Journal of Biomedical Informatics 37 (2004) 86–98

www.elsevier.com/locate/yjbin

Cognitive schema and naturalistic decision making in

evidence-based practices
Paul R. Falzer*
Department of Psychiatry, Yale School of Medicine, CMHC, 34 Park Street, Room 144, New Haven, CT 06508, USA
Received 11 November 2003

Abstract

A recent article in this journal proposed a naturalistic approach to decision making that overcomes problems intrinsic to classical
decision theory. The approach emphasizes cognitive and multi-level processes, the development of expert reasoning, and the role of
decision support in individual and organizational decision making. The current paper builds on this effort by suggesting a natu-
ralistic, multi-level, theory that can facilitate the dissemination of evidence-based practices (EBPs). The paper presents ‘‘Image
Theory,’’ a theory that has been extensively investigated in other disciplines, but has yet to be utilized in medical decision research. It
is suggested that its rich, empirically tested, distinctions among kinds of cognitive and organizational processes and types of de-
cisions and tasks make Image Theory especially valuable in describing impediments to implementing EBPs. The paper discusses how
naturalistic theory can assist clinicians, administrators, researchers, and policy makers in achieving a balance between evidence-
based medicine and patient-centered practice.
Ó 2004 Elsevier Inc. All rights reserved.

Keywords: Medical decision making; Naturalistic decision making; Classical decision theory; Image Theory; Cognition; Dissemination; Heuristics;
Sub-optimality; Diagnostic reasoning; Psychiatry; Mental health; Schizophrenia

1. Introduction value’’ and using information in an ‘‘optimal’’ fashion.

The decision making practices of healthcare practi-
tioners have long been of interest to administrators,
researchers, and educators. Recent attention that has
focused on the subject is owing in part to the growing
popularity of evidence-based practice (EBP) initiatives.
According to Sackett and associates, ‘‘Evidence-based
medicine (EBM) is the conscientious, explicit, and ju-
dicious use of current best evidence in making decisions
about the care of individual patients’’ ([1], p. 72). As the
definition indicates, there is an intimate relationship
between EBM and clinical decision making.
According to Elstein [2], this relationship has been
predicated on the conceptual framework and terminol-
ogy of Classical Decision Theory, or ‘‘CDT.’’ In its
original form, CDT focuses on strategies of rational
decision making, particularly on ‘‘maximizing expected
*
Fax: 1-203-974-7719.
E-mail address: paul.falzer@yale.edu.
Rationality and optimality are normative concepts: They
presume an inclination to aggregate information accu-
rately and consistently, and an ability to make judg-
ments that are at least logically sound, if not empirically
correct [3].
Though most medical practitioners are eager to base
clinical decisions on the best available evidence [4], there
has been noticeable reluctance to implement EBP ini-
tiatives [5–7]. The resistance is owing in part to the
normative thrust of CDT. Some critics have argued that
the deliberate and judicious application of evidence that
is requisite to sound clinical practice is inconsistent with
the normative standards and algorithmic applications
that characterize EBPs [8].
There have been exemplary adaptations of the origi-
nal expected value model in psychology [9] and eco-
nomics [10]. In addition, theoretical variations such as
behavioral decision theory [11] and multi-attribute util-
ity theory [12], and new applications in risk management
and communication [13,14] have demonstrated CDTÕs
resilience. Nonetheless, discontinuity is evident when

1532-0464/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.jbi.2004.02.002
 P.R. Falzer / Journal of Biomedical Informatics 37 (2004) 86–98
principles of CDT are applied to practical situations.
Thoughtful observers who are committed to CDT-based
approaches find this discontinuity troubling [15], while
less sanguine critics suggest that even the most malleable
forms of CDT are inadequate to the tasks of describing,
evaluating, and aiding human decisions [16]. Alternative
approaches to classical theory, inspired principally by
Simon [17,18], began appearing in economics, sociology,
and communication over half a century ago. Within the
past 15 years, these approaches began to coalesce under
the rubric of Naturalistic Decision Making, or ‘‘NDM’’
[19].
This paper discusses why NDM theories are better
able than CDT-based theories to assist clinicians, edu-
cators, and administrators in understanding the appar-
ent resistance to EBM, and in developing strategies to
overcome the disparity between principle and practice.
The discussion begins by indicating why optimality
presents an intractable problem for medical decision
making, then introduces an NDM-inspired approach
that was developed specifically for medical decision
making. This discussion leads to presenting another
NDM theory that has yet to be applied to medicine, but
has distinctive features that make it especially attractive
for medical decision making. The paper concludes by
indicating how this theory may be helpful in addressing
the disparity between principle and practice, and in
promoting the adoption of EBPs.
2. Optimality in classical decision theory
According to Hammond ([20], p. 53), two metatheo-
ries have been persistent rivals in the history of science
and particularly in research on judgment and decision
making. There is ‘‘correspondence’’ metatheory, that
strives for empirical accuracy, and ‘‘coherence’’ me-
tatheory, that focuses on achieving logical or statistical
rationality. In the decision theory literature, correspon-
dence is exemplified in BrunswikÕs probabilistic func-
tionalism [21,22] and by the cognitive heuristics theory
of Tversky and Kahneman [23], which will be discussed
momentarily. Prime applications of coherence in the
decision theory literature include Peterson and BeachÕs
Bayesian-inspired claim that persons function as intui-
tive statisticians [24], and studies by Hoffman and as-
sociates on regression models as representations of
clinical judgment [25,26]. A brief account of the coher-
ence-inspired concept of expected value illustrates the
normative aspect of both correspondence and coher-
ence, and the importance they afford the concept of
optimality.
In rudimentary form, expected value is a linear model
that expresses a multiplicative relationship between two
variables: probability and utility. To illustrate, suppose
that a clinician must choose between two therapies, a
87
conventional treatment of choice and a newer alterna-
tive. A matrix that represents this decision appears in
Table 1, where an expected value is calculated for each
therapy by multiplying the positive and negative utilities
by their respective probabilities, then subtracting the
negative result from the positive. This calculation shows
that conventional treatment has a higher expected value,
even though the alternative has a better positive out-
come (+8 versus +5). The reasons for this apparent
anomaly are that the alternative also has a worse neg-
ative outcome ()4 versus )2) and a lower probability of
success (.6 versus .9). Given the data in Table 1, a cli-
nician who chooses to prescribe conventional treatment
is making a rational decision. However, the rationality
standard requires more than reaching the correct con-
clusion: The choice between conventional and alterna-
tive therapies must be made by discerning the relevant
utilities and probabilities, then aggregating them cor-
rectly [27].
Grounding EBPs on CDT requires that there is sub-
stantial data from randomized clinical trials to conclude
that a given treatment has a sufficiently high probability
of a good outcome. In Table 1, the probability of .6
suggests that while the alternative treatment has prom-
ise, the evidence is insufficient to warrant its recom-
mendation as an EBP, even if results to date (as
represented by the utilities) are highly favorable. To say
that a treatment is ‘‘evidence-based’’ is to assert that
both determinants of expected value are sufficiently
high. EBPs are practices that follow normative stan-
dards. Evidence-based treatment guidelines function as
decision aids that identify evidence-based treatments,
summarize supporting evidence, and compare preferred
treatments to alternatives.
2.1. The problems of optimality
Three points should be emphasized about the concept
of optimality: First, optimal standards are embedded in
the logic of a normative model. In models such as ex-
pected value or BayesÕ Theorem, procedures that pro-
duce an optimal decision are properties of the norm.
