Schemas are psychological constructs and can be described as mental representations of some aspect of the world, including objects, concepts and events¹. Schema theorists argue that individuals may continue adapting or constructing schemas throughout their lives². Schemas are not decision-making constructs as such, but they provide a context in which decision-making processes occur. Although a great deal of research has been done on the processes involved in medical decisions³, it is important to locate them within such a context. This study forms part of a larger study on the appropriateness of long term prescribing decisions. It aims to interpret the thinking and behaviour of hospital doctors in terms of schema theory, focussing on prescribing and especially 'appropriate' prescribing.

Eight house officers and five consultants were purposively selected from a range of medical specialties. Qualitative interviews of approximately one-hour duration were taped and transcribed. The main topics were the role of the interviewee as a doctor, their approach to prescribing and to appropriateness of prescribing and the factors that impinged on these. The data were analysed and interpreted from a qualitative standpoint and within the general context of schema theory.

Each doctor articulated some form of schema, and it is possible to argue that they fitted together into a cognitive system that informed their behaviour. Overall, the house officers appeared to have schemas that were more basic or simplistic and their respective schemas had much in common. Conversely, the consultants had more sophisticated or complex schemas and there was a greater degree of individual variation. However, it appeared that the schemas adopted by the house officers did not contradict those of the consultants but rather could be subsumed within them. The most noticeable distinction was the greater emphasis by consultants on a holistic approach to patient care and their schemas for appropriate prescribing tended to stem from this premise. In contrast, the house officers tended to view their role in terms of a relatively small number of discrete functions and the patient was viewed as a passive receptor, with no holistic context in which to place these functions.

It could be hypothesised that house officers possess 'simpler' schemas as a way of coping with their job demands. With greater experience, they may become more comfortable and thereby have the resources to evolve more complex schemas and a more holistic approach to patient care. It may also be possible that certain personality types are prone to more simplistic schemas, raising the possibility that the type of people who become consultants are inherently more prone to complex schemas. Further research is required to investigate these hypotheses.

References

1. Bartlett, F.C. (1932) Remembering . Cambridge: Cambridge University Press.
2. Fiske, S.T. and Taylor, S. (1992) Social Cognition . Reading: Addison-Wesley
3. Bornstein, B.H. and Emler, A.C. (2000) Rationality in medical decision making: a review of the literature on doctor's decision-making biases. Journal of Evaluation in Clinical Practice. 7 ,2, 97-107.