What is the problem of 'clinical reasoning' represented to be in medical education policy?

Recent policy proposals call for formal integration of clinical reasoning into medical education competency frameworks. We describe how these proposals represent and problematize clinical reasoning, and what they allow health professionals subject to them to say, do, and be in their teaching, assessment and practice of clinical reasoning.

Using Carol Bacchi's "What is the problem represented to be?" approach, we conducted a discourse analysis comparing two policy proposals calling for integration of clinical reasoning into competency frameworks in Canada and the United States.

In the policy proposals, the problem of clinical reasoning is represented as: (1) an educational problem, characterized by poor teaching and assessment, and (2) as a problem of medical error, with poor clinical reasoning described as a source of errors. By calling to policy changes in individual competency frameworks, these policy proposals could codify clinical reasoning as an issue of individual competency, focusing research, teaching, and assessment at this level, rather than as a situated, relational, or collective competence. This problem representation constrains pluralistic forms of understanding clinical reasoning that view it as arising from interactions between patients, healthcare teams, and care contexts.

Representing clinical reasoning as an individual problem that requires educational intervention centers physicians as decision-makers and responsible for the outcomes of clinical reasoning. This silences the voices of patients and other health professions while elevating the role of education to resolve the problem of clinical reasoning and absolving health systems of their responsibility in mitigating error.