I can’t remember the first time I heard the term ‘clinical reasoning’, but it wasn’t mentioned when I was in medical school. We were brought up on the concept of the ‘differential diagnosis’, which was introduced by William Osler (1849-1919),[1] an English physician working in Canada who promulgated the then radical idea of medical students spending more time at the bedside rather than in lecture theatres. The differential diagnosis exercise recognises that many conditions and diseases have similar symptoms and therefore results in a list of probable and possible diagnoses that must be considered and most ruled out until the correct one is identified.
As a medical student this involved starting with the full history and physical examination (also known as clerking a patient). Lots of questions generated many answers. As a novice clinical student with little experience of real-life patient presentations it was difficult to make sense of the information. Our two years at university had given us a patch work understanding of anatomy, biochemistry and physiology and how the body might malfunction. However, we were less knowledgeable about what disease looks like in practice. We knew about the mechanism of heart failure for example and that it could cause shortness of breath and swollen ankles, but little about the patient’s lived experience: what it is like to live with heart failure.
In the past, within the hierarchical culture of medicine, many thought that only medical doctors can diagnose. Others have opined that doctors make medical diagnoses and nurses make nursing diagnoses. Such an opinion doesn’t stand up (if it ever did) when we consider the role of nurse practitioners and specialist nurses. The role of pharmacists in diagnosing common illnesses is also controversial. However, whatever one’s perspective on the diagnostic process, there is agreement that clinical reasoning is a core component of clinical practice.
As with many terms, clinical reasoning has been conceptualised in diverse ways by clinicians, educators and researchers. A scoping review of how ‘clinical reasoning’ is described makes interesting reading. The authors included 625 papers spread across dentistry, medicine, nursing, occupational therapy and physical therapy. The review highlights the nature of clinical reasoning as a multi-dimensional construct.[2] In another paper, a different group of authors reflect on their work in this area and argue for greater clarity in definition and assessment methodology.[3] In summary, clinical reasoning has many shapes: it is a skill, a process; its purpose is to make a diagnosis; it is a competence to be assessed; it seems familiar but is hard to pin down; its expression depends on context.
I consider the term to refer to the process of defining a patient problem or need through communication, observation, examination and investigation as appropriate. Subsequently, the health professional, hopefully in partnership with the patient, decides on the best and safest way to proceed, considering the patient’s preferences and context. Thus, clinical reasoning is a complex skill that involves much more than making a diagnosis. Therefore, it is difficult to assess as a single competence.
Can and should clinical reasoning be learned through an interprofessional process? Do the different health professions undertake clinical reasoning in similar ways?
One of the findings from implementing interprofessional learning activities, in which students from a range of health professions work together to elicit a patient history, is that students are surprised at the differences in the areas explored with patients across the professions.
Rola Ajjawi, Rosemary Brander and I have written a chapter on ‘Interprofessional programs to develop clinical reasoning’ in the 4th edition (2019) and soon to be available 5th edition (2023) of the comprehensive book, ‘Clinical reasoning in the health professions,’ published by Elsevier. We focus on collaborative clinical reasoning, acknowledging that differences arise from variations in health professionals’ knowledge, roles, responsibilities and scope of practice.
[1] https://www.ncbi.nlm.nih.gov/books/NBK543756/
[2] Young, M.E., Thomas, A., Lubarsky, S. et al. Mapping clinical reasoning literature across the health professions: a scoping review. BMC Med Educ 2020; 20: 107
https://doi.org/10.1186/s12909-020-02012-9
[3] Gordon, D., Rencic, J.J., Lang, V.J. et al. Advancing the assessment of clinical reasoning across the health professions: Definitional and methodologic recommendations. Perspect Med Educ 2022; 11: 108–114
Health professional education and practice 