Understanding Clinical Reasoning from Multiple Perspectives: A Conceptual and Theoretical Overview

Abstract

Rather than a historical overview as in Chap. 2, this chapter provides the reader with insight into the various approaches that have been used to understand clinical reasoning. We review concepts and major scholars who have been involved in such investigations. Cognitive psychologists Newel and Simon theorized about problem-solving skills and artificial intelligence and initiated the use of computers as metaphors of thinking. Elstein and colleagues found that there is no such thing as a general problem-solving skill, independent of medical knowledge, and thus clinical reasoning is case specific. Reasoning then became analyzed in approaches, including forward reasoning from data to diagnosis; hypothetico-deductive reasoning with backward nature, from hypothesis to diagnosis; and abductive reasoning to understand early hypothesis generation that is so characteristic in clinical reasoning, elaborated by Patel and colleagues. Bordage introduced prototypes to characterize how physicians may remember illness presentations and semantic qualifiers to denote the shortened conceptual language and labels physicians use to store medical information systematically in memory. Illness scripts represent how encounters with diseases are remembered by physicians and were introduced by Feltovich and Barrows. Schmidt and Boshuizen elaborated the concept further and propose encapsulation of knowledge as a hypothetical process that happens when physicians regularly and routinely apply shortcuts in thinking typically ellaborated as pathophysiology. Reasoning ability appears not only to be case specific-- it is also situation or context specific. Clinicians with broad reasoning ability have extensive experience. Deliberate practice with many cases and in varying contexts is recommended by Ericsson to acquire reasoning expertise. To improve reasoning, some authors have focused on cognitive biases and error prevention. Norman, however, concludes that bias reduction strategies are unlikely to be successful but correcting knowledge deficiencies is likely to lead to reasoning success. Kahnemann promoted System 1 and System 2 thinking for instant pattern recognition (nonanalytic reasoning) and analytic reasoning, respectively. What actually happens in the brain during clinical reasoning is the domain of neuroscience, which may provide insights from research in the near future.