Management Reasoning: Implications for Health Professions Educators and a Research Agenda

Reasoning on Rounds Volume 2: a Framework for Teaching Management Reasoning in the Inpatient Setting

Management reasoning (MR) is a key domain of clinical reasoning that is distinct from the more heavily studied and taught diagnostic reasoning (DR). Despite MR's importance to patient care, there are few published strategies for incorporating MR education into the clinical learning environment. In this perspective, the authors review key theories and clinical principles relevant to MR and integrate these concepts with previously described tools for teaching MR to provide frontline clinical teachers with practical, theory-informed framework for teaching MR during inpatient rounds.

Virtual Patients Using Large Language Models: Scalable, Contextualized Simulation of Clinician-Patient Dialogue With Feedback

BACKGROUND

Virtual patients (VPs) are computer screen-based simulations of patient-clinician encounters. VP use is limited by cost and low scalability.

OBJECTIVE

We aimed to show that VPs powered by large language models (LLMs) can generate authentic dialogues, accurately represent patient preferences, and provide personalized feedback on clinical performance. We also explored using LLMs to rate the quality of dialogues and feedback.

METHODS

We conducted an intrinsic evaluation study rating 60 VP-clinician conversations. We used carefully engineered prompts to direct OpenAI's generative pretrained transformer (GPT) to emulate a patient and provide feedback. Using 2 outpatient medicine topics (chronic cough diagnosis and diabetes management), each with permutations representing different patient preferences, we created 60 conversations (dialogues plus feedback): 48 with a human clinician and 12 "self-chat" dialogues with GPT role-playing both the VP and clinician. Primary outcomes were dialogue authenticity and feedback quality, rated using novel instruments for which we conducted a validation study collecting evidence of content, internal structure (reproducibility), relations with other variables, and response process. Each conversation was rated by 3 physicians and by GPT. Secondary outcomes included user experience, bias, patient preferences represented in the dialogues, and conversation features that influenced authenticity.

RESULTS

The average cost per conversation was US $0.51 for GPT-4.0-Turbo and US $0.02 for GPT-3.5-Turbo. Mean (SD) conversation ratings, maximum 6, were overall dialogue authenticity 4.7 (0.7), overall user experience 4.9 (0.7), and average feedback quality 4.7 (0.6). For dialogues created using GPT-4.0-Turbo, physician ratings of patient preferences aligned with intended preferences in 20 to 47 of 48 dialogues (42%-98%). Subgroup comparisons revealed higher ratings for dialogues using GPT-4.0-Turbo versus GPT-3.5-Turbo and for human-generated versus self-chat dialogues. Feedback ratings were similar for human-generated versus GPT-generated ratings, whereas authenticity ratings were lower. We did not perceive bias in any conversation. Dialogue features that detracted from authenticity included that GPT was verbose or used atypical vocabulary (93/180, 51.7% of conversations), was overly agreeable (n=56, 31%), repeated the question as part of the response (n=47, 26%), was easily convinced by clinician suggestions (n=35, 19%), or was not disaffected by poor clinician performance (n=32, 18%). For feedback, detractors included excessively positive feedback (n=42, 23%), failure to mention important weaknesses or strengths (n=41, 23%), or factual inaccuracies (n=39, 22%). Regarding validation of dialogue and feedback scores, items were meticulously developed (content evidence), and we confirmed expected relations with other variables (higher ratings for advanced LLMs and human-generated dialogues). Reproducibility was suboptimal, due largely to variation in LLM performance rather than rater idiosyncrasies.

CONCLUSIONS

LLM-powered VPs can simulate patient-clinician dialogues, demonstrably represent patient preferences, and provide personalized performance feedback. This approach is scalable, globally accessible, and inexpensive. LLM-generated ratings of feedback quality are similar to human ratings.

[The concordance approach to nursing training: an innovation worth discovering]

The Learning by Concordance approach is a teaching method that uses digital technology to practice clinical reasoning in common practice situations where elements of uncertainty remain. This article outlines the characteristics and theoretical foundations of this pedagogical modality, as well as its principles of design and use. Examples drawn from experience will be presented, as well as a review of nursing studies on the subject.

