## 2 Discussion
### The Processes of Clinical Decision Making: The Four Models, with Clinical Examples
#### 2.2.1 Overview  
The objective of this segment is to diverge from the models of clinical decision making discussed in the previous segment and focus on the separate models of the physician-patient relationship. The interlocking and reciprocal relationship between the overall models of clinical decision making and those of the physician-patient relationship will be elaborated in Segment V.  
The modern-day study of the physician-patient relationship commenced with the writings of [PERSON], Professor of Sociology at Harvard University, who described and championed an asymmetric Paternalistic Model, in which the physician acts as a fatherly figure and as a trained and institutionally certified expert caring autonomously and knowing the best course of action, with no input by the patient [16]. In rare circumstances, elements of this model may still be applicable. This professionally dominant model was preeminent following World War Two until the mid-1960s, during a period coined as the Golden Age of Medicine. This period served as the springboard for the evolution of the physician-patient relationship due to the growing \"commodification\" of healthcare, in which the medical landscape was forced to change due to numerous external pressures to include insurance companies, the rapidly growing pharmaceutical industry, and federal governments around the world [17]. In 1972, [PERSON], Professor Emeritus of Medical Ethics and Philosophy at Georgetown University, was the first to accommodate to the new medical landscape by proposing four models of the physician-patient relationship, upon which all the subsequent literature and scholarly discussion has been based: Priestly Model, Engineering Model, Contractual Model, and Collegial Model [18]. Parenthetically, I am honored to have been a student of Professor [PERSON] in my early collegiate years. Similar to the Paternalistic Model, the Priesly Model assumes that the physician makes all the medical decisions without input from the patient or recognition of their system of values. The Engineering/Scientific Model can be construed as the antithesis of the above and as the foundation of a consumerism approach, in which the patient asymmetrically makes the medical decision after the data, technical information, and options are presented by the physician. Both the Contractual and Collegial Models are very similar, with slight variations, in which a collaboration exists between the physician and patient, thus presaging shared decision making in the current era of patient autonomy and patient-centered care. Twenty years later, [PERSON] and [PERSON], from the Dana Farber Cancer Institute (Boston, MA, USA) and the Kennedy School of Government of Harvard University, respectively, elaborated upon four models of the physician-patient relationship (paralleling those of [PERSON]), which remain the basis for current-day scholarship and practice: Paternalistic Model, Informative Model, Interprettive Model, and the Deliberative/Shared Decision-Making Model [19]. The Paternalistic and Informative Models retain their age-old characteristics. The latter is based on [PERSON]'s Engineering/Scientific Model, which portrays the physician as the provider of information and the patient as the consumer, thus representing a relationship presupposing the modern-day \"commodification\" of medicine. Examples of the above include the not-so-infrequent patient referred to as the \"doctor shopper\", who will often admit that they have not been satisfied with their previous physicians (or the advice given); therefore, multiple different clinicians are sought. In my experience, these patients typically do not seek partnerships or alliances in their interactions with physicians. On the other hand, the Interpretive Model connotes a collaborative relationship between the physician and the patient, with the nuance that the physician acts as a counselor of sorts, assisting the patient in understanding their own value systems and goals in arriving at treatment plans.