title: Making sense of clinical reasoning: judgement and the evidence of the senses.
abstract: BACKGROUND
  Close noticing, as keen discrimination and judgement between qualities, is a key capability for work in visual domains in medicine. This generic capability is normally assumed, and its specifics are left to develop through experience, as traditional apprenticeship in a specialty. Discrimination is an outcome of learning in the affective domain, and introduces a vital aesthetic dimension to clinical work that aligns with the interests of the medical humanities. An aesthetic approach to clinical reasoning, however, remains largely unexplored as an explicit focus for medical education.
  We offer a framework for an explicit education of perceptual discrimination in the visual domain as a form of practice 'artistry', turning a surface 'looking' into a deeper 'seeing'. Such an education, however, raises certain paradoxes. While novices typically 'see' what they expect to see in visual images (sign and symptom), experts also make similar errors. Further, experts become familiar with the use of visual heuristics in diagnosis, such as vivid natural referents to aid in rapid pattern recognition in an encompassing diagnostic 'glance', yet this appears to defeat the first principle of describing what you see. Employing a model of imagination as a tacit form of knowing that 'prepares' and enhances perception, we suggest, however, that the judicious use of such heuristics can be positive. Moreover, the mechanics of the process of clinical judgement in visual domains can be detailed to inform educational agendas. A further paradox is that of experts using both idiosyncratic heuristics and protocol-driven practices, where these seem to offer contradictory approaches to gaining knowledge. We recognise this as a facet of medicine's inherent uncertainty, in the face of complex, ambiguous and unique material, that must be addressed through clinical education.
  
  
  CONCLUSIONS
  We equate 'aesthetics' with 'sensibility' and describe clinical expertise as 'connoisseurship' of informational images. Such connoisseurship, a particular form of knowing, can, in turn, be defined as an aesthetic sensibility informing practice artistry. It can be articulated and analysed to provide a basis for educational enhancement. Connoisseurship is not a technical-rational procedure but is inherently paradoxical and such paradox may be valued as an educational resource, rather than seen as a hindrance.
authors.affiliation: Cornwall Postgraduate Education Centre, Royal Cornwall Hospitals Trust, Truro, Cornwall, UK. alan.bleakley@rcht.swest.nhs.uk
authors.forename: Alan
authors.initials: A
authors.lastname: Bleakley
authors.forename: Richard
authors.initials: R
authors.lastname: Farrow
authors.forename: David
authors.initials: D
authors.lastname: Gould
authors.forename: Robert
authors.initials: R
authors.lastname: Marshall
mesh_terms: D001633:Bible; D002983:Clinical Competence; D003479:Curriculum; D003657:Decision Making; D003933:Diagnosis; D004504:Education, Medical, Undergraduate / Q000379:methods*; D006809:Humanities / Q000193:education*; D006801:Humans; D010808:Physical Examination / Q000379:methods