Clinical reasoning in traditional medicine exemplified by the clinical encounter of Korean medicine: a narrative review

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Integrative Medicine Research

jou rn al h o m e p a g e :w w w . i m r - j o u r n a l . c o m

Original Article

Clinical reasoning in traditional medicine exempliﬁed by the clinical encounter of Korean medicine: a narrative review

Tae-hun Kim

^a,b

, Terje Alraek

^c,d

, Zhao-Xiang Bian

^e,f

, Stephen Birch

^g

, Mark Bovey

^h

, Juah Lee

ⁱ

, Myeong Soo Lee

^j

, Nicola Robinson

^k

, Christopher Zaslawski

^l,∗

aCollegeofKoreanMedicine,KyungHeeUniversity,Seoul,RepublicofKorea

bKoreanMedicineClinicalTrialCenter,KoreanMedicineHospital,KyungHeeUniversity,Seoul,RepublicofKorea

cFacultyofHealthScience,DepartmentofCommunityMedicine,TheNationalResearchCenterinComplementaryandAlternativeMedicine,NAFKAM,UiT TheArcticUniversityofNorway,Tromsø,Norway

dNorwegianSchoolofHealthSciences,KristianiaUniversityCollegeOslo,Oslo,Norway

eInstituteofBrainandGutResearch,SchoolofChineseMedicine,HongKongBaptistUniversity,HongKong,SAR,PRChina

fHongKongChineseMedicineClinicalStudyCentre,HongKongBaptistUniversity,HongKong,SAR,PRChina

gDepartmentofHealthSciences,KristianiaUniversityCollege,Oslo,Norway

hBritishAcupunctureCouncil,London,UK

iHwa-pyeongInstituteofIntegrativeMedicine,Incheon,RepublicofKorea

jClinicalMedicineResearch,KoreaInstituteofOrientalMedicine,Daejeon,SouthKorea

kSchoolofHealthandSocialCare,LondonSouthBankUniversity,London,UK

lChineseMedicineDiscipline,SchoolofLifeSciences,UniversityofTechnology,POBox123,Broadway2007,Sydney,Australia

a r t i c l e i n f o

Articlehistory:

Received16July2020

Receivedinrevisedform28July2020 Accepted31July2020

Availableonline11August2020

Keywords:

Clinicalreasoning Clinicalencounter Theoreticalmodels Jinchal

TraditionalKoreanmedicineandnarrative review

a b s t r a c t

Background:Clinicalreasoningisgenerallydeﬁnedtobeawayofthinkingfordiagnosticortherapeutic decisionmakinginclinicalpractice.Differentcognitivemodelshavebeenproposedfortheclinicalrea- soningwhichtakesplaceduringtheclinicalencounterwithapatient.Thismayhavesimilaritieswith similarapproachesusedinTraditionalKoreanMedicine(TKM).Jinchal,theclinicalencounter,hasspe- ciﬁcfeaturesinTKManddifferentJinchalprocessesarecloselyrelatedtoseveralunderlyingcognitive modelsinclinicalreasoning.Itisanecessaryprocesstoseethepatient,butinTKM,themethodhasa characteristicaspectandemphasisisplacedonimportance.

Methods:Expertsconsensuswerereachedthroughpaneldiscussion.Narrativedescriptionontheconcept ofclinicalreasoningandexplanationonJinchalprocessinTKMweresuggested.

Results:ThisarticleanalysestheJinchalprocessusingtheoreticalconceptsfromfourauthenticKMschools ofclinicalreasoningwhicharecurrentlyusedincontemporarypractice.

Conclusion:Futureresearchshouldfocusonthesimilaritiesanddifferencesinunderstandingclinical reasoninginKMaswellasthebroaderﬁeldoftraditionalEastAsianMedicine.

1. Introduction

Clinical reasoning is animportant aspectof clinicalpractice andunderliesallmedicalandtherapeuticpractices.¹ Ithasbeen definedas“acontext-dependentwayofthinkinganddecisionmak- inginprofessionalpracticetoguidepracticeactions”.²Theprocess requiresa robust knowledgebase,theability tothinkcritically andreasonreflectively,andasenseofmetacognition(reflective self-awareness).Thecurrenthealthcaresettingiscomplex,andthe diseaseconditionspresentedtocliniciansareoftenill-structured,

∗Correspondingauthor.

ambiguous,andfrequentlyincomplete.Additionally,decisionmak- ing may change over time as new information emerges and conditionschange.Instarkcontrasttothedevelopmentofclini- calreasoningmodelshasbeentherecentdevelopmentofclinical practiceguidelines.³ While clinicalreasoningacknowledges the individuallydevelopedcognitivemodelsthatunderliethereality ofclinicalpractice,clinicalpracticeguidelinesarealignedwiththe perspectivethataprescriptiveandmanagedapproachbasedon researchevidenceshouldtakeprecedence.Inreality,ameasured balancebetweenthese twoapproaches warrants consideration.

