Challenges in the Pedagogy of Clinical Reasoning: a philosophical reframing

نوع مقاله : مقاله علمی- پژوهشی

نویسنده

دانشیار گروه فلسفه علم و فناوری- پژوهشگاه علوم انسانی و مطالعات فرهنگی، تهران، ایران.

چکیده

Clinical reasoning lies at the heart of medical practice, yet its teaching remains one of the most conceptually complex challenges in medical education. Contemporary approaches, largely informed by cognitive science, have illuminated the mental mechanisms underlying diagnosis but have simultaneously reduced reasoning to an individual, decontextualized act of information processing. This reduction has led to a subtle yet pervasive dehumanization of clinical reasoning, obscuring its social, embodied, and interpretive dimensions. This paper argues that a comprehensive understanding of clinical reasoning requires a philosophical reframing that integrates insights from the philosophy of science, medicine, and technology, i.e. TRI-P model. In this sense, Medicine is best understood as a scientific practice realized through the mediation of technology, yet always oriented toward its ultimate telos: the care and healing of the patient. Through this synthesis, the study shows that reasoning in medicine is not a neutral cognitive operation but an interpretive, dialogical, and technologically mediated form of human understanding. Accordingly, a rehumanized pedagogy—grounded in epistemic pluralism, dialogical humanism, and critical technological literacy—is essential for cultivating responsible clinical judgment. From this perspective, clinical reasoning cannot be captured by cognitive models alone but must be reframed as phronesis: a form of practical wisdom enacted in moral and interpretive contexts. Drawing on Gadamer’s hermeneutic philosophy and Kenneth Sharpe’s conception of phronetic practice, the paper situates clinical reasoning as an embodied, dialogical, and ethically responsive activity. It concludes that medical education should nurture reflective judgment and moral discernment rather than mere analytical accuracy.

کلیدواژه‌ها

موضوعات


عنوان مقاله [English]

Challenges in the Pedagogy of Clinical Reasoning: a philosophical reframing

نویسنده [English]

  • Alireza Monajemi
Associate Professor, Philosophy of Science and Technology Department, Institute for Humanities and Cultural Studies, Tehran, Iran
چکیده [English]

Clinical reasoning lies at the heart of medical practice, yet its teaching remains one of the most conceptually complex challenges in medical education. Contemporary approaches, largely informed by cognitive science, have illuminated the mental mechanisms underlying diagnosis but have simultaneously reduced reasoning to an individual, decontextualized act of information processing. This reduction has led to a subtle yet pervasive dehumanization of clinical reasoning, obscuring its social, embodied, and interpretive dimensions. This paper argues that a comprehensive understanding of clinical reasoning requires a philosophical reframing that integrates insights from the philosophy of science, medicine, and technology, i.e. TRI-P model. In this sense, Medicine is best understood as a scientific practice realized through the mediation of technology, yet always oriented toward its ultimate telos: the care and healing of the patient. Through this synthesis, the study shows that reasoning in medicine is not a neutral cognitive operation but an interpretive, dialogical, and technologically mediated form of human understanding. Accordingly, a rehumanized pedagogy—grounded in epistemic pluralism, dialogical humanism, and critical technological literacy—is essential for cultivating responsible clinical judgment. From this perspective, clinical reasoning cannot be captured by cognitive models alone but must be reframed as phronesis: a form of practical wisdom enacted in moral and interpretive contexts. Drawing on Gadamer’s hermeneutic philosophy and Kenneth Sharpe’s conception of phronetic practice, the paper situates clinical reasoning as an embodied, dialogical, and ethically responsive activity. It concludes that medical education should nurture reflective judgment and moral discernment rather than mere analytical accuracy.

کلیدواژه‌ها [English]

