Unveiling the Mosaic: The adoption of diverse cognitive styles in the approach to clinical reasoning among junior doctors

Background
Transitioning from being a medical graduate to a junior doctor presents significant challenges, particularly in developing clinical reasoning skills. This steep learning curve is observed in junior doctors worldwide.

Summary of work
This longitudinal study aimed to explore the development of clinical reasoning skills among junior doctors to identify areas for support and bridge the learning gap. A hermeneutic phenomenology study was conducted among junior doctors (n=8) at a main teaching hospital in Sri Lanka. The doctor-patient consultations of study participants were audio recorded and subsequent post-consultation discussions were conducted (n=48) to explore the underlying reasoning process. Thematic analysis was used to identify recurring themes and patterns within the dataset.

Summary of results
Junior doctors employed their own definitions for common and difficult presentations. Nevertheless, they approached both with a similar cognitive orientation during early clinical practice, utilizing an "exhaustive approach" that prioritised obtaining a detailed history rather than reaching a specific diagnosis. Towards later clinical practice, they employed pattern recognition, with common presentations. This was followed by a “focused approach” to clinical reasoning, a limited analytic approach, attempting to validate the diagnoses. In contrast, for difficult presentations, junior doctors employed an analytical approach, continually building up the list of differentials based on examination and investigation findings.
They also employed a “system-based approach” to clinical reasoning that involved asking about symptoms related to different organ systems, regardless of their relevance to the presenting complaint. The “problem-based approach” to clinical reasoning is another variant of the analytic approach used by junior doctors which aided a realistic assessment of patient problems. Both these approaches enabled a more holistic assessment of patient problems, addressing not only the main presentation but also associated issues.
Discussion and conclusion
Junior doctors employ diverse approaches to clinical reasoning, including analytic reasoning, non-analytic reasoning (pattern recognition), exhaustive reasoning, focused reasoning, system-based approach, and problem-based approach, each with its own advantages and challenges.

Take home message
Clinical teachers need to be aware of the various approaches to clinical reasoning employed by junior doctors in order to identify deficiencies and risks of reasoning errors and facilitate the development of their clinical reasoning skills.