Knowing what event precipitated a client's abnormal behaviors makes the client appear more normal than if the event is not known (Meehl, 1973). Does such knowledge also influence judgments of the need for psychological treatment, and if so, does it matter whether the precipitating event was inside or outside the client's control? We presented undergraduates with cases of hypothetical clients exhibiting abnormal behaviors and manipulated whether they were also told of a precipitating event explaining those behaviors. Knowing the precipitant significantly reduced perceptions of clients’ need for treatment, but only when the precipitating event was outside the client's control. These findings call into question the notion that it need always be beneficial for an outside reasoner to uncover the root cause of a client's psychological problems, particularly when the root cause is still unknown to the client. The rationality of the effect and additional implications for decision-making are discussed.

The field of clinical decision making is polarized by two predominate views. One holds that treatment recommendations should conform with guidelines; the other emphasizes clinical expertise in reaching case-specific judgments. Previous work developed a test for a proposed alternative, that clinical judgment should systematically incorporate both general knowledge and patient-specific information. The test was derived from image theory’s two phase-account of decision making and its “simple counting rule”, which describes how possible courses of action are pre-screened for compatibility with standards and values. The current paper applies this rule to clinical forecasting, where practitioners indicate how likely a specific patient will respond favorably to a recommended treatment. Psychiatric trainees evaluated eight case vignettes that exhibited from 0 to 3 incompatible attributes. They made two forecasts, one based on a guideline recommendation, the other based on their own alternative. Both forecasts were predicted by equally- and unequally-weighted counting rules. Unequal weighting provided a better fit and exhibited a clearer rejection threshold, or point at which forecasts are not diminished by additional incompatibilities. The hypothesis that missing information is treated as an incompatibility was not confirmed. There was evidence that the rejection threshold was influenced by clinician preference. Results suggests that guidelines may have a de-biasing influence on clinical judgment. Subject to limitations pertaining to the subject sample and population, clinical paradigm, guideline, and study procedure, the data support the use of a compatibility test to describe how clinicians make patient-specific forecasts.

In the present study, the correspondence between clinician-assessed and self-reported neurocognitive performance was contrasted with scores obtained from psychometric neuropsychological tests in 148 psychiatric in-patients. Results revealed that self-reported cognitive functioning was strongly associated with depressive symptomatology but was only poorly related to psychometric neurocognitive performance, particularly in schizophrenia. After illness denial was controlled for, the overall association between subjective and objective test performance was slightly increased but still failed to reach significance in six out of eight analyses. In approximately 20% to 40% of all cases, clinicians judged memory performance to be normal despite substantial impairment revealed by neuropsychological test results (attention parameters: 7–51%). Since (ecological) validity and reliability have been demonstrated for many neurocognitive paradigms, the present results question the validity of non-psychometric neurocognitive assessment and call for a complementation of clinical judgment with neurocognitive assessment. Reasons for decreased sensitivity of self-reported and clinician-assessed neurocognitive functioning are discussed. (JINS, 2004, 10, 623–633.)

Clinicians make judgments under conditions of uncertainty. Decision research has shown that in uncertain situations individuals do not always act rationally, coherently, or to maximize their expected utility. Advocates of clinical guidelines believe that these guidelines will eliminate some of the cognitive biases that the practitioner may introduce into the medical decision-making process in an attempt to reduce its uncertainty. Other physicians have grave doubts about guidelines' application in practice. Guideline implementation lags well behind their development. Studies of practicing physicians and a survey of clinicians in one specialty and setting indicate that experienced clinicians may be implementing guidelines selectively. Many clinicians are concerned that guidelines are based on randomized trials and do not reflect the complexity of the real world, in which a decision's context and framework are important. Their reluctance also may be due to the difficulty of applying general guidelines to specific clinical situations. The problem will only increase in the future. The patients of the 21st century will be older and have more complex disease states. Physicians will have more patient-specific therapies and need to exercise more sophisticated clinical judgment. They may be more willing to use guidelines in making those judgments if research can demonstrate guidelines' effectiveness in improving decision making for individual patients.

Development of competence in exercising therapeutic judgment skills represents the goal of clinical education. Time (clock hours) is not a valid predictor of attainment of competence in paramedic clinical education. Quantity of patient contact experiences facilitates development of judgment skills, and offers a valid measure of progress toward competence. This project uses national survey data from accredited programs to describe the availability and accessibility of patient contact experiences within paramedic clinical education. Data from this local program supplements the national survey results. The components of clinical judgment are enumerated, and strategies to teach and evaluate clinical judgment skills are discussed.

A narrative understanding of clients is needed to supplement traditionally developed research for making clinical judgments about which approaches should be used in working with older adults. Narrative biographical knowledge of clients integrates the historical events and happenings of their lives with the social and cultural contexts through which they attribute meaning to their distresses and symptoms. Applications based on narrative knowledge differ from those based on the conventional model. The conventional model draws on general knowledge of what interventions are likely to be effective in treating particular diagnoses. Narrative understanding is concerned in knowing the configuration of past events and present tasks that compose individual lives. Expert practitioners make use of a narrative understanding of their clients in judging their intervention activities. Development of a narrative understanding of present clients can be assisted by consulting narratives of clients with whom a practitioner has previously worked. Narratives are remembered as stories, retaining the patterns and details of the individual clients’ lives. Through experience, practitioners develop a collection of remembered narratives of the clients they have assisted. A practitioner's experiential collection of narratively known clients can be supplemented with narrative biographies and case studies of clients treated by other practitioners. When working with a new client, practitioners can draw on these narratively retained past understandings by comparing the similarities and differences of their present client to a remembered past client. The process of comparison with past narratively understood clients helps the practitioner compose a new narrative that expressly captures the individual life of the present client. This narrative understanding of the client provides an integrated view of the influence of general social and biological contexts with the unique values, aims, and history of the client.