Thisarticlewilloutlinesomeofthecurrenttheoriesaboutwhat constitutesclinicalreasoningandwilluseasanexampletheprac-

https://doi.org/10.1016/j.imr.2020.100641

creativecommons.org/licenses/by-nc-nd/4.0/).

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2 T.-h.Kim,T.Alraek,Z.-X.Bianetal./IntegrativeMedicineResearch10(2021)100641

ticeofcontemporaryKoreanMedicine(KM)andtheconceptof Jinchal.

2. Methods

ThisarticleisanarrativereviewaboutclinicalreasoninginKM.

Clinicalreasoningisnotafamiliarconceptintraditionalmedicine, sowetriedtointroducebasicconceptofclinicalreasoningusing JinchalprocessinKMasanexamplecase.Forbetterunderstanding, we suggested severaldiagnosticschools in KM.The basiccon- ceptaroundclinicalreasoningintraditionalmedicinewasadopted fromthestructureofFarquhar’sbook,“KnowingPractice”.⁴Speciﬁc typeofclinicalreasoningindifferentdiagnosticprocedureswere deﬁnedthroughthediscussionbetweentheauthorsofthisstudy.

2.1. Clinicalreasoninginbiomedicineanddifferentaspects comparedwithtraditionalmedicine

Severaltheorieshavebeenproposedthatattempttoexplain theclinicalreasoninginconventionalmedicinethatoccursatthe various levels of clinical experience development.⁵ One of the firstproposalstoemergewasthatofhypothetico-deductivereasoning(HDR).^6,7Thismodelinvolvesthegenerationofmultiple clinicalhypothesesbasedonclinicaldataandknowledgethatare testedin aniterative manner.Diagnostic hypothesesare either refutedorconfirmeduntiloneormorehypothesesremain.This typeofreasoningiscommonlyusedbynoviceorexpertclinicians inaproblematicoruncommonsituation.Animportantcognitive processunderlyingthistypeofreasoningis“chunking”whereby successiveexposuretoindividual“bits of knowledge” areinte- gratedintoalargercognitivenetworkallowingincreasinglylarger amountsofknowledgetobeutilizedinamoreefficientmanner duringthereasoningprocess.Thechunkingprocessreducesthe demandonthe workingmemory, which haslimited ability, to processmanypiecesofunrelated anddisparatedata.⁸ Untilthe clinicianhaschunked(networkedindividualaspectsofknowledge) vastamountsofclinicaldatainameaningfulway,theHDRprocess tendstobeslowanddetailedandrequiresconsiderableeffortby theclinician.Fig.1showsanexampleofhowHDRmaybecon- sideredwhendiagnosingacaseofthecommoncold.Notably,at alltimesduringtheinitialformationofthehypothesis andthe iterativeconfirmationandrefutationprocessthatoccurswithfeed- backand forwardcycles, thephysicianis continuouslyutilizing theirknowledgebaseinbothaninductive(arisingfromtheinitial datacollectionandthegenerationofhypotheses)andadeductive (usingatypeofreasoningthatleadstoaconclusion)clinicalrea- soningmanner.Assubsequentlydescribed,KMalsoutilizessuch HDRprocessesinacontextualandidentifiablemanner.

Thesecondclinicalreasoningprocessisoftentermedpattern recognition.Thistypeofclinicalreasoningusuallyemergesfrom experiencedcliniciansinnon-problematicclinicalsituations⁹and appearsintuitive,wherebyclinicalinformationisrapidlyretrieved fromawell-structuredcognitiveknowledgebase.Anewclinical case is quicklycategorized according to signs, symptoms, out- comes,treatment,andcontextandcomparedtopreviouscases.The closertheﬁtandsimilaritiestothepreviouscase,themorerapid andefﬁcienttheprocessappears.¹⁰Assubsequentlyproposed,the Decoction-PatternmatchingmethodusedinKMisanexampleof thisapproach.

