What Makes a Clinical Expert? A Scoping Review in Medical Education

What Makes a Clinical Expert? 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A Scoping Review in Medical Education Eric Owens, Oliver Buchholz, Vibhuti Thapliyal, Alessandro Blasimme This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9469558/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The Evidence-Based Medicine paradigm has dominated modern medicine since its inception in the 1990s. Despite occupying the lowest position in the methodological hierarchy, clinical expertise is fundamental for evidence-based practice and a crucial component of effective medical education. However, little attention has been paid to the concept of clinical expertise. To fill this gap, this study addresses how clinical expertise is conceptualized in medical education literature. Methods We systematically conducted a scoping review to map how medical education literature conceptually addresses clinical expertise. We queried PubMed, Web of Science, and Scopus databases with a search string of terms related to clinical expertise. Results In total, 69 articles spanning 49 years were included for full text review. Upon thematic analysis, we discovered three main interconnected trends across the literature. First, we identified a polyphony of terminologies used to define or allude to clinical expertise, with most of the literature tending to use ‘clinical reasoning’ as a stand-in or proxy. Second, this use of clinical reasoning as a proxy for clinical expertise appears to downplay non-cognitive aspects such as communication skills, teamwork, and ethical deliberation. Lastly, this bias appears in medical education through a notable heterogeneity of approaches to teaching, manifesting as disjunctions between how clinical expertise is taught and how it is developed and recognized in real-world settings. Conclusions Our findings highlight the relative conceptual neglect of clinical expertise, as seen in the often-vague approaches in definition and subsequent dominance of clinical reasoning as a proxy. In turn, cognitive elements of clinical practice are given more priority while important non-cognitive elements receive considerably less attention/run the risk of being neglected. Future research should focus on clearly conceptualizing clinical expertise to foster the cultivation of a fuller spectrum of capacities enabling integrated, patient-centered, and contextually attuned clinical practice and healthcare delivery. Furthermore, a shared conceptual foundation of clinical expertise may help reduce divergence between medical education and the realities of clinical practice. Translational Medicine Medical Ethics Educational Philosophy and Theory Clinical Expertise Medical Education Evidence-Based Medicine Expertise Clinical Reasoning Figures Figure 1 Figure 2 1. Background Since at least the 1990s, modern medicine has been increasingly associated with scientific precision and rigorous, objective methodology based on high-quality experimentation and evidence gathering. This movement largely grew out of a 1992 report disseminated by the now-famous Evidence-Based Medicine (EBM) Working Group and effectively set the trajectory for medical practice and medical education to come [ 1 – 3 ]. Utilizing the most widely cited definition of EBM, this paradigm is viewed as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” [ 4 ]. The “best evidence” to be utilized has often been expressed as a hierarchy, with more comprehensive, quantitative or qualitative studies such as meta-analyses and systematic reviews being ranked above randomized controlled trials, observational studies, and, lastly, clinical expertise [ 5 – 7 ]. However, when practice reaches areas in which evidence has yet to catch up, or is not widely accepted, physicians must fall back on their clinical expertise. Thus, despite occupying the lowest position in the traditional evidence hierarchy, clinical expertise is still a fundamental tenet of good clinical practice. Subsequently, it is crucial that physicians and medical bodies understand the nature of clinical expertise and how it may be taught and developed. However, as methodological primacy has been given to various forms of empirical study, little attention has been paid to the concept of clinical expertise, making common understanding difficult [ 6 ]. Notable attempts in the literature have been made to acknowledge and/or fill this gap by looking toward clinical reasoning , highlighting the polyphony of terminologies used to describe clinical reasoning across various fields of study [ 8 , 9 ]. However, these studies notably leave out what clinical expertise entails and how it is described in the literature. There remains a gap in research; specifically, a conceptual neglect of clinical expertise and what it entails. Herein lie several issues for medical education. For one, a lack of shared understanding of such a fundamental part of modern medicine may distort educational objectives and assessments; curricular design and educational milestones may become complicated or unintentionally prioritize some skills or knowledge sources over others, especially if the educators, themselves, may have varying understandings of the concept or cognate terminologies. Additionally, comparative studies and knowledge building become problematic. Studies using the same terminology could be addressing different concepts while other studies using differing terminologies could be addressing the same concept. With these issues in mind, the study addresses the following guiding question: How is clinical expertise conceptualized in medical education literature? 2. Methodology To systematically explore the breadth of literature regarding conceptualizations of clinical expertise in medical education, we conducted a scoping review [ 10 , 11 ]. The study was designed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews [ 12 ]. 2.1 Operational Definitions The study was motivated by, and formulated around, the most widely cited definition of clinical expertise by Sackett et al. [ 4 ]: “the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice.” Despite its dominance in usage, this definition appears to be conceptually vague, largely inactionable, and in need of further analysis. Therefore, an informal literature review was undertaken to probe the literature further and search for other approaches to defining and understanding clinical expertise. This search elucidated cognate terminologies such as clinical reasoning, diagnostic expertise, or clinical competence, and informed our final search string development (see Section 2.2 ). Throughout, we view the terms ‘expertise’ and ‘expert’ as distinct, with ‘expertise’ being understood as a gradient ranging from ‘novice’ (the lowest level of expertise) to ‘expert’ (the highest level of expertise). We also hold ‘expertise’ and ‘competence’ to be similar, but ultimately distinct concepts. Specifically, we view competence as the sufficient ability to complete a task or solve a problem, whereas expertise not only involves the ability to complete a task, but to do so at a higher level of proficiency that is formed through experience and active exercise of learned clinical skills [ 13 ]. Essentially, expertise is viewed as competence plus some additional performance or application of knowledge/understanding, adaptability, skill(s), or characteristics. 2.2 Eligibility Criteria We included studies that were peer-reviewed, English-language articles published before 2026 that were conceptually focused on clinical expertise (defined or alluded to) and medical education. We excluded studies that were either not written in English, non-peer-reviewed (e.g., editorials, opinions, conference proceedings), empirical studies (e.g., testing the clinical reasoning abilities of medical students via tools, frameworks, etc.), related to AI, discussed the clinical expertise of non-physicians (e.g., nurses, physician assistants, chiropractors), or were specialty-specific (e.g., focused on dermatology, radiology, cardiology, etc.). Systematic, scoping, or narrative reviews were included if they were focused on clinical expertise and medical education. Studies addressing clinicians other than physicians (e.g., nurses, physician assistants, dentists, etc.) were excluded as the focus of this review was on physician clinical expertise. Physicians occupy various roles in the clinical environment that are distinct from other clinicians; thus, grouping all clinicians across their distinct roles would risk obscuring group-specific patterns and reduce the interpretability of the results. Specialty-specific papers were excluded to keep the focus on the education of broad, foundational clinical expertise as specialties may differ in their reasoning processes, patient interactions, and required skills, making comparison difficult. Empirical studies were excluded as their aims are often distinct from those of reviews; while empirical studies necessarily operationalize clinical expertise for measurement, this does not reflect a systematic examination of the concept itself—how it is understood, debated, and utilized throughout literature. 2.3 Search Strategy & Selection Process To systematically search these criteria and cognate terminologies of clinical expertise, relevant keywords were combined with Boolean operators to be utilized across PubMed, Web of Science, and Scopus databases (see Table 1). The search took place on Dec. 17, 2025. The articles yielded were then exported into Rayyan (Cambridge, MA 02142 USA), a systematic review software. After the removal of duplicates, the remaining articles were screened for title and abstract relevance. Two reviewers (EO and VT) screened title and abstracts; differences were resolved through discussion between the two reviewers; additional reviewers (AB and OB) were consulted upon continued disagreement. Initially included articles, after title and abstract screening, were imported into Zotero for full text review. Final included articles were then imported into Nvivo 13 (Denver, CO 80202 USA) for qualitative coding. 2.4 Data Analysis Reflexive thematic analysis was performed iteratively with codes tested for robustness and consistency by all authors [ 14 , 15 ]. Initial familiarization of the data took place with a first pass reading of the articles; annotations were compiled into a preliminary coding frame by EO. VT read a selection of articles (n = 15) with the coding frame to test reliability as well as potential gaps; EO and VT formulated a codebook that was used for formal coding of all articles. Additions were made iteratively throughout the entire process with any questions or differences resolved through discussion between all authors. Final themes were developed and discussed across multiple meetings between EO, OB, and AB. Our database searches yielded 3,596 initial articles; Scopus yielded the most (n = 1,840), followed by Web of Science (n = 935) and PubMed (n = 821). After the removal of duplicates (n = 1,114), 2,482 articles remained for title and abstract screening. An additional 2,301 articles were excluded after title and abstract screening, leaving 181 for full-text review. Removed articles were those that, for example, were focused on AI (n = 154) or empirical studies only assessing clinical expertise (n = 294) rather than discussing its conceptualization. After full-text screening, 112 additional articles were removed; for example, some articles (n = 10) contained titles and abstracts in English, but full texts were found to be published in other languages; others made no mention to expertise (n = 9). The final number of studies included was 69 (see Fig. 1). 2.5 Study Characteristics The final 69 articles were published over a span of 49 years, beginning in 1976 (n = 1) and steadily increasing until 2025 with most articles (n = 19) being published between 2020–2024 (see Fig. 2). The articles were published across 34 academic journals, representing five different global regions. The U.S.