Managing the Complexity‐Coherence Trade‐Off in Clinical Reasoning: A Two‐Stage Graph Ontology Based on WHO International Classifications

ABSTRACT

Background

Clinical reasoning in contemporary practice often involves ill‐structured, poorly defined problems that span the biopsychosocial domain and require reasoning under high relational complexity. Despite sustained scholarly attention to clinical reasoning, few models are both theoretically grounded and usable for clinicians who face this complexity. At the same time, the World Health Organization Family of International Classifications (WHO‐FIC) offers a rich but complex ontology that was not designed primarily to support clinical reasoning in practice.

Aim

To develop a two‐stage WHO‐FIC‐based ontological model of clinical reasoning that is conceptually coherent yet remains cognitively tractable in the face of complexity.

Methods

A conceptual analysis was undertaken. It integrated three strands: (1) WHO‐FIC classification theory, including recent work on harmonisation; (2) empirical and theoretical literature on clinical reasoning; and (3) cognitive theories of bounded rationality, fast‐and‐frugal heuristics, relational complexity, and framing. These strands were used to derive design constraints for a clinically usable ontology. They were then synthesised into a two‐stage, graph‐based model designed to manage the complexity‐coherence trade‐off in clinical reasoning.

Results

Stage 1 introduces a parsimonious triad—Body, Activity, and Environment—represented as a complete three‐node graph with bidirectional relations. This triad provides an etiologically neutral and cognitively economical starting point for framing complex clinical problems. Stage 2 introduces three emergent constructs—Health Condition, Participation, and Intervention—derived compositionally from Stage 1 relations and aligned with ICD‐11, ICF, and ICHI, respectively. The model supports iterative movement between stages through composition and decomposition. It incrementally increases complexity while keeping relational load within cognitively feasible bounds and preserves the value of diagnosis while reducing its tendency to dominate problem framing. A worked case illustrates how the ontology supports reasoning about complex, time‐dependent problems through repeated movement between stages.

Conclusions

The proposed ontology addresses key ambiguities within WHO‐FIC, including the relationship between Activity and Participation and the perceived hierarchical privileging of diagnosis. It offers a more coherent and cognitively usable framework while respecting limits on human reasoning and managing the complexity‐coherence trade‐off. The model provides a theoretically grounded heuristic scaffold for clinicians and educators who work with complexity. It also contributes to clinical reasoning literature by emphasising reasoning about concepts, not only cases, with implications for interprofessional education and practice.

1. Introduction

Clinical reasoning has been examined for decades through both empirical and theoretical work [1, 2, 3]. Despite this sustained attention, important questions remain about how clinicians conceptualise and structure problems encountered in everyday practice. Much of the literature focuses on cognitive processes, including pattern recognition, hypothetico‐deductive reasoning, and dual‐process accounts of thinking [1, 2, 3, 4]. Other work has explored how reasoning is taught, assessed, and improved in educational settings [1, 2, 4]. However, comparatively less explicit attention has been given to the ontological status of the concepts that clinicians use when they reason.

At the same time, healthcare practice is increasingly shaped by large‐scale classification systems and information infrastructures. These systems do more than organise data; they can influence what is recognised as clinically relevant, what is recorded, and what is acted upon in practice [5, 6, 7, 8]. The structures embedded within such systems therefore participate in framing clinical problems, often in ways that remain implicit within routine practice [9].

The World Health Organization Family of International Classifications (WHO‐FIC) is a key example of such an infrastructure [5, 6, 7, 8]. It includes three reference classifications: ICD‐11, ICF, and ICHI [5, 6, 10]. ICD‐11 provides a contemporary disease classification with an increasingly explicit semantic architecture. ICF offers a framework for understanding functioning and disability within context. ICHI provides a structured classification of interventions across healthcare [5, 6, 10].

Recent efforts to harmonise these classifications within the WHO‐FIC Foundation signal an ambition to create a more unified conceptual framework [7, 8]. At the same time, this work highlights areas of potential tension. ICD‐11 must remain compatible with earlier versions, which preserves a strong disease‐centred orientation [5, 7]. This orientation can sit uneasily alongside the broader perspectives embodied in ICF and ICHI, both of which emphasise functioning, context, and intervention as fundamental domains.