Thethirdapproachusesasystematicreviewofthebodysystems andistermedsystematicscanning.Itinvolvesidentifyingthecen- tralfeaturesofaclinicalsituationandisconsideredtheinitialphase oftheclinicalreasoningprocess.Informationiscollectedusingan establishedprotocolthatattemptstosurveyallaspectsofaclin- icalencounter.OneofthebestexamplescomesfromTraditional

ChineseMedicine(TCM).Thetraditional10questions werefirst formulatedbyZhangJingyueintheMingDynasty(1368–1644), knownastheTenRhythmicalQuestions:“First,askhotandcold, secondasksweat,thirdaskheadandbody,fourthaskstoolsand urine,fifthaskfoodanddrink,sixthaskchest,seventhaskhear- ing,eighthaskthirst,ninthaskolddiseases,tenthaskcause.When takingmedicinals,whatchangesappear?(For)womeninquirepar- ticularlyaboutthetimeofmenses,(whethertheyare)slow,fast, blockedorflooding.Forchildren,addexperiencewithmeaslesand chickenpox”.¹¹

Recently,anewperspectiveonclinicalreasoninghasalsobeen emerging.Thisinterpretationviewstheclinicalreasoningprocess asinteractiveandmaybecharacterizedasnarrative,collaborative,multidisciplinaryandethicalinnature.Thisperspectiveisbest reﬂectedintheemergingpatient-centeredclinicalmodelwhereby clinical encounters and the development of clinical stories are acknowledgedasahumanconstructandassociallyandhistorically situated.¹²Thekeyfeaturesofapatient-centeredapproachinclude collaboration,ahighlevelofcommunication,culturalcompetence, shareddecisionmaking,andethicalpractice.²

Finally, a variety of diverse and sometimes similar models notablyexisttorepresenttheclinicalreasoningprocess.Indeed, Norman⁵hassuggestedthatnoonesinglemodelorrepresenta- tionofclinicalreasoningmayexisttosolveaclinicalproblemand thattheexpertclinicianutilizes“multidimensionalcomponentsof knowledgeandskill.”Furthermore,theclinicianmustpossesspro- ceduraladaptabilityinordertoachievethegoalofeffectivepatient care.

2.2. Jinchal—theKoreanclinicalgaze

JinchalistheKoreantermfortheChineseKanbing,whichinTCM means“examiningandinvestigatingdisease”or“clinicalgaze.”It isanimportantstepin understandingspeciﬁccharacteristicsof traditionalEastAsianmedicine.Jinchalisanecessaryprocessto assessthepatientinbothwesternmedicineandTKM;however,in TKM,themethodhasacharacteristicfocusandemphasisisplaced onitsimportance.

Jinchal is a process for inquiring into a patient’s condition through a collaborative interaction between the physician and patient.AsinTCM,thefourexaminationmethodsofinspection, listeningandsmelling,inquiry,andpalpationarealsotheinitial stepsofJinchal,whichareaimedatidentifyingthemostappro- priatetypeofdiagnosticpatternthatmightexplainthepatient’s statusandsupportaclinicaldecisionforthefurtherdevelopment ofatherapeuticprincipleandsubsequenttreatment.

In TCM,physicians analyzea patient’s subjective and objec- tivesymptomsusingthefourexaminationmethodsbasedonthe existingcognitiveframeworksthathavebeendevelopedfromstan- dardizeddiagnosticguidelines(clinicalguidelines)and personal experiencegainedfromtrainingwithseniorphysicianmentorsor fromtheirownexperientialpractice.Thisclinicalinformationis thenusedtoidentifydiagnosticpatternsaccordingtothecurrent clinicaldiagnosticsystems,includingEightPrinciplesPatternIden- tiﬁcation(PI),DiseaseCausePI,VisceralPI,Defense,Qi,Nutrientand BloodPIs,andSix-MeridianPI,whicharethemostfrequentlyused PIsystemsinTCM.Thus,acrucialfeatureoftheclinicalencounter inTCMisaseriesofcognitiveprocedurestocollectpatientinfor- mationandidentifypatterns.^4,13,14

KM,oneofseveralEastAsianmedicines,originatedasanindige- nousmedicineofKorea.KoreanMedicine(KM)physiciansadopt aPIsystemofpracticesimilartothat ofTCMphysicians.How- ever,differentdiagnosticsystemsbasedontheparticularhistorical developmentandmedicine-traditional context, forexamplethe Dongeuibogamand Sasang constitutiondiagnosticmodels,were developedandreﬂecttheuniqueperspectiveofKM.Thepractice

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Fig.1. Anexampleofhypothetico-deductivereasoningprocesswhendiagnosingcommoncoldintraditionalChinesemedicine.

