Clinical Reasoning in Medicine: A Concept Analysis
AbstractBackground: Clinical reasoning plays an important role in the ability of physicians to make diagnoses and decisions. It is considered the physician’s most critical competence, but it is an ambiguous concept
in medicine that needs a clear analysis and definition. Our aim was to clarify the concept of clinical reasoning in medicine by identifying its components and to differentiate it from other similar concepts.
It is necessary to have an operational definition of clinical reasoning, and its components must be precisely defined in order to design successful interventions and use it easily in future research.
Methods: McKenna’s nine-step model was applied to facilitate the clarification of the concept of clinical reasoning. The literature for this concept analysis was retrieved from several databases, including Scopus, Elsevier, PubMed, ISI, ISC, Medline, and Google Scholar, for the years 1995– 2016 (until September 2016). An extensive search of the literature was conducted using the electronic database. Accordingly, 17 articles and one book were selected for the review. We applied McKenna’s method of concept analysis in studying clinical reasoning, so that definitional attributes, antecedents, and consequences of this concept were extracted.
Results: Clinical reasoning has nine major attributes in medicine. These attributes include: (1) clinical reasoning as a cognitive process; (2) knowledge acquisition and application of different types of knowledge; (3) thinking as a part of the clinical reasoning process; (4) patient inputs; (5) contextdependent and domain-specific processes; (6) iterative and complex processes; (7) multi-modal cognitive processes; (8) professional principles; and (9) health system mandates. These attributes are influenced by the antecedents of workplace context, practice frames of reference, practice models of the practitioner, and clinical skills. The consequences of clinical reasoning are the metacognitive improvement of reasoning and tacit knowledge production.
Conclusion: The present concept analysis tries to clarify the concept of clinical reasoning in medicine and reduces the ambiguity of this concept to design successful interventions and use it easily in future research.
Keywords: CLINICAL REASONING, MEDICINE, CONCEPT ANALYSIS, MCKENNA’S MODEL
Higgs J, Jones M, Loftus S, Christensen N.Clinical reasoning in the health professions.
Elsevier Health Sciences; 2008.
Pelaccia T, Tardif J, Triby E, Charlin B. An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory. Med Educ Online 2011; 16.
Norman G. Research in clinical reasoning: past history and current trends. Med Educ 2005; 39(4):418-27.
Thomson OP, Petty NJ, Moore AP. Clinical reasoning in osteopathy–more than just principles? Int J Osteopath Med 2011; 14(2):71-6.
Barrows HS, Tamblyn RM. Problembased learning: An approach to medical education. Springer Publishing Company; 1980.
Marcum JM. An integrated model of clinical reasoning: dual-process theory of cognition and metacognition. J Eval Clin Pract 2012; 18:954-61.
Barrows HS, Feltovich PJ. The clinical reasoning process. Med Educ 1987; 21(2):86-91.
Round A. Introduction to clinical reasoning. J Eval Clin Pract 2001; 7(2):109-17.
Frohna Ldgaaz. Clinical reasoning international handbook of research in medical education. Kluwer Academic Publishers; 2002. p. 1093.
Torre DM. Cognitive Processes of Medical Students in Clinical Reasoning. The University of Wisconsin - Milwaukee, ProQuest Dissertations Publishing; 2009. 3363452. Available from: https://search. proquest.com/openview/a0deb74f7076c770a869b17cf6a0204d/1?pq-origsite=gsch
McKenna H. Nursing theories and models (Routledge Essentials for Nurses). 1th ed.Routledge; 2006.
Glanze WD, Anderson K, Anderson LE. Mosby’s medical, nursing, and allied health dictionary. University of Minnesota: Mosby; 1990.
Venes D. Taber’s cyclopedic medical dictionary. 22th ed. United States: FA Davis Company; 2013.
Audétat MC, Lubarsky S, Blais JG, Charlin B. Clinical reasoning: where do we stand on identifying and remediating difficulties? Creat Educ 2013; 4(6A):42-8.
Montgomery K. How doctors think: Clinical judgment and the practice of medicine. Oxford University Press; 2005.
Linn A, Khaw C, Kildea H, Tonkin A. Clinical reasoning: A guide to improving teaching and practice. Aust Fam Physician 2012; 41(1-2):18-20.
Woods NN. Science is fundamental: the role of biomedical knowledge in clinical reasoning. Med Educ 2007; 41(12):1173-7.
Gordon D, Wallenstein J, Guth T. CORD Clerkship Directors in Emergency Medicine Intuitive Clinical Reasoning. https://www.cordem.org
Kriewaldt J, Turnidge D. Conceptualising an approach to clinical reasoning in the education profession. The Australian Journal of Teacher Education. 2013; 38(6).
Brookfield S. Clinical reasoning and generic thinking skills. In: Higgs J, Jones M, Loftus S, Christensen N. Clinical Reasoning in the Health Professions. 3th ed. Elsevier; 2008.
Delany C, Golding C. Teaching clinical reasoning by making thinking visible: an action research project with allied health clinical educators. BMC Med Educ 2014; 14:20.
Expertise and clinical reasoning. In: Higgs J, Jones M, Loftus S, Christensen N. Clinical Reasoning in the Health Professions. 3th ed. Elsevier Health Sciences; 2008.