Exploring management reasoning when discharging high-risk postoperative patients from the post-anaesthesia care unit

INTRODUCTION

Decision-support tools for detecting physiological deterioration are widely used in clinical medicine but have been criticised for fostering a task-oriented culture and reducing the emphasis on clinical reasoning. Little is understood about what influences clinical decisions aided by decision-support tools, including professional standards, policies, and contextual factors. Therefore, we explored management reasoning employed by anaesthesiologists and PACU nurses in the post-anaesthesia care unit during the discharge of high-risk postoperative patients.

METHODS

A qualitative constructivist study, conducting 18 semi-structured with 6 anaesthesiologists and 12 nurses across three Danish teaching hospitals. We analysed data through thematic analysis, utilising Michael Lipsky's theory of "street-level bureaucracy" in combination with David A. Cook's Management Reasoning Framework as a sensitising concept.

RESULTS

Standards are frequently ambiguous, requiring interpretation and prioritisation. This allows for professional discretion by circumventing established policies, reducing task-oriented culture and enhancing the clinical reasoning processes. However, discretion in management reasoning depends on whether the clinician is inclined to uphold or adjust policies to maintain professional standards, influencing discharge decisions.

CONCLUSION

While decision-support tools offer cognitive aid and help standardise patient trajectories, they also limit professional discretion in management reasoning and can potentially compromise care and treatment. This highlights the need for a balanced approach that considers both the benefits and limitations of these tools in clinical decision-making.

Assessment of management reasoning: Design considerations drawn from analysis of simulated outpatient encounters

PURPOSE

Management reasoning is a distinct subset of clinical reasoning. We sought to explore features to be considered when designing assessments of management reasoning.

METHODS

This is a hybrid empirical research study, narrative review, and expert perspective. In 2021, we reviewed and discussed 10 videos of simulated (staged) physician-patient encounters, actively seeking actions that offered insights into assessment of management reasoning. We analyzed our own observations in conjunction with literature on clinical reasoning assessment, using a constant comparative qualitative approach.

RESULTS

Distinguishing features of management reasoning that will influence its assessment include management scripts, shared decision-making, process knowledge, illness-specific knowledge, and tailoring of the encounter and management plan. Performance domains that merit special consideration include communication, integration of patient preferences, adherence to the management script, and prognostication. Additional facets of encounter variation include the clinical problem, clinical and nonclinical patient characteristics (including preferences, values, and resources), team/system characteristics, and encounter features. We cataloged several relevant assessment approaches including written/computer-based, simulation-based, and workplace-based modalities, and a variety of novel response formats.

CONCLUSIONS

Assessment of management reasoning could be improved with attention to the performance domains, facets of variation, and variety of approaches herein identified.

On context specificity and management reasoning: moving beyond diagnosis

OBJECTIVES

Diagnostic error is a global emergency. Context specificity is likely a source of the alarming rate of error and refers to the vexing phenomenon whereby a physician can see two patients with the same presenting complaint, identical history and examination findings, but due to the presence of contextual factors, decides on two different diagnoses. Studies have not empirically addressed the potential role of context specificity in management reasoning and errors with a diagnosis may not consistently translate to actual patient care.

METHODS

We investigated the effect of context specificity on management reasoning in individuals working within a simulated internal medicine environment. Participants completed two ten minute back to back common encounters. The clinical content of each encounter was identical. One encounter featured the presence of carefully controlled contextual factors (CF+ vs. CF-) designed to distract from the correct diagnosis and management. Immediately after each encounter participants completed a post encounter form.

RESULTS

Twenty senior medical students participated. The leading diagnosis score was higher (mean 0.88; SEM 0.07) for the CF- encounter compared with the CF+ encounter (0.58; 0.1; 95 % CI 0.04-0.56; p=0.02). Management reasoning scores were higher (mean 5.48; SEM 0.66) for the CF- encounter compared with the CF+ encounter (3.5; 0.56; 95 % CI 0.69-3.26; p=0.01). We demonstrated context specificity in both diagnostic and management reasoning.

CONCLUSIONS

This study is the first to empirically demonstrate that management reasoning, which directly impacts the patient, is also influenced by context specificity, providing additional evidence of context specificity's role in unwanted variance in health care.