-based journal Medical Education was the highest represented journal (n = 13). Most articles (n = 37) were published from European-based journals, while only a single article was published from a journal based in the Middle East (see Table 2). The most common type of articles were original research articles (n = 42), followed by reviews (n = 18), perspectives (n = 6), and book chapters (n = 2). The remaining two articles marked as ‘Other’ in Table 2 were a consensus paper and a published guideline. A full list of included articles is found in Appendix B. 2.6 Terminologies The initial informal review of literature revealed notable attempts to ameliorate issues of conceptual vagueness by proposing distinct definitions of clinical expertise. Yet it also showed great disagreement. The most cited definition, proposed by Sackett et al. [ 4 ], sees clinical expertise as “the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice.” However, Petty [ 16 ] states that clinical expertise is “the ability of the practitioner to effectively integrate their practice knowledge with the patient's clinical presentation, values, and preferences to maximize the therapeutic encounter for the patient.” Haynes [ 17 ] notes clinical expertise includes “the general basic skills of clinical practice as well as the experience of the individual practitioner.” Some provide more in-depth explanations of clinical expertise, like Mylopoulos & Regehr [ 18 ], noting that clinical expertise (i) takes time to develop, (ii) involves the accumulation of organized resources, (iii) is flexible in its use, and (iv) is “remarkably idiosyncratic.” Others, like Dewitt et al. [ 19 ], given that there is little consensus on the term, utilize proxy terms like “proven experience” as “it can function as test or evidence, that professionals acquire it (someone becomes experienced/competent) and that it originates from or is accepted in practice.” An additional ambiguity arises due to often associated or cognate terminologies used alongside clinical expertise. For instance, some articles discuss concepts such as clinical reasoning, clinical decision-making, etc. [ 20 – 22 ]. It appears that there is a lack of consensus around not only definitions of clinical expertise but also how and when similar concepts (e.g., clinical reasoning) should be used; this trend continues across the study articles. 3. Results Of the 69 included articles in the study, all mentioned expertise in some form; however, we discovered 26 different terminologies to represent expertise (see Table 3). Most articles (n = 57) utilized the broad term ‘expert’ with variations such as ‘expert physician’ or ‘adaptive expert’ found throughout (see Table 3). Most articles (n = 52) also utilized ‘expertise’ with additional variations such as ‘medical expertise’ or ‘clinical expertise,’ highlighting significant overlap between usage of ‘expert’ and ‘expertise,’ although no articles specifically addressed their distinction. The terminologies were grouped by their parent classifier (‘expert’ or ‘expertise’). Seven additional terminologies were grouped together due to their lack of direct reference to expertise or expert. The most common additional terminology was ‘clinical competence,’ appearing in 18 articles. This was followed by ‘mastery,’ which appeared in 14 articles (see Table 3). Additional cognate terminologies appeared in tandem with references to expertise; the most prevalent being clinical reasoning, highlighted across 59 articles. Like clinical expertise, definitions of clinical reasoning ranged from being broad to being more specific. Shea & Chan [ 23 ] note that “Clinical reasoning ultimately describes all mental processes associated with the provision of healthcare and is considered a core competency.” While Cooper et al. [ 24 ] note that “Clinical reasoning can be defined as, ‘A skill, process, or outcome wherein clinicians observe, collect and interpret data to diagnose and treat patients.” Many of these articles (n = 30) understood clinical reasoning as the primary means to achieve clinical expertise, without explaining what clinical expertise itself entailed and despite the connection between the two remaining relatively mysterious [ 25 ]. Only a handful of articles (n = 9) provided direct definitions of clinical expertise, although they varied in their terminology utilized (see Table 4). Most articles (n = 42) provided negative definitions of clinical expertise, in the sense that no strict definition was given; instead, clinical expertise was contrasted against skills (or lack thereof) typically associated with being a novice. For instance, Barrows & Feltovich [ 26 ] note that “The expert, with more experience in variations and permutations of disease expression, may come to a diagnosis more readily than the novice.” The remaining articles (n = 18) merely alluded to elements of clinical expertise. Some expositions emphasized clinical experience as being the driving factor distinguishing novices from experts. In all, direct definitions or references to clinical expertise in the literature appeared to paint clinical expertise as a variable constellation of four main elements. Namely, clinical expertise may be seen as some combination of biomedical knowledge, clinical knowledge, clinical skills, and clinical experiences. Biomedical knowledge and clinical knowledge are deliberately noted as distinct forms of knowledge, with biomedical knowledge being the basic underpinnings of the human body, biochemical mechanisms, and pathophysiology, whereas clinical knowledge is the knowledge of how diseases manifest in clinical settings (e.g., signs and symptoms, treatments, etc.) [ 27 ]. Biomedical knowledge was emphasized as being the foundation upon which all other forms of knowledge rest: “Background knowledge is the foundation of clinical practice without which [clinical reasoning] is meaningless” [ 28 ]. However, its importance was sometimes downplayed in the grand scheme of clinical expertise development, with McColl et al. [ 29 ] noting that the current structure of curricula “may not be the most effective way of developing clinical expertise from bioscience knowledge.” Instead, clinical knowledge was often touted as (more) crucial for clinical expertise and heavily linked to clinical experiences. Ju & Choi [ 27 ] note that medical experts “predominantly use clinical knowledge accumulated from their clinical experiences, rather than biomedical knowledge, to represent and diagnose a patient’s problem.” As for clinical skills, these were also viewed as essential for clinical expertise as they are “tools for doctors to find new information about patients in their [clinical reasoning] process” [ 28 ]. Epstein & Hundert [ 30 ] similarly emphasized that “Competence builds on a foundation of basic clinical skills, scientific knowledge, and moral development.” However, mentions of clinical skills development varied as some articles (n = 6) equated clinical skills with procedural skills (e.g., venipuncture, surgical techniques, etc.). Others (n = 9) utilized clinical skills in a broader sense to encompass not only procedural skills but communication. Nevertheless, references to clinical skills predominantly focused on cognitive elements of clinical practice (see Section 3.1 ). Lastly, clinical experience was often praised as the main driver of clinical expertise, with some noting that the title of expert comes primarily through years of experience and the assumed knowledge accumulated during those years [ 31 ]. 3.1 Cognitive Elements of Clinical Expertise Notable trends appeared throughout the literature emphasizing various elements of medical education, ranging from theoretical understandings of cognition to concrete pedagogical methods. We highlight the most recurring trends in the following subsections. Theories of cognition and references to various cognitive processes or shortcuts were dominant in the literature, appearing across 61 articles. The most prevalent reference, appearing across 35 articles, was the concept of illness scripts. Illness scripts are defined as “mental scenarios of the conditions under which a disease emerges, the disease process itself, and its consequences in terms of possible signs, symptoms, and management alternatives” [ 32 ]. These were often mentioned in conjunction with distinctions between novices and experts, noting that scripts develop and become more efficient with clinical experience [ 33 – 35 ]. More specifically, the development from novice to expert often sees an accumulation and later maturation of illness scripts, leading to encapsulation, the “subsuming or ‘packaging’ of lower-level, detailed concepts and their inter-relations, under a smaller number of higher-level concepts with the same explanatory power” [ 36 ]. The second most common reference (n = 31) was to the Dual-Process Theory (DPT). References to DPT were often linked with contrasts between novices and experts, typically equating heavier reliance upon more intuitive, System 1 thinking with experts, and more effortful, analytic System 2 thinking with novices. For instance, Dumas et al. [ 37 ] state that “it is understood that novices in any discipline must necessarily effortfully use system 2 as they acclimate to their discipline, while experts tend to rely more heavily on automated system 1 processing to make decisions.” Despite this understanding, some articles point out that diagnostic and clinical errors tend to occur more through System 1 thinking, with Patel et al. [ 38 ] noting that “Experts make fewer diagnostic errors than nonexperts, but when they do make errors, they are most often errors of overconfidence, which arise from their overreliance on heuristics.” A further consequence of this noted reliance upon intuitive, System 1 thinking, is that “Although the physicians’ intuitive clinical experience is usually the main source of learning about the diagnostic value of clinical findings, such unsystematic experience may not be as accurate as the information obtained from high-quality diagnostic studies” [ 39 ]. Following illness scripts and DPT, the concepts of metacognition and heuristics appeared the third most, both across 20 articles. Metacognition is viewed as a deliberate reflection upon one’s own thinking, or, thinking about thinking [ 34 , 40 ]. This process of reflection is often emphasized as a key component for clinical expertise, and a vital skill for avoiding clinical, primarily diagnostic, errors [ 8 , 41 ]. Often, this deliberate reflection was viewed as a fundamental aspect of clinical expertise, with Lane & Roberts [ 42 ] stating that metacognitive processes are “an essential requirement to develop both a therapeutic relationship and professional expertise.” In contrast, heuristics are seen as cognitive shortcuts or rules of thumb that may be utilized for quicker thinking and decision-making [ 43 , 44 ]. Associated with System 1 thinking, these are fast, non-analytical shortcuts that are seen as prevalent throughout clinical practice. Despite this, many articles emphasize that these rules of thumb may be a cause of significant diagnostic errors or biases [ 8 , 25 , 45 ]. Although this appears to be contentious as “other authors argue that heuristics are usually efficient and point to specific knowledge deficits rather than particular reasoning processes as the explanation for reasoning flaws” [ 32 ]. Overall, the literature is dominated by approaches to cognition and the reasoning processes that are seen as crucial for the development of clinical expertise. Relating to clinical reasoning, these discussions largely focus on theories from cognitive psychology and studies of cognition such as illness scripts, DPT, metacognition, and heuristics. 