Conditions of optimality cannot be arbitrary, subjective,
Table 1
An expected value decision matrix
Therapy Variable Outcome EV
Positive Negative
Conventional Probability .9 .1
Utility 5 )2
P
U 4.5 ).2 4.3
Alternative Probability .6 .4
Utility 8 )4
P
U 4.8 )1.6 3.2
88 P.R. Falzer / Journal of Biomedical Informatics 37 (2004) 86–98
or externally imposed. Second, optimality is a single
universal standard that applies to all of the phenomena
that fall within a normative or procedural domain. All
EBPs are evaluated by the same procedures; applying
these procedures in every instance is a sine qua non of
optimal decision making. Third, optimality is an ab-
stract standard that is two steps removed from concrete
information and actual clinical situations. The first re-
move refers to the aggregation of individual phenomena
into a domain (for instance, all cases of acute schizo-
phrenia). The second remove extracts normative prin-
ciples from this domain, and these principles become the
standards of optimality ([28], p. 253).
The argument advanced here is that the quest for
optimality is daunted by two intractable problems: First,
optimality is not feasible in the domains that comprise
decision making; second, optimality has marginal rele-
vance to medical practice. The three characteristics
identified above will guide a discussion of these prob-
lems.
Since CDT-based approaches depict optimality as a
predicate of sound decision making, the results of hun-
dreds of studies conducted over the past 50 years should
give us pause. Beginning with MeehlÕs [29] research that
compared clinical with actuarial predictions, and pro-
ceeding through the work of Goldberg [30], Dawes [26],
and others, studies have found almost universally that
medical practitioners lack the perceptive and integrative
power that are requisite to optimal decision making.
(Kleinmuntz [31] gives a comprehensive review of these
studies.) According to Fischhoff [15], the inclination to
make sub-optimal decisions is owing to inherent limi-
tations of cognitive capacity, compounded by a lack of
proper training and reluctance to employ counter-intu-
itive processes. The work of Peterson, Beach, and as-
sociates [32] supports this observation. They conducted
studies that compared subject responses to normative
predictions of BayesÕ Theorem and found consistent
patterns of sub-optimal decision making. However,
other lines of research found that clinicians utilize in-
formation so poorly and inconsistently that they are
outperformed even by a simplified model of their own
judgments [33].
Tversky, Kahneman, and associates suggest that de-
cision making is sub-optimal because people simply do
not follow normative strategies [34]. Instead, we employ
a variety of cognitive short-cuts known as heuristics. The
first heuristic they identified is a tendency to treat dis-
tributional characteristics of a sample as representing a
parent population [35]. A profusion of studies has
shown that employing this ‘‘representativeness’’ heuris-
tic, or others such as ‘‘availability’’ and ‘‘anchoring,’’
leads to incorrect decisions [23,36]; moreover, experts
are as inclined to use heuristics as laypersons [35]. Per-
haps the most intriguing studies of all concern the
heuristic known as ‘‘framing’’ [37,38], which refers to the
effect of positive and negative phrasing on perceptions
of risk.
Owing to compelling explanations, clever procedures,
and recent adaptations, work on cognitive heuristics has
won a prominent place in the medical decision making
literature [39]. Together, these studies offer considerable
support for the claim that decision making is so rife with
sub-optimal tendencies that optimality is nothing more
than a will-
o-the-wisp: Optimality is an unfeasible ob-
jective because the standards of an optimal decision are
embedded in the logic of normative models, and medical
practitioners do not follow normative models when they
make decisions.
The universal and abstract qualities of CDT limit its
value even as a descriptive tool or benchmark. In ev-
eryday medical practice, decision making is affected by a
variety of contingencies and constraints. But at two
levels of abstraction, these variegations fade into a single
procedure and a universal set of norms. For CDT, there
is significant transfer of decision skills across contexts.
In principle, all decisions are essentially identical, whe-
ther they pertain to taking an umbrella to work, be-
ginning a relationship, engaging in arbitrage, or
recommending surgery. In practice, however, medical
decision making requires specialized training, skill, and
expertise. Applying a model to medical decision making
that is equally appropriate to buying a set of tires raises
the specter of EBM as a degenerate form of medical
practice. The discontinuity between universality in
principle and variety in practice is responsible in part for
what has been depicted as a stalemate between EBP
initiatives and the aims of patient-centered medicine
[40].
Optimality is a universal standard with abstract
conditions that operate simultaneously in two domains:
Along with two removes of data, there is an abstraction
from individual decision maker to an idealized entity. As
described by Beach and Lipshitz, what results ‘‘is an
abstract system of propositions that is designed to de-
scribe the choices of an ideal hypothetical decision ma-
ker—omniscient and computationally omnipotent
Economic Man’’ ([16], p. 21). The idealization exacts a
price, because Economic Man exists in a world of om-
niscience and omnipotence. Medicine is not practiced in
that world, but in situations that require decisions to be
made urgently, oftentimes with scarce and unreliable
information, using quality and effectiveness criteria that
are evolving to meet the demands of a dynamic health-
care system. Standards of optimality can assist decision
makers in identifying errors and isolating problems.
However, in developing solutions, whether they take
form of decision support, educational programming, or
organizational initiatives, optimality yields to standards
that emerge from a variety of fallible sources, including
expert opinion, consensus, objective assessment, and
administrative procedure.
 P.R. Falzer / Journal of Biomedical Informatics 37 (2004) 86–98
3. A naturalistic alternative to classical decision theory
Of the naturalistic alternatives to CDT that have been
advanced over the past 15 years, one stands out as par-
ticularly relevant for medical researchers, clinicians, and
educators. This is the cognitive naturalistic approach of
Patel and associates. Their earliest work was inspired by
SimonÕs research on cognitive patterns in expert decision
making [41]. A series of studies [42,43] contributed to the
medical education literature by describing the develop-
ment of medical knowledge and expert use of clinical
information. With the publication of several landmark
papers [44–46], the original thrust has expanded to in-
clude extensive work on cognition, on the relationship
between individual and organizational decisions [47],
and the affect of technology on decision processes [48].
A recent paper by Patel et al. [49] drew the concepts
and findings of previous work together. It offered a co-
gent critique of CDT, made a case for expanding the
scope of decision research beyond the confines of nor-
mative modeling, and proposed rudiments of a cogni-
tively-rich NDM theory. It is also suggested that this
approach can facilitate the dissemination of EBPs:
The principal thrust of evidence-based medicine is on the dis-
semination of cutting-edge clinical evidence in order to improve
decision-making practices. . . However, the availability of evi-
dence does not guarantee that it will be applied in a given deci-
sion-making context. Evidence is invariably perceived evidence
in the physicianÕs mind ([50], p. 162).
One might argue that adaptations of classical theory,
exemplified by the studies of heuristics, give the cogni-
tive aspects of decision making their due. However, even
the most cognitively oriented CDT approaches give an
inadequate account, owing to their consuming interest
in optimality ([49], pp. 58–59). Under optimal condi-
tions, decision makers become transducers, with a cog-
nitive apparatus that works like a choice-selecting
mechanism. But cognition has a more significant role
when decisions are made with limited information, un-
der the pressure of time, when uncertainties are incal-
culable, and there is no universally correct answer. In
such cases, medical decision making is more about
problem-solving than deliberation and choice. Expert
decision makers frequently are called upon to engage in
original thinking; at these times, they are generating
options as well as selecting from them.
PatelÕs naturalistic theory is cast in the tradition of
cognitive psychology [51], which expanded the study of
behavior to include situations that are novel and lacking
sufficient recognition. To be sure, there are events in
which people know their way about and can respond
routinely. These are what Svenson [52] refers to as
‘‘Level 1’’ decisions. But, higher up the ladder of cog-
nitive complexity are decisions at level 3, where situa-
tions are novel and coping with them requires original
89
thought. In SvensonÕs schema, there is even a level 4, in
which unfamiliarity is palpable and novel alternatives
must be elicited or created (p. 22). For Patel and asso-
ciates, these cognitively demanding situations are the
grist of medical decision making. They are the reason
why medicine is practiced with expertise, but never
mastered.