These tensions are not merely theoretical. They can influence how clinicians frame problems in practice. ICF was explicitly designed to be etiologically neutral and to foreground functioning in context [6, 11, 12]. ICHI adopts a profession‐neutral structure for classifying interventions [10, 13]. Yet in everyday clinical work, diagnosis often remains a dominant organising principle, with activity, participation, and environmental factors treated as secondary layers rather than integral components of the problem itself [14, 15, 16].

This creates a persistent conceptual imbalance. When diagnosis is treated as the primary organising principle, clinicians may find it difficult to engage fully with problems in which functioning, context, and intervention interact dynamically over time [1, 2, 16]. This is particularly evident in ill‐structured problems, where boundaries are unclear and multiple domains influence one another [17, 18]. Within such problems, participation, for example, cannot be reduced to discrete activities alone, but reflects involvement in socially situated roles that emerge from interactions among bodily states, actions, and environmental conditions [6, 11, 19].

The aim of this article is to address this imbalance by proposing a two‐stage ontological model of clinical reasoning based on the WHO‐FIC. Stage 1 introduces a minimal triad—Body, Activity, and Environment—as a cognitively tractable starting point. Stage 2 introduces a second triad—Health Condition, Participation, and Intervention—that emerges from Stage 1 relations and aligns with the WHO reference classifications [5, 6, 7, 8, 10].

The central contribution of this model is to show how a two‐stage structure can support reasoning in complex, ill‐structured problems without prematurely reducing them to diagnosis‐centred schemas [1, 11, 17]. It also contributes to discussions about the relationship between activity and participation by proposing an account grounded in levels of abstraction, relational complexity, and socially situated participation, rather than competing category lists [6, 11, 19, 20].

2. Methods

This article adopts a conceptual analytic approach rather than an empirical design [1, 3]. Its purpose is to develop and justify an ontological model of clinical reasoning by bringing several strands of literature into explicit relation.

2.1. Conceptual Framework

This article adopts a conceptual framework in which complexity is understood primarily as a property of interactions. Complexity increases as more elements are considered and as the relations among them become denser and more interdependent, such that the system cannot be understood adequately by analysing components in isolation [20, 21, 22]. Within this framework, relational complexity refers to the number of elements that must be coordinated within a single relational structure at a given time [23].

This account draws on relational complexity theory, in which processing demand depends on the arity of the relation under consideration [23]. In graph‐based terms, this can be represented by the number of nodes and relations that must be jointly coordinated within a subgraph [23, 24]. Each stage of the model is therefore represented as a complete three‐node graph, making all pairwise relations explicit while keeping relational load within cognitively feasible bounds [23, 24]. The model manages complexity by constraining the size of the fully connected structure, rather than by removing clinically important interactions [23, 25, 26].

Ontologically, the model is framed at the level of conceptual representation rather than at the level of fundamental metaphysics. In line with information‐science uses of the term, ‘ontology’ here denotes an explicit specification of the concepts and relations that clinicians use to structure complex problems, informed by the architectures of ICD‐11, ICF, and ICHI [5, 6, 7, 8, 10, 13, 27]. The two‐stage graph thus functions as an ontology of clinical problem representations: it identifies a limited set of clinically salient entities and the permissible relations among them, within which more detailed classification codes and narratives can be situated [5, 6, 7, 8, 10, 13, 27]. This does not resolve philosophical debates about the nature of health, disease, or personhood, but it does make explicit how particular ontological assumptions embedded in WHO‐FIC shape the way problems are framed in practice [5, 6, 7, 8, 10, 13, 27, 28].

