Learning to reason like a doctor: a theoretical and empirical examination of medical students’ sensemaking in the clinical context

Sammanfattning: The overall aim of this thesis is to explore how the concept of clinical reasoning is understood in the literature, and its relationship with context, as well as to develop a conceptual learning model of how medical students learn to reason in the clinical environment. The thesis consists of two theoretical studies (I and III) and two empirical studies (II and IV). Studies I and III attempt a theoretical analysis of the concepts of clinical reasoning and context, while Studies II and IV use observations and interviews with 23 medical students analysed using grounded theory to describe how clinical reasoning is learned in the clinical environment. Studies I and III identified three conceptualisations of clinical reasoning: “Reasoning as cognitive activity”, characterised as internal cognitive processes, where context is relevant inasmuch as it acts as a specific stimulus for the individual mental processes; “Reasoning as contextually situated activity”, characterised as an emergent process of interaction between the mind and the external world, where context assumes the quality of a co-determinant of clinical reasoning; and “Reasoning as socially mediated activity”, characterised as the social practice of assigning meaning to the patient's illness experience, emphasizing its narrative, linguistic and interpretative nature, where context assumes the quality of the embeddedness of the mind in a world of meaning and experience. Study II developed a conceptual learning model of clinical reasoning. At the core of this model, which attends to the contextually-situated nature of reasoning, are the tensions experienced by the medical students, when elements in a clinical patient encounter challenge their implicit ways of understanding. Study IV further developed the conceptual model introducing the term of clinical sensemaking, which attends both to the contextual and the interpretational nature of reasoning. At the heart of this model are three interdependent processes, which co-constitute clinical sensemaking. These three procedures seek to answer the questions “what is going on here in this situation?”, “what should I do to find out?”, and “how should I manage this?” This thesis proposes clinical sensemaking as an empirically and theoretically informed conceptual model of clinical reasoning and its learning. Clinical sensemaking shifts the attention from the duality of diagnosis and management, as prime determinants of competent practice, to the problem-orientated activity of transforming a clinical situation, into a tangible clinical problem, necessitating appropriate action.