3.1. Requisite Variety in naturalistic theory
It was Ashby [53] who posited as a fundamental thesis
that only variety can destroy variety (p. 207). There is an
analogous principle in NDM, that only a theory that
allows a broad range of description can encompass the
variegations of human activity. The inclination of CDT
to treat all decisions as the same inherently limits its
descriptive power. Patel et al. [49] illustrate this limita-
tion by noting that CDT-based research treats proba-
bility principally as a strength-of-belief indicator. But
the concept of probability does not translate so readily
from the self-contained world of logic to the mediated
world of experience.
Suppose that the probability of recovery from a
chronic disease is estimated at about 60%. But when a
physician tells a patient, ‘‘based on what we know, there
are about 6 chances in 10 that you will recover from this
condition,’’ it is not likely that she is saying: ‘‘The strength
of my belief about your recovering is 6 on a scale of 10.’’
We know it is inaccurate to gauge individual performance
from a population percentage, but this grammatical
mistake is so common that we simply assume the physi-
cian to be saying: ‘‘Given that you are a typical member of
the population of persons with this condition. . .’’ How-
ever, she might mean something entirely different, such as:
‘‘You have the disease now, but based on what we know
about it, we should assume that you will recover.’’ Saying
‘‘6 out of 10’’ can mean a number of things, but the sheer
variety of possibilities can only be grasped by a model that
is able to account for empirically diverse meanings. Ra-
ther than performing expected value calculations or
comparing actual behavior with optimal performance,
Patel and co-workers [54] utilize empirical methods such
as think-aloud protocols and semantic network analysis
[44] to examine cognitive and organizational processes,
and patient–physician interaction [55].
NDM approaches offer greater variety of explanation
than their CDT counterparts, while retaining one of the
features that has made CDT attractive to medical deci-
sion makers. Purely descriptive approaches tend over-
look the intrinsically prescriptive nature of certain
decision making situations [56]. For instance, replacing
normative principles with descriptive models would
lead to an unsatisfactory result in medical practice,
which is driven by standards such as ‘‘health,’’ ‘‘quality
of care,’’ and ‘‘expertise.’’ When norms are instilled with
the imprint of optimality they become abstract and
90 P.R. Falzer / Journal of Biomedical Informatics 37 (2004) 86–98

unapproachable. By contrast, a naturalistic theory al-
lows norms to be averred—not as unrealistic ideals, but
as desirable regularities.
For instance, one recommendation for the treatment
of acute episodes of schizophrenia is that the dosage of
anti-psychotic medication should fall in the range of
300–1000 mg. chlorpromazine equivalent units per day
[57]. Lehman et al. [58] found a conformance rate to this
standard of 62.4%. Attending physicians, administra-
tors, and members of quality improvement committees
would not read these findings as illustrating sub-stan-
dard practice and them dismiss them. Instead, they will
acknowledge that a 100% conformance rate is neither
possible nor desirable because there are instances in
which a dosage outside the standard range is clinically
indicated. Then, a quality improvement goal might be
established at 70% conformance this year and 75% in the
following year. Some administrators would expect to see
bottom-line results only, but others will want to know
whether (or which) physicians are practicing polyphar-
macy, or whether a combination of medications is tar-
geting a specific sub-set of cases, and whether these
deviations are producing a good clinical outcome.
As optimality has no organizational analog, the only
way for a CDT-based approach to study organizational
decision making is to treat organizational units as if they
were individual entities. However, Patel and associates
note that practices occurring at the individual level are
not fully accounted for by organizational processes, and
vice-versa. In their words: ‘‘Team decision-making is
characterized by emergent properties that cannot be
captured by merely studying individual decision-mak-
ers’’ ([49], p. 66). At least two (and usually more) or-
ganizational levels are at work in any medical decision,
and these respective decisions have a complex relation-
ship. Organizational initiatives reciprocally effect the
ways that cognitive data are conceptualized and insti-
tutionalized [59], while interpersonal and organizational
dynamics affect the implementation of EBPs in organi-
zational arenas [60,61].
In sum, Patel and associates have developed a cog-
nitive naturalistic approach that regards medical deci-
sion making as a complex process of problem-solving. It
depicts cognitive activity as a generative capacity whose
study requires a variety of descriptive means and
methods. Unlike CDT-based approaches, decision
making is conceived as a multi-level process, with norms
that are established and implemented by organizational
initiatives. The following section examines a different
NDM-inspired theory, developed by experimental and
organizational psychologists, that has made a sub-
stantial contribution to the literature on management
and decision making. Its similarities to the approach of
Patel and associates are remarkable, considering that the
two were developed independently. It is suggested
nonetheless that ‘‘Image Theory,’’ whose principal fea-
tures are discussed below, has distinctive characteristics
that make it attractive to medical decision making, es-
pecially in assisting the efforts of administrators, prac-
titioners, educators, and researchers to address the
disparity between principle and practice that has daun-
ted EBM.
4. Image Theory
Image Theory, or ‘‘IT’’, [62,63] is one of the most
fully developed and extensively researched applications
of NDM. Like the approach of Patel and associates, IT
emphasizes descriptive modeling; it is cognitively rich
and is designed to work with multi-level data. IT rep-
resents an intersection of three traditions: empirical
theories of decision making, cognitive psychology, and
organizational behavior. The term ‘‘image’’ hearkens to
Miller, Galanter, and PibramÕs classic work on cognitive
theory [51], where images are portrayed as complex

Table 2
The principal concepts of IT
Concept Explanation
Schemata The cognitive apparatus that organizes plans for action
Trajectory image Goal agenda and vision of the future
Strategic image Means of achieving the goal agenda
Value image Imperatives for behavior
Decisions Processes for implementing a plan
Progress Assessment of the current plan
Adoption Consideration of candidate goals or plans
Strategies Tasks involved in developing a plan
Screening Non-compensatory elimination of unacceptable candidates
Choice Compensatory selection of the best candidate

Assessments Procedures for evaluating a plan

Image compatibility Relationship between a goal and a forecast of progress
Violations Interferences with accomplishing a plan (sources of image incompatibility)
 P.R. Falzer / Journal of Biomedical Informatics 37 (2004) 86–98
cognitive schema with pictorial, semantic, and emo-
tional constituents. The principal function of cognitive
schemata is to formulate, test, and execute behavioral
plans.
IT exists into two forms: The form that focuses on
processes of individual decision making has been re-
searched more extensively than the other, which de-
scribes organizational processes. The multi-level aspect
of IT will be illustrated in a subsequent section. In the
meantime, this presentation will concentrate on the
individual form, whose principal concepts appear in
Table 2. The concepts that are delineated in Table 2 are
best introduced informally. A discussion of the three
images of IT leads to a more detailed consideration of
decisions, strategies, and assessments.
4.1. The three images of IT
When people make decisions, they are making plans
to do something. For instance, we decide to move,
marry, or take a new job. These are big decisions with
major consequences. Plans are operative in smaller
decisions as well, such as ordering from a menu at a
restaurant or buying a bottle of water at a local stand.
In all cases, we are formulating a goal (or set of goals)
and projecting this goal into the future. For example,
we move to a new town for a better quality of life or
closer proximity to work. We buy water to quench an
immediate thirst or quell the urge to stop for a meal. In
IT, a decision includes all the aspects of a cognitive
plan.
As noted in Table 2, IT consists of three images:
There is a ‘‘trajectory’’ image, which comprises the goal
agenda and future vision, a ‘‘strategic’’ image, which
comprises the means of achieving this agenda and ful-
filling the vision, and a ‘‘value’’ image, which consists of
principles and imperatives. For instance, we marry in
order to solidify our lives and raise children. Of course,
marriage is no guarantee, nor is it requisite for living a
full life or having children. The decision to pursue these
goals in this way involves a principle, and value-driven
principles are routinely invoked when people make de-
cisions. For instance, we decide to do what is right by
ordering food that is inexpensive and low in cholesterol.
This decision may follow imperatives, such as ‘‘eat
healthy!’’ or ‘‘save for a vacation!’’. The importance of
the value image is discussed in the final section of this
paper.
