Epistemological Issues in Clinical Reasoning: A Scoping Review

Clinical reasoning (CR) is fundamental to medical practice, serving to distinguish justified belief from mere opinion, achieve accurate diagnoses, and optimize treatment. However, significant uncertainty persists regarding its definition, scope, and method. This conceptual imprecision and the inherent opacity of CR-when framed merely as tacit knowledge-have profound theoretical and practical consequences, including the occurrence of medical errors and the loss of patient trust. This study aims to map how CR is defined and conceptually framed in the medical and health sciences literature, specifically addressing the core issues of explainability and accountability.

A scoping review was conducted in strict accordance with the PRISMA-ScR guidelines. A systematic literature search was performed across PubMed, Scopus, Web of Science Core Collection, and PhilPapers to identify articles discussing definitions, conceptual models, or epistemological analyses of CR. Eligible studies were screened independently by two reviewers, and data extraction and charting were synthesized descriptively.

A total of 26 studies met the inclusion criteria. The descriptive synthesis identified five major conceptual perspectives: Integrative/Contextual (n = 18), which views CR as a situated process; Dual-Process (n = 13), which distinguishes between intuitive and analytical reasoning; Expertise/Tacit (n = 12), grounded in practical experience; Hypothetico-Deductive (n = 11), centered on hypothesis formulation and testing; and Outcome-Oriented (n = 6), focused primarily on decision-making. Notably, six studies failed to provide any explicit definition of CR, further reinforcing its conceptual opacity.

The literature exhibits significant diversity and a critical lack of consensus regarding what constitutes CR. The field remains epistemologically and ethically divided between the appreciation of intuition and the demand for systematization. CR inherently belongs to the "logical space of reasons", requiring conceptual clarity, explainability, and public justification. Making these underlying cognitive and normative processes explicit is both an epistemological and ethical imperative to mitigate medical error, enhance the doctor-patient relationship, and foster a more critical and responsible medical education.