3.2 Non-Cognitive Elements of Clinical Expertise Only 17 articles noted non-cognitive elements such as communication skills, teamwork, and ethical deliberation as significant components of clinical expertise. Most of these articles (n = 9) placed emphasis on the development of communication skills with their effective development noted as “essential for accurate and efficient data collection, developing rapport with patients and facilitating teamwork with other health professionals. Communication skills training is therefore an essential component of medical school programs” [ 46 ]. As for teamwork, mentioned across 8 articles, discussions often reflected upon the growing complexity of healthcare systems, interdisciplinary teams, and the importance of developing therapeutic relationships with patients. Because of this, Taha et al. [ 47 ] argue that “System integration demands not only clinical acumen but also skills in teamwork, communication, and systems navigation, positioning physicians as facilitators of a seamless, patient-centered healthcare experience.” Despite these deliberate references to communication skills and teamwork, their importance for the development of clinical expertise remained largely underexplored across the literature, with cognitive training elements taking precedence. Additionally, the importance of ethical deliberation skills for clinical practice was notably lacking in the literature, only appearing across 7 articles—only 3 of which overlapped with the 9 articles emphasizing communication skills and only 2 with the 8 articles emphasizing teamwork. These articles made efforts to discuss elements of ethical deliberation as a key element for developing clinical expertise. Ng et al. [ 48 ] note that “In real-world settings, clinical decision-making is often not simply driven by fixed cognitive models, but also influenced by contextual and emotional influences.” These articles often emphasized the importance of medical or clinical ethics courses for the development of ethical deliberation and the moral development needed for clinical expertise [ 29 ]. Additional but rare discussions (n = 2) occurred surrounding the role of empathy and emotions in clinical practice and the development of empathetic physicians. For instance, the emotional state of physicians may be crucial for patient outcomes as Pelaccia et al. [ 49 ] note that “Labelling patients as ‘plaintive’, ‘difficult’, ‘manipulative’ or ‘borderline personality’ is also likely to influence reasoning." Crucially, only one article [ 30 ] highlighted all three non-cognitive elements as important factors for developing clinical expertise. 3.3 Teaching Approaches & Perceived Shortcomings Complementing the emphasis on various cognitive processes and theories, the literature often (n = 40) mentions specific teaching strategies for developing and strengthening clinical expertise. Many articles stress the importance of utilizing case-based learning (n = 14) or problem-based learning (n = 13) schemes to develop the clinical expertise of students. Some articles also suggest tests or methods of measurement for the clinical reasoning process or examining clinical competencies, ranging from approaches like the Script Concordance Test (n = 11) or Objective Structured Clinical Examinations (n = 6). Mentions of perceived shortcomings in current medical educational practices were prevalent, appearing across 29 articles and almost 25 years (2003–2025). These mentions predominantly discussed elements wholly neglected in medical education, approaches deemed ineffective, or disjunctions between what is taught and what is needed or used in everyday practice. As Mohd Mohd Tambeh & Yaman [ 50 ] state, “A lack of knowledge transfer and application from pre-clinical to clinical students, as well as limited opportunities to practice [clinical reasoning], are several identified environmental barriers.” Clinical reasoning was, again, the predominant focus of these discussions. These articles often noted that current medical education curricula and/or literature appear to be either ineffective in their teaching of clinical reasoning or wholly neglecting the topic. For instance, Durning et al. [ 44 ] emphasize that “Despite [the] widely held perception of clinical reasoning there are a number of barriers to effective clinical reasoning instruction. For example, prior publications cite clinical reasoning as having a variety of definitions […], faculty do not feel adequately prepared to teach this topic and medical school curricula are not believed to spend ample time on teaching this essential ability.” On the other hand, Pelaccia [ 49 ] states that “although medical educators share the view of clinical reasoning as a major determinant of physicians’ expertise, it is not often an explicit educational objective in medical universities.” Overall, despite the discussion of shortcomings in medical education spanning more than 20 years, literature persists in pointing out gaps, primarily around the deliberate teaching of clinical reasoning and the disjunction between educational and real-world settings. Guidry et al. [ 43 ] emphasize that medical education tends to neglect the considerable complexity of the clinical setting with all its uncertainty, rapid pace, and distracting elements. This further appears as a relative heterogeneity of approaches for teaching and measuring clinical expertise and a tendency to overshadow other vital elements of clinical practice [ 51 , 52 ]. 4. Discussion We have identified 26 different terminologies for clinical expertise, largely focused on a constellation of four main elements: a biomedical knowledge base, clinical knowledge, clinical skills, and clinical experiences. Despite the relative simplicity of these component parts, tensions often arose when these elements were viewed together, with literature often questioning the importance of a biomedical knowledge base as well as overshadowing the development of clinical skills. Nevertheless, these four elements have proven difficult to conceptualize and operationalize. To deal with these issues, much of the literature associates these four main elements with the term clinical reasoning . This trend is seen through the dominance of cognitive theories and focus on the cognitive elements of clinical practice. Clinical reasoning is thus operationalized as a proxy for clinical expertise; although, what clinical expertise ultimately entails is considerably under-developed. Looking beyond the study articles, this emphasis on cognitive theories and the cognitive elements of clinical practice may have begun in the wake of the 1910 Flexner report with the emphasis placed on the biomedical sciences, scientific rationalism, and technical progress, often overshadowing the healing, patient-centered aspects of medical care [ 53 ]. The post-Flexnerian emphasis on scientific discovery and technical mastery in medical education has arguably led to physicians developing into technical experts, while diminishing the cultivation of the beneficent healer role [ 53 ]. This trend has been recognized by Michel Foucault’s infamous The Birth of the Clinic , in which he develops the concept of the “medical gaze,” an objectifying lens through which patients are seen as specimens or subjects to be diagnosed rather than people to be cared for [ 54 , 55 ]. The favoring of technicality and rationality has had the effect of diminishing experiential, narrative elements of medicine—although the rise of narrative medicine and phenomenological approaches to health have grown since the late 1990s to counter this historical trend [ 55 ]. In medicine and beyond, academic research in the 1960s into expertise focused primarily on epistemic expertise, or knowledge-that , favoring factual or knowledge-based expertise over other forms of expertise that have only more recently entered the discussion (e.g., know-how or performative expertise) [ 56 ]. Regarding practices in medical education, the literature specifically addressing teaching methodologies often noted the teaching of clinical reasoning as a considerably neglected element. Despite its neglect, it remained a recurring topic of discussion as a notable foundation of clinical expertise. This tension often manifested in the historical trend of new physicians, to a large degree, implicitly developing their clinical expertise through the often-passive accumulation of clinical experiences. In some sense, the literature appears to often assume that mere exposure to clinical environments, at least in the presence of relative experts, act to aid in the development of clinical expertise. Although important, these experiences may suffer from considerable variability, depending on the environment or clinical context. Like the noted polyphony of terminologies for clinical expertise, this likely persists due to a considerable polyphony of terminologies for clinical reasoning, again, highlighting the importance of conceptual clarity for educational purposes. Even as pedagogical methods have arisen to teach clinical reasoning elements to medical students, there remains a notable disjunction between the teaching environment and real-world practice. This finding in the literature stresses the importance of early and targeted clinical experiences for medical students to aid in bridging the curated, “kind” environment of the classroom and the “wicked” environment of the clinic [ 57 ]. Nevertheless, the centrality of teaching clinical reasoning and the importance clinical experience accumulation for clinical expertise stands in notable tension with the ideals of EBM. Questions of objectivity, evidence-gathering, and expertise are fundamentally conceptual and philosophical issues. Indeed, despite the rapid methodological development of the EBM paradigm, its conceptual development, particularly with respect to clinical expertise, has not appeared to keep pace. Addressing this disjunction requires a more intentional effort to combine philosophical analysis with medical literature. Still, EBM remains the guiding paradigm in modern medicine; indeed, we do not wish to reject it, nor do we think it should be. However, as noted in the introduction, deeper conceptual analyses of the paradigm, particularly clinical expertise, has fallen by the wayside, in favoring empirical approaches to evidence gather, such as randomized controlled trials [ 58 , 59 ]. Philosophical analyses and accounts of various elements of EBM have arisen in tandem with, yet often siloed from, medical literature. We wish this review to act as a key catalyst for further conceptual analysis and a deliberate merging of the two domains to rebut the previous patterns of conceptual neglect surrounding clinical expertise. This task has become exceedingly important given the rapid advances and integration of AI tools into healthcare, especially into clinical domains. The increasing integration of AI-based tools into medical research, medical education, and clinical practice carry a range of epistemic and ethical concerns and add elements of uncertainty to clinical practice that must be addressed [ 60 ]. As AI will likely continue to develop and be integrated into clinical environments, it is vital that we clarify and understand such fundamental concepts as clinical expertise. 4.1 Takeaways Our study highlights the current polyphony of terminologies surrounding clinical expertise. Nevertheless, clinical expertise is broadly seen in the literature as a constellation of a biomedical knowledge base, clinical knowledge, clinical skills, and clinical experiences. It remains unclear which elements, if any, are considered the best or most effective representation of clinical expertise. Likely because of this ambiguity, clinical reasoning has taken precedence as a proxy for clinical expertise, appearing as a process more amenable to deliberate teaching and assessment. Despite the importance of cognitive structures and approaches in clinical practice, this dominance has appeared to bias conceptualizations of clinical expertise, notably overlooking non-cognitive factors such as communication skills, teamwork, and ethical deliberation. The wide range of terminologies used, as well as the bias toward cognition, have appeared to manifest in perceived shortcomings in pedagogical approaches. Medical educators and students face the challenge of bridging the educational and clinical environments; this already challenging task is compounded by conceptual confusion around clinical expertise. In essence, further conceptualizations of clinical expertise must account not only for epistemic expertise, but also performative, adaptive, and virtuous forms of expertise that constantly interact with each other in clinical environments. 