Re-visioning clinical reasoning, or stepping out from the skull.

The Problem: Progress in teaching and learning clinical reasoning depends upon more sophisticated modelling of the reasoning process itself. Current accounts of clinical reasoning, grounded in experimental psychology, show a bias towards situating reasoning inside the skull, further reduced to neural processes signified by imaging. Such a model is necessary but not sufficient to explain the clinical reasoning process where it fails to embrace cognition extended to the environment and social contexts.

A Solution: Sufficiency for a model of clinical reasoning must include dialogues between doctor, patient, and colleagues, including the complex influences of history and culture, where artefacts and semiotics such as computers, testing, and narrative structures augment cognition. Here, 'extended' cognition is configured as an outside-in process of 'sensemaking' or 'adaptive expertise'.

The Future: Current 'predictive processing' cognition models place emphasis on anticipatory cognition, where memory is reconfigured as active reconstruction rather than recall and recognition. Such an 'ecological perception' or 'externalistic' model provides a counter to the current dominant paradigm of 'ego-logical' cognitive reasoning - the latter, again, abstracted from context and located inside the skull. New models of clinical reasoning as an open, dynamic, nonlinear, complex system are called for.