Publication Date


Document Type


Committee Members

Mary Ellen Bargerhuff (Committee Member), Helen Klein (Committee Member), Valerie Shalin (Advisor), Debra Steele-Johnson (Committee Member)

Degree Name

Doctor of Philosophy (PhD)


The increasing emphasis in the medical community on shared decision making and patient centered care suggests that patients play a role in their care, but research on clinical reasoning almost exclusively addresses practitioner cognition. As patient involvement increases, it is important to understand the effect patients have on clinical cognition. This necessitates moving beyond a model that equates clinical cognition with practitioner cognition to incorporate the influence of patient cognition and dyadic patient-practitioner cognition. In this dissertation, I suggest that patient-practitioner interactions constitute a distributed cognitive system. As a result patient cognition and the nature of the interaction inherently contribute to clinical cognition. By analyzing different aspects of clinical interactions involved in managing Multiple Sclerosis (MS), I provide an exploratory observational study of how patient-practitioner dyads engage in clinical cognition that may serve as a guide to more conventional future hypothesis testing. To assess clinical interactions, I observed twenty-three patients interacting with three medical practitioners at a clinic specializing in the chronic disease of Multiple Sclerosis. Consistent with Institutional Review Board review, patients agreed to observations of their clinical session including audio recording and/or taking field notes and participated in follow-up phone interviews. Analysis employed techniques from grounded theory, task analysis, and discourse analysis. The results comprise four separate analyses focusing on different aspects of patient-practitioner cognition outlining the core functions of MS management, the fundamental role of the patient in the reconceptualization of management as a distributed task, the effect of patient expertise on clinical reasoning and the role of narrative in facilitating the exchange of information. Specifically, in the first analysis, I decompose the interactions involved in MS management into a series of core functions each of which depends upon different cognitive elements. I analyze the contributions of patients and practitioners to each of these tasks showing that patients and practitioners engage in distributed cognition during all major tasks except interpretation of technical test results. Across the clinical session, practitioners and patients collaborate to create a common trajectory that guides clinical reasoning. The second analysis focuses specifically on the patterns of patient and practitioner responsibility during decision making. To execute the range of decision making tasks, participants navigate through a decision space that includes situational understanding (the state space) and possible actions (the action space). While making decisions, practitioners and patients can each exert control over different constituent tasks, creating four patterns for distributed decision making: practitioner dominated, practitioner defined-patient made, patient defined-practitioner made, and patient dominated. The specific pattern used in a given decision depends upon the access patients and practitioners have to different portions of the decision space. As practitioners and patients navigate through the decision space, they negotiate shared decisions as inflection points in the process of creating a common trajectory for clinical cognition and care. The third analysis examines the effect of patient expertise in MS self-management on distributed clinical cognition. I first demonstrate that patients vary in their level of medical expertise in the management of a chronic disease such as MS. Experienced patients actively constructed representations of clinically relevant experience and presented initial evaluations for the practitioner to refine and validate. By contrast, conversations between newly diagnosed patients and practitioners demonstrated the practition...

Page Count


Department or Program

Department of Psychology

Year Degree Awarded