The analysis integrates four domains: WHO‐FIC classification theory, clinical reasoning theory, cognitive theory relevant to complex problem solving, and basic graph theory used to formalise relationships among clinical concepts. WHO‐FIC classification theory is drawn primarily from ICD‐11, ICF, ICHI, and associated harmonisation work [5, 6, 7, 8, 10, 13]. Clinical reasoning theory is informed by conceptual and empirical work on reasoning processes, diagnosis, and adaptive expertise [1, 2, 3, 4, 14, 15, 16, 17, 18]. Cognitive theory and complexity science contribute accounts of ill‐structured problems, relational and informational complexity, heuristic decision‐making, and the complexity‐coherence trade‐off [17, 21, 23, 24, 25, 26, 29, 30]. Basic graph theory provides tools for representing relationships among clinical concepts [24]. In addition, the analysis draws on sociological work on framing to account for how problems are structured and interpreted in practice [9].

In addition to these literatures, the analysis is grounded in the author's long‐standing clinical and educational use of the WHO Family of International Classifications in rehabilitation medicine across hospital and community settings [18, 31]. Since the publication of the ICF more than 20 years ago, and more recently with the introduction of ICHI, the author has used these classifications in everyday case formulation, service development, and education [6, 10, 31]. The two‐stage model presented here crystallises patterns that have emerged through this longitudinal engagement. It can therefore be understood partly as a product of reflective practice and the development of adaptive expertise in working with WHO‐FIC in complex rehabilitation contexts [18, 31]. This reflexive stance acknowledges that the proposed ontology is shaped by the author's own positioning as a rehabilitation physician and educator working at the interface of hospital and community services.

This interpretation is also consistent with reflexive uses of the ICF in rehabilitation practice, where professional actions and perspectives can themselves be located within the classificatory field rather than treated as neutral or external to it [31]. The model therefore assumes that clinicians are not outside the problem they are reasoning about; they are participants in the relational environment through which the clinical problem is framed and reframed. This also points toward a phenomenological dimension of complexity, in which classifications and cognitive artefacts shape not only what is represented, but how clinical situations are experienced, interpreted, and acted upon in practice [31].

The model is framed as a response to the problem of managing complexity without losing coherence. This aligns with emerging work on trade‐offs between the complexity of cognitive processes and the coherence of the attitudes they produce [30]. Increasing complexity can improve representational adequacy but also heighten the risk of incoherence, making the structure of the reasoning process itself a central concern [30].

Graph‐based representations model concepts as nodes and relationships as edges [24]. This provides a transparent way to represent interactions within complex systems. From a complexity perspective, graphs make both informational and relational structure explicit: additional nodes and edges permit richer representations, but each added relation increases processing demands [23, 24].

The model is also informed by work on heuristic decision making [25, 26]. This literature shows that simple, structured procedures can support effective reasoning under uncertainty and limited cognitive resources [25, 26]. It highlights the importance of constraining complexity rather than assuming that additional information or more elaborate processes will necessarily improve decisions [25, 26].

Design constraints for the model are therefore derived from two complementary considerations. First, cognitive theory highlights limits on processing capacity, particularly with respect to relational complexity, and supports the use of simple heuristic structures [23, 25, 26, 29]. Second, work on clinical reasoning and complex problem solving emphasises the need to accommodate ill‐structured problems that evolve over time and span multiple domains [11, 17, 18, 21]. These constraints motivate an approach that balances representational richness with cognitive tractability. In dual‐process terms, constraining the number of elements that must be jointly coordinated at any given time is expected to bias initial use of the ontology toward rapid, heuristic (Type 1) patterning of nodal relations, while still permitting slower, reflective (Type 2) elaboration when time, uncertainty, and available knowledge demand it [26, 32, 33].

Each stage of the model is represented as a complete graph with three nodes. This structure is intentionally simple but expressive. It allows all concepts to be directly related and supports reasoning about composition and decomposition [24]. From a cognitive perspective, this design remains within feasible bounds of relational complexity while extending beyond purely diagnostic schemas [23, 26].