Creating virtual patients using large language models: scalable, global, and low cost

Virtual patients (VPs) have long been used to teach and assess clinical reasoning. VPs can be programmed to simulate authentic patient-clinician interactions and to reflect a variety of contextual permutations. However, their use has historically been limited by the high cost and logistical challenges of large-scale implementation. We describe a novel globally-accessible approach to develop low-cost VPs at scale using artificial intelligence (AI) large language models (LLMs). We leveraged OpenAI Generative Pretrained Transformer (GPT) to create and implement two interactive VPs, and created permutations that differed in contextual features. We used systematic prompt engineering to refine a prompt instructing ChatGPT to emulate the patient for a given case scenario, and then provide feedback on clinician performance. We implemented the prompts using GPT-3.5-turbo and GPT-4.0, and created a simple text-only interface using the OpenAI API. GPT-4.0 was far superior. We also conducted limited testing using another LLM (Anthropic Claude), with promising results. We provide the final prompt, case scenarios, and Python code. LLM-VPs represent a 'disruptive innovation' - an innovation that is unmistakably inferior to existing products but substantially more accessible (due to low cost, global reach, or ease of implementation) and thereby able to reach a previously underserved market. LLM-VPs will lay the foundation for global democratization via low-cost-low-risk scalable development of educational and clinical simulations. These powerful tools could revolutionize the teaching, assessment, and research of management reasoning, shared decision-making, and AI evaluation (e.g. 'software as a medical device' evaluations).

Radiologist preferences for faculty development initiatives to improve resident feedback in the era of competency-based medical education

INTRODUCTION

Since 2022, all Canadian post-graduate medical programs have transitioned to a Competence by Design (CBD) model within a Competency-Based Medical Education (CBME) framework. The CBME model emphasized more frequent, formative assessment of residents to evaluate their progress towards predefined competencies in comparison to traditional medical education models. Faculty members therefore have increased responsibility for providing assessments to residents on a more regular basis, which has associated challenges. Our study explores faculty assessment behaviours within the CBD framework and assesses their openness to opportunities aimed at improving the quality of written feedback. Specifically, we explore faculty's receptiveness to routine metric performance reports that offer comprehensive feedback on their assessment patterns.

METHODS

Online surveys were distributed to all 28 radiology faculty at Queen's University. Data were collected on demographics, feedback practices, motivations for improving the teacher-learner feedback exchange, and openness to metric performance reports and quality improvement measures. Following descriptive statistics, unpaired t-tests and one-way analysis of variance were conducted to compare groups based on experience and subspecialty.

RESULTS

The response rate was 89% (25/28 faculty). 56% of faculty were likely to complete evaluations after working with a resident. Regarding the degree to which faculty felt written feedback is important, 62% found it at least moderately important. A majority (67%) believed that performance reports could influence their evaluation approach, with volume of written feedback being the most likely to change. Faculty expressed interest in feedback-focused development opportunities (67%), favouring Grand Rounds and workshops.

CONCLUSION

Assessment of preceptor perceptions reveals that faculty recognize the importance of offering high-quality written feedback to learners. Faculty openness to quality improvement interventions for curricular reform relies on having sufficient time, knowledge, and skills for effective assessments. This suggests that integrating routine performance metrics into faculty assessments could serve as a catalyst for enhancing future feedback quality.

A graphical model to make explicit pharmacist clinical reasoning during medication review

Pharmacists' roles have evolved substantially from traditional drug compounding and dispensing to encompass patient-centred clinical services. Pharmacist clinical reasoning, though fundamental to these new roles, generally remains implicit and understudied, particularly compared with that of other healthcare professionals, such as physicians. However, teaching and supervising the clinical services provided by pharmacists require a thorough understanding of the reasoning process involved. Several models describing pharmacist clinical reasoning have been developed, but they lack unified mapping. Here, we used an instrumental case study approach to develop a model of pharmacist clinical reasoning during medication review. Our model is adapted from a previously published modelling-using-typified-objects model of physician clinical reasoning in all its cognitive complexity. Our pharmacist model, validated after iterative development and expert consultation, aligns components of pharmacist clinical reasoning with those of physician clinical reasoning. The clinical case contains drug-related problems of variable clinical relevance, as well as numerous key elements (e.g., laboratory results, vital signs) necessary for conducting a medication review. The case serves both as the foundation for model development and as an illustrative step-by-step example within this article. Our model delineates the subprocesses of pharmacist clinical reasoning during medication review, offering a flexible, multipath structure that underscores the dynamic, nonlinear nature of the reasoning. The model might be able to clarify implicit cognitive processes, thus furthering the overarching objective of promoting reflective skill development among learners rather than relying solely on tacit knowledge gained through practice experience.

