Smart Thinking in Clinical Practice

By Adam Widdison, author of The Expert Clinician

In previous posts, we explored the skills that make consultations work, from choosing the right words to examining with care. But good communication and careful examination are only part of the story.

Information—what we know, including facts, concepts, disease processes, and guidelines—only becomes useful when we properly understand, interpret, and apply it. This requires cognitive intelligence: our capacity to acquire, reason, solve problems, think abstractly, process, and apply information. It is distinct from emotional intelligence (explored in a previous post, “Beyond Words: Understanding Emotion”), which helps us listen beyond words and recognise feelings.

Medical knowledge matters. Cognitive skills matter even more.

The Clinical Mind

Medical training has traditionally, and rightly, emphasised knowledge. But as information and decision-support tools become more readily available, the focus has shifted to understanding and applying knowledge effectively. In other words, understanding a patient takes more than gathering facts; it also requires a clinical mind. Cognitive skills are the mental processes that help us focus, learn, recall, reason, solve problems, plan and make clinical decisions.

Core cognitive skills used in clinical work include:

Sensory comprehension: especially auditory, visual and tactile, in clinical practice.
Insight: the step that moves beyond a list of facts to ask how they fit together, why they matter, and what should happen next.
Learning and memory: learning from reading, patients and experience, and recalling knowledge, patient details and local pathways.
Reasoning, analysis and critical thinking: interpreting available information, such as vital signs, history and examination findings, to recognise patterns or changes.
Pattern recognition and problem-solving: developing a differential diagnosis, weighing risks and benefits, and incorporating new evidence.
Prioritisation, planning and decision-making: deciding what needs attention first, coordinating investigations and treatments, and acting under time pressure.
Cognitive flexibility: adapting to change or when findings contradict a first impression.
Clinical judgement (often called “wisdom”): the ability to integrate knowledge and intelligence with experience, context, and values, and to recognise one’s own limits honestly. It is knowing when and how to apply what you know, and when to pause or seek help.
Reflection and awareness of uncertainty: recognising limitations and questioning conclusions.

These skills work together: for example, examining a patient simultaneously demands attention, multisensory processing, working memory (recalling knowledge and the patient’s history), and real-time reasoning.

How Clinicians Think

Mental models are the internal frameworks of expert clinical practice. They help us navigate clinical uncertainties and think under pressure, shaping the questions we ask, the findings we seek, how we organise and cross-reference information, the investigations we request, and the treatments we recommend.

Patients also hold mental models—their beliefs about what causes their symptoms, what a diagnosis means, and how treatment should work. These beliefs shape expectations and decisions, so understanding them is essential to meaningful information exchange.

Several approaches illustrate how mental models support clinical thinking:

Illness scripts: recognising a familiar pattern. For example, sudden, severe back or abdominal pain accompanied by shock should raise concern for a ruptured abdominal aortic aneurysm (AAA).
Inversion: asking not only “What is the most likely diagnosis?” but also “What serious, time-critical condition must I not miss?”
Dual-process reasoning: combining rapid, intuitive pattern recognition with slower, more analytical consideration of the evidence, including gaps, inconsistencies and alternatives.
Mechanistic models: explaining why an intervention is proposed in terms patients can understand.

When HCPs and patients have a shared understanding of a problem and how to manage it, communication, decision-making, and satisfaction improve. Within teams, shared understanding helps ensure safer, more consistent care.

Mental models have limits. They can embed bias, lead us to dismiss contradictory evidence, overlook gaps or inconsistencies, and become outdated. The answer is not to abandon them, but to recognise their influence, question them, and update them as new evidence emerges.

Why Cognitive Skills Stall at the Bedside

General thinking skills alone are not enough; they must be supported by sound clinical knowledge, experience, and opportunities to put them into practice.

Cognitive skills have constraints and limits. Time pressure, interruptions, poorly designed IT systems and excessive workloads can undermine even well-developed skills.

Time is always a factor. The world we live in is governed by deadlines and conflicting demands on our time. Patient care is similarly constrained, sometimes to the detriment of thinking time.

Attention is essential. HCPs need to be fully present and mentally engaged, not interrupted, distracted or thinking about something else.

Self-awareness of our internal state is also important. Fatigue, physical activity, emotions, stress, hunger, and illness shape how we think.

Personal traits and biases, including education, motivation, personal experiences, cultural beliefs and stereotyping, can also negatively affect cognitive skills.

Everyone needs opportunities to think, reflect, and learn, supported by systems that enable sound decision-making: not every error is an individual failure.

Upgrading Cognitive Skills

Cognitive skills can develop, but improvement requires effort and often depends on working conditions: time, resources, and support.

Useful approaches for strengthening your cognitive skills include:

Reflect on your thinking: consider not only what you decided, but also how and which assumptions influenced you.
Choose active, challenging learning: test your understanding rather than relying on passive reading.
Learn from complex cases: revisit difficult decisions and consider alternative explanations.
Teach others: explaining your reasoning can reveal gaps in your understanding.
Update mental models: change your view when new evidence or experience challenges it.
Protect the conditions for clear thinking: sleep, physical health and manageable workloads matter because fatigue and chronic stress impair attention, memory and reasoning.

Putting It into Practice

Information matters only when it is understood, interpreted, and applied in the patient’s service.

Knowledge lays the foundation; cognitive skills shape how effectively we use it.

A Challenge

In your next few consultations, choose one cognitive skill or mental model to examine deliberately. Ask yourself:

What framework am I using to interpret this information?
What might I be missing, and what evidence might challenge my initial impression?
How is my current state affecting my thinking?
Have I understood the patient’s perspective, and do we share an understanding of the problem?

Small, consistent acts of self-observation can make a difference over time. Start by noticing how you think, then share what you learn with a colleague.

In my next blog, I explore why self-awareness is an essential first step to truly understanding the patient in front of you—and the impact you have on them.

If you’re interested in developing a more adaptive, patient-centred approach, you can read more here: