Grounding judgement in context: A conceptual learning model of clinical reasoning.

Context: Contemporary research on clinical reasoning focuses on cognitive problem-solving processes. However, the decisive role that clinical context plays in clinical reasoning is often overlooked. We explored how novice learners make sense of the patient encounter in the clinical situation. In particular, we examined medical students' own judgements concerning diagnostic and management decisions and how the clinical context impacts on this. We aimed to produce a conceptual model of how students learn clinical reasoning in the clinical environment.

Method: We used grounded theory methodology to develop a conceptual learning model. A total of 23 medical students in their third academic year were recruited. Qualitative data were gathered from semi-structured interviews, participant observations and field interviews, during clinical clerkships.

Results: Learners participating in the clinical environment experienced tensions, called 'Disjunctions.' These disjunctions emerged in the context of the student-patient encounter and in particular in situations where an element from the interaction with the patient was perceived as being inconsistent with existing frames of reference. We categorised the sources of disjunctions into four subcategories: (a) observing the manifestations of clinical signs in reality; (b) fitting the symptoms to a diagnosis; (c) considering management decisions, and (d) communicating a medical decision to the patient. Disjunctions involved an affective component and were associated with feelings of uncertainty. These tensions provoked reactions from the learners, leading them to reassess and modify held assumptions in order to accommodate the encountered inconsistent elements. This facilitated changes in judgement. When making a judgement, participants learned to take into consideration situational elements.

Conclusions: Students experience disjunctions in the clinical environment as they encounter situations that challenge their frames of reference. These disjunctions carry significant learning potential. This study can contribute to knowledge concerning the role of the patient encounter in advancing clinical reasoning by transforming problematic habits of the mind.