4.2. Adoption and progress decisions
Like the cognitive naturalistic approach of Patel and
associates, IT models a multiplicity of decision strate-
gies. However, IT invokes a different set of concepts in
describing these strategies. There are instances in which
a choice is made from several good candidates. (Will it
91
be one of the five salads on the menu or one of the eight
pastas?) In other instances, decisions are made from a
limited set of options that remain after others are
screened out. (If the choice is a salad, then will the
dressing be Italian or oil and vinegar?) In a few cases,
decisions begin de novo and lead to adopting a new
goal. But typically, decisions involve an assessment of
progress to date, and this assessment affects subsequent
determinations.
Most clinical decisions are what IT calls progress
decisions. Yet, IT is perhaps unique in the way it dis-
tinguishes progress from adoption. Investigations of IT
have devoted considerable attention to the progressive
aspect of decision making [28,64]. For instance, Dune-
gan [65] investigated progress decision phenomena by
giving subjects the following scenario:
Six months ago, you succeeded in obtaining money for a special
advertising campaign. Now, you are deciding whether to con-
tinue this campaign, using the remaining 20% of the budget that
was allocated.
Half of the subjects received a positive message about
progress. The other half received a negative message that
had essentially the same information, but framed nega-
tively. Results showed that the progress accounted for
over half of the variance in the decision of whether to
continue the project. When the framing condition and
overall satisfaction with the project were entered first in
a hierarchical regression equation, progress was still
statistically significant.
This study shows that image compatibility—in this
instance, compatibility between a goal and progress to
date—gives a reasonable explanation of the ‘‘framing’’
phenomenon that was identified by studies of cognitive
heuristics. Indeed, the way information is framed exerts
an influence on subsequent decisions. However, cog-
nitive heuristics theory depicts framing as an enigmatic
source of sub-optimality, but IT studies have found
that positive and negative messages evoke different
cognitive strategies: A positive frame promotes pro-
cesses that are performed quickly, whereas a negative
frame leads to greater deliberation. IT and heuristics
studies obtain the same results, but IT sheds additional
light on why positive and negative messages evoke
different responses.
4.3. Screening and choice strategies
Along with studies of image compatibility in progress
decisions, IT research has also examined compatibility
assessments in adopting a course of action. Adoption
decisions involve a comparison between attributes of a
decision option and a set of criteria [66]. There is a
compatibility test for adoption decisions, in which each
instance of a disjunction between attribute and criterion
counts as a ‘‘violation.’’ An option is discarded when the
92 P.R. Falzer / Journal of Biomedical Informatics 37 (2004) 86–98
violation count exceeds an arbitrary critical number that
is known as the ‘‘rejection threshold’’ [67]. The mecha-
nism of counting and discarding is a simple, conserva-
tive, and non-compensatory strategy called screening.
Patel and associates have investigated a screening
mechanism in the filtering of non-salient cues [68]. IT
builds on this work by having developed a compatibility
test, as expressed by formula (1):
Xn X m
I¼ Wc Vtc ; ð1Þ
t¼1 c¼1
where I ¼ incompatibility score; V ¼ incompatibility
value (1 or 0); and W ¼ value weight.The incompatibility
score is obtained by multiplying each value by its re-
spective weight, then summing the products. In a
screening decision, this total is compared against an
arbitrary but consistent standard. IT studies have found
that unit weighting (W ¼ 1 in formula (1)) is appropriate
for some decisions and differential weighting (W > 0 and
6¼ 1) is more appropriate for others [69]. In either case, a
stable application of this standard produces a consistent
rejection pattern [70].
The companion to screening is choice, which involves
the selection of one option from among others by a
compensatory process of weighing and valuing. In the
practice of choice, attributes of various candidates are
compared with one another and the candidate is selected
that has the highest value [71]. IT proposes that choice
decisions typically occur after screening is concluded. For
instance, in evaluating candidates for a job, a list is win-
nowed first, then a selection is made by choosing among
the survivors. Findings from IT research indicate that
identical criteria may be utilized in screening and choice,
but they are utilized differently because decision makers
make multi-stage decisions by partitioning screening
tasks from choice [72]. Screening, choice, and multi-stage
decision making are discussed further in the following
section, which highlights the value of IT for clinical de-
cision making.
4.4. Image Theory and clinical decision making
Image Theory is a naturalistic theory that resembles
the cognitive naturalistic approach of Patel and associ-
ates. IT posits that decision processes involve three
cognitive schemata: A trajectory image represents the
formulation of goals; a strategic image represents the
means of achieving the goal agenda, and a value image
represents the behavioral imperatives that affect both
goals and strategies. IT offers a rich account of medical
decision making as consisting of adoption and progress
decisions, screening and choice strategies, and compat-
ibility assessments. This section identifies four ways that
IT can make a distinctive contribution to the literature
on clinical decision making, particularly on investigating
factors that influence the adoption of EBPs:
1. Image compatibility may be a crucial factor in clinical
decisions. Studies have demonstrated that image com-
patibility is more important than overall satisfaction and
exhibits a more powerful effect than message framing [73].
These findings also suggest ways that image incompati-
bility may be inhibiting the implementation of EBPs: New
guidelines are expected to be adopted wholesale, with
minimal deliberation. However, if new EBPs imply sig-
nificant changes in clinical practice, they are likely to
promote greater deliberation and incline practitioners to
minimize risk [74]. A conservative tendency implies re-
sistance to new ideas. But the principal impediment may
be owing to the way that clinicians are processing the call
to alter their decision making practices, especially in light
of how the new guidelines are presented to them.
The extent of image compatibility may further com-
pound a conservative tendency. New EBPs are likely to
be rejected when a patientÕs progress comes close to
matching a treatment goal or when progress falls far
short. In the former case, clinicians are inclined to stay
the course instead of opting for an alternative. In the
latter case, they may be inclined to adjust the trajec-
tory—the goal of treatment—rather than adopting a new
means of achieving the current goal [75].
2. Progress decisions may be foremost in clinical de-
cision making. While some clinical decisions are pri-
marily concerned with adopting treatment goals and
prescribing therapies, adoption yields to progress as-
sessments as clinicians begin to gauge a patientÕs current
condition against expected results. Progress decisions
are occurring concomitantly on organizational levels, as
administrators compare current data with previous
quarters and use these comparisons to make projections.
If clinical decisions eventually become progress deci-
sions, it is mistaken to treat the implementation of an
EBP solely as the adoption of a new strategy. If EBPs
are to have staying power, they must be adopted in the
first place and then survive a series of progress assess-
ments. As the implementation of EBPs involves both
adoption and progress decisions, factors affecting im-
plementation will not be fully comprehended by models
that neglect or deemphasize the aspect of progress.
3. Screening is a powerful and conservative mechanism
of clinical decision making. IT research suggests that
alternatives are routinely discarded once they reach a
rejection threshold, and candidates that fail to survive
screening are not considered further. Note how the
screening mechanism may have a determinative effect on
a decision to implement an EBP. The Schizophrenia
PORT treatment recommendations [57] recommend
conventional neuroleptic medications such as haloperi-
dol rather than atypical medications such as olanzapine,
except for treatment-refractory patients. This is a con-
troversial claim, given that that there is limited evidence
suggesting that atypicals may be associated with better
symptomatic relief than conventional neuroleptics
 P.R. Falzer / Journal of Biomedical Informatics 37 (2004) 86–98
[76,77], especially for cases that present both positive
and negative symptoms [78]. Moreover, these guidelines
do not take into account the considerable evidence that
some atypicals are more easily tolerated than conven-
tional neuroleptics and lead to fewer side effects [79].
For patients and physicians, tolerability, and comfort
may be at least as important as symptomatic relief [80].
In the language of IT, the presence of side effects, neg-
ative symptoms, and a patientÕs reluctance to take a
medication totals three violations, and this number may
exceed the rejection threshold. Consequently, a medi-
cation choice may be made among the atypicals and not
the neuroleptics, as required by the PORT guidelines.
