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Clarifying Assumptions to Enhance Our Understanding and Assessment of Clinical Reasoning

Durning, Steven J. MD, PhD; Artino, Anthony R. Jr PhD; Schuwirth, Lambert MD, PhD; van der Vleuten, Cees PhD

Academic Medicine:
doi: 10.1097/ACM.0b013e3182851b5b

Deciding on a diagnosis and treatment is essential to the practice of medicine. Developing competence in these clinical reasoning processes, commonly referred to as diagnostic and therapeutic reasoning, respectively, is required for physician success. Clinical reasoning has been a topic of research for several decades, and much has been learned. However, there still exists no clear consensus regarding what clinical reasoning entails, let alone how it might best be taught, how it should be assessed, and the research and practice implications therein.

In this article, the authors first discuss two contrasting epistemological views of clinical reasoning and related conceptual frameworks. They then outline four different theoretical frameworks held by medical educators that the authors believe guide educators’ views on the topic, knowingly or not. Within each theoretical framework, the authors begin with a definition of clinical reasoning (from that viewpoint) and then discuss learning, assessment, and research implications. The authors believe these epistemologies and four theoretical frameworks also apply to other concepts (or “competencies”) in medical education.

The authors also maintain that clinical reasoning encompasses the mental processes and behaviors that are shared (or evolve) between the patient, physician, and the environment (i.e., practice setting). Clinical reasoning thus incorporates components of all three factors (patient, physician, environment). The authors conclude by outlining practical implications and potential future areas for research.

Author Information

Dr. Durning is professor of medicine and pathology, Uniformed Services University of the Health Sciences, Bethesda, Maryland.

Dr. Artino is associate professor of preventive medicine and biometrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.

Dr. Schuwirth is professor of medical education, Flinders University, Adelaide, Australia.

Dr. van der Vleuten is professor of medical education, Maastricht University, Maastricht, the Netherlands.

Correspondence should be addressed to Dr. Durning, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814; telephone: (301) 295-3603; e-mail:

© 2013 Association of American Medical Colleges