Clinical sensemaking: Advancing a conceptual learning model of clinical reasoning

CONTEXT

Much remains unanswered regarding how clinical reasoning is learned in the clinical environment. This study attempts to unravel how novice medical students learn to reason, by examining how they make sense of the clinical patient encounter.

METHOD

The current study was part of a greater research project employing constructivist grounded theory (CGT) to develop a learning model of clinical reasoning. Introducing the sensemaking perspective, as a sensitising concept, we conducted a second level analytic phase with CGT, to further advance our previously developed model. This involved re-examining collected data from semi-structured interviews, participant observations and field interviews of novice students during their early clinical clerkships.

RESULTS

A learning model of how medical students make sense of the patient encounter emerged from the analysis. At its core lie three interdependent processes that co-constitute the students' clinical sensemaking activity. Framing the situation is the process whereby students discern salient situational elements, place them into a meaningful relationship and integrate them into a clinical problem. Inquiring into the situation is the process whereby students gain further insight into the situation by determining which questions need to be asked. Lastly, taking meaningful action is the process whereby students carve out a pathway of action, appropriate for the circumstances. Tensions experienced during these processes impair clinical sensemaking.

CONCLUSIONS

The study provides an empirically informed learning model of clinical reasoning, during the early curricular stages. The model attempts to capture the complexity of medical practice, as students learn to recognise and respond to what constitutes the essence of a clinical situation. In this way, it contributes to a conceptual shift in how we think and talk about clinical reasoning. It introduces the concept of clinical sensemaking, as the act of carving a tangible clinical problem out of an often undetermined clinical situation and pursuing justified action.

Reasoning about reasoning - using recall to unveil clinical reasoning in stroke rehabilitation teams

PURPOSE

The study objective was to investigate how health care providers in stroke teams reason about their clinical reasoning process in collaboration with the patient and next of kin.

MATERIALS AND METHODS

An explorative qualitative design using stimulated recall was employed. Audio-recordings from three rehabilitation dialogs were used as prompts in interviews with the involved staff about their clinical reasoning. A thematic analysis approach was employed.

RESULTS

A main finding was the apparent friction between profession-centered and person-centered clinical reasoning, which was salient in the data. Five themes were identified: the importance of different perspectives for a rich picture and well-informed decisions; shared understanding in analysis and decision-making - good intentions but difficult to achieve; the health care providers' expertise directs the dialog; the context's impact on the rehabilitation dialog; and insights about missed opportunities to grasp the patient perspective and arrive at decisions.

CONCLUSIONS

Interprofessional stroke teams consider clinical reasoning as a process valuing patient and next of kin perspectives; however, their professional expertise risks preventing individual needs from surfacing. There is a discrepancy between professionals' intentions for person-centeredness and how clinical reasoning plays out. Stimulated recall can unveil person-centered practice and enhance professionals' awareness of their clinical reasoning.

Enhancing therapeutic reasoning: key insights and recommendations for education in prescribing

BACKGROUND

Despite efforts to improve undergraduate clinical pharmacology & therapeutics (CPT) education, prescribing errors are still made regularly. To improve CPT education and daily prescribing, it is crucial to understand how therapeutic reasoning works. Therefore, the aim of this study was to gain insight into the therapeutic reasoning process.

METHODS

A narrative literature review has been performed for literature on cognitive psychology and diagnostic and therapeutic reasoning.