4. IT examines decision making practices by using
simple empirical measures. Considering the richness of
findings from IT studies, it is surprising how easily the
concept of image compatibility is assessed. For instance,
DuneganÕs research [65] utilizes single Likert-type scales
with questions such as, ‘‘How close is the current image
to the target image?’’ and, ‘‘In terms of the ultimate
objective, how well is the project doing?’’ The advantage
of simple measures with high face validity is evident,
particularly in applied research, where complex psy-
chometric instruments may be resisted and results ig-
nored.
5. An application of Image Theory: treatment planning as
a multi-level and longitudinal process
As noted previously, IT exists both as an organiza-
tional theory and a theory of individual decision
making. The organizational and corresponding cogni-
tive images appear in Table 3. The two sets of images
are isomorphic, which enables an exploration of multi-
level relationships and cross-level interactions. How-
ever, the organizational form of IT has yet to be tested
extensively, but studies to date [81] suggest that IT has
potential as a multi-level theory. The value of a multi-
level naturalistic theory is apparent when clinical and
administrative practices are joined or juxtaposed. For
instance, the adoption of an EBP requires organiza-
tional initiative along with individual implementation.
Even when they work in harmony, these two levels
Table 3
The organizational images of IT
Organizational Description
Image
Vision Goal agenda and timelines
Strategy Blueprint for accomplishing the goals that
comprise the vision
Culture Collective beliefs and values shared by members
of an organization
93
have different trajectories and may invoke different
strategies.
However, there is one activity in medicine that dis-
plays most directly the complex relationships among
individual and organizational decision making. This is
the activity known as treatment planning. Even given
ITÕs limited study of organizations, its amenability to
describing treatment planning is an outstanding feature.
This section indicates how IT can assist clinicians, ad-
ministrators, and decision support staff in assessing a
range of phenomena that affect treatment decisions, in-
cluding resource allocation, clinical outcomes, quality
improvement initiatives, and organizational policies.
Treatment planning practices vary widely across or-
ganizations and across programs or units within an or-
ganization. However, planning is directly or indirectly
influenced by almost every aspect of the healthcare
system: There are factors unique to individual patients,
such as their distinctive problems and goals. The way
that these issues are addressed depends on the patientÕs
diagnosis and specific symptoms, their resources, atti-
tudes toward treatment, and their support systems.
Treatment goals and strategies also are affected by the
abilities and interests of clinicians and clinical staff, by
the availability of programs, and by unit- and organi-
zational-level culture, habit, camaraderie, and morale.
Programmatic factors are influenced by caseloads and
level of care assignments, which are affected in turn by
funding levels, administrative directives and initiatives,
accreditation standards, and ultimately, agency and in-
stitutional policies. Some programs and agencies regard
treatment planning as a deliberative process that is tai-
lored to the needs of individual patients. The burden of
decision making may be carried instead by algorithms
and critical pathways, making treatment planning rou-
tine and almost superfluous. Nonetheless, the interplay
of clinical, social support, organizational, fiscal, ad-
ministrative, and regulatory forces is evident even when
discretion is highly circumscribed.
Despite wide ranging differences in organizational
vision and culture, the basic structure of a treatment
plan is remarkably similar across agencies and
programs. Generally, there is a problem list and perhaps
a companion list of goals. Specific interventions or
Related Cognitive Guiding Question
Image
Trajectory Where are we going and what are we trying
to become?
Strategic How are we striving to achieve the goals
that constitute our vision?
Value Who are we and what do we stand for?
94 P.R. Falzer / Journal of Biomedical Informatics 37 (2004) 86–98
treatments are invoked to address the problems and
achieve the goals over a specified period. A plan also
may include elements of a diagnostic assessment, such as
a formulation and clinical summary, and contingencies
in the event of emergency or non-responsiveness. To
utilize the language of IT: Treatment plans specify the
trajectory and strategic images. They may also include
criteria for assessing progress and contingencies in the
anticipation of image incompatibility.
Consider the following extract from a plan that may
have been formulated in a public mental health setting
for treating a person with schizophrenia: This patient is
experiencing auditory hallucinations, and the treatment
goal is to reduce their intensity and frequency. The
planÕs problem and goal comprise the trajectory image.
The intervention is medication therapy with haloperidol
PO 10 mg bid, daily medication delivery and monitoring
by the treatment team, and a follow-up appointment in
30 days. This intervention, which comprises the strategic
image, was chosen from a list of alternatives, which in-
clude other traditional neuroleptics and atypicals, and
other supportive and psychosocial interventions. Some
candidates on this list were screened out immediately—
for instance, treatment with chlorpromazine or thiorid-
azine—and the psychiatrist made a choice from the items
that remained.
The plan is scheduled for a progress assessment after
30 days. At that time, the psychiatrist evaluates the
patientÕs condition and decides whether to continue or
modify the current therapy. This evaluation compares
the patientÕs current condition to the goal of treatment.
Incompatibilities may be found in the course of assess-
ing progress. For instance, the patient may be showing
extra-pyramidal side effects or lethargy, or report that
hallucinations have not diminished. These incompati-
bilities may lead to the consideration of alternatives—for
instance, a different medication, a modification of the
current regimen, or the addition of another treatment
such as an anticholinergic agent.
At the individual patient level, treatment planning is
a straightforward application of IT, with trajectories,
strategies, and progress assessments. The IT conception
applies, no matter how individualized and complex is
the plan, or how standardized and routine. While
treatment planning decisions may be scrutinized against
a variety of normative standards, IT does not prescribe
an optimal resolution. In one given instance, a pattern
of violations might lead to a change in strategy; the same
incompatibilities in another situation might precipitate a
change in the treatment goal.
As IT describes individual progress, it also enables
the effects of fiscal, programmatic, administrative, and
policy decisions to be evaluated by combining progress
assessments across units, programs, and service lines. It
is through these assessments that determinations are
made about the clinical- and cost-effectiveness of par-
ticular treatments. Compliance with standards, regula-
tions, and initiatives can be assessed, and the role of
various organizational factors on treatment and effec-
tiveness can be gauged as well. These capabilities dem-
onstrate that IT can work with a combination of
decision making processes, including decisions made by
a single clinician, micro-organizational decisions of a
treatment team, and macro-organizational decisions of
an administrative or oversight body.
This treatment planning example also illustrates the
potential of IT in longitudinal tracking, which is partic-
ularly important for work with chronic conditions such
as schizophrenia. If treatment plans are created carefully
and updated regularly, they will comprise a record of
progress in alleviating problems and achieving goals.
This record can form a narrative that sheds light on the
long-term effects of treatment. The task of creating such
a record is facilitated by decision-support tools. In par-
ticular, logical data modeling techniques describe the
treatment planning process in a manner that reflects the
ways that decision-makers are using information [82].
Data modeling and IT are natural companions.
6. Discussion: narrowing the gap between principle and
practice
This paper began by suggesting that EBP initiatives
have been daunted by a disparity between principle and
practice. It has been contended that a reliance on CDT
and the pursuit of optimality have upset the balance
between the application of best evidence and the pro-
vision of patient-centered care. Though some critics may
insist that these are polarities of medical practice and
inherently at odds, others are searching for a synthesis,
of medical practice informed by a combination of clin-
ical expertise and empirical data. Even the staunchest
advocates of EBM acknowledge that the vicissitudes of
medical practice require normative standards to be re-
laxed. CDT has demonstrated the ability to be flexible
[83]; along with the momentum that results from a
myriad of studies and a wealth of accumulated knowl-
edge, this flexibility has allowed CDT-based approaches
to thrive, despite their limitations.
Yet another reason for the continued popularity of
CDT is the presumption that medicine and CDT share
common values. The final section of this paper discusses
how NDM, and IT specifically, can enable researchers,
practitioners, educators, and others to address the role
that values play in medicine and medical decision
making. It is suggested that in the realm of values, or
what IT refers to as the value image, EBM meets patient-
centered practice.