4.2 Strengths and Limitations Our study has several notable strengths. First, the large sample size of analyzed literature increases the representativeness of the conceptual landscape. Second, we believe that calling attention to the various forms of expertise better matches common narratives about the physician as not only a superior source of knowledge but also as a healing, beneficent figure [ 61 ]. Lastly, the study proves timely with recent developments in AI and integrated clinical practice, especially as the technological advances of these tools present increasing epistemic and ethical quandaries. Understanding the current landscape of clinical expertise in medical education is an important steppingstone to ensuring these forms of expertise are considered and keep pace with AI integration. Our study should be interpreted considering the following limitations. First, we chose to limit articles to those that focus on conceptualizations of clinical expertise, foregoing experimental studies that operationalize clinical expertise. In this regard, some experimental studies may have introduced definitions of clinical expertise that were thus not captured by our search. Second, we focused on physicians given their distinct roles in clinical practice; however, other clinicians such as physician assistants, nurses, or pharmacists may have differing conceptions of clinical expertise that are worth exploring in future studies. Additionally, we chose to focus on clinical expertise as discussed in relation to undergraduate medical education; thus, articles addressing the real-world clinical application or understanding of clinical expertise were not captured. This decision was made with the intention to understand how clinical expertise may be understood and taught in the beginning phases of medical education, which likely aids in giving a broader picture of its necessary component parts (as opposed to continuing medical education which may stress just one or two elements, like clinical knowledge or clinical experiences). Lastly, we acknowledge that there is a geographic bias toward Western nations, predominantly in Europe and parts of North America. This bias must be kept in mind as understandings of clinical expertise and pedagogical approaches may differ across other healthcare systems. 5. Conclusion The present study highlights the considerable polyphony of terminologies used to describe clinical expertise and the heterogeneous nature of pedagogical practices in medical education. Specifically, our findings indicate the relative conceptual neglect of clinical expertise, as seen in the numerous and often vague approaches to defining it, with the primary approach focusing on clinical reasoning as a proxy more amenable to study. The literature is subsequently skewed toward theories of cognition, tending to view clinical expertise largely as a cognitive attribute, neglecting non-cognitive elements of clinical expertise, such as communication skills, teamwork, and ethical deliberation. The myriad terminologies and bias toward cognition manifest in shortcomings in educational practices, as educators struggle to grasp or assess clinical expertise. Future research should focus on clearly conceptualizing clinical expertise to aid in more structured, homogenous medical education and assist in broadening understandings of expertise in medicine. Abbreviations • AI Artificial Intelligence • DPT Dual-Process Theory • EBM Evidence-Based Medicine Declarations Ethics Approval Not applicable. Consent for Publication Not applicable. Data Availability All data analyzed during this study are included in this published article and its supplementary files. Competing Interests The authors declare that they have no competing interests. Funding This study received no specific grant or funding. Author Contributions EO, OB, and AB conceptualized the initial study design and search string development. Database searches and data gathering were done by EO. Title and abstract screening were done by EO and VT; full-text reading completed by EO. EO and VT coded included articles. Data preparation was completed by EO. The original manuscript was created by EO, with all other authors assisting in the subsequent editing and review process. Acknowledgments The authors thank Dr. Edward Hundert, MD for his insightful comments during initial project development. References Guyatt G, Cairns J, Churchill D, Cook D, Haynes B, Hirsh J et al (1992) Evidence-Based Medicine: A New Approach to Teaching the Practice of Medicine. JAMA 268(17):2420–2425. 10.1001/jama.1992.03490170092032 Lewis SJ, Orland BI (2004) The Importance and Impact of Evidence Based medicine. JMCP. ;10(5 Supp A):S3–5. 10.18553/jmcp.2004.10.S5-A.S3 Dickersin K, Straus SE, Bero LA (2007) Evidence based medicine: increasing, not dictating, choice. 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Interdisciplinary J Problem-Based Learn 12(1). 10.7771/1541-5015.1638 Khin-Htun S, Kushairi A (2019) Twelve Tips for Developing Clinical Reasoning Skills in the Pre-Clinical and Clinical Stages of Medical School. Med Teach 41(9):1007–1011. 10.1080/0142159X.2018.1502418 McColl GJ, Bilszta J, Harrap S (2012) The requirement for bioscience knowledge in medical education. Med J Aust 196(6):409–409. 10.5694/mja11.10474 Epstein RM, Hundert EM (2002) Defining and Assessing Professional Competence. JAMA 287(2):226. 10.1001/jama.287.2.226 Mylopoulos M, Woods NN (2009) Having our cake and eating it too: seeking the best of both worlds in expertise research. Med Educ 43(5):406–413. 10.1111/j.1365-2923.2009.03307.x Schmidt HG, Mamede S (2015) How to improve the teaching of clinical reasoning: a narrative review and a proposal. Med Educ 49(10):961–973. 10.1111/medu.12775 Custers EJFM (2015) Thirty years of illness scripts: Theoretical origins and practical applications. 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Reviews Hum Factors Ergon 8(1):149–190. 10.1177/1557234X13492978 Moosapour H, Raza M, Rambod M, Soltani A (2011) Conceptualization of category-oriented likelihood ratio: a useful tool for clinical diagnostic reasoning. BMC Med Educ 11(1):94. 10.1186/1472-6920-11-94 Hege I, Kononowicz AA, Berman NB, Lenzer B, Kiesewetter J (2018) Advancing clinical reasoning in virtual patients - development and application of a conceptual framework. GMS J Med Educ 35(1):Doc12. 10.3205/zma001159 Dreicer JJ, Parsons AS, Joudi T, Stern S, Olson APJ, Rencic JJ (2023) Framework and Schema are False Synonyms: Defining Terms to Improve Learning. Perspect Med Educ 12(1). 10.5334/pme.947 Lane AS, Roberts C (2022) Contextualised reflective competence: a new learning model promoting reflective practice for clinical training. BMC Med Educ 22(1):71. 10.1186/s12909-022-03112-4 Guidry MM, Drennan RH, Weise J, Hamm LL, Hamm LL (2011) Serum Sepsis, not Sickness. Am J Med Sci 341(2):88–91. 10.1097/MAJ.0b013e3182083f14 Durning SJ, Jung E, Kim DH, Lee YM (2024) Teaching clinical reasoning: principles from the literature to help improve instruction from the classroom to the bedside. Korean J Med Educ 36(2):145–155. 10.3946/kjme.2024.292 Westen D, Weinberger J (2005) In praise of clinical judgment: Meehl’s forgotten legacy. J Clin Psychol 61(10):1257–1276. 10.1002/jclp.20181 Conn JJ, Lake FR, McColl GJ, Bilszta JLC, Woodward-Kron R (2012) Clinical teaching and learning: from theory and research to application. Med J Aust 196(8):527–527. 10.5694/mja10.11473 Taha MH, Mukhtar WNO, Preston R (2025) The Evolving Role of the Medical Profession and Medical Graduates. In: Abdalla ME, Taha MH, Boelen C (eds) Social Accountability of Medical Schools. Springer Nature Switzerland, Cham, pp 17–29. doi: 10.1007/978-3-031-94435-2_2 Ng IKS, Goh WGW, Teo DB, Chong KM, Tan LF, Teoh CM (2024) Clinical reasoning in real-world practice: a primer for medical trainees and practitioners. Postgrad Med J 101(1191):68–75. 10.1093/postmj/qgae079 Pelaccia T, Tardif J, Triby E, Charlin B (2011) An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory. Med Educ Online 16(1):5890. 10.3402/meo.v16i0.5890 Mohd Tambeh SN, Yaman MN (2023) Clinical reasoning training sessions for health educators—A scoping review. J Taibah Univ Med Sci 18(6):1480–1492. 10.1016/j.jtumed.2023.06.002 Mylopoulos M, Kulasegaram K, Woods NN (2018) Developing the experts we need: Fostering adaptive expertise through education. Evaluation Clin Pract 24(3):674–677. 10.1111/jep.12905 Kulasegaram KM, Grierson LEM, Norman GR (2013) The roles of deliberate practice and innate ability in developing expertise: evidence and implications. Med Educ 47(10):979–989. 10.1111/medu.12260 Duffy TP (2011) The Flexner Report ― 100 Years Later. Yale J Biol Med 84(3):269–276. https://pmc.ncbi.nlm.nih.gov/articles/PMC3178858/ Foucault M (1973) The Birth of the Clinic: An Archaeology of Medical Perception Svenaeus F (2023) The Phenomenology of Objectification in and Through Medical Practice and Technology Development. J Med Philos 48(2):141–150. 10.1093/jmp/jhad007 Weinstein BD (1993) What is an expert? Theoret Med 14(1):57–73. 10.1007/BF00993988 Schwartzstein Richard M (2024) Clinical Reasoning and Artificial Intelligence: Can AI Really Think? Trans Am Clin Climatol Assoc 134:133–145. https://pmc.ncbi.nlm.nih.gov/articles/PMC11316886/ Goldenberg MJ (2006) On evidence and evidence-based medicine: Lessons from the philosophy of science. Social Science & Medicine. ;Part Special Issue: Gift Horse or Trojan Horse? Social Science Perspectives on Evidence-based Health Care62(11):2621–32. 10.1016/j.socscimed.2005.11.031 Worrall J (2002) What Evidence in Evidence-Based Medicine? Philos Sci 69(S3):S316–S330. 10.1086/341855 Ning Y, Teixayavong S, Shang Y, Savulescu J, Nagaraj V, Miao D et al (2024) Generative artificial intelligence and ethical considerations in health care: a scoping review and ethics checklist. Lancet Digit Health 6(11):e848–e856. 10.1016/S2589-7500(24)00143-2 Jecker NS (2005) Health Care Reform: What History Doesn’t Teach. Theor Med Bioeth 26(4):277–305. 10.1007/s11017-005-8184-1 Tables Tables are available in the Supplementary Files section. Additional Declarations The authors declare no competing interests. Supplementary Files Appendicesupdated.docx Appendices CESupplementaryTable.xlsx Supplementary Table PRISMAScRChecklist.docx PRISMA Scoping Checklist Table1.png Search String Table2.png Articles Overview Table3.png Terminologies Table4.png Varying Definitions Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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15:30:41","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":103099,"visible":true,"origin":"","legend":"\u003cp\u003eTerminologies\u003c/p\u003e","description":"","filename":"Table3.png","url":"https://assets-eu.researchsquare.com/files/rs-9469558/v1/9c65e31c2ff72ee6db30aa6c.png"},{"id":107490182,"identity":"9e92991b-5ae8-404e-bcdb-bae61155274d","added_by":"auto","created_at":"2026-04-22 02:51:07","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":218602,"visible":true,"origin":"","legend":"\u003cp\u003eVarying Definitions\u003c/p\u003e","description":"","filename":"Table4.png","url":"https://assets-eu.researchsquare.com/files/rs-9469558/v1/10672b8256bfcdc8d80fc412.png"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eWhat Makes a Clinical Expert? A Scoping Review in Medical Education\u003c/p\u003e","fulltext":[{"header":"1. Background","content":"\u003cp\u003eSince at least the 1990s, modern medicine has been increasingly associated with scientific precision and rigorous, objective methodology based on high-quality experimentation and evidence gathering. This movement largely grew out of a 1992 report disseminated by the now-famous Evidence-Based Medicine (EBM) Working Group and effectively set the trajectory for medical practice and medical education to come [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Utilizing the most widely cited definition of EBM, this paradigm is viewed as \u0026ldquo;the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients\u0026rdquo; [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The \u0026ldquo;best evidence\u0026rdquo; to be utilized has often been expressed as a hierarchy, with more comprehensive, quantitative or qualitative studies such as meta-analyses and systematic reviews being ranked above randomized controlled trials, observational studies, and, lastly, clinical expertise [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, when practice reaches areas in which evidence has yet to catch up, or is not widely accepted, physicians must fall back on their clinical expertise. Thus, despite occupying the lowest position in the traditional evidence hierarchy, clinical expertise is still a fundamental tenet of good clinical practice.