoning has failed to consider contextual factors, most techniques designed to avoid biases seem to fail in promoting sound and safer medical practice. In particular, we argue that an unbiased process requires the use of a cognitive balanced model, in which analytical and intuitive mind skills should be properly integrated. In order to improve medical decision making and thereby lessen incidence of adverse events, it is fundamental to include the patient perspective in a balanced model. Physicians and patients should improve their collective intelligence by sharing mental models within a framework of distributed intelligence.