How clinicians think: The 
evolution of clinical reasoning

"To be conscious that you are ignorant is a great 
step to knowledge."


—Benjamin Disraeli (1804-1881), 
British writer and former Prime Minister


I remember vividly standing next to my first preceptor in a brief pediatric encounter. I was in awe as he swiftly obtained a history from a mother over the screams of her ill 2-year-old, performed an ENT exam, listened to the chest, surveyed the skin, and printed instructions for the symptomatic management of herpangina. He did all this before I could even pull the notebook out of the pocket of my short white coat. The decision-making process seemed completely effortless for this pediatrician of 12 years.


If you are a practicing clinician, stop and think for a minute about how you learned to think like a clinician. 
In the course of your medical education, you no doubt memorized goofy mnemonics, read medical textbooks until your eyes blurred, and practiced your awkward physical exam skills on your classmates, family members, and anyone else that would let you shine a light in their eyes. But how did that knowledge culminate in the ability to enter a patient exam room and, in a matter of minutes or even seconds, diagnose a problem and formulate a plan? This process of translating textbook knowledge into patient care occurs through the development of clinical reasoning. 


Clinical reasoning is defined very broadly as the thinking and decision-making processes associated with clinical practice. The clinician's ability to provide safe, high-quality care is dependent on the ability to think. 


Clinical reasoning can be broken down into three key components: knowledge, cognition, and metacognition.¹ The foundation of all clinical practice is the knowledge of biomedical science and clinical medicine. Knowledge is first gained through formal education, then through the lifelong learning process via personal experience, medical journals and conferences, and collaboration with peers. Clinicians learn through the examples of others and through personal successes and errors. Knowledge alone, however, is not sufficient to care for patients, which also requires the process of cognition. Through cognition, we are able to distinguish relevant from irrelevant information and then analyze, synthesize, and evaluate the collected data. The final component of clinical reasoning is metacognition, which is the process of thinking about our thinking. Through metacognition, we reflect on our decisions, recognize the limitations of the data, and become aware of the boundaries of our own knowledge and skills. 


The journey from knowledge to cognition to metacognition does not occur in a vacuum, but in the context of the health care system and the patient's concerns, goals, and culture. Add another layer of complexity to the task when the patient has multiple ill-defined problems or when the diagnosis involves delivering bad news. Experienced clinicians manage these factors within their clinical reasoning process, but new clinicians often feel their guts tighten and their brains shrink in the face of this onerous task. The process of refining and honing clinical reasoning skills continues to develop over an entire clinical career. Every patient encounter and every consultation with peers enhances pattern recognition and adds to the knowledge bank for managing complex scenarios. 


I am no longer that wide-eyed, fumbling student, but I am still very aware of how much I don't know in the world of medicine. From my vantage point as a clinician turned PA educator, I have gained a new appreciation for the infinitely complex process of learning to think clinically. Educators are tasked with guiding students through the vast reservoir of foundational knowledge and onto their own path of clinical reasoning. Eventually, students set out from the classroom to learn from clinical mentors and have their own moments of awe. Watching students struggle to develop their clinical reasoning skills has heightened my awareness of how I apply clinical reasoning with patients in my own practice and has reminded me to not take this critical skill for granted. JAAPA

REFERENCE 


1. Higgs J, Jones MA, Loftus S, Christensen N. Clinical Reasoning in the Health Professions. 3rd ed. Amsterdam, Netherlands: Elsevier (Butterworth Heinemann); 2008.