Thisisanexamplecaseofhypothetico-deductivereasoningprocesswhichcanbeobservedduringthediagnosisofcommoncoldintraditionalChinesemedicine.

ofusingtheseKMdiagnosticsystemshasresultedinmodiﬁcation of the Jinchal process in KM. The Jinchal process is an observ- ablephenomenoninmedicalpractice;therefore,cognitiveaspects underlyingtheclinicalreasoningmaybeidentiﬁedthroughanaly- sisoftheJinchalprocess.Theaimofthisreviewistodescribethe JinchalprocessesofseveralKMschoolsthatareroutinelyusedby KMphysiciansincontemporarypractice.

2.3. TheJinchalprocessandthePatternIdentificationsystem PIisoneofthemostfrequentlyuseddiagnosticapproachesin TCMandisgenerallyusedinmanyothercountieswhere tradi- tionalEastAsianmedicineispracticed.¹⁵Itresemblestheprocess ofHDR.Theconceptualbasis ofPIisthat whenpathologic fac- torsthatoriginatedfromtheoutside(exteriorcauses)ortheinside (interiorcauses)ofthehumanbodyaffectahealthyperson,var- ioussignsandsymptomsoccur,whichmaybesummarizedand classifiedintospecific typesofsymptomclustersor patterns.¹⁵ Thepurposeof PImaybeunderstoodfromtheTCMstatement,

“BianzhengLunzhi,”or“Treatmentfollowsthepattern”,whereby thepattern is principallya meanstodeterminethe treatment.

PIalsohasthepotentialtodeterminepatternsofsymptomsthat explaintheunderlyingmechanismofthedisorderedorunhealthy illness state. Whenselecting the possible symptomclusters or patterns,inJinchal,physiciansexaminepatientsinteractivelyand confirmorrefutediagnosticpossibilitiesorhypothesesassociated withthepattern-specificconditions,ofwhichthepatientmaynot beconscious.Duringthisstage,physiciansdetermineapossible listofpatternsintermsofdiseaselocation(channelsandviscera), nature(threecauses),andstrengthofdisease(repleteorvacuous), whichmaycollectivelyexplainthepatient’sconditionwhensum- marized.Togeneratethislist,sixtotenclassificationsystemsare generallyused.¹⁶Aftertheinitialdiseasepatternsandtreatment

strategyareconfirmed,physiciansfurtherconsidermodifications afteranalyzingthepatient’s responsetotheseveralsessionsof pattern-specifictreatment.Althoughthechiefcomplaintmaynot beresolvedcompletely,expectedchangesinapatient’scondition mayindicateacorrectPIdiagnosis(Fig.2).

ThespecificaimofPIintheJinchalprocessistoidentifyspecific clusteringof information gatheredfromthepatient’s responses and through observation of the patient.According to thelevel ofthephysician’sexperience,thepatient’s signsandsymptoms are collectedsystematically without attempting tointerpret or deductivelyprovetheinitialhypothesizedpatterns.¹⁷Atthisstage, symptomsaresortedbasedonwhethertheymightbeclassified intocoldorheat,repleteorvacuous,exteriororinterior,andyinor yang.Robustcoherenceacrossthesubjectiveandobjectivecondi- tions,symptoms,andsignssuggestsagreaterpossibilityofaclear anddefinitePIdiagnosis.ThecoreoftheJinchalprocessinthePI systemistoclusterrelatedandothersymptomsaroundthechief complaintandtoidentifythemostappropriatepatternreflecting thecurrentpatient’scondition.Additionally,thedefinitionofpat- ternsisconsideredanactiveprocess,whichmayresultinchangesof thePIsduringthecourseofadisease’shistory.Varioussigns,includ- ingpulseandtonguebodyandcoat,providecriticalinformationfor thedeterminationofPIwhenthepatient’ssignsandsymptomsdo notreadilyconformtoauniformpatternpresentation

2.4. TheJinchalprocessandtheDecoction-Patternsystem

TheDecoction-Patternsystemisgenerallyusedbyphysicians whofollowtreatmentprinciplesfromtheclassicalChinesemedi- caltext,“Shanghanlun,”or“TreatiseonColdDiseases”.Physicians who utilize this diagnostic approach are representative of the Japanese Kohu, or“Antiquity”school.¹⁵ Thissystem hassimilar aspectstothediagnosticmethodsappliedintheJapanesesystem

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Fig.2.JinchalprocessinthePatternIdentiﬁcationsystem.