The analysis proceeds in four steps. First, it examines the current WHO‐FIC architecture and harmonisation work. Second, it identifies the persistence of a disease‐centred orientation alongside broader frameworks. Third, it draws on cognitive and sociological theory to define constraints for a usable ontology, including limits on cognitive capacity, the role of framing in structuring problems, and the risks associated with increasing complexity. Fourth, it synthesises these elements into a two‐stage model.

The resulting model is both normative and explanatory. It does not aim to describe all current reasoning practices. Instead, it proposes a framework evaluated in terms of conceptual coherence, representational adequacy, cognitive usability, and relevance to complex clinical practice [1, 11, 17, 23].

3. Results

3.1. The Two‐Stage Model

The model is organised into two stages, each consisting of three core concepts arranged as a complete graph. All nodes are connected by bidirectional relationships. This structure reflects the design constraint of balancing representational adequacy with cognitive tractability. Limiting each stage to three elements constrains relational complexity while preserving enough structure to represent clinically meaningful interactions [23, 24]. Figure 1 illustrates the two‐stage graph ontology for clinical reasoning proposed in this paper.

Figure 1.

Two‐stage graph model of clinical reasoning based on the WHO‐FIC. Stage 1 comprises a complete graph with Body(B), Activity(A), and Environment(E). Stage 2 comprises a complete graph with Health Condition(H), Participation(P), and Intervention(I). The stages interact through iterative composition and decomposition.

Across both stages, the model functions as a structured approach to problem framing [9]. Stage 1 supports an initial framing that is deliberately non‐diagnostic, while Stage 2 enables the construction of more abstract, classification‐aligned concepts. Movement between stages allows reframing as new information becomes available.

3.1.1. Stage 1: Body, Activity, and Environment

Stage 1 introduces three broad domains: Body, Activity, and Environment. These form the initial representation of the clinical problem and provide a structured but etiologically neutral starting point.

In this paper, Body refers to anatomical structures, physiological and pathophysiological processes, symptoms, impairments, and measurable biological states [6, 11]. Additionally, the Body concept refers to the ‘whole body’ thereby collapsing the division between body structure and function present in the ICF. The term Body is retained deliberately, rather than person, patient, or client, as a measured ontological commitment. This measured stance acknowledges legally and philosophically contested notions such as personhood to be viewed as a more emergent, abstract concept. The term Body rather than Person also avoids privileging states of health, disease, functioning and disability as singularly human; these states are cross‐species phenomena. Furthermore, following Mol's account of “the body multiple”, Body is not intended as a purely biomedical object but as a clinically coherent locus that can hold both traditional biomedical and lived dimensions together in practice [34].

Activity refers to tasks, actions, and observable performance [6, 11, 18]. Environment refers to the physical, social, institutional, and material context [6, 11, 18].

Within Stage 1, the person‐practitioner relationship is not external to the model but embedded within the relations among the three nodes. The Body node may be instantiated as the patient's or person's body, while the Environment node includes ‘supports and relationships’, and therefore provides a natural home for individual health professionals, teams, and the broader systems, services, and policy arrangements within which they work. The Activity node also includes interpersonal interactions and relationships, allowing the clinical encounter itself to be understood as an evolving pattern of action and response. On this reading, the clinical situation is represented not as an isolated patient plus external clinician, but as a relational configuration in which embodied states, interpersonal activity, and professional and institutional environments interact dynamically.

The primary function of Stage 1 is to support initial problem framing under conditions of uncertainty [9]. By constraining the representation to three domains and their relationships, the model reduces relational complexity while ensuring that key dimensions of the problem are considered.

The emphasis is on relationships rather than isolated variables. Bodily states influence activity, and activity in turn shapes bodily states. Environment both constrains and enables activity, while activity may modify the environment. Environment also affects bodily processes [6, 11, 18]. This bidirectional structure supports a dynamic representation of the clinical situation.

3.1.2. Stage 2: Health Condition, Participation, and Intervention

Stage 2 introduces three higher‐level constructs: Health Condition, Participation, and Intervention. These align broadly with ICD‐11, ICF, and ICHI respectively [5, 6, 7, 8, 10].