The claim still resonates that science should be ‘‘value
free.’’ Without delving into the intent of this statement
when it was first uttered by Max Weber, there is a
 P.R. Falzer / Journal of Biomedical Informatics 37 (2004) 86–98
distinction to be drawn between basic science and the
applied science of medicine. Patel and associates [49]
express concern that equating the two has carried for-
ward the mistaken belief that medical practice is indif-
ferent to human values (pp. 58–59). In the nineteenth
century, the physiologist Claude Bernard spoke of his
discipline as ‘‘the difference between a well-functioning
heart and a mal-functioning one.’’ As Toulmin [84]
observes, ‘‘If that was not a ÔvalueÕ difference, it is hard
to say what is!’’ (p. 106).
It is appropriate that Patel and associates speak of
their critique of CDT as having a philosophical basis
([49], p. 58), because CDT is part of a distinct philo-
sophical tradition. Today, Pascal is remembered prin-
cipally for his contributions to mathematics. But for
him, rationality and optimality were not mere features
of mathematical formulae, but metaphysical concepts.
PascalÕs distrust of ordinary human senses was legend-
ary, as was his disdain for empirical evidence ([85], pp.
231–249). The tradition of rationalism dates back to
Descartes, a contemporary of PascalÕs, who is princi-
pally responsible for ushering in the modern age.
Toulmin, a severe critic of rationalism, depicts it as
championing abstraction and the quest for universal
principles over practical understanding ([86], pp. 32–33).
The critique of optimality that Patel and associates have
advanced resonates with ToulminÕs vehement dismissal
of the rationalistic tradition.
Universality and abstraction are not mere goals: They
are values that were ingrained into CDT by the ratio-
nalism of Descartes and his vision of indubitable truth.
In the 21st century, the injunction that science be value
free is a call to adhere to these principles, so that uni-
versality, optimality, and rationality are not contami-
nated by mere impression or subjective belief ([86], pp.
31–34). When Ioannidis and Law [87] claim that EBP is
an effort to supplant traditional ‘‘experienced-based’’
medicine with a medical practice that is derived from
sound empirical evidence, they are speaking on behalf of
a tradition that began over three centuries ago. This
tradition is sustained not only by the progress that has
occurred in the interim, but also by the values that have
predicated this tradition from the outset.
Clinicians who work with schizophrenia are re-
sponding to a pervasive disorder of thought and cog-
nition, but they are also treating something that vitiates
functioning and creates a miserable life. An assessment
of values is built into the current nomenclature of
mental disorders [88], and a diagnosis of schizophrenia
requires a disturbance in psychosocial functioning as
well as evidence of symptoms and course. Trained cli-
nicians recognize schizophrenia as both a disorder, in
the narrowest sense, and a patently bad state; they gauge
the effectiveness of treatments by how substantially
symptoms are diminished, and no less important, by the
improvement in their patientsÕ lives.
95
There is another value-based initiative whose promi-
nence has coincided with the rising interest in EBM.
Over the past decade, we have witnessed a growing ur-
gency for scientists to demonstrate the practical benefits
of their work. In the telling words of Congressman
George Brown: ‘‘All the basic science funding in the
world will have no positive effect on the well-being of
our nation if the research is not carried out within a
system that can effectively digest and apply the results’’
([89], p. 131). The Carnegie Commission on Science,
Technology, and Government [90] was a guiding force
in promoting efforts to enhance the utility of scientific
knowledge. Recently, the National Advisory Mental
Health Council issued a call to enhance the translation
of scientific findings into practice [91]. In response, the
National Institute of Mental Health has established new
priority areas for behavioral translation research [92].
According to Hammond, the conceptual problems of
uncertainty and sub-optimality have posed major ob-
stacles to realizing the practical benefits of scientific
knowledge ([89], p. 133). It is suggested here that these
problems have been exacerbated by a hands-off ap-
proach to values. Abstraction and universality are stip-
ulated, but they are not made the subject of further
discussion or analysis. Fortunately, NDM has changed
the landscape by regarding values as legitimate subjects
of investigation and assessing their role empirically.
In IT, the value image is one of the theoryÕs three
cognitive schema. This image comprises the collection of
standards, principles, and norms of practice that deter-
mine why decisions are made. IT enables values to enter
into decision making as either screening and choice
criteria [81,93]. The importance of this capability ought
not be overlooked. For instance, in the treatment
planning illustration in the previous section, the goal of
treatment was a reduction of auditory hallucinations.
The question that must be asked is, whose goal is this?
The patient may be taking an anti-psychotic medication
because it helps him to go to work, not to reduce hal-
lucinations. One might suppose that the two goals are
compatible, but in practice, patients and physicians are
frequently choosing between a medication that is less
effective in relieving symptoms, but interferes less with
the ability to concentrate. A non-EBP may be preferred
when values such as engaging the patient, promoting
independent living, improving social functioning, or
increasing self esteem outweigh the value of symptom
reduction. Determining which course of action is most
appropriate becomes a matter of expert judgment, pro-
gram priority, and administrative policy. Values clearly
play a role in these decisions, but not the values of op-
timality and universality. Evidence plays a role as well,
but what is most relevant to medical decision making is
how the evidence is applied.
CDT-based approaches can make allowances, but
ultimately they are striving for an optimal solution. For
96 P.R. Falzer / Journal of Biomedical Informatics 37 (2004) 86–98
NDM, values are ingrained in clinical decisions, but
they can be explicated. Perhaps a crucial step in facili-
tating the implementation of EBPs is an acknowledge-
ment that values are too important to be left outside the
domain of theory. Surely, we can acknowledge that as
physicians learn their craft, they learn the values of the
traditions in which they operate, and eventually they
will incorporate these values into their practice. It is
through the development of expertise that values be-
come practical, and without the ability to study how
values affect practice, the gap between knowledge and
implementation will not be abated.
References
[1] Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Rich-
ardson WS. Evidence based medicine: what it is and what it isnÕt.
Br Med J 1996;312(7023):71–2.
[2] Elstein AS. Naturalistic decision making and clinical judgment. J
Behav Decis Making 2001;14(5):363–5.
[3] Garb HN. Studying the clinician: judgment research and psycho-
logical assessment. Washington, DC: American Psychological
Association; 1998.
[4] Carey S, Hall DJ. PsychiatristsÕ views of evidence-based psychi-
atric practice. Psychiatr Bull 1999;23(3):159–61.
[5] Buchanan RW, Kreyenbuhl J, Zito JM, Lehman A. The schizo-
phrenia PORT pharmacological treatment recommendations:
conformance and implications for symptoms and functional
outcome. Schizophr Bull 2002;28(1):63–74.
[6] Marinelli-Casey P, Domier CP, Rawson RA. The gap between
research and practice in substance abuse treatment. Psychiatr Serv
2002;53(8):984–7.
[7] Sernyak MJ, Dausey D, Desai R, Rosenheck R. PrescribersÕ
nonadherence to treatment guidelines for schizophrenia when
prescribing neuroleptics. Psychiatr Serv 2003;54(2):246–8.
[8] Williams DDR, Garner J. The case against Ôthe evidenceÕ: a
different perspective on evidence-based medicine. Br J Psychiat
2002;180(1):8–12.
[9] Edwards W. The theory of decision making. Psychol Bull
1954;51:380–417.
[10] von Neumann J, Morgenstern O. Theory of games and economic
behavior. Princeton, NJ: Princeton University Press; 1947.
[11] Slovic P, Fischhoff B, Lichtenstein S. Behavioral decision theory.
Annu Rev Psychol 1977;28:1–39.
[12] Keeney RL, Raiffa H. Decisions with multiple objectives: prefer-
ences and value tradeoffs. New York: Wiley; 1976.