JinchalprocessinthePatternIdentificationsystemisconsideredtobethemostbasicprocedureofthediagnosisinKoreanMedicine.Thecircledportionofthefigureisthe specificpointofthisclinicalreasoningsystem.

ofKampomedicine,whichpursuesdiagnosticinformationfrom abdominalpalpationandusesacoupledformula-patterndiagno- sisandtreatmentsystem.Kampomedicinewasintroducedtothe KoreanmedicalsystembyphysicianswhohadstudiedtheJapanese medicalliterature.¹⁸ However,it furtherevolved,resulting in a speciﬁcKorean context.In oneof the Kohu schools, physicians additionallyincludedpalpationofthetrapeziusmuscle,bicepsand tricepsbrachii,andspinalmuscles,concurrentlyretainingabdomi- nalpalpation,asdiagnosticmethods.Thisdevelopmentledtonew interpretations(andprescriptions)ofindividualherbsandformu- lasoftheShanghanlun.¹⁹

Inthe Decoction-Patternsystem,theJinchal process aimsto identifythemostappropriatepatternsforthepatient’spresenting condition,whicharecloselyrelatedtoaspeciﬁcherbaldecoction (Fig.3).ComparedwithotherPIsystems,theDecoction-Pattern systemshowsadirect relationshipbetweenthefeatured symp- tomsandtheherbalformulasfoundintheShanghanlun,withouta conceptualizedclinicalreasoningprocess.²⁰ Thisprocess isvery similartotheclinicalreasoning conceptof patternrecognition.

Therefore, when a patient presents with anychief complaints, thephysician,whohasacomprehensiveknowledgeofthepatho- logicpatternsandspeciﬁcherbalformulas,attempts toidentify anyvalidationforwhetheradecoctionmightbeprescribedbased ontheShanghanluntext.Individual herbsarealsoconsidered relatedtospeciﬁcsymptomsandmaythusbeaddedtoorsub- tractedfrom theformula according tothe patient’s symptoms.

Correspondingly,physiciansfocusonlocatingspeciﬁcsymptoms rather than scanning thebody systematically through thefour examinationsintheJinchalprocess.Becauseabdominalpalpation isparticularlyacceptedasanobjectiveindicatorwhendeciding anyDecoction-Patternsystem,ithascorediagnosticvalueinthis system.²¹

2.5. TheJinchalprocessandtheCondition-Decoctionsystem TheCondition-Decoctionsystemisthetreatmentschoolcur- rently followedby mostKMdoctors.It is basedontheKorean medicalclassic, the“Dongeuibogam,”or“Principlesand Practice ofEasternMedicine”,which waswrittenbyHeoJunin1610.²² TheUNESCOincludedthebookintheMemoryoftheWordreg- isterin2009becauseofitsspecialvalueinKMpractice,whichhas withstoodthetestoftime.

The conceptual value of the Condition-Decoction system is drawnfrom thetextofthis historical KMclassic.The Dongeui- bogam consists of five chapters, including Naegyeong (inner body), Oehyeong (external body), Japbyeong (various diseases), Tang-aek (herbal medication) and acupuncture. The Naegyeong chapterincludes fourmajor body constituents,Jeong (essence), Qi (qi),Shin (spirit) and Hyeol (blood),along withthefive vis- ceraandsixbowels.TheOehyeongchapterdescribestheexternal parts of body from head to foot. In the Japbyeong chapter, various diseases and symptoms are assigned. The chapters on Tang-aek and acupuncture describe herbal decoction prescrip- tionsand acupuncture.In the Dongeuibogam, differentpatterns are assigned to the relevant body constituents and body parts andareclassifiedaccordingtotherepresentativepatientsymp- toms.

IntheCondition-Decoctionsystem,theJinchalprocessfocuses onidentifyingkeysymptomsconsideredeasilydiscerned.Whena doctordiagnosesdiseasesorspecificsymptomsusingtheDongeui- bogam,appropriatesections(orkeypoints)arelistedintherelated chapter.Thesekeypointsareusually importantsymptomsthat reflectthebody constituentsorparts.Oncethekeysymptomis identified,themostsuitabledecoctionmustbeselectedbasedon otheraccompanyingsymptomsandsigns,whicharedistinguishing

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Fig.3. JinchalprocessintheDecoction-Patternsystem.

SpecificfeaturesofclinicalreasoninginDecoction-PatternsystemisdecidedbythedecisionprocedureofdecoctionbasedontheShanghanluntext.Thecircledportionof thefigureisthespecificpointofthisclinicalreasoningsystem.

Fig.4. JinchalprocessintheCondition-Decoctionsystem.

SpecificfeaturesofclinicalreasoninginCondition-Decoctionsystemistofindmostappropriatepatternanddecoctionbasedonthepatient’schiefcomplaint.Thecircled portionofthefigureisthespecificpointofthisclinicalreasoningsystem.

featuresofpatternsassociatedwiththekeysymptom.Forexample, ifapatientcomplainsofheadache,thephysicianreviewsthe“head”

sectionoftheOehyeongchapter,identiﬁesthemostappropriate patternsbasedonothersymptoms,andsubsequentlydecideson thetherapeuticapproach(Fig.4).ComparedwiththeDecoction- Patternsystemthatrequireswell-trainedexpertswithprofound knowledgeofShanghanlun,thissystemiseasierforinexperienced practitionersandlaypersonstouse.