\u003c/p\u003e \u003cp\u003eSubsequently, it is crucial that physicians and medical bodies understand the nature of clinical expertise and how it may be taught and developed. However, as methodological primacy has been given to various forms of empirical study, little attention has been paid to the \u003cem\u003econcept\u003c/em\u003e of clinical expertise, making common understanding difficult [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Notable attempts in the literature have been made to acknowledge and/or fill this gap by looking toward clinical \u003cem\u003ereasoning\u003c/em\u003e, highlighting the polyphony of terminologies used to describe clinical reasoning across various fields of study [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, these studies notably leave out what clinical \u003cem\u003eexpertise\u003c/em\u003e entails and how it is described in the literature. There remains a gap in research; specifically, a conceptual neglect of clinical expertise and what it entails.\u003c/p\u003e \u003cp\u003eHerein lie several issues for medical education. For one, a lack of shared understanding of such a fundamental part of modern medicine may distort educational objectives and assessments; curricular design and educational milestones may become complicated or unintentionally prioritize some skills or knowledge sources over others, especially if the educators, themselves, may have varying understandings of the concept or cognate terminologies. Additionally, comparative studies and knowledge building become problematic. Studies using the same terminology could be addressing different concepts while other studies using differing terminologies could be addressing the same concept. With these issues in mind, the study addresses the following guiding question: How is clinical expertise conceptualized in medical education literature?\u003c/p\u003e"},{"header":"2. Methodology","content":"\u003cp\u003eTo systematically explore the breadth of literature regarding conceptualizations of clinical expertise in medical education, we conducted a scoping review [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The study was designed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Operational Definitions\u003c/h2\u003e \u003cp\u003eThe study was motivated by, and formulated around, the most widely cited definition of clinical expertise by Sackett et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]: \u0026ldquo;the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice.\u0026rdquo; Despite its dominance in usage, this definition appears to be conceptually vague, largely inactionable, and in need of further analysis. Therefore, an informal literature review was undertaken to probe the literature further and search for other approaches to defining and understanding clinical expertise. This search elucidated cognate terminologies such as clinical reasoning, diagnostic expertise, or clinical competence, and informed our final search string development (see Section \u003cspan refid=\"Sec4\" class=\"InternalRef\"\u003e2.2\u003c/span\u003e). Throughout, we view the terms \u0026lsquo;expertise\u0026rsquo; and \u0026lsquo;expert\u0026rsquo; as distinct, with \u0026lsquo;expertise\u0026rsquo; being understood as a gradient ranging from \u0026lsquo;novice\u0026rsquo; (the lowest level of expertise) to \u0026lsquo;expert\u0026rsquo; (the highest level of expertise). We also hold \u0026lsquo;expertise\u0026rsquo; and \u0026lsquo;competence\u0026rsquo; to be similar, but ultimately distinct concepts. Specifically, we view competence as the sufficient ability to complete a task or solve a problem, whereas expertise not only involves the ability to complete a task, but to do so at a higher level of proficiency that is formed through experience and active exercise of learned clinical skills [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Essentially, expertise is viewed as competence plus some additional performance or application of knowledge/understanding, adaptability, skill(s), or characteristics.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Eligibility Criteria\u003c/h2\u003e \u003cp\u003eWe included studies that were peer-reviewed, English-language articles published before 2026 that were conceptually focused on clinical expertise (defined or alluded to) and medical education. We excluded studies that were either not written in English, non-peer-reviewed (e.g., editorials, opinions, conference proceedings), empirical studies (e.g., testing the clinical reasoning abilities of medical students via tools, frameworks, etc.), related to AI, discussed the clinical expertise of non-physicians (e.g., nurses, physician assistants, chiropractors), or were specialty-specific (e.g., focused on dermatology, radiology, cardiology, etc.). Systematic, scoping, or narrative reviews were included if they were focused on clinical expertise and medical education. Studies addressing clinicians other than physicians (e.g., nurses, physician assistants, dentists, etc.) were excluded as the focus of this review was on \u003cem\u003ephysician\u003c/em\u003e clinical expertise. Physicians occupy various roles in the clinical environment that are distinct from other clinicians; thus, grouping all clinicians across their distinct roles would risk obscuring group-specific patterns and reduce the interpretability of the results. Specialty-specific papers were excluded to keep the focus on the education of broad, foundational clinical expertise as specialties may differ in their reasoning processes, patient interactions, and required skills, making comparison difficult. Empirical studies were excluded as their aims are often distinct from those of reviews; while empirical studies necessarily operationalize clinical expertise for measurement, this does not reflect a systematic examination of the concept itself\u0026mdash;how it is understood, debated, and utilized throughout literature.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Search Strategy \u0026amp; Selection Process\u003c/h2\u003e \u003cp\u003eTo systematically search these criteria and cognate terminologies of clinical expertise, relevant keywords were combined with Boolean operators to be utilized across PubMed, Web of Science, and Scopus databases (see Table\u0026nbsp;1). The search took place on Dec. 17, 2025. The articles yielded were then exported into Rayyan (Cambridge, MA 02142 USA), a systematic review software. After the removal of duplicates, the remaining articles were screened for title and abstract relevance. Two reviewers (EO and VT) screened title and abstracts; differences were resolved through discussion between the two reviewers; additional reviewers (AB and OB) were consulted upon continued disagreement. Initially included articles, after title and abstract screening, were imported into Zotero for full text review. Final included articles were then imported into Nvivo 13 (Denver, CO 80202 USA) for qualitative coding.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data Analysis\u003c/h2\u003e \u003cp\u003eReflexive thematic analysis was performed iteratively with codes tested for robustness and consistency by all authors [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Initial familiarization of the data took place with a first pass reading of the articles; annotations were compiled into a preliminary coding frame by EO. VT read a selection of articles (n\u0026thinsp;=\u0026thinsp;15) with the coding frame to test reliability as well as potential gaps; EO and VT formulated a codebook that was used for formal coding of all articles. Additions were made iteratively throughout the entire process with any questions or differences resolved through discussion between all authors. Final themes were developed and discussed across multiple meetings between EO, OB, and AB.\u003c/p\u003e \u003cp\u003eOur database searches yielded 3,596 initial articles; Scopus yielded the most (n\u0026thinsp;=\u0026thinsp;1,840), followed by Web of Science (n\u0026thinsp;=\u0026thinsp;935) and PubMed (n\u0026thinsp;=\u0026thinsp;821). After the removal of duplicates (n\u0026thinsp;=\u0026thinsp;1,114), 2,482 articles remained for title and abstract screening. An additional 2,301 articles were excluded after title and abstract screening, leaving 181 for full-text review. Removed articles were those that, for example, were focused on AI (n\u0026thinsp;=\u0026thinsp;154) or empirical studies only \u003cem\u003eassessing\u003c/em\u003e clinical expertise (n\u0026thinsp;=\u0026thinsp;294) rather than discussing its conceptualization. After full-text screening, 112 additional articles were removed; for example, some articles (n\u0026thinsp;=\u0026thinsp;10) contained titles and abstracts in English, but full texts were found to be published in other languages; others made no mention to expertise (n\u0026thinsp;=\u0026thinsp;9). The final number of studies included was 69 (see Fig.\u0026nbsp;1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Study Characteristics\u003c/h2\u003e \u003cp\u003eThe final 69 articles were published over a span of 49 years, beginning in 1976 (n\u0026thinsp;=\u0026thinsp;1) and steadily increasing until 2025 with most articles (n\u0026thinsp;=\u0026thinsp;19) being published between 2020\u0026ndash;2024 (see Fig.\u0026nbsp;2). The articles were published across 34 academic journals, representing five different global regions. The U.S.-based journal \u003cem\u003eMedical Education\u003c/em\u003e was the highest represented journal (n\u0026thinsp;=\u0026thinsp;13). Most articles (n\u0026thinsp;=\u0026thinsp;37) were published from European-based journals, while only a single article was published from a journal based in the Middle East (see Table\u0026nbsp;2). The most common type of articles were original research articles (n\u0026thinsp;=\u0026thinsp;42), followed by reviews (n\u0026thinsp;=\u0026thinsp;18), perspectives (n\u0026thinsp;=\u0026thinsp;6), and book chapters (n\u0026thinsp;=\u0026thinsp;2). The remaining two articles marked as \u0026lsquo;Other\u0026rsquo; in Table\u0026nbsp;2 were a consensus paper and a published guideline. A full list of included articles is found in Appendix B.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Terminologies\u003c/h2\u003e \u003cp\u003eThe initial informal review of literature revealed notable attempts to ameliorate issues of conceptual vagueness by proposing distinct definitions of clinical expertise. Yet it also showed great disagreement. The most cited definition, proposed by Sackett et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], sees clinical expertise as \u0026ldquo;the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice.\u0026rdquo; However, Petty [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] states that clinical expertise is \u0026ldquo;the ability of the practitioner to effectively integrate their practice knowledge with the patient's clinical presentation, values, and preferences to maximize the therapeutic encounter for the patient.\u0026rdquo; Haynes [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] notes clinical expertise includes \u0026ldquo;the general basic skills of clinical practice as well as the experience of the individual practitioner.