RESULTS

Based on these insights, The European Model of Therapeutic Reasoning has been developed, building upon earlier models and insights from cognitive psychology. In this model, it can be assumed that when a diagnosis is made, a primary, automatic response as to what to prescribe arises based on pattern recognition via therapy scripts (type 1 thinking). At some point, this response may be evaluated by the reflective mind (using metacognition). If it is found to be incorrect or incomplete, an alternative response must be formulated through a slower, more analytical and deliberative process, known as type 2 thinking. Metacognition monitors the reasoning process and helps a person to form new therapy scripts after they have chosen an effective therapy. Experienced physicians have more and richer therapy scripts, mostly based on experience and enabling conditions, instead of textbook knowledge, and therefore their type 1 response is more often correct.

CONCLUSION

Because of the important role of metacognition in therapeutic reasoning, more attention should be paid to metacognition in CPT education. Both trainees and teachers should be aware of the possibility to monitor and influence these cognitive processes. Further research is required to investigate the applicability of these insights and the adaptability of educational approaches to therapeutic reasoning.

Ethical dilemmas surrounding patients´ "unwise" treatment preferences and suboptimal decision quality: case series of three renal cell carcinoma patients who developed local recurrences after non-guideline-concordant care choices

Patient engagement and shared decision-making (SDM) between patients and clinicians is the foundation of patient-centered care. It aims to reach a treatment option that fits the patient's preference and is guideline-concordant. We sought to evaluate the possible causes and outcomes of patient's non-guideline-concordant care choices. Using a retrospective analysis of the medical records of patients who underwent cryoablation for small renal masses between January 2010 and January 2023. Inclusion criteria were patients with renal tumor(s) who underwent cryoablation which was not recommended by the multidisciplinary team (MDT). We present three patients with unilateral clear cell renal cell carcinoma. Based on imaging and other findings, the oncology MDT recommended partial/radical nephrectomy. Upon consultation, each refused surgery and preferred cryoablation. Respecting their choice, cryoablation was undertaken. The patients had treatment failure and developed recurrences that could have possibly been avoided with guideline-concordant care. Shared decision-making in healthcare involves several aspects: patient/family; uncertainty of available evidence of various treatments; MDT meetings; and treatment team. For patients to select 'wise' treatment preferences i.e. guideline-concordant care, multi-layered complex intellectual and cognitive processes are required, where experience may play a role. Healthcare professionals require guidance and training on appropriate SDM in clinical settings, and awareness of tools to solicit patient choice to guideline-concordant care whilst observing patient autonomy. Patients and treatment teams need the capacity, knowledge, and skills to reach a 'wise' guideline-concordant care treatment preference jointly. Patients' unwise preference could lead to suboptimal outcomes, in the case of our patients, tumor recurrence.

Pharmacists and pharmacy students' perceptions on how a new teaching model supports their clinical decision-making

BACKGROUND AND PURPOSE

Clinical decision-making (CDM) is crucial in pharmacy practice, necessitating effective teaching in undergraduate and postgraduate pharmacy education. This study aims to explore undergraduates and postgraduates' perceptions of how a new teaching model supports their CDM when addressing patient cases.

EDUCATIONAL ACTIVITY AND SETTING

Implemented in a full-day CDM course for pharmacy students and a half-day course for pharmacists in the Netherlands, the model, accompanied by a learning guide, facilitated CDM in patient cases. Eight courses were conducted between September 2022 to June 2023, followed by an online survey measuring participants' agreement on how the model supported their CDM, using a 5-point Likert scale. Additionally, three open-ended questions were included to elicit learning outcomes and self-development opportunities.

FINDINGS

Of 175 invited participants, 159 (91%) completed the survey. Most agreed the teaching model supported their CDM, particularly in considering the patient's healthcare needs and context (96%), and exploring all available options (96%). Participants found the model provided a clear structure (97%), and fostered critical thinking (93%). The most frequently mentioned learning outcomes and self-development opportunities included collecting sufficient relevant information, maintaining a broad perspective, and decelerating the process to avoid premature closure.

SUMMARY

Participants agreed that the teaching model helped them to make clinical decisions. Both undergraduate and postgraduate pharmacy education could possibly benefit from the teaching model's implementation in supporting pharmacy students and pharmacists conducting CDM in pharmacy practice.

