## 2 Discussion
### The Processes of Clinical Decision Making: The Four Models, with Clinical Examples
#### 2.2.1 Overview
As a means of conceptualizing the intricacies of these four models, I will again propose a novel metaphorical geometric schematic paradigm (never previously introduced in the literature) consisting of a 3-dimensional tetrahedral triangular pyramid composed of four triangular-plane figure faces, six straight edges, and four vertices (Figure 4). This is the same geometric figure used in the schematization of the models of clinical decision making in Figures 2 and 3, although they involve a different subject matter. This geometric figure represents the summation and integration of the four models of the physician-patient relationship as a Principal paradigm. Each vertex represents one individual model of the physician-patient relationship, with the entire geometric figure consisting of and broken down into four separate metaphorical plane figure \"triangulations\" with the following reciprocal relationships:  
* Sub-paradigm a: Shared Decision-Making Model--Counselor/Interpretive Model--Paternalistic Model (Figure 5a),
* Sub-paradigm b: Shared Decision-Making Model--Counselor/Interpretive Model--Counselor/Interpretive Model--Counselor/Interpretive Model (Figure 5b),
* Sub-paradigm c: Shared Decision-Making Model--Paternalistic Model/Consumerism/Informative Model (Figure 5c),
* Sub-paradigm d: Counselor/Interpretive Model--Paternalistic Model--Consumerism/Informative Model (Figure 5d). Figure 5: Cont. Figure 5: (**a–d**) The four separate triangular sub-paradigms which as a composite constitute the principal tetrahedral pyramid depicted in Figure 4. These plane figures metaphorically subtype all the interrelationships involved in the physician-patient relationships. As with clinical decision making, the essence of the four separate \"triangulations\" of the physician-patient relationship is that no single model can be considered in isolation; rather, patient care involves a synthesis of elements from the multiple models. At a higher level, in order for the tetrahedral pyramid to take geometric form, each individual vertex must share a straight line with and thus be connected in a reciprocal fashion to each of the other three individual vertices. The mechanics of this novel paradigm follow those of the models of clinical decision making previously elaborated in Figures 2 and 3. The integration of the above results in a relative confluence of all four models of the physician-patient relationship, which is operative in the care of patients. That is, one individual model may take precedence during one period of time in the care of patients, although it does not exist alone, but rather as a convergence with the others to various degrees. Certain models may also contribute to a greater or lesser extent to the physician-patient relationship based on multiple factors: the nature and complexity of the disease processes, the preferences of the patient and the physician in the delivery and acceptance of care, the individual value systems of the physician and patient (as discussed above), social and cultural determinants, geographic and logistical issues, and patient \"health literacy\" (understanding of health-related issues), in addition to other considerations. 2.3 Clinical Examples of the Convergence of the Individual Models of the Physician Patient Relationship  
Real-life examples of the intersection of the models of the physician-patient relationship are ubiquitous in the day-to-day practice of medicine. An example would include a patient followed for years with stable lung and kidney disease developing a rapidly progressive primary cancer of another organ system. The relationship has been built and based on years of mutual decision making, although benefits may ensue with the physician assisting in redefining the patient's own past system of values as a counselor/interpreter without his or her direct input.