Health Condition refers to disease or disorder constructs [5, 18]. Participation refers to involvement in socially situated roles and life situations [6, 11, 19]. Intervention refers to structured actions intended to bring about change [10, 13]. These constructs are not assumed at the outset. Rather, they emerge from the configuration of relationships in Stage 1.

The transition from Stage 1 to Stage 2 represents a shift from relational description to conceptual organisation. This shift increases informational and relational complexity: it requires abstraction, integration of heterogeneous information, and coordination of multiple conceptual elements [9, 23, 24, 29, 30]. The model is designed to manage this increase without loss of coherence.

Participation is treated as explicitly emergent. It arises from patterns of interaction among Body, Activity, and Environment, rather than being reducible to activity alone. This reflects its status as involvement in socially situated roles, which cannot be fully specified without reference to context and relational structure [6, 11, 19]. Treating participation in this way clarifies its distinction from activity and avoids category‐based ambiguities. In this model, Participation is not treated as a simple list of social roles or as a derivative of activity alone. Qualitative work with people with disabilities has described participation as active and meaningful engagement, choice and control, access and opportunity, social connection, inclusion, membership, and having an impact, while also emphasising that participation must be defined on the person's own terms rather than by predetermined external norms [35]. Framed in this way, Participation aligns closely with contemporary person‐centred and person‐led care, in which clinical reasoning and decision‐making are shaped by the person's own goals, values, preferences, and circumstances, and enacted through shared decision‐making rather than clinician‐defined functional outcomes alone [32, 36].

Personal factors are not represented as a separate node. Introducing an additional node would increase relational complexity and reduce cognitive usability. Instead, personal factors are implied as emergent attributes of Stage 1 interactions.

More broadly, Stage 2 can be understood as a reframing of the problem at a higher level of abstraction [9]. Health Condition, Participation, and Intervention provide a structured way to organise and act upon the relationships identified in Stage 1, while remaining open to revision.

The model supports bidirectional movement between stages. Clinicians may move from Stage 1 to Stage 2 through composition and return to Stage 1 through decomposition. This enables iterative reasoning and reframing as new information becomes available or as existing interpretations are challenged [23, 24].

From a cognitive perspective, the model operates as a fast‐and‐frugal heuristic scaffold [25, 26]. It reduces the initial problem space to a small number of high‐yield elements while structuring their interrelations. This controlled increase in informational and relational complexity helps to avoid incoherence that can arise when multiple elements are considered without an organising framework [23, 24, 25, 26, 29, 30].

3.2. Worked Case Example

To illustrate how the model operates in practice, consider the following case.

Rahul, a 52‐year‐old man, collapses in the waiting room of a general practice clinic after several days of progressive weakness in his arms and legs. He is unable to stand or walk independently.

At this point, clinicians construct an initial Stage 1 framing. The Body domain includes acute limb weakness and reduced reflexes. The Activity domain includes loss of walking and transfers. The Environment includes the primary care setting, limited diagnostic resources, and the urgency created by collapse in a public space.

This configuration highlights a rapidly evolving interaction between body and activity within a high‐risk environment. The structured framing supports urgent transfer to hospital without requiring premature diagnostic commitment.

In the emergency department, clinicians develop an initial Stage 2 representation. Based on the pattern of weakness and reflex changes, the registrar considers acute inflammatory demyelinating polyneuropathy (AIDP). Health Condition is therefore provisionally framed as AIDP. Participation is implicitly threatened through loss of mobility and independence. Intervention includes hospital admission and initiation of intravenous immunoglobulin.

At this stage, diagnosis plays a central organising role. However, within the model it remains provisional and open to reframing.

Over the next few days, the clinical picture becomes less clear. Cerebrospinal fluid results are inconclusive, and nerve conduction studies show only mild abnormalities inconsistent with AIDP. On the third day of admission, during a longer conversation on the ward, Rahul tells the social worker about drinking heavily since his wife died, the approaching anniversary of her death, and recent losses of his driver's licence and job, with his rental accommodation now at risk. The social worker brings this account back to the treating team in a case conference, prompting a collective return to Stage 1, where information can be updated, re‐explored, and reframed.