Intervention skills - a neglected field of research in medical education and beyond

Intervention reasoning as a critical component of clinical reasoning has been understudied in medical education in contrast to the well-established field of diagnostic reasoning. This resonates in a lack of comprehensive understanding of the cognitive processes involved and a deficit in research to promote intervention skills in future clinicians. In this commentary, we present a conceptual framework for intervention reasoning that includes four phases: generating, selecting, implementing, and evaluating interventions. The conceptualization highlights cognitive processes such as developing interventions based on a patient's diagnosis and signs and symptoms; selecting the most appropriate option by contrasting, prioritizing, and evaluating interventions in terms of feasibility, effectiveness, and the patient's context-specific needs; and predicting patient outcomes within so-called "developmental corridors" to adjust treatments accordingly. In addition to these cognitive processes, interventions require collaborative activities, such as sharing information with other care providers, distributing roles among care teams, or acting together. Future research should validate the proposed framework, examine the impact of intervention reasoning on clinical outcomes, and identify effective training methods (e.g., simulation and AI-based approaches). In addition, it would be valuable to explore the transferability and generalizability of the model to other areas of health education and contexts outside of health education.

'Walking together': How relationships shape physicians' clinical reasoning

INTRODUCTION

The clinical reasoning literature has increasingly considered context as an important influence on physicians' thinking. Physicians' relationships with patients, and their ongoing efforts to maintain these relationships, are important influences on how clinical reasoning is contextualised. The authors sought to understand how physicians' relationships with patients shaped their clinical reasoning.

METHODS

Drawing from constructivist grounded theory, the authors conducted semi-structured interviews with primary care physicians. Participants were asked to reflect on recent challenging clinical experiences, and probing questions were used to explore how participants attended to or leveraged relationships in conjunction with their clinical reasoning. Using constant comparison, three investigators coded transcripts, organising the data into codes and conceptual categories. The research team drew from these codes and categories to develop theory about the phenomenon of interest.

RESULTS

The authors interviewed 15 primary care physicians with a range of experience in practice and identified patient agency as a central influence on participants' clinical reasoning. Participants drew from and managed relationships with patients while attending to patients' agency in three ways. First, participants described how contextualised illness constructions enabled them to individualise their approaches to diagnosis and management. Second, participants managed tensions between enacting their typical approaches to clinical problems and adapting their approaches to foster ongoing relationships with patients. Finally, participants attended to relationships with patients' caregivers, seeing these individuals' contributions as important influences on how their clinical reasoning could be enacted within patients' unique social contexts.

CONCLUSION

Clinical reasoning is influenced in important ways by physicians' efforts to both draw from, and maintain, their relationships with patients and patients' caregivers. Such efforts create tensions between their professional standards of care and their orientations toward patient-centredness. These influences of relationships on physicians' clinical reasoning have important implications for training and clinical practice.

Distributed cognition: Theoretical insights and practical applications to health professions education: AMEE Guide No. 159

Distributed cognition (DCog) is a member of the family of situativity theories that widens the lens of cognition from occurring solely inside the head to being socially, materially and temporally distributed within a dynamic system. The concept of extending the view of cognition to outside the head of a single health professional is relatively new in the healthcare system. DCog has been increasingly used by researchers to describe many ways in which health professionals perform in teams within structured clinical environments to deliver healthcare for patients. In this Guide, we expound ten central tenets of the macro (grand) theory of DCog (1. Cognition is decentralized in a system; 2. The unit of analysis is the system; 3. Cognitive processes are distributed; 4. Cognitive processes emerge from interactions; 5. Cognitive processes are interdependent; 6. Social organization is a cognitive architecture; 7. Division of labour; 8. Social organization is a system of communication; 9. Buffering and filtering; 10. Cognitive processes are encultured) to provide theoretical insights as well as practical applications to the field of health professions education.

