Keeping the question open: How clinical understanding emerges as process

John Goldie is a retired GP and medical educator

Clinical understanding does not precede the consultation; it takes shape within it. It is not a finished product applied to clinical situations but something that emerges through interpretation, negotiation, and revision. By the time patients arrive, they have encountered symptoms, internet searches, risk scores, and previous explanations. Clinicians bring their own experiences, habits of attention, and institutional frameworks. Understanding forms within the consultation but is also shaped by wider clinical systems. This sits uneasily with the assumptions that underlie medical education, which frequently treats diseases as stable entities awaiting identification and clinical knowledge as something applied to them.

Yet the consultation feels less like applying knowledge and more like participating in an unfolding process. Here Alfred North Whitehead is illuminating: what matters is not a static situation but the formation of meaning as it unfolds. ¹ A patient’s story shifts as it is told; a clinician’s understanding shifts as it is heard. Understanding forms through what Gadamer called a fusion of horizons, where patient and clinician bring different histories, assumptions, and expectations into dialogue. ²

From this perspective, diagnosis becomes not a destination but an achievement — a way of making sense of a situation rather than the discovery of a fixed truth. Understanding remains open to revision as symptoms, experiences, and interpretations emerge. Clinical reasoning therefore involves a continuing question: how has this understanding come into being, and how might it need to change?

Michael Polanyi’s account of tacit knowledge clarifies how clinicians navigate this shifting interpretive space. We know more than we can tell. ^3,4 Clinical understanding often depends on integrating countless subsidiary clues: a patient’s manner of speaking, a hesitation, a remembered consultation. These clues are rarely attended to in isolation. Rather, they are interiorised and held tacitly as we attend to the patient as a whole. Polanyi called this indwelling — looking through the particulars towards a provisional sense of what may be happening. Such understanding cannot be reduced to explicit rules or algorithms because it emerges from participation. ^3,4

Karl Weick’s work on sensemaking highlights another dimension. ⁵ Healthcare relies on protocols, risk calculators, pathways, and electronic records. These tools are indispensable, yet they shape what becomes visible. Weick argued that people do not encounter experience as a neutral given; they actively construct meaning by selecting certain features of experience and organising them into coherent accounts.

In the consultation, this can lead to interpretive drift. A chosen frame can organise attention so strongly that alternative meanings become harder to see. The patient’s account may be translated into the language of the framework rather than explored in its own terms. Occasionally, however, something disrupts the frame: a detail that refuses to fit, or a remark that unsettles the emerging explanation. Such moments exemplify what Donald Schön called reflection‑in‑action. ⁶ They puncture routine understanding and prompt a return to the situation itself. Here the friction between Weick’s sensemaking and Schön’s reflection‑in‑action becomes visible: the split‑second when a frame fails and understanding must pivot. The question becomes not how to defend the existing interpretation but whether it still remains adequate.

This movement back towards the patient’s experience has an important relational dimension. Martin Buber’s distinction between I‑It and I‑Thou offers a way of understanding this shift. ⁷ Clinical systems inevitably encourage categorisation and objectification: symptoms become data points, patients become cases, consultations become transactions. Yet practice contains moments that resist this reduction. When a patient describes what worries them about a symptom, or how it emerged, the encounter may shift from I‑It to I‑Thou. The patient becomes not an object of investigation but a person whose experience contributes to the formation of understanding. This shift is not sentimental; it is epistemically generative, guarding against forms of epistemic injustice in which institutional categories prematurely displace lived experience.

Clinical understanding emerges not only within a clinician’s mind but through interactions that extend beyond the consultation. Drawing on Edwin Hutchins’ framework of distributed cognition, ⁸ clinical thinking is distributed across a sociotechnical system. Electronic records, guidelines, and specialist opinions shape what counts as relevant, plausible, or visible. A risk score foregrounds one possibility; a specialist letter another; the electronic record a third. Clinical understanding is interpretive, not arbitrary. Interpretations succeed or fail according to how well they accommodate both lived experience and the subsequent behaviour of the body. For instance, a persistent cough initially framed as a simple respiratory infection may, through its refusal to resolve, force the recognition of heart failure. Meaning is constructed through practice, yet remains answerable to biological realities that can confirm, resist, or overturn our explanations.

Yet this interpretive activity encounters limits. Biological reality is not infinitely malleable. Symptoms persist, conditions evolve, and bodies resist our explanations. Medically unexplained symptoms illustrate this clearly. Patients may suffer in ways that exceed existing diagnostic categories. Such situations reveal the limits of our concepts and remind us that our descriptions remain provisional attempts to make sense of realities that exceed our frameworks.

The challenge for clinical practice is therefore not to eliminate uncertainty but to work well within it. Contemporary healthcare often rewards speed, efficiency, and closure. Yet premature certainty may be more hazardous than acknowledged uncertainty. When interpretations harden too quickly, the consultation risks becoming a transaction rather than an inquiry.

What seems valuable is the cultivation of interpretive openess: an awareness of how understandings are formed and a willingness to revise them when necessary. This requires holding interpretations lightly while staying attentive to what does not fit. In practice, this may appear as hesitation, an additional question, or curiosity about something that seemed settled. John Keats described a related quality as “negative capability”: the ability to remain with uncertainties, mysteries, and doubts without an immediate rush towards resolution. ⁹

Ultimately, we return to Whitehead’s process philosophy: clinical understanding is better conceived as an event than an object, a continuous process of becoming rather than a finished state. The task of clinical practice is not to eliminate uncertainty but to cultivate an understanding that can remain open to change.

References

1. Whitehead AN. Process and Reality. New York: Free Press; 1978.
2. Gadamer HG. Truth and Method. London: Continuum; 2004.
3. Polanyi M. Personal Knowledge: Towards a Post-Critical Philosophy. London: Routledge; 1958.
4. Polanyi M. The Tacit Dimension. Chicago: University of Chicago Press; 1966.
5. Weick KE. Sensemaking in Organizations. Thousand Oaks (CA): Sage; 1995.
6. Schön DA. The Reflective Practitioner. Aldershot: Ashgate; 1983.
7. Buber M. I and Thou. Edinburgh: T&T Clark; 1937.
8. ​Hutchins E. Cognition in the Wild. Cambridge (MA): MIT Press; 1995.
9. Keats J. Letter to George and Thomas Keats, 21 December 1817. In: Gittings R, editor. Letters of John Keats. Oxford: Oxford University Press; 1970

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