Clinical Reasoning: Defining It, Teaching It, Assessing It, Studying It

Defining it Like the fable of the blind men and the elephant, each of whom, feeling a different part of the elephant, described it in very different ways, clinical reasoning is a vast, complex construct that is described and used in different ways by different people. There is no generally accepted definition of clinical reasoning and, indeed, many articles about clinical reasoning never define it explicitly; it is often assumed as a universally understood construct. For the present commentary, we can describe the clinical reasoning process as including the physician’s integration of her own (biomedical and clinical) knowledge with initial patient information to form a case representation of the problem. The physician uses this problem representation to guide the acquisition of additional information and then, on the basis of this information, revises the problem representation. She repeats the information gathering – representation revision cycle until she reaches a threshold of confidence in that representation to support a final diagnosis and/or management actions.1 This very broad description subsumes numerous additional phenomena and questions: how is knowledge organized and accessed, how does expertise manifest itself in clinical reasoning, how are alternative representations evaluated, and so forth. It is readily apparent to anyone reading the literature that “clinical reasoning” is used for a considerable variety of activities. Indeed, a skeptic may well ask “what is NOT clinical reasoning?” If the term comes to encompass any physician thinking about clinical problems, the concept becomes so expansive as to risk becoming useless as a guide University of Michigan Medical School, Department of Learning Health Sciences, Ann Arbor, Michigan