A scoping review of therapeutic reasoning process research

Therapeutic reasoning is when the purpose, task, or goal for engaging in reasoning is to determine the patient's management plan. As the field's understanding of the process of therapeutic reasoning is less well understood, we focused on studies that collected data on the process of therapeutic reasoning. To synthesize previous studies of therapeutic reasoning characteristics, methodological approaches, theoretical underpinnings, and results. We conducted a scoping review with systematic searching for English language articles with no date limits. Databases included MEDLINE, CINAHL Plus, Scopus, Embase, Proquest Dissertations and Theses Global, and ERIC. Search terms captured therapeutic reasoning in health professions education research. Initial search yielded 5450 articles. The title and abstract screening yielded 180 articles. After full-text review, 87 studies were included in this review. Articles were excluded if they were outside health professions education, did not collect data on the process of therapeutic reasoning, were not empirical studies, or not focused on therapeutic reasoning. We analyzed the included articles according to scoping questions using qualitative content analysis. 87 articles dated from 1987 to 2019 were included. Several study designs were employed including think-aloud protocol, interview and written documentation. More than half of the articles analyzed the data using qualitative coding. Authors often utilized several middle-range theories to explain therapeutic reasoning processes. The hypothetico-deductive model was most frequently mentioned. The included articles rarely built off the results from previous studies. Six key result categories were found: identifying themes, characterizing and testing previous local theory, exploring factors, developing new local theory, testing tools, and testing hypothesis. Despite the cast body of therapeutic reasoning research, individual study results remain isolated from previous studies. Our future recommendations include synthesizing pre-existing models, developing novel methodologies, and investigating other aspects of therapeutic reasoning.

Management reasoning and patient-clinician interactions: Insights from shared decision-making and simulated outpatient encounters

PURPOSE

To expand understanding of patient-clinician interactions in management reasoning.

METHODS

We reviewed 10 videos of simulated patient-clinician encounters to identify instances of problematic and successful communication, then reviewed the videos again through the lens of two models of shared decision-making (SDM): an 'involvement-focused' model and a 'problem-focused' model. Using constant comparative qualitative analysis we explored the connections between these patient-clinician interactions and management reasoning.

RESULTS

Problems in patient-clinician interactions included failures to: encourage patient autonomy; invite the patient's involvement in decision-making; convey the health impact of the problem; explore and address concerns and questions; explore the context of decision-making (including patient preferences); meet the patient where they are; integrate situational preferences and priorities; offer >1 viable option; work with the patient to solve a problem of mutual concern; explicitly agree to a final care plan; and build the patient-clinician relationship. Clinicians' 'management scripts' varied along a continuum of prioritizing clinician vs patient needs. Patients also have their own cognitive scripts that guide their interactions with clinicians. The involvement-focused and problem-focused SDM models illuminated distinct, complementary issues.

CONCLUSIONS

Management reasoning is a deliberative interaction occurring in the space between individuals. Juxtaposing management reasoning alongside SDM generated numerous insights.

Reframing context specificity in team diagnosis using the theory of distributed cognition

Context specificity refers to the vexing phenomenon whereby a physician can see two patients with the same presenting complaint, identical history and physical examination findings, but due to specific situational (contextual) factors arrives at two different diagnostic labels. Context specificity remains incompletely understood and undoubtedly leads to unwanted variance in diagnostic outcomes. Previous empirical work has demonstrated that a variety of contextual factors impacts clinical reasoning. These findings, however, have largely focused on the individual clinician; here we broaden this work to reframe context specificity in relation to clinical reasoning by an internal medicine rounding team through the lens of Distributed Cognition (DCog). In this model, we see how meaning is distributed amongst the different members of a rounding team in a dynamic fashion that evolves over time. We describe four different ways in which context specificity plays out differently in team-based clinical care than for a single clinician. While we use examples from internal medicine, we believe that the concepts we present apply equally to other specialties and fields in health care.

Cognitive and Metacognitive Processes Demonstrated by Pharmacy Students When Making Therapeutic Decisions

Objective. To characterize the types of cognitive and metacognitive processes demonstrated by third-year pharmacy students during a therapeutic reasoning activity.Methods. A qualitative, descriptive study following a think-aloud protocol was used to analyze the cognitive (analytical) and metacognitive processes observed by third-year pharmacy students as they completed a 25-minute therapeutic reasoning activity. Using a deductive codebook developed from literature about reasoning, two independent coders characterized processes from students' audio-recorded, transcribed think-aloud episodes while making therapeutic decisions about simulated clinical cases.Results. A total of 40 think-aloud episodes were transcribed among the cohort. Categorization of the think-aloud transcriptions revealed a series of cognitive analytical and metacognitive processes demonstrated by students during the therapