Understanding the Assessment of Clinical Reasoning

Clinical reasoning assessment is an essential component of determining a health professional’s competence. Clinical reasoning cannot be assessed directly. It must be gleaned from a health professional’s choices and decisions. Clinical knowledge and knowledge organization, rather than a general problem solving process, serve as the substrate for clinical reasoning ability. Unfortunately, the lack of a gold standard for the clinical reasoning process and the observation of context specificity make it difficult to assess clinical reasoning. Information processing theory, which focuses on the way the brain processes and organizes knowledge, has provided valuable insights into the cognitive psychology of diagnostic and therapeutic reasoning but failed to explain the variance in health professional’s diagnostic performance. Situativity theory has emerged suggesting that this variance relates to context-specific factors that impact a health professional’s clinical reasoning performance. Both information processing and situativity theory inform the way in which we assess clinical reasoning. Current assessment methods focus on standardized testing of knowledge to maximize psychometric parameters and work-based assessments which evaluate clinical reasoning under authentic, uncertain conditions that can decrease the reliability of these measurements. Issues of inter-rater reliability and context specificity require that multiple raters assess multiple encounters in multiple contexts to optimize validity and reliability. No single assessment method can assess all aspects of clinical reasoning; therefore, in order to improve the quality of assessments of clinical reasoning ability, different combinations of methods that measure different components of the clinical reasoning process are needed.