A novel model of clinical reasoning: cognitive zipper model

Clinical reasoning is a vital aspect of physician competence. It has been the subject of academic research for decades, and various models of clinical reasoning have been proposed. The aim of the present study was to develop a theoretical model of clinical reasoning.

To conduct our study, we applied the process of theory synthesis in accordance with the Walker and Avant's approach. First, we considered clinical reasoning as a focal concept of our study. Second, a search was carried out for the period 1984-2018, using the PubMed, Google Scholar, PsycINFO, ERIC, ScienceDirect and Web of Science databases to review the literature to identify factors related to the clinical reasoning and the nature of their relationships. Third, we organized clinical reasoning into an integrated and efficient representation of the clinical reasoning.

According to this study clinical reasoning is the iterative process of intermediation between the recalled clinical knowledge and the patient's represented problem in the clinicians' active memory. We analogize the process of clinical reasoning to the process of closure of a cognitive zipper. The recalled knowledge in clinician's memory resembles to one side of zippers teeth and the evolving representation of the patient's problem resembles the other side of zippers teeth. So, the results of this study are presented in three models: [1] multi-layer knowledge structure model, [2] problem representation model and [3] cognitive zipper model of diagnostic reasoning.

We propose a developmental model of clinical reasoning. Several studies have tried to present models and theories to clarify clinical reasoning, but it seems that these theories and models could only explain part of this complex process and not the whole process. Cognitive zipper model, due to its developmental structure, can illustrate the clinical reasoning process in more details than other models do.