Clinicians reassess the relationships between Body, Activity, and Environment. The bodily findings appear milder than expected, while the severity of activity limitation appears disproportionate. The environmental context now appears more salient given Rahul's bereavement, alcohol use, financial stress, and precarious housing.

The Stage 1 representation is now more complex. Body‐level considerations include chronic alcohol exposure and probable functional components within a challenging emotional and psychological context. Activity considerations include loss of mobility and work‐related functions. Environmental factors include bereavement, legal issues, financial stress, limited social support, and a health‐care team that now understands more of his story.

From this revised foundation, a new Stage 2 configuration emerges. Health Condition is reframed as mild neuropathy with functional neurological features. Participation is understood as disruption of multiple socially situated roles, including employment, housing stability, and community engagement. Intervention shifts from a curative biomedical frame to a focus on rehabilitation, addiction support, and social services.

This case illustrates the iterative and dynamic nature of the model. Clinicians move between stages as new information becomes available, using each stage to reframe the problem. Diagnosis is not abandoned but repositioned within a broader conceptual structure.

Importantly, Participation is not reduced to activities like mobility or work alone. Rather, it emerges from the interaction of bodily, functional, and contextual factors over time, enabling a more comprehensive understanding of the patient's situation.

4. Discussion

This article proposes a two‐stage ontological model of clinical reasoning that integrates WHO‐FIC classifications with cognitive and sociological theory. In this sense, the two‐stage graph functions as a scaffold that links macro‐level WHO‐FIC classification infrastructures with the micro‐level, case‐based reasoning of clinicians, without requiring changes to the underlying classifications. The central contribution is to show how clinical reasoning can be structured as an iterative process of framing and reframing, in which a minimal relational representation (Body, Activity, Environment) supports the emergence of higher‐level constructs (Health Condition, Participation, Intervention). In doing so, the model addresses a persistent tension between the representational richness required for complex clinical problems and the cognitive constraints under which clinicians reason [23, 24, 25, 26, 29, 30].

A key implication is the repositioning of diagnosis. Within the model, diagnostic constructs are not eliminated but are situated within a broader conceptual structure. This contrasts with reasoning approaches in which diagnosis functions as the primary organising principle from the outset [1, 2, 3, 4]. By deferring diagnostic commitment and grounding early reasoning in relational structure, the model supports more flexible engagement with ill‐structured problems [17, 18]. This is particularly relevant in contemporary practice, where increasingly complex problems are encountered across the biopsychosocial domain [6, 11, 21].

The model also offers a more precise account of Participation. Within the WHO‐FIC, the distinction between Activity and Participation has long been recognised as conceptually and practically challenging [6, 11]. In this model, Participation is not treated as a predefined category but as an emergent construct arising from the interaction of bodily states, activities, and environmental conditions in socially situated contexts [19]. This shifts the focus from classification to configuration and provides a clearer basis for integrating Participation into clinical reasoning.

More broadly, the model foregrounds the role of framing in clinical reasoning [9]. Clinical problems are not simply given; they are constructed through selective attention to particular elements and relationships. Stage 1 provides a constrained but flexible framing that ensures consideration of key domains without imposing a diagnostic hierarchy. Stage 2 enables reframing at a higher level of abstraction, supporting coordination of Health Condition diagnosis, Participation, and Intervention. The ability to move iteratively between these stages reflects the dynamic nature of reasoning in complex practice.