\u0026rdquo; Some provide more in-depth explanations of clinical expertise, like Mylopoulos \u0026amp; Regehr [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], noting that clinical expertise (i) takes time to develop, (ii) involves the accumulation of organized resources, (iii) is flexible in its use, and (iv) is \u0026ldquo;remarkably idiosyncratic.\u0026rdquo; Others, like Dewitt et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], given that there is little consensus on the term, utilize proxy terms like \u0026ldquo;proven experience\u0026rdquo; as \u0026ldquo;it can function as test or evidence, that professionals acquire it (someone becomes experienced/competent) and that it originates from or is accepted in practice.\u0026rdquo; An additional ambiguity arises due to often associated or cognate terminologies used alongside clinical expertise. For instance, some articles discuss concepts such as clinical reasoning, clinical decision-making, etc. [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. It appears that there is a lack of consensus around not only definitions of clinical expertise but also how and when similar concepts (e.g., clinical reasoning) should be used; this trend continues across the study articles.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eOf the 69 included articles in the study, all mentioned expertise in some form; however, we discovered 26 different terminologies to represent expertise (see Table\u0026nbsp;3). Most articles (n\u0026thinsp;=\u0026thinsp;57) utilized the broad term \u0026lsquo;expert\u0026rsquo; with variations such as \u0026lsquo;expert physician\u0026rsquo; or \u0026lsquo;adaptive expert\u0026rsquo; found throughout (see Table\u0026nbsp;3). Most articles (n\u0026thinsp;=\u0026thinsp;52) also utilized \u0026lsquo;expertise\u0026rsquo; with additional variations such as \u0026lsquo;medical expertise\u0026rsquo; or \u0026lsquo;clinical expertise,\u0026rsquo; highlighting significant overlap between usage of \u0026lsquo;expert\u0026rsquo; and \u0026lsquo;expertise,\u0026rsquo; although no articles specifically addressed their distinction. The terminologies were grouped by their parent classifier (\u0026lsquo;expert\u0026rsquo; or \u0026lsquo;expertise\u0026rsquo;). Seven additional terminologies were grouped together due to their lack of direct reference to expertise or expert. The most common additional terminology was \u0026lsquo;clinical competence,\u0026rsquo; appearing in 18 articles. This was followed by \u0026lsquo;mastery,\u0026rsquo; which appeared in 14 articles (see Table\u0026nbsp;3). Additional cognate terminologies appeared in tandem with references to expertise; the most prevalent being clinical reasoning, highlighted across 59 articles. Like clinical expertise, definitions of clinical reasoning ranged from being broad to being more specific. Shea \u0026amp; Chan [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] note that \u0026ldquo;Clinical reasoning ultimately describes all mental processes associated with the provision of healthcare and is considered a core competency.\u0026rdquo; While Cooper et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] note that \u0026ldquo;Clinical reasoning can be defined as, \u0026lsquo;A skill, process, or outcome wherein clinicians observe, collect and interpret data to diagnose and treat patients.\u0026rdquo; Many of these articles (n\u0026thinsp;=\u0026thinsp;30) understood clinical reasoning as the primary means to achieve clinical expertise, without explaining what clinical expertise itself entailed and despite the connection between the two remaining relatively mysterious [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOnly a handful of articles (n\u0026thinsp;=\u0026thinsp;9) provided direct definitions of clinical expertise, although they varied in their terminology utilized (see Table\u0026nbsp;4). Most articles (n\u0026thinsp;=\u0026thinsp;42) provided negative definitions of clinical expertise, in the sense that no strict definition was given; instead, clinical expertise was contrasted against skills (or lack thereof) typically associated with being a novice. For instance, Barrows \u0026amp; Feltovich [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] note that \u0026ldquo;The expert, with more experience in variations and permutations of disease expression, may come to a diagnosis more readily than the novice.\u0026rdquo; The remaining articles (n\u0026thinsp;=\u0026thinsp;18) merely alluded to elements of clinical expertise. Some expositions emphasized clinical experience as being the driving factor distinguishing novices from experts. In all, direct definitions or references to clinical expertise in the literature appeared to paint clinical expertise as a variable constellation of four main elements. Namely, clinical expertise may be seen as some combination of biomedical knowledge, clinical knowledge, clinical skills, and clinical experiences. Biomedical knowledge and clinical knowledge are deliberately noted as distinct forms of knowledge, with biomedical knowledge being the basic underpinnings of the human body, biochemical mechanisms, and pathophysiology, whereas clinical knowledge is the knowledge of how diseases manifest in clinical settings (e.g., signs and symptoms, treatments, etc.) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Biomedical knowledge was emphasized as being the foundation upon which all other forms of knowledge rest: \u0026ldquo;Background knowledge is the foundation of clinical practice without which [clinical reasoning] is meaningless\u0026rdquo; [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. However, its importance was sometimes downplayed in the grand scheme of clinical expertise development, with McColl et al. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] noting that the current structure of curricula \u0026ldquo;may not be the most effective way of developing clinical expertise from bioscience knowledge.\u0026rdquo; Instead, \u003cem\u003eclinical\u003c/em\u003e knowledge was often touted as (more) crucial for clinical expertise and heavily linked to clinical experiences. Ju \u0026amp; Choi [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] note that medical experts \u0026ldquo;predominantly use clinical knowledge accumulated from their clinical experiences, rather than biomedical knowledge, to represent and diagnose a patient\u0026rsquo;s problem.\u0026rdquo;\u003c/p\u003e \u003cp\u003eAs for clinical skills, these were also viewed as essential for clinical expertise as they are \u0026ldquo;tools for doctors to find new information about patients in their [clinical reasoning] process\u0026rdquo; [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Epstein \u0026amp; Hundert [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] similarly emphasized that \u0026ldquo;Competence builds on a foundation of basic clinical skills, scientific knowledge, and moral development.\u0026rdquo; However, mentions of clinical skills development varied as some articles (n\u0026thinsp;=\u0026thinsp;6) equated clinical skills with procedural skills (e.g., venipuncture, surgical techniques, etc.). Others (n\u0026thinsp;=\u0026thinsp;9) utilized clinical skills in a broader sense to encompass not only procedural skills but communication. Nevertheless, references to clinical skills predominantly focused on cognitive elements of clinical practice (see Section \u003cspan refid=\"Sec10\" class=\"InternalRef\"\u003e3.1\u003c/span\u003e). Lastly, clinical experience was often praised as the main driver of clinical expertise, with some noting that the title of expert comes primarily through years of experience and the assumed knowledge accumulated during those years [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Cognitive Elements of Clinical Expertise\u003c/h2\u003e \u003cp\u003eNotable trends appeared throughout the literature emphasizing various elements of medical education, ranging from theoretical understandings of cognition to concrete pedagogical methods. We highlight the most recurring trends in the following subsections.\u003c/p\u003e \u003cp\u003eTheories of cognition and references to various cognitive processes or shortcuts were dominant in the literature, appearing across 61 articles. The most prevalent reference, appearing across 35 articles, was the concept of illness scripts. Illness scripts are defined as \u0026ldquo;mental scenarios of the conditions under which a disease emerges, the disease process itself, and its consequences in terms of possible signs, symptoms, and management alternatives\u0026rdquo; [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. These were often mentioned in conjunction with distinctions between novices and experts, noting that scripts develop and become more efficient with clinical experience [\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. More specifically, the development from novice to expert often sees an accumulation and later maturation of illness scripts, leading to encapsulation, the \u0026ldquo;subsuming or \u0026lsquo;packaging\u0026rsquo; of lower-level, detailed concepts and their inter-relations, under a smaller number of higher-level concepts with the same explanatory power\u0026rdquo; [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe second most common reference (n\u0026thinsp;=\u0026thinsp;31) was to the Dual-Process Theory (DPT). References to DPT were often linked with contrasts between novices and experts, typically equating heavier reliance upon more intuitive, System 1 thinking with experts, and more effortful, analytic System 2 thinking with novices. For instance, Dumas et al. [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] state that \u0026ldquo;it is understood that novices in any discipline must necessarily effortfully use system 2 as they acclimate to their discipline, while experts tend to rely more heavily on automated system 1 processing to make decisions.\u0026rdquo; Despite this understanding, some articles point out that diagnostic and clinical errors tend to occur more through System 1 thinking, with Patel et al. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] noting that \u0026ldquo;Experts make fewer diagnostic errors than nonexperts, but when they do make errors, they are most often errors of overconfidence, which arise from their overreliance on heuristics.\u0026rdquo; A further consequence of this noted reliance upon intuitive, System 1 thinking, is that \u0026ldquo;Although the physicians\u0026rsquo; intuitive clinical experience is usually the main source of learning about the diagnostic value of clinical findings, such unsystematic experience may not be as accurate as the information obtained from high-quality diagnostic studies\u0026rdquo; [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFollowing illness scripts and DPT, the concepts of metacognition and heuristics appeared the third most, both across 20 articles. Metacognition is viewed as a deliberate reflection upon one\u0026rsquo;s own thinking, or, thinking about thinking [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. This process of reflection is often emphasized as a key component for clinical expertise, and a vital skill for avoiding clinical, primarily diagnostic, errors [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Often, this deliberate reflection was viewed as a fundamental aspect of clinical expertise, with Lane \u0026amp; Roberts [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] stating that metacognitive processes are \u0026ldquo;an essential requirement to develop both a therapeutic relationship and professional expertise.