The development of reasoning skills and expertise in primary care

Clinical reasoning has been described as the cognitive process determining appropriate decision making and action in a specific context'. However, research suggests that reasoning and problem-solving skills transfer poorly across domains within medicine. How does this apply to a field such as primary care, which demands multidisciplinary expertise? This article proposes an educational framework benchmarking the various stages of development of reasoning skills (and therefore expertise) within primary care from novice to experienced practitioner. Using a new concept of disease incorporating a psychosocial perspective ('a perceived change from normal behaviour or function') this paper discusses the generic problem-solving skills required of students, with the subsequent transition Io pattern recognition amongst other reasoning strategies employed by expert practitioners. The role of feedback and validation of the features of illness (vectors) within consultations is discussed in terms of both narrative histories and examination details, where significant case-based exposure is paramount for learning. In spite of the enhanced exposure on community attachments in medical school programmes, and the augmented changes in the foundation scheme for junior doctors, the most appropriate stage in which to significantly develop expertise remains during vocational training schemes. Extending this period accepts the premise that expertise in primary care is best enhanced in the practice context, whereby follow-up mechanisms for illness are vital to experience the natural history of illness and recovery. © 2006 Radcliffe Publishing Limited.