Representation, Interaction, Interpretation. Making sense of the context in clinical reasoning

Med Educ. 2021 May 1. doi: 10.1111/medu.14545. Online ahead of print.

Abstract

Background: All thinking occurs in some sort of context, rendering the relation between context and clinical reasoning a matter of significant interest. Context however has a notoriously vague and contested meaning and there is a profound disagreement between different research traditions studying clinical reasoning in how context is understood. Empirical evidence examining the impact (or not) of context on clinical reasoning cannot be interpreted without reference to the meaning ascribed to context. Such meaning is invariably determined by assumptions concerning the nature of knowledge and knowing. The epistemology of clinical reasoning determines in essence how context is conceptualized.

Aims: Our intention is to provide a sound epistemological framework of clinical reasoning that puts context into perspective and demonstrates how context is understood, and researched in relation to clinical reasoning.

Discussion: We identify three main epistemological dimensions of clinical reasoning research, each of them corresponding to fundamental patterns of knowing: The representational dimension views clinical reasoning as an act of categorization, the interactional dimension as a cognitive state emergent from the interactions in a system, while the interpretative dimension as an act of intersubjectivity and socialization. We discuss the main theories of clinical reasoning under each dimension as well as how the implicit epistemological assumptions of these theories determine the way context is conceptualized. These different conceptualizations of context have important implications for the phenomenon of context specificity as well as for learning of clinical reasoning.

Conclusion: The study of context may be viewed as the study of the epistemology of clinical reasoning. Making sense of "what is going on with this patient" necessitates reading the context in which the encounter is unfolding and deliberating a path of response justified in that specific context. Mastery of the context in this respect becomes a core activity of medical practice.