\u0026rdquo;\u003c/p\u003e \u003cp\u003eIn contrast, heuristics are seen as cognitive shortcuts or rules of thumb that may be utilized for quicker thinking and decision-making [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Associated with System 1 thinking, these are fast, non-analytical shortcuts that are seen as prevalent throughout clinical practice. Despite this, many articles emphasize that these rules of thumb may be a cause of significant diagnostic errors or biases [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Although this appears to be contentious as \u0026ldquo;other authors argue that heuristics are usually efficient and point to specific knowledge deficits rather than particular reasoning processes as the explanation for reasoning flaws\u0026rdquo; [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, the literature is dominated by approaches to cognition and the reasoning processes that are seen as crucial for the development of clinical expertise. Relating to clinical reasoning, these discussions largely focus on theories from cognitive psychology and studies of cognition such as illness scripts, DPT, metacognition, and heuristics.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Non-Cognitive Elements of Clinical Expertise\u003c/h2\u003e \u003cp\u003eOnly 17 articles noted non-cognitive elements such as communication skills, teamwork, and ethical deliberation as significant components of clinical expertise. Most of these articles (n\u0026thinsp;=\u0026thinsp;9) placed emphasis on the development of communication skills with their effective development noted as \u0026ldquo;essential for accurate and efficient data collection, developing rapport with patients and facilitating teamwork with other health professionals. Communication skills training is therefore an essential component of medical school programs\u0026rdquo; [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. As for teamwork, mentioned across 8 articles, discussions often reflected upon the growing complexity of healthcare systems, interdisciplinary teams, and the importance of developing therapeutic relationships with patients. Because of this, Taha et al. [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] argue that \u0026ldquo;System integration demands not only clinical acumen but also skills in teamwork, communication, and systems navigation, positioning physicians as facilitators of a seamless, patient-centered healthcare experience.\u0026rdquo; Despite these deliberate references to communication skills and teamwork, their importance for the development of clinical expertise remained largely underexplored across the literature, with cognitive training elements taking precedence.\u003c/p\u003e \u003cp\u003eAdditionally, the importance of ethical deliberation skills for clinical practice was notably lacking in the literature, only appearing across 7 articles\u0026mdash;only 3 of which overlapped with the 9 articles emphasizing communication skills and only 2 with the 8 articles emphasizing teamwork. These articles made efforts to discuss elements of ethical deliberation as a key element for developing clinical expertise. Ng et al. [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] note that \u0026ldquo;In real-world settings, clinical decision-making is often not simply driven by fixed cognitive models, but also influenced by contextual and emotional influences.\u0026rdquo; These articles often emphasized the importance of medical or clinical ethics courses for the development of ethical deliberation and the moral development needed for clinical expertise [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Additional but rare discussions (n\u0026thinsp;=\u0026thinsp;2) occurred surrounding the role of empathy and emotions in clinical practice and the development of empathetic physicians. For instance, the emotional state of physicians may be crucial for patient outcomes as Pelaccia et al. [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] note that \u0026ldquo;Labelling patients as \u0026lsquo;plaintive\u0026rsquo;, \u0026lsquo;difficult\u0026rsquo;, \u0026lsquo;manipulative\u0026rsquo; or \u0026lsquo;borderline personality\u0026rsquo; is also likely to influence reasoning.\" Crucially, only one article [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] highlighted all three non-cognitive elements as important factors for developing clinical expertise.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Teaching Approaches \u0026amp; Perceived Shortcomings\u003c/h2\u003e \u003cp\u003eComplementing the emphasis on various cognitive processes and theories, the literature often (n\u0026thinsp;=\u0026thinsp;40) mentions specific teaching strategies for developing and strengthening clinical expertise. Many articles stress the importance of utilizing case-based learning (n\u0026thinsp;=\u0026thinsp;14) or problem-based learning (n\u0026thinsp;=\u0026thinsp;13) schemes to develop the clinical expertise of students. Some articles also suggest tests or methods of measurement for the clinical reasoning process or examining clinical competencies, ranging from approaches like the Script Concordance Test (n\u0026thinsp;=\u0026thinsp;11) or Objective Structured Clinical Examinations (n\u0026thinsp;=\u0026thinsp;6).\u003c/p\u003e \u003cp\u003eMentions of perceived shortcomings in current medical educational practices were prevalent, appearing across 29 articles and almost 25 years (2003\u0026ndash;2025). These mentions predominantly discussed elements wholly neglected in medical education, approaches deemed ineffective, or disjunctions between what is taught and what is needed or used in everyday practice. As Mohd Mohd Tambeh \u0026amp; Yaman [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] state, \u0026ldquo;A lack of knowledge transfer and application from pre-clinical to clinical students, as well as limited opportunities to practice [clinical reasoning], are several identified environmental barriers.\u0026rdquo; Clinical reasoning was, again, the predominant focus of these discussions. These articles often noted that current medical education curricula and/or literature appear to be either ineffective in their teaching of clinical reasoning or wholly neglecting the topic. For instance, Durning et al. [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] emphasize that \u0026ldquo;Despite [the] widely held perception of clinical reasoning there are a number of barriers to effective clinical reasoning instruction. For example, prior publications cite clinical reasoning as having a variety of definitions [\u0026hellip;], faculty do not feel adequately prepared to teach this topic and medical school curricula are not believed to spend ample time on teaching this essential ability.\u0026rdquo; On the other hand, Pelaccia [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] states that \u0026ldquo;although medical educators share the view of clinical reasoning as a major determinant of physicians\u0026rsquo; expertise, it is not often an explicit educational objective in medical universities.\u0026rdquo; Overall, despite the discussion of shortcomings in medical education spanning more than 20 years, literature persists in pointing out gaps, primarily around the deliberate teaching of clinical reasoning and the disjunction between educational and real-world settings. Guidry et al. [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] emphasize that medical education tends to neglect the considerable complexity of the clinical setting with all its uncertainty, rapid pace, and distracting elements. This further appears as a relative heterogeneity of approaches for teaching and measuring clinical expertise and a tendency to overshadow other vital elements of clinical practice [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eWe have identified 26 different terminologies for clinical expertise, largely focused on a constellation of four main elements: a biomedical knowledge base, clinical knowledge, clinical skills, and clinical experiences. Despite the relative simplicity of these component parts, tensions often arose when these elements were viewed together, with literature often questioning the importance of a biomedical knowledge base as well as overshadowing the development of clinical skills. Nevertheless, these four elements have proven difficult to conceptualize and operationalize. To deal with these issues, much of the literature associates these four main elements with the term clinical \u003cem\u003ereasoning\u003c/em\u003e. This trend is seen through the dominance of cognitive theories and focus on the cognitive elements of clinical practice. Clinical reasoning is thus operationalized as a proxy for clinical expertise; although, what clinical expertise ultimately entails is considerably under-developed.\u003c/p\u003e \u003cp\u003eLooking beyond the study articles, this emphasis on cognitive theories and the cognitive elements of clinical practice may have begun in the wake of the 1910 Flexner report with the emphasis placed on the biomedical sciences, scientific rationalism, and technical progress, often overshadowing the healing, patient-centered aspects of medical care [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. The post-Flexnerian emphasis on scientific discovery and technical mastery in medical education has arguably led to physicians developing into technical experts, while diminishing the cultivation of the beneficent healer role [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. This trend has been recognized by Michel Foucault\u0026rsquo;s infamous \u003cem\u003eThe Birth of the Clinic\u003c/em\u003e, in which he develops the concept of the \u0026ldquo;medical gaze,\u0026rdquo; an objectifying lens through which patients are seen as specimens or subjects to be diagnosed rather than people to be cared for [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. The favoring of technicality and rationality has had the effect of diminishing experiential, narrative elements of medicine\u0026mdash;although the rise of narrative medicine and phenomenological approaches to health have grown since the late 1990s to counter this historical trend [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. In medicine and beyond, academic research in the 1960s into expertise focused primarily on epistemic expertise, or \u003cem\u003eknowledge-that\u003c/em\u003e, favoring factual or knowledge-based expertise over other forms of expertise that have only more recently entered the discussion (e.g., \u003cem\u003eknow-how\u003c/em\u003e or performative expertise) [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding practices in medical education, the literature specifically addressing teaching methodologies often noted the teaching of clinical reasoning as a considerably neglected element. Despite its neglect, it remained a recurring topic of discussion as a notable foundation of clinical expertise. This tension often manifested in the historical trend of new physicians, to a large degree, implicitly developing their clinical expertise through the often-passive accumulation of clinical experiences. In some sense, the literature appears to often assume that mere exposure to clinical environments, at least in the presence of relative experts, act to aid in the development of clinical expertise. Although important, these experiences may suffer from considerable variability, depending on the environment or clinical context. Like the noted polyphony of terminologies for clinical expertise, this likely persists due to a considerable polyphony of terminologies for clinical reasoning, again, highlighting the importance of conceptual clarity for educational purposes. Even as pedagogical methods have arisen to teach clinical reasoning elements to medical students, there remains a notable disjunction between the teaching environment and real-world practice. This finding in the literature stresses the importance of early and targeted clinical experiences for medical students to aid in bridging the curated, \u0026ldquo;kind\u0026rdquo; environment of the classroom and the \u0026ldquo;wicked\u0026rdquo; environment of the clinic [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Nevertheless, the centrality of teaching clinical reasoning and the importance clinical experience accumulation for clinical expertise stands in notable tension with the ideals of EBM.