Sefton AG, Field M. Teaching clinical reasoning to medical students. In: Higgs J, Jones M, Loftus S, Christensen N. Clinical Reasoning in the Health Professions. 3thed. Elsevier Health Sciences; 2008.
Clinical decision making and multiple problem spaces; p.3- 17. In: Higgs J, Jones
M, Loftus S, Christensen N. Clinical Reasoning in the Health Professions. 3thed. Elsevier Health Sciences; 2008.
Adams L. Clinical Reasoning and Causal Attribution in Medical Diagnosis [Thesis]. University of Plymouth; 2013.
Hawkins D, Elder L, Paul R. Clinical Reasoning. Tomales, CA: Foundation for Critical Thinking; 2010.
Learning the language of clinical reasoning. In: Higgs J, Jones M, Loftus S, Christensen N. Clinical Reasoning in the Health Professions. 3th ed. Elsevier Health Sciences; 2008.
A place for new research directions. In: Higgs J, Jones M, Loftus S, Christensen N. Clinical Reasoning in the Health Professions. 3th ed. Elsevier Health Sciences; 2008.
Charlin B, Lubarsky S, Millette B, Crevier F, Audétat MC, Charbonneau A, et al. Clinical
reasoning processes: unravelling complexity through graphical representation. Med Educ
Bleakley A, Farrow R, Gould D, Marshall R. Making sense of clinical reasoning: judgement and the evidence of the senses. Med Educ 2003; 37(6):544-52.
Hoyt DB. Clinical practice guidelines. Am J Surg 1997; 173(1):32-4.
Walker LO, Avant KC. Strategies for theory construction in nursing. Pearson/Prentice Hall; 2005.
Norcini J, Burch V. Workplace-based assessment as an educational tool: AMEE Guide No. 31. Med Teach 2007; 29(9-10):855-71.
Norcini JJ. The Mini Clinical Evaluation Exercise (mini-CEX). Clin Teach 2005; 2(1):25-30.
Charlin B, Roy L, Brailovsky C, Goulet F, Van Der Vleuten C. The Script Concordance test: a tool to assess the reflective clinician. Teach Learn Med 2000; 12(4):189-95.
Charlin B, van der Vleuten C. Standardized assessment of reasoning in contexts of uncertainty the script concordance approach. Eval Health Prof 2004; 27(3):304-19.
Nouh T, Boutros M, Gagnon R, Reid S, Leslie K, Pace D, et al. The script concordance test as a measure of clinical reasoning: a national validation study. Am J Surg 2012; 203(4):530-4.
Rubenstein W, Talbot Y. Medical teaching in ambulatory care. Toronto: University of
Toronto Press; 2012.
Page G, Bordage G. The Medical Council of Canada’s key features project: a more valid written examination of clinical decision-making skills. Acad Med 1995; 70(2):104-10.
Farmer EA, Page G. A practical guide to assessing clinical decision-making skills using the key features approach. Med Educa 2005; 39(12):1188-94.
Hurtz GM, Chinn RN, Barnhill GC, Hertz NR. Measuring clinical decision making: do key features problems measure higher level cognitive processes? Eval Health Prof 2012; 35(4):396-415.
Amin Z, Chong YS, Khoo HE. Practical guide to medical student assessment. World Scientific Publishing; 2006.
Wood EJ. What are extended matching sets questions? Bioscience Education 2003; 1(1):1-8.
Ryding H, Murphy H. Employing oral examinations (viva voce) in assessing
dental students’ clinical reasoning skills. J Dent Educ 1999; 63(9):682-7.
California Critical Thinking Skills Test (CCTST). California Academic Press, San Jose, CA: Insight Assessment; 2013.
Monajemi A, Yaghmaei M. Puzzle test: A tool for non-analytical clinical reasoning assessment. Med J Islam Repub Iran 2016; 30(1):1000-4.
Turnbull J, Mac Fadyen J, Van Barneveld C, Norman G. Clinical work sampling. J Gen Intern Med 2000; 15(8):556-61.
Victor-Chmil J. Critical thinking versus clinical reasoning versus clinical judgment: Differential diagnosis. Nurse Educ 2013; 38(1):34-6.
Simmons B. Clinical reasoning: concept analysis. J Adv Nurs 2010; 66(5):1151-8.
Bissessur SW, Geijteman EC, Al-Dulaimy M, Teunissen P, Richir MC, Arnold AE, et al. Therapeutic reasoning: from hiatus to hypothetical model. J Eval Clin Pract 2009; 15(6):985-9.
Loftus SF. Language in clinical reasoning: using and learning the language of collective clinical decision making. [PhD Doctorate Thesis]. The University of Sydney; 2006.
Copyright is the term used to describe the rights related to the publication and distribution of research. It governs how authors (as well as their employers or funders), publishers and the wider general public can use, publish and distribute manuscripts or books. Authors who publish their manuscripts or studies in the JME agree to release their manuscripts. Any previous introductory work on the same or similar subject by the same authors must be well referenced in the new submission and permission must be acquired from the original publisher.
* Copyright is a set of exclusive rights that belongs to a publication and distribution of research. It also guides authors, publishers and general users how to use, publish and distribute manuscripts.