Re-visioning clinical reasoning, or stepping out from the skull

Abstract

The problem

Progress in teaching and learning clinical reasoning depends upon more sophisticated modelling of the reasoning process itself. Current accounts of clinical reasoning, grounded in experimental psychology, show a bias towards situating reasoning inside the skull, further reduced to neural processes signified by imaging. Such a model is necessary but not sufficient to explain the clinical reasoning process where it fails to embrace cognition extended to the environment and social contexts.

A solution

Sufficiency for a model of clinical reasoning must include dialogues between doctor, patient, and colleagues, including the complex influences of history and culture, where artefacts and semiotics such as computers, testing, and narrative structures augment cognition. Here, ‘extended’ cognition is configured as an outside-in process of ‘sensemaking’ or ‘adaptive expertise’.

The future

Current ‘predictive processing’ cognition models place emphasis on anticipatory cognition, where memory is reconfigured as active reconstruction rather than recall and recognition. Such an ‘ecological perception’ or ‘externalistic’ model provides a counter to the current dominant paradigm of ‘ego-logical’ cognitive reasoning – the latter, again, abstracted from context and located inside the skull. New models of clinical reasoning as an open, dynamic, nonlinear, complex system are called for.

Keywords:

• Decision-making
• clinical
• theory

Acknowledgments

The author would like to acknowledge the continuing value of conversations around the topic of clinical reasoning with Dr David Levine.

Disclosure statement

The author reports no conflicts of interest. The author alone is responsible for the content and writing of the article.

Glossary

Ecological clinical reasoning: Describes an ‘extended’ clinical reasoning process where the individual is part of a complex system and thinking and feeling are ‘afforded’ by environmental cues. For example, reasoning is shared across a clinical team and a number of artefacts such as test results.

Egological clinical reasoning: Is situated in the individual and often explored through a psychological or a neurological lens, where it is reduced to individual psychological strategies ultimately reducible to brain activity.

Externalism: A philosophical position that argues for ‘extended’ cognition, or that thinking and feeling are contextual and social.

Object-oriented ontology: A philosophical position that gives equal status to persons and objects (or artefacts) in any social situation. For example, a ‘crash call’ team gathering to treat a cardiac arrest is dependent upon a variety of artefacts such as drugs and devices on a ‘crash cart’.

Semiotics: The study of signs and symbols in language. For example, a team ‘briefing’ signifies a collaborative act; a ‘crash call’ signifies a cardiac arrest emergency.

Additional information

Notes on contributors

Alan Bleakley

Alan Bleakley, DPhil, is a Life Emeritus Professor of Medical Education and Medical Humanities at the University of Plymouth UK. He has published many books, book chapters and articles, and is a high-profile figure, within the fields of medical education and medical humanities.