An Ecological Account of Clinical Reasoning

Abstract

Purpose The prevailing paradigms of clinical reasoning conceptualize context either as noise that masks, or as external factors that influence, the internal cognitive processes involved in reasoning. The authors reimagined clinical reasoning through the lens of ecological psychology to enable new ways of understanding context-specific manifestations of clinical performance and expertise, and the bidirectional ways in which individuals and their environments interact. Method The authors performed a critical review of foundational and current literature from the field of ecological psychology to explore the concepts of clinical reasoning and context as presented in the health professions education literature. Results Ecological psychology offers several concepts to explore the relationship between an individual and their context, including affordance, effectivity, environment, and niche. Clinical reasoning may be framed as an emergent phenomenon of the interactions between a clinician’s effectivities and the affordances in the clinical environment. Practice niches are the outcomes of historical efforts to optimize practice and are both specialty-specific and geographically diverse. Conclusions In this framework, context specificity may be understood as fundamental to clinical reasoning. This changes the authors’ understanding of expertise, expert decision making, and definition of clinical error, as they depend on both the expert’s actions and the context in which they acted. Training models incorporating effectivities and affordances might allow for antiableist formulations of competence that apply learners’ abilities to solving problems in context. This could offer both new means of training and improve access to training for learners of varying abilities. Rural training programs and distance education can leverage technology to provide comparable experience to remote audiences but may benefit from additional efforts to integrate learners into local practice niches.

Medical competence as a multilayered construct

“…This visualisation is also meant to counter any misconception that our model suggests a complete separation of layers of competence in education or assessment. The integration of layers will happen, as the layers develop in parallel, even if they are still hierarchical (e.g., without prior biomedical knowledge, proper clinical reasoning cannot happen 113 and clinical reasoning may be trained in a classroom setting but in patient care the context requires adaptation 114 ). A medical student in a senior clerkship may still build new canonical knowledge in self‐directed learning in the evenings (Layer 1), while finding that contributing to an interprofessional team requires adaptation to local rules and habits (Layer 2), and they may begin to discover personal strengths, interests and convictions (Layer 3).…”

Fostering Adaptive Expertise Through Simulation

“…Simulation scenarios geared toward prototypical presentations and clear-cut diagnoses miss opportunities for appropriately advanced learners to experience tensions, such as how their own abilities and experiences are aligned (or misaligned) with the unique problem(s) at hand or how different clinicians might (appropriately) manage the same situation differently. 61 As a result, much of the beneficial cognitive work of navigating uncertainty and clinical ambiguity may be lost. Said differently, existing approaches emphasizing the fidelity of the mannikin, clinical environment, or clinical tools provide structural fidelity (i.e., physical realism) to the experience.…”

Centering Criticality in Medical Education Research: A Synthesis of the 2022 RIME Papers

“…Watsjold et al 9 critically reviewed the foundational and current literature on clinical reasoning from the field of ecological psychology to explore its concepts and use in HPE. They argue that clinical reasoning could be reframed as a phenomenon that emerges out of the clinician’s effectivities and facilitators in the clinical environment, thus challenging the way clinical reasoning is currently positioned as an activity that occurs within the individual.…”