The messy world of causality in medical practice

Introduction
Physicians are supposed to practice medicine that is based on the best available evidence. Evidence based medicine (EBM) -including randomized controlled trials (RCTs)- is therefore seen as the golden standard for good practice. But we also know that quick decisions are made differently than decisions for which we have more time, i.e. automatic vs controlled thinking. (Bargh and Ferguson 2000) In a clinical setting physicians are supposed to help as many patients as possible in one day. Do patients have an insight in the quick causal inferences of the physician?
Methods
A philosophical and ethnographic study in the UZ Brussel is being conducted. Patients with internal medical complaints at the emergency department, two wards and five departments at the outpatient clinic were included. The entire medical setting was observed, open interviews were taken from patients and their family. These data are analyzed with the grounded theory approach.
Results and discussion
Physicians look in their knowledge base (combined of 1° scholarly/scientific or explicit knowledge, and 2° tacit or implicit knowledge (Polanyi 1958) that cannot be made explicit easily) for a similar case in the past as the case of the particular patient they need to diagnose this time. We call this "looking for a story that fits".
Standard: Automatic thinking: "Looking for a story that fits"
If fail: Controlled thinking: consulting RCTs and a more experienced colleagues (who, on their turn, use explicit and implicit knowledge when automatic thinking)
The patient is ignorant about the "similar case" and the knowledge base of the physician
The causal inferences in automatic reasoning are partly based on implicit knowledge and thus not transferrable to the patient. This may lead, for the patient, to a lack of understanding of their own health status.
Conclusion
Patients have no clear insights in the quick inferences of physicians. Physicians do not start with looking for a causal relation based on RCTs; but they rather start with looking for a story that fits. This makes it hard for the patient to entirely grasp the causal reasoning of the physician; and thus fully understand her/his health status