\u003c/p\u003e \u003cp\u003eQuestions of objectivity, evidence-gathering, and expertise are fundamentally conceptual and philosophical issues. Indeed, despite the rapid \u003cem\u003emethodological\u003c/em\u003e development of the EBM paradigm, its \u003cem\u003econceptual\u003c/em\u003e development, particularly with respect to clinical expertise, has not appeared to keep pace. Addressing this disjunction requires a more intentional effort to combine philosophical analysis with medical literature. Still, EBM remains the guiding paradigm in modern medicine; indeed, we do not wish to reject it, nor do we think it should be. However, as noted in the introduction, deeper conceptual analyses of the paradigm, particularly clinical expertise, has fallen by the wayside, in favoring empirical approaches to evidence gather, such as randomized controlled trials [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Philosophical analyses and accounts of various elements of EBM have arisen in tandem with, yet often siloed from, medical literature. We wish this review to act as a key catalyst for further conceptual analysis and a deliberate merging of the two domains to rebut the previous patterns of conceptual neglect surrounding clinical expertise. This task has become exceedingly important given the rapid advances and integration of AI tools into healthcare, especially into clinical domains. The increasing integration of AI-based tools into medical research, medical education, and clinical practice carry a range of epistemic and ethical concerns and add elements of uncertainty to clinical practice that must be addressed [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. As AI will likely continue to develop and be integrated into clinical environments, it is vital that we clarify and understand such fundamental concepts as clinical expertise.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Takeaways\u003c/h2\u003e \u003cp\u003eOur study highlights the current polyphony of terminologies surrounding clinical expertise. Nevertheless, clinical expertise is broadly seen in the literature as a constellation of a biomedical knowledge base, clinical knowledge, clinical skills, and clinical experiences. It remains unclear which elements, if any, are considered the best or most effective representation of clinical expertise. Likely because of this ambiguity, clinical reasoning has taken precedence as a proxy for clinical expertise, appearing as a process more amenable to deliberate teaching and assessment. Despite the importance of cognitive structures and approaches in clinical practice, this dominance has appeared to bias conceptualizations of clinical expertise, notably overlooking non-cognitive factors such as communication skills, teamwork, and ethical deliberation. The wide range of terminologies used, as well as the bias toward cognition, have appeared to manifest in perceived shortcomings in pedagogical approaches. Medical educators and students face the challenge of bridging the educational and clinical environments; this already challenging task is compounded by conceptual confusion around clinical expertise. In essence, further conceptualizations of clinical expertise must account not only for epistemic expertise, but also performative, adaptive, and virtuous forms of expertise that constantly interact with each other in clinical environments.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Strengths and Limitations\u003c/h2\u003e \u003cp\u003eOur study has several notable strengths. First, the large sample size of analyzed literature increases the representativeness of the conceptual landscape. Second, we believe that calling attention to the various forms of expertise better matches common narratives about the physician as not only a superior source of knowledge but also as a healing, beneficent figure [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. Lastly, the study proves timely with recent developments in AI and integrated clinical practice, especially as the technological advances of these tools present increasing epistemic and ethical quandaries. Understanding the current landscape of clinical expertise in medical education is an important steppingstone to ensuring these forms of expertise are considered and keep pace with AI integration.\u003c/p\u003e \u003cp\u003eOur study should be interpreted considering the following limitations. First, we chose to limit articles to those that focus on \u003cem\u003econceptualizations\u003c/em\u003e of clinical expertise, foregoing experimental studies that operationalize clinical expertise. In this regard, some experimental studies may have introduced definitions of clinical expertise that were thus not captured by our search. Second, we focused on \u003cem\u003ephysicians\u003c/em\u003e given their distinct roles in clinical practice; however, other clinicians such as physician assistants, nurses, or pharmacists may have differing conceptions of clinical expertise that are worth exploring in future studies. Additionally, we chose to focus on clinical expertise as discussed in relation to undergraduate medical education; thus, articles addressing the real-world clinical application or understanding of clinical expertise were not captured. This decision was made with the intention to understand how clinical expertise may be understood and taught in the beginning phases of medical education, which likely aids in giving a broader picture of its necessary component parts (as opposed to continuing medical education which may stress just one or two elements, like clinical knowledge or clinical experiences). Lastly, we acknowledge that there is a geographic bias toward Western nations, predominantly in Europe and parts of North America. This bias must be kept in mind as understandings of clinical expertise and pedagogical approaches may differ across other healthcare systems.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe present study highlights the considerable polyphony of terminologies used to describe clinical expertise and the heterogeneous nature of pedagogical practices in medical education. Specifically, our findings indicate the relative conceptual neglect of clinical expertise, as seen in the numerous and often vague approaches to defining it, with the primary approach focusing on clinical reasoning as a proxy more amenable to study. The literature is subsequently skewed toward theories of cognition, tending to view clinical expertise largely as a cognitive attribute, neglecting non-cognitive elements of clinical expertise, such as communication skills, teamwork, and ethical deliberation. The myriad terminologies and bias toward cognition manifest in shortcomings in educational practices, as educators struggle to grasp or assess clinical expertise. Future research should focus on clearly conceptualizing clinical expertise to aid in more structured, homogenous medical education and assist in broadening understandings of expertise in medicine.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; AI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eArtificial Intelligence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; DPT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDual-Process Theory\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; EBM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEvidence-Based Medicine\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data analyzed during this study are included in this published article and its supplementary files.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no specific grant or funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEO, OB, and AB conceptualized the initial study design and search string development. Database searches and data gathering were done by EO. Title and abstract screening were done by EO and VT; full-text reading completed by EO. EO and VT coded included articles. Data preparation was completed by EO. The original manuscript was created by EO, with all other authors assisting in the subsequent editing and review process. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank Dr. Edward Hundert, MD for his insightful comments during initial project development.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGuyatt G, Cairns J, Churchill D, Cook D, Haynes B, Hirsh J et al (1992) Evidence-Based Medicine: A New Approach to Teaching the Practice of Medicine. 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Theor Med Bioeth 26(4):277\u0026ndash;305. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11017-005-8184-1\u003c/span\u003e\u003cspan address=\"10.1007/s11017-005-8184-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"ETH Zurich","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Clinical Expertise, Medical Education, Evidence-Based Medicine, Expertise, Clinical Reasoning","lastPublishedDoi":"10.21203/rs.3.rs-9469558/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9469558/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe Evidence-Based Medicine paradigm has dominated modern medicine since its inception in the 1990s. Despite occupying the lowest position in the methodological hierarchy, clinical expertise is fundamental for evidence-based practice and a crucial component of effective medical education. However, little attention has been paid to the concept of clinical expertise. To fill this gap, this study addresses how clinical expertise is conceptualized in medical education literature.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe systematically conducted a scoping review to map how medical education literature conceptually addresses clinical expertise. We queried PubMed, Web of Science, and Scopus databases with a search string of terms related to clinical expertise.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn total, 69 articles spanning 49 years were included for full text review. Upon thematic analysis, we discovered three main interconnected trends across the literature. First, we identified a polyphony of terminologies used to define or allude to clinical expertise, with most of the literature tending to use \u0026lsquo;clinical reasoning\u0026rsquo; as a stand-in or proxy. Second, this use of clinical reasoning as a proxy for clinical expertise appears to downplay non-cognitive aspects such as communication skills, teamwork, and ethical deliberation. Lastly, this bias appears in medical education through a notable heterogeneity of approaches to teaching, manifesting as disjunctions between how clinical expertise is taught and how it is developed and recognized in real-world settings.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eOur findings highlight the relative conceptual neglect of clinical expertise, as seen in the often-vague approaches in definition and subsequent dominance of clinical reasoning as a proxy. In turn, cognitive elements of clinical practice are given more priority while important non-cognitive elements receive considerably less attention/run the risk of being neglected. Future research should focus on clearly conceptualizing clinical expertise to foster the cultivation of a fuller spectrum of capacities enabling integrated, patient-centered, and contextually attuned clinical practice and healthcare delivery. Furthermore, a shared conceptual foundation of clinical expertise may help reduce divergence between medical education and the realities of clinical practice.\u003c/p\u003e","manuscriptTitle":"What Makes a Clinical Expert? A Scoping Review in Medical Education","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-21 15:30:29","doi":"10.21203/rs.3.rs-9469558/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"76e981e3-3258-40f7-b381-38994ddf401d","owner":[],"postedDate":"April 21st, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":66637062,"name":"Translational Medicine"},{"id":66637063,"name":"Medical Ethics"},{"id":66637064,"name":"Educational Philosophy and Theory"}],"tags":[],"updatedAt":"2026-04-21T15:30:29+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-21 15:30:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9469558","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9469558","identity":"rs-9469558","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}