[13] Monahan J, Heilbrum K, Silver E, Nabors E, Bone J, Slovic P.
Communicating violence risk: frequency formats, vivid outcomes,
and forensic settings. Int J Forensic Ment Health 2002;1(2):121–6.
[14] Bogardus Jr ST, Holmboe E, Jekel JF. Perils, pitfalls, and
possibilities in talking about medical risk. JAMA 1999;281(11):
1037–41.
[15] Fischhoff B, Goitein B. The informal use of formal models. Acad
Manage Rev 1984;9(3):512–5.
[16] Beach LR, Lipshitz R. Why classical decision theory is an
inappropriate standard for evaluating and aiding most human
decision making. In: Beach Klein GA, Lipshitz Orasanu J,
Calderwood R, Zsambok CE, editors. Decision making in action:
models and methods. Norwood, NJ: Ablex; 1993.
[17] Simon HA. A behavioral model of rational choice. Q J Econ
1955;69:99–118.
[18] Simon HA. Models of man. New York: Wiley; 1957.
[19] Lipshitz R, Klein G, Orasanu J, Salas E. Taking stock of naturalistic
decision making. J Behav Decis Making 2001;14(5):331–52.
[20] Hammond KR. Coherence and correspondence theories in
judgment and decision making. In: Connolly T, Arkes HR,
Hammond KR, editors. Judgment and decision making: an
interdisciplinary reader. 2nd ed. Cambridge: Cambridge Univer-
sity Press; 2000. p. 53–65.
[21] Brunswik E. Systematic and representative design of psychological
experiments, with results in physical and social perception.
Berkeley, CA: University of California Press; 1947.
[22] Gigerenzer G, Hoffrage U, Kleinbolting H. Probabilistic mental
models: a Brunswikian theory of confidence. Psychol Rev
1991;98(4):506–28.
[23] Tversky A, Kahneman D. Judgment under uncertainty: heuristics
and biases. In: Connolly T, Arkes HR, Hammond KR, editors.
Judgment and decision making: an interdisciplinary reader. New
York: Cambridge University Press; 2000. p. 38–55.
[24] Peterson CR, Beach LR. Man as an intuitive statistician. Psychol
Bull 1967;68(1):29–46.
[25] Hoffman PJ. The paramorphic representation of clinical judg-
ment. Psychol Bull 1960;57:116–31.
[26] Dawes RM. Proper and improper linear models. In: Connolly T,
Arkes HR, Hammond KR, editors. Judgment and decision
making: an interdisciplinary reader. 2nd ed. Cambridge: Cam-
bridge University Press; 2000. p. 378–94.
[27] Round A. Introduction to clinical reasoning. J Eval Clin Pract
2001;7(2):109–17.
[28] Connolly T, Beach LR. The theory of Image Theory: an
examination of the central conceptual structure. In: Beach LR,
editor. Image Theory: theoretical and empirical foundations.
Mahwah, NJ: Lawrence Erlbaum; 1998. p. 249–59.
[29] Meehl PE. Clinical versus statistical predictions: a theoretical
analysis and revision of the literature. Minneapolis MN: Univer-
sity of Minnesota Press; 1954.
[30] Goldberg LR, Faust D, Kleinmuntz B, Dawes RM. Clinical
versus statistical prediction. In: Cicchetti D, Grove WM, editors.
Thinking clearly about psychology: essays in honor of Paul E
Meehl. Minneapolis, MN: University of Minnesota Press; 1991. p.
173–264.
[31] Kleinmuntz B. Why we still use our heads instead of formulas:
toward an integrative approach. Psychol Bull 1990;107(3):296–
310.
[32] Peterson CR, Ulehla ZJ, Miller AJ, Bourne Jr LE, Stilson DW.
Internal consistency of subjective probabilities. J Exp Psychol
1965;70(5):526–33.
[33] Goldberg LR. Simple models or simple processes? Some research
on clinical judgments. In: Arkes HR, Hammond KR, editors.
Judgment and decision making: an interdisciplinary reader 1986.
p. 335–53.
[34] Kahneman D, Tversky A. Subjective probability: a judgment of
representativeness. Cogn Psychol 1972;3(3):430–54.
[35] Tversky A, Kahneman D. Belief in the law of small numbers.
Psychol Bull 1971;76(2):105–10.
[36] Kahneman D, Tversky A. On the reality of cognitive illusions.
Psychol Rev 1996;103(3):582–91.
[37] Tversky A, Kahneman D. The framing of decisions and the
psychology of choice. Science 1981;211(4481):453–8.
[38] McNeil BJ, Pauker SG, Tversky A. On the framing of
medical decisions. In: Bell DE, Raiffa H, Tversky A, editors.
Decision making: descriptive, normative, and prescriptive inter-
actions. New York: Cambridge University Press; 1988. p.
562–8.
[39] Cebul RD, Beck LH, editors. Teaching clinical decision making.
New York: Praeger; 1985.
[40] Bensing J. Bridging the gap. The separate worlds of evidence-
based medicine and patient-centered medicine. Patient Educ
Couns 2000;39(1):17–25.
 P.R. Falzer / Journal of Biomedical Informatics 37 (2004) 86–98
[41] Larkin J, McDermott J, Simon DP, Simon HA. Expert and novice
performance in solving physics problems. Science 1980;208:1335–
42.
[42] Patel VL, Cranton PA. Transfer of student learning in medical
education. J Med Educ 1983;58(2):126–35.
[43] Patel VL, Groen GJ. Knowledge based solution strategies in
medical reasoning. Cogn Sci 1986;10(1):91–116.
[44] Groen GJ, Patel VL. The relationship between comprehension
and reasoning in medical expertise. In: Chi MT, Glaser R, Farr
MJ, editors. The nature of expertise. Mahwah, NJ: Lawrence
Erlbaum Associates; 1988. p. 287–310.
[45] Patel VL, Arocha JF, Kaufman DR. Diagnostic reasoning and
medical expertise. In: Medin DL, editor. The psychology of
learning and motivation: advances in research and theory. New
York: Academic Press; 1994. p. 187–250.
[46] Patel VL, Kaufman DR. Medical informatics and the science of
cognition. J Am Med Inform Assoc 1998;5(6):493–502.
[47] Patel VL, Cytryn KN, Shortliffe EH, Safran C. The collaborative
health care team: the role of individual and group expertise. Teach
Learn Med 2000;12(3):117–32.
[48] Patel VL, Arocha JF, Kaufman DR. A primer on aspects of
cognition for medical informatics. J Am Med Inform Assoc
2001;8(4):324–43.
[49] Patel VL, Kaufman DR, Arocha JF. Emerging paradigms of
cognition in medical decision-making. J Biomed Inform
2002;35(1):52–75.
[50] Kaufman DR, Kushnirukb AW, Yalec J-F, Patel VL. Conceptual
knowledge and decision strategies in relation to hypercholester-
olemia and coronary heart disease. Int J Med Inf 1999;55(3):159–
77.
[51] Miller GA, Galanter E, Pribram KH. Plans and the structure of
behavior. New York: Holt, Rinehart and Winston; 1960.
[52] Svenson O. Some propositions for the classification of decision
situations. In: Borcherding K, Larichev OI, Messick DM, editors.
Contemporary issues in decision making. New York: North-
Holland; 1990. p. 17–32.
[53] Ashby WR. An introduction to cybernetics. London: Metheun;
1964.
[54] Kushniruk AW, Patel VL. Cognitive evaluation of decision
making processes and assessment of information technology in
medicine. Int J Med Inf 1998;51(2–3):83–90.
[55] Patel VL, Evans DA, Kaufman DR. A cognitive framework for
doctor-patient interaction. In: Evans DA, Patel VL, editors.
Cognitive science in medicine: biomedical modeling. Cambridge,
MA: MIT Press; 1989. p. 257–312.
[56] Bordley RF. Naturalistic decision making and prescriptive deci-
sion theory. J Behav Decis Making 2001;14(5):355–7.