  • Clinical Reasoning
  • Pedagogy
  • Philosophy of Medicine
  • Philosophy of Science
  • Philosophy of Technology
Barrows, H. S. (1986). A taxonomy of problem-based learning methods. Medical Education, 20(6), 481–486.
Beresford, E. B. (1991). Uncertainty and the shaping of medical decisions. Hastings Center Report, 21(4), 6–11.
Bleakley, A., Bligh, J., & Browne, J. (2011). Medical education for the future: Identity, power and location. Springer.
Bordage, G. (2007). Prototypes and semantic qualifiers: From past to present. Medical Education, 41(12), 1117–1121.
Croskerry, P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine, 78(8), 775–780.
Croskerry, P. (2009). A universal model of diagnostic reasoning. Academic Medicine, 84(8), 1022–1028.
D’Amour, D., & Oandasan, I. (2005). Interprofessionality as the field of interprofessional practice and interprofessional education: An emerging concept. Journal of Interprofessional Care, 19(S1), 8–20.
Durning, S. J., & Artino, A. R. (2011). Situativity theory: A perspective on how participants and the environment can interact. Medical Teacher, 33(3), 188–199.
Durning, S. J., Artino, A. R., Schuwirth, L., & van der Vleuten, C. (2013). Clarifying assumptions to enhance our understanding and assessment of clinical reasoning. Academic Medicine, 88(4), 442–448.
Elstein, A. S., Shulman, L. S., & Sprafka, S. A. (1978). Medical problem solving: An analysis of clinical reasoning. Harvard University Press.
Eva, K. W. (2005). What every teacher needs to know about clinical reasoning. Medical Education, 39(1), 98–106.
Eva, K. W., & Regehr, G. (2007). Knowing when to look it up: A new conception of self-assessment ability. Academic Medicine, 82(10), S81–S84.
Evans, J. St. B. T. (2008). Dual-processing accounts of reasoning, judgment, and social cognition. Annual Review of Psychology, 59, 255–278.
Feenberg, A. (2008). Critical theory of technology: An overview. Information technology in librarianship: New critical approaches, 31-46.
Fox, R. C. (1957). Training for uncertainty. In Merton, R. K., Reader, G. G., & Kendall, P. L. (Eds.), The student-physician: Introductory studies in the sociology of medical education (pp. 207–241). Harvard University Press.
Gadamer, H.-G. (1996). The enigma of health: The art of healing in a scientific age. Stanford University Press.
Ghosh, A. K. (2004). On the challenges of using evidence-based medicine: When evidence conflicts with clinical judgment. Journal of Postgraduate Medicine, 50(1), 14–19.
Greenhalgh, T., Howick, J., & Maskrey, N. (2014). Evidence based medicine: A movement in crisis? BMJ, 348, g3725.
Higgs, J., Jensen, G. M., Loftus, S., & Christensen, N. (2019). Clinical reasoning in the health professions (4th ed.). Elsevier.
Lubarsky, S., Dory, V., Duggan, P., Gagnon, R., & Charlin, B. (2013). Script concordance testing: From theory to practice. AMEE Guide No. 75. Medical Teacher, 35(3), 184–193.
Monajemi, A. (2025). Why is the idea of AI completely replacing physicians a pseudo-problem? A philosophical analysis. Journal of Medical Ethics and History of Medicine, 18 (1), 1-17.
Monajemi, A. (2021a). On the Nature of Medicine: Necessities, Approaches, and Challenges. Journal of Philosophical Investigations, 15(37), 153-177.
Monajemi, A. (2021b). Philosophy of Science Meets the Scientific Research: Metatheorizing expertise theories in Cognitive Psychology. Journal of Philosophical Investigations, 15(36), 104-114. doi: 10.22034/jpiut.2021.48331.3006
Monajemi, A., & Rikers, R. M. (2011). The role of patient management in medical expertise development: Extending the contemporary theory. International Journal of Person Centered Medicine, 1(1), 161-166.
Monajemi, A., & Rikers, R. M. J. P. (2012). How does patient management knowledge integrate into an illness script? Education for Health, 25(3), 153–159.
Montgomery, K. (2006). How doctors think: Clinical judgment and the practice of medicine. Oxford University Press.
Moulton, C. A. E., Regehr, G., Mylopoulos, M., & MacRae, H. (2007). Slowing down when you should: A new model of expert judgment. Academic Medicine, 82(10), S109–S116.
Norman, G. (2005). Research in clinical reasoning: Past history and current trends. Medical Education, 39(4), 418–427
Norman, G., Young, M., & Brooks, L. (2017). Non-analytical models of clinical reasoning: The role of experience. Medical Education, 41(12), 1140–1145.
Sadeghzadeh, K. (2015). Handbook of analytic philosophy of medicine. Springer.
Schmidt, H. G. (1993). Foundations of problem-based learning: Some explanatory notes. Medical Education, 27(5), 422–432.
Schmidt, H. G., & Mamede, S. (2015). How to improve the teaching of clinical reasoning: A narrative review and a proposal. Medical Education, 49(10), 961–973.
Schmidt, H. G., & Rikers, R. M. J. P. (2007). How expertise develops in medicine: Knowledge encapsulation and illness script formation. Medical Education, 41(12), 1133–1139.
Sharpe, K. E., & Schwartz, B. (2010). Practical wisdom: The right way to do the right thing.
Schön, D. A. (2017). The reflective practitioner: How professionals think in action. Routledge.
Stempsey, W. E. (2013). Clinical reasoning: New challenges. Theoretical Medicine and Bioethics, 34(5), 357–371.
Svrenaeus, F. (2000). The hermeneutics of medicine and the phenomenology of health. Steps toward a philosophy of medical practice. The Netherlands: Kluwer Academic Publishers.
Tanenbaum, S. J. (1993). What physicians know. New England Journal of Medicine, 329(17), 1268–1271.
Tonelli, M. R. (2006). Integrating evidence into clinical practice: An alternative to evidence-based approaches. Journal of Evaluation in Clinical Practice, 12(3), 248–256.
Verbeek, P. P. (2005). What things do: Philosophical reflections on technology, agency, and design. Penn State Press.
Young, J. Q., Van Merrienboer, J., Durning, S., & Ten Cate, O. (2014). Cognitive load theory: Implications for medical education. Medical Teacher, 36(5), 371–384.
CAPTCHA Image