From a cognitive perspective, the model can be understood as a structured heuristic. It constrains informational and relational complexity by limiting each stage to three elements and making relationships explicit, aligning with evidence that simple, well‐structured approaches can support effective reasoning under conditions of uncertainty and limited cognitive capacity [23, 25, 26, 29]. At the same time, the model preserves enough complexity to represent interactions across domains, addressing concerns that overly simplified frameworks may fail in complex cases [23, 24, 29]. Rather than assigning each stage to a distinct processing mode, the small, fixed set of nodes across the ontology as a whole can be expected to preferentially support Type 1 processing, because it constrains both representational search space and relational load at the point of initial problem framing [26, 32, 33]. With only three elements arranged in a fully connected structure at each stage, all pairwise relationships can be apprehended simultaneously without requiring sequential decomposition or working‐memory‐intensive coordination of higher‐arity relations, thereby promoting rapid pattern completion and cue integration characteristic of Type 1 reasoning while still allowing the same representation to be held and interrogated more deliberately when Type 2 analysis is required [26, 32, 33]. In this sense, the ontology is globally biased toward intuitive, recognition‐based processing through structural parsimony, but does not exclude slower, more analytic reorganisation of the problem; instead, it offers a representational scaffold within which fast and slow modes of reasoning can interact over time [26, 32, 33].

These contributions have implications for both education and practice. For clinicians, the model offers a practical scaffold for structuring reasoning in complex cases, particularly where early diagnostic closure may be problematic. For educators, it provides a way to teach reasoning at the level of concepts and their relationships, rather than focusing solely on case typologies or diagnostic accuracy [1, 2, 3, 4]. For interprofessional teams, the model offers a shared representational framework that accommodates multiple perspectives without privileging a single domain [5, 6, 7, 8, 10, 13].

The model should be understood as both normative and exploratory. It does not aim to describe all instances of clinical reasoning, but to propose a structure that can be evaluated in terms of coherence, usability, and relevance to complex practice [1, 11, 17, 23]. Its value therefore depends on its ability to support reasoning across a range of contexts and to integrate with existing clinical and educational workflows. The model also reflects an adaptive‐expertise trajectory, emerging from repeated attempts to reconcile classification structures with the evolving demands of complex rehabilitation practice.

Several limitations should be acknowledged. The model is conceptual and has not yet been empirically evaluated [1, 2, 3, 4, 11, 17, 18]. Its cognitive and practical benefits remain to be demonstrated in real‐world settings. The treatment of personal factors as distributed attributes, rather than as a separate domain, is a pragmatic design choice that requires further evaluation. In addition, while the model provides a principled account of the relationship between Activity and Participation, this distinction warrants empirical investigation [6, 11, 19].

The model also presupposes some familiarity with the conceptual structures of ICD‐11, ICF, and ICHI; without such knowledge, the potential of the model to support more deliberate, classification‐aligned reasoning is likely to be constrained [12]. In addition, the present analysis focuses on complexity as it bears on cognitive load and problem representation, and does not directly formalise narrative, phenomenological, or Indigenous ways of knowing. Alongside these directions, narrative approaches to clinical reasoning and narrative medicine more broadly offer complementary ways of engaging with patients’ stories and lived experience, and future work could explore how such narrative structures might interface with, or be represented within, the proposed two‐stage ontology [2, 31].

Future work could examine how the model influences case formulation, diagnostic accuracy, and interprofessional communication. It may also be productive to explore its relationship to dual‐process theories of reasoning and to concepts such as adaptive expertise [3, 4, 17, 23, 25, 26, 29, 30]. More broadly, the model raises the possibility that clinical reasoning can be understood not only as a cognitive process but as an interaction between cognitive constraints and the conceptual structures through which problems are represented. This is consistent with phenomenological accounts in which classifications and cognitive artefacts participate in shaping how clinical situations are perceived and lived, not merely how they are recorded [31].

In summary, this article advances a theoretically grounded model of clinical reasoning that integrates classification systems, cognitive theory, and sociological accounts of framing. By structuring reasoning as a two‐stage process of relational representation and conceptual organisation, the model offers a way to engage with complex clinical problems while maintaining coherence and cognitive tractability [9, 23, 24, 25, 26, 29, 30].

Author Contributions

Single author contribution. All content was reviewed and approved by the author.

Funding

The author has nothing to report.

Ethics Statement

Ethics approval was not required for this conceptual article because it did not involve human participants, identifiable personal data, or animal subjects.

Conflicts of Interest

The author declares no conflicts of interest.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

No new data were generated or analysed in support of this conceptual article.