[57] Lehman AF, Steinwachs DM, Dixon LB, Goldman HH,
Osher F, Postrado L, et al. Translating research into
practice: the schizophrenia patient outcomes research team
(PORT) treatment recommendations. Schizophr Bull 1998;
24(1):1–10.
[58] Lehman AF, Steinwachs DM, Dixon LB, Postrado L, Scott JE,
Fahey M, et al. Patterns of usual care for schizophrenia:
initial results from the schizophrenia patient outcomes
research team (PORT) client survey. Schizophr Bull 1998;
24(1):11–20.
[59] Elstein AS. Cognitive processes in clinical inference and decision
making. In: Turk DC, Salovey P, editors. Reasoning, inference,
and judgment in clinical psychology. New York: The Free Press;
1988. p. 17–50.
[60] Corrigan PW, Steiner L, McCracken SG, Blaser B, Barr M.
Strategies for disseminating evidence-based practices to staff who
treat people with serious mental illness. Psychiatr Serv
2001;52:1598–606.
[61] Rosenheck RA. Organizational process: a missing link between
research and practice. Psychiatr Serv 2001;52(12):1597–607.
97
[62] Beach LR. Image Theory: decision making in personal and
organizational contexts. New York: Wiley; 1990.
[63] Beach LR. The psychology of decision making: people in
organizations. Thousand Oaks, CA: Sage; 1997.
[64] Beach LR, Mitchell TR. The basics of Image Theory. In: Beach
LR, editor. Image Theory: theoretical and empirical foundations.
Mahwah, NJ: Lawrence Erlbaum; 1998. p. 3–18.
[65] Dunegan KJ. Image Theory: testing the role of image compati-
bility in progress decisions. Organ Behav Human Decis Process
1995;62(1):79–86.
[66] Beach LR, Smith B, Lundell J, Mitchell TR. Image Theory:
descriptive sufficiency of a simple rule for the compatibility test. J
Behav Decis Making 1988;1(1):17–28.
[67] Beach LR, Strom E. A toadstool among the mushrooms:
screening decisions and Image TheoryÕs compatibility test. Acta
Psychol 1989;72(1):1–12.
[68] Patel VL, Groen GJ, Arocha JF. Medical expertise as a function
of task difficulty. Mem Cogn 1990;18(4):394–406.
[69] Beach LR, Puto CP, Heckler SE, Naylor G, Marble TA.
Differential versus unit weighting of violations, framing, and the
role of probability in Image TheoryÕs compatibility test. Organ
Behav Human Decis Process 1996;65(2):77–82.
[70] Ordonez LD, Benson III L, Beach LR. Testing the compatibility
test: how instructions, accountability, and anticipated regret affect
prechoice screening of options. Organ Behav Hum Decis Process
1999;78(1):63–80.
[71] Beach LR, Mitchell TR. A contingency model for the selection of
decision strategies. In: Beach LR, editor. Image Theory: theoret-
ical and empirical foundations. Mahwah, NJ: Lawrence Erlbaum;
1998. p. 145–58.
[72] Van Zee EH, Paluchowski TF, Beach LR. The effects of screening
and task partitioning upon evaluations of decision options. J
Behav Decis Making 1992;5(1):1–19.
[73] Dunegan KJ. Image compatibility and framing. In: Beach LR,
editor. Decision making in the workplace: a unified perspective.
Mahwah, NJ: Lawrence Erlbaum; 1996. p. 181–95.
[74] McNeil BJ, Pauker SG, Sox Jr HC, Tversky A. On the elicitation
of preferences for alternative therapies. In: Connolly T, Arkes
HR, Hammond KR, editors. Judgment and decision making: an
interdisciplinary reader. 2nd ed. Cambridge: Cambridge Univer-
sity Press; 2000. p. 272–80.
[75] Beach LR. EditorÕs introduction to part two—the compatibility
test: screening and progress decisions. In: Beach LR, editor. Image
Theory: theoretical and empirical foundations. Mahwah, NJ:
Lawrence Erlbaum; 1998. p. 21–30.
[76] Breier A, Berg PH. The psychosis of schizophrenia: prevalence,
response to atypical antipsychotics, and prediction of outcome.
Biol Psychiat 1999;46(3):361–4.
[77] Harvey PD, Meltzer H, Simpson GM, Potkin SG, Loebel A, Siu
C, et al. Improvement in cognitive function following a switch to
ziprasidone from conventional antipsychotics, olanzapine, or
risperidone in outpatients with schizophrenia. Schizophr Res
2004;66(2–3):101–13.
[78] Hamilton SH, Revicki DA, Genduso LA, Beasley Jr CM.
Olanzapine versus placebo and haloperidol: quality of life and
efficacy results of the North American double-blind trial. Neuro-
psychopharmacology 1998;18(1):41–9.
[79] Emsley RA. Risperidone in the treatment of first-episode psy-
chotic patients: a double-blind multicenter study. Risperidone
Working Group. Schizophr Bull 1999;25(4):721–9.
[80] Ubell E. It quiets the torment. Parade 1992 22 August.
[81] Weatherly KA, Beach LR. Organizational culture and decision
making. In: Beach LR, editor. Decision making in the workplace:
a unified perspective. Mahwah, NJ: Lawrence Erlbaum; 1996. p.
117–32.
[82] Fleming CC, von Halle B. Handbook of relational database
design. Menlo Park, CA: Addison-Wesley; 1989.
98 P.R. Falzer / Journal of Biomedical Informatics 37 (2004) 86–98
[83] Klayman J. Ambivalence in (not about) naturalistic decision
making. J Behav Decis Making 2001;14(5):372–3.
[84] Toulmin SE. Return to reason. Cambridge, MA: Harvard
University Press; 2001.
[85] Jonsen AR, Toulmin S. The abuse of casuistry: a history of moral
reasoning. Berkeley, CA: University of California Press; 1988.
[86] Toulmin SE. Cosmopolis: the hidden agenda of modernity.
Chicago: University of Chicago Press; 1990.
[87] Ioannidis JPA, Lau J. Evidence-based medicine: a quantitative
approach to decision making. In: Chapman GB, Sonnenberg FA,
editors. Decision making in health care. New York: Cambridge
University Press; 2000. p. 110–41.
[88] American Psychiatric Association. Diagnostic and statistical
manual of mental disorders: DSM-IV-TR (4th edition, text
revision 2000). Washington DC: American Psychiatric Associa-
tion; 2000.
[89] Hammond KR, Harvey Jr LO, Hastie R. Making better use of
scientific knowledge: separating truth from justice. In: Connolly T,
Arkes HR, Hammond KR, editors. Judgment and decision
making: an interdisciplinary reader. 2nd ed. Cambridge: Cam-
bridge University Press; 2000. p. 131–43.
[90] Carnegie Commission on Science, Technology, and Government.
Science, Technology, and Congress: Expert Advice and the
Decision-Making Process. [Text document] 1991 [Retrieved Dec.
31 2003 Feb.]. Available from: http://www.carnegie.org/sub/pubs/
science_tech/cong-exp.txt.
[91] National Advisory Mental Health CouncilÕs Clinical Treatment
and Services Research Workgroup. Bridging Science and Service.
[World Wide Web document] 2002 [Retrieved 2002 August 16].
Available from: http://www.nimh.nih.gov/research/bridge.htm.
[92] National Advisory Mental Health Council Behavioral Science
Workgroup. Translating Behavioral Science into Action. [Adobe
Acrobat document] 2002 [Retrieved 2002 August 16]. Available
from: http://www.nimh.nih.gov/council/bswreport.pdf.
[93] Nelson KA, Puto CP. Using Image Theory to examine value-
laden decisions: the case of the socially responsible consumer. In:
Beach LR, editor. Image Theory: theoretical and empirical
foundations. Mahwah, NJ: Lawrence Erlbaum; 1998. p. 199–210.