2.6. JinchalprocessandtheSasangconstitutionalmedicine system

Fora Sasangphysician,identifyingthespeciﬁcconstitutional typeofthepatientistheprimarystep.IntheSasangconstitutional system,everyindividualisassumed tohaveoneuniqueconsti- tution,thatis,Taeyang,Taeeum,SoyangorSoeum,whichpersists lifelong.²³ Accordingto“Dongeuisoosebowon,” or“Longevityand

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LifePreservationinOrientalMedicine” byLee Jae-ma,which is themainSasangmedicinetextbook,eachindividualhasadifferent physiologyandpathologybasedontheirownconstitution;therefore,thetreatmentstrategyis additionallydeterminedbytheir speciﬁctypeof constitution.²⁴ Physiciansfocusonthepatient’s constitutionintheﬁrstclinicalencounterandcontinuetoassess whethertheirinitialconstitutionaldecisionwascorrectduringsuc- cessivevisits.

Aperson’sconstitutiontypeisdeterminedbyseveralfactors.

Thesefactorsincludeexternalappearance,includingcharacteris- ticsoftheface,bodyshapeandvoice;covertbehavior,including temperament and personalitytype; symptoms in both healthy or diseased states; and response to the constitution-speciﬁc treatments.²⁴ Severalcurrentconstitutional diagnosticmethods weredevelopedbasedontheprincipaltheoryofSasangconstitu- tionalmedicine.Examplesinclude measuringthecircumference ofthetrunksegmentsfortheevaluationofbodyshape²⁵;using surveyorquestionnairemeasurements,includingtheShortForm Sasang Classiﬁcation Questionnaire (SF-SSCQ)²⁶; and gathering auditoryinformationthroughvoiceanalysisusingrecentlydevel- opedtechnology.²⁷Thesemethodshavebeenupdatedandrevised throughtheaccumulatedclinicalexperiencesamongtheindividual expertphysiciansandschools.

Oncethepatient’sconstitutionisidentiﬁed, thepathological symptomsareanalyzedindetailwithintheboundaryofthespe- ciﬁcconstitutiontoselectthemostappropriatetreatmentstrategy.

Physiciansapplyconstitution-specificherbalformulas,acupunc- turetreatmentandlifestylemodifications,whichaimtoaddress thepatient’shypothesizedconstitution.Atthisstage,becausethe patient’sconstitutionisnot confirmed,thephysicianprescribes onlyafewdaysoftreatmenttoobservethetherapeuticresponse.

Generally, experienced physicians may diagnose a constitution morepreciselyandrapidlythaninexperiencedpractitioners.After severalsessionsoftrialanderror,thephysicianmayﬁnallycon- ﬁrmtheconstitution.Shouldthepatientnotshowanyexpected responseoradverseeventsaftertreatment,thephysicianmight considerotherpossibilitiesandaddressanymistakesintheselec- tionoftreatmentandinthedifferentiationofconstitution.

Sasang medicine reflects specific features during a clinical encounter(Fig.5).Incontrastwiththeothersystemswherepresent symptomsaremore criticalforthepurposeofdiagnosisofcur- rent patterns, diseases or syndromes, Sasang medicine regards consistentfactorsasmoreimportant todeterminethepatient’s constitutionintheclinicalpractice.Thisconceptmayhaveorig- inatedfromthespecificperceptionofpathologycomparedwith othertraditionalEasternAsianmedicineschoolswhichholdthe viewthatdiseasesoccurwhenexternalorinternalpathogenicfac- toraffectthechannelororgansystem.InSasangmedicine,internal imbalancesamongorgans,whichareaffectedbyconstitutionalfac- tors,areperceivedtobethemainpathologicfactors,andexternal factorsareviewedasadditionalcomponentsofadisease.^28,29From thisperspective,factorssuchaspersonalityandsymptomsin a healthyindividualareconsideredmoreimportantlythanchang- ingbio-informationsuchaspulseortonguefeatures.IntheSasang approach,gatheringinformationthroughinquiryhaspriorityover theotherthreeexaminations,includinginspection,thelistening and smellingexamination, and palpation. When evaluatingthe clinicaloutcomeoftheconstitution-specifictreatments,symptoms relatedtotheconstitution,suchassweating,urineandstoolsta- tus,and digestivefunction,comprisekeyinformation thatis as importantasthechiefcomplaints.Additionally,theconstitution isconsideredtopersistoveranindividual’slifetime.Ifanindivid- ual’sconstitutionisconfirmed,thetreatmentstrategyisminimally changedduringthatperson’slife,althoughherbalformulasmight bechangedwithintheconstitution-specificdruglist.

