Re-Imagining Clinical Reasoning: An Updated Cognitive Framework for Real-World Medical Practice

Rational For decades, clinical reasoning has occupied a central place in the discourse of medical education, often generating extensive debate regarding its conceptual foundations and optimal pedagogical approaches. Despite the volume of scholarship, there remains little consensus. To date, conceptualisations of cognitive processes in clinical practice have largely centered around the conventional dual-process model, which dichotomises judgments on clinical problems in terms of intuitive ("fast") or analytical ("slow") processes. However, this conventional clinical reasoning framework has been increasingly critiqued for its limitations in construct validity and its restricted applicability to real-world clinical settings. In this article, we review the core domains of clinical reasoning to formulate a three-tiered expert intuitionist model that is more applicable in real-world medical practice. Specifically, we synthesise theories of skilled intuition, 4E theorem of mind-body-environment interactions, and higher-order metacognition to articulate a more ecologically valid understanding of how clinicians think in practice. We further discuss practical applications of this three-tiered clinical reasoning model in terms of medical educational and training pedagogy.