This essay reviews the origins, findings and influence of the monograph Medical Problem Solving: An Analysis of Clinical Reasoning. Majorfindings of the monograph are reviewed in the light of subsequent work and the results of selected studies of clinical cognition are related to the book's conclusions, thus sketching the growth of this field of research in the decade since publication. Several remaining methodologicalproblems and scholarly issues in the field are discussed, including: sampling cases and subjects, the definition of medical expertise, the role of verbal report in analyzing thinking, the level of clinical realism needed in research, and the relation of informationprocessing approaches to more quantitative approaches such as behavioral decision theory and social judgment theory.
The formal reasoning strategy used in medical diagnostic problem solving can be conceptualised as composed of four more elementary processes -cue acquisition, hypothesis generation, cue interpretation and hypothesis evaluation. These processes are closely linked to the clinician's store of medical knowledge. The acquisition, retention and recall of content cannot ensure its effective application, yet training in problem-solving skills with inadequate attention to factual content will not be effective either. Two educational programmes are described which aim to increase the effective linking of clinical strategy and clinical memory in undergraduate medical students. Clinical problem-solving sessions use simulated cases to provide experience in blending clinical knowledge and problem-solving strategies. Problemsolving examinations offer the opportunity for students to display the reasoning and planning behind their actions. They assess students' ability to use a problem-solving model and to document the medical work-up using the Problem Oriented Medical Record. Both educational programmes use concepts and theory developed in empirical research on medical problem solving. Fundamental research is used to raise questions about educational practice, while the practical concerns of education raise questions for substantive inquiry.
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