2.7. SpeciﬁccognitivemodelsofclinicalreasoningindifferentKM schools

Jinchaliscloselyrelatedtotheclinicalreasoningprocess.InTCM, threetypesofcognitivemodelsweregenerallysuggested,including hypothetic-deductivereasoning,systematicscanning,andpattern recognitionmodels,basedontheirreasoningprocesses.³⁰InKM, although thesethree models are used interactivelyin practice, diagnosticschools providespecific cognitivemodelsforclinical reasoningatanovicelevel.ThePIschoolandSasangconstitution schoolusetheHDRstrategy;theycommonlyrecognizeagrosslabel forpatternsorconstitutiontypesearlyinthediagnosisandrefine thediagnosisthroughdeductivereasoning.Adiscriminatingdiffer- encebetweenthesetwosystemsiswhetherthediagnosticfocusis onthecharacteristicsofthediseaseortheconstitutionoftheper- son.InPI,thealignmentofsymptomstopatternsisimportant;thus, differentiatingsymptomsacrossdifferentcompetingcategoriesis akeyprocessinJinchal.Consequently,physicianstypicallyactively seektoidentifysymptomsandphysicalsignsrelatedtoadisease- specificpattern duringthediagnosticprocess.³⁰However, with Sasang,decidingthepersonalconstitutiontypeistheinitialstagein Jinchal.Toidentifytheindividualconstitutiontype,personalchar- acteristics,includingexternalappearanceandvoice,thephysical conditionsduringhealthyandillstates,personalitytraits,including introversion-extroversion,andresponsestocertainherbaldrugs are closely observed as a whole before investigating the chief complaintorillness.²⁹Subsequently,allthepatient’scomplaints areanalyzedwithinthespecificconstitutionalboundary.Because symptomsareclassifiedbytheconstitution,constitution-specific signsandsymptomsareregardedasmoreimportantthanthechief complaint.

The Condition-Decoction system and the Decoction-Pattern system mainly adopt a systematic scanning model for clinical reasoning. Inthese systems,diagnostic information is collected andclinicalreasoningoccursfollowingthestructureofthemed- icaltextbookswithoutgenerationofahypothesis ofpatterns.³⁰ Becausethepatient’sconditionismatcheddirectlywiththesymp- tomssuggested inthetextbooks during thediagnosticprocess, individualinterpretationisnotprimaryduringthereasoningpro- cess.Furthermore,theCondition-Decoctionsystemiseasytouse, evenfor theinexperienced. Whena physicianidentifies achief complaint,heorshewillthen refertothekey symptominthe chapterofDongeuibogamandselectthemostappropriatepatterns andtreatmentsfromthoseprovidedinthatsection.TheDecoction- Patternsystemrequiresamorecomprehensiveunderstandingof thestructureoftheShanghanluntextbecausepatternsarenotclas- sifiedaccordingtothemajorcategoriesofsymptoms.Therefore, physiciansmustknowthediagnosticpatternscomprehensively, orthecorrectdecoction,toconfidentlyselectanappropriatetreat- ment.Fromthis perspective,theDecoction-Pattern systemmay involvethepatternrecognitionmodel,whichusesimplicitknowl- edgeintuitivelyintheclinicalreasoningprocess.³⁰Whenapatient hascomplexsymptoms,physiciansidentifythemostsimilarpat- ternsandtreatments(decoctions)suggestedintheShanghanlun, similartosolvingajigsawpuzzle,wherebythephysicianattempts tofitpuzzlepieces(symptoms)intothejigsawpuzzleframe(pattern)(Table1).

2.8. Clinicalreasoningresearch

Severaldifferentresearchmethodsandapproacheshavebeen usedtoinvestigatethereasoningprocessesthatcliniciansusein practice.³⁰Thesemethodsmaybecategorizedaseitherqualitative or quantitative and involve both group and individual analy- ses.Quantitativemethodsusuallyrevolvearounddecision-making approachesthatuseregressionmodelsandBayesianestimatemod-

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Fig.5. JinchalprocessintheSasangconstitutionalmedicinesystem.

SpecificfeaturesofclinicalreasoninginSasangconstitutionalmedicinesystemistodefineaperson’sconstitutionfirstandclinicalreasoningproceedsbasedonthe constitution.Thecircledportionofthefigureisthespecificpointofthisclinicalreasoningsystem.

Table1

ComparisonsbetweendifferentJinchalprocessesindifferentsystemKMschools.

TypeofJinchalprocessin TraditionalKoreanMedicine schools

Rationale Deﬁnition Majorclinicalreasoningmodels

PatternIdentiﬁcationsystem “BianzhengLunzhi”,“Treatment followsthepattern”

Identifyingaspeciﬁcclusteringof information

Hypothetico-deductivereasoning Decoction-Patternsystem “Shanghanlun”,“TreatiseonCold

Diseases”

Matchingspeciﬁcsymptomsto correspondingherbalformulas

Systematicscanningandpattern recognition

Condition-Decoctionsystem “Dongeuibogam”,“Principlesand PracticeofEasternMedicine”

Identifyingspeciﬁcherbalformulas listedforrelatedsymptoms

Systematicscanning Sasangconstitutionalmedicine

system

“Dongeuisoosebowon”,“Longevity andLifePreservationinOriental Medicine”

Identifyingthespeciﬁc constitutionaltype

Hypothetico-deductivereasoning

elsasthebasisforanalysis.Thesemodelshaveoftenbeenusedasa rationalapproachtodecisionmaking,andcriticshavearguedthat decisionmakingisfrequentlynotrationaleandthatthisapproach cannotbeemployedasaguideforaction.Incontrast,qualitative approachesarebasedonreallifeorsituationsthatareveryclosely relatedtoreallifeandperceivedexperiences,forexample,verbal reportsthatutilize“thinkaloud”protocolsandretrospectiveproto- colsthatuseverbaldata(verbalizedthoughtsprovidedbysubjects), whichattempttocapture“thick”individualizeddataratherthan the“grossaveragedmeasuresofmanysituations”.³⁰Recently,an interpretativeapproachtodatacollectionhasbeenused.³¹Often usingsituated cognitivemethodsin a naturalisticenvironment, suchastheclinicorhospital,thisapproachpermitsnotonlythe collectionofverbaldatabutalsothatoftheactionsandtasksper- formed,whicharecapturedonvideoandlateranalyzed.Research approachessuchastheselendthemselveseasilytoTKMclinical situations,whichtodatehavenotyetbeenused.

3. Conclusion

ThisstudyisanexploratoryreviewontheJinchalprocessesthat haveevolvedindifferentTKMschoolsthroughthefourrepresen- tativeTKMschoolsreviewed.EachschooladoptsaspeciﬁcJinchal

processforpracticeandseveralJinchalprocesseswereidentiﬁed thatarecurrentlyusedbycontemporaryKMphysicians.

The Jinchal process allows the physician to have a clearer understandingofdiagnosticclinicalreasoningamongthedifferent schoolsofKM.Additionally,thestudyofJinchalprovidesinforma- tiononthespecificmodelsofreasoningusedinvariousindigenous medicinesandwillbeusefulforthefurthereducationofKMdoctors inexperiencedinthosemedicinesystems.Thisstudyisexpectedto representanimportantfirststepinunderstandingthespecificfea- turesormodesofcognitivereasoninginthediagnosticaspectsof traditionalEastAsianmedicalsystems.

Inthefuture,qualitativeresearchontheperceptionofKMprac- titionersshouldbeundertakentoidentifyadditionalkeyfeatures underlyingtheclinicalreasoningprocessesofKM.Moreover,cross- culturalandinterdisciplinarystudiesarerequiredtogainabetter understandingoftheclinicalreasoningprocessintraditionalEast Asianmedicine.

Authorcontributions

Conceptualization:THKandCZ.Investigation:THKandCZ.Writ- ing–OriginalDraft:THKandCZ.Writing–Review&Editing:TA, Z-XB,SB,MB,JL,MSL,NR,andCZ.

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8 T.-h.Kim,T.Alraek,Z.-X.Bianetal./IntegrativeMedicineResearch10(2021)100641 Conﬂictofinterest

Theauthorsdeclarenoconﬂictsofinterest.

Funding

ThisworkwasfundedbyKoreaInstituteofOrientalMedicine (KSN2013210andK14130).

Ethicalstatement

Thereisnodatawhichmightberelatedtotheethicalissue.

Dataavailability

Thereisnoavailabledataasthisworkusedavailableliterature.

Acknowledgment

Thebasicideaofthismanuscriptwasoriginallypresentedinthe 2015Internationalpatternidentiﬁcationnetworkgroup(i-PING) meetingand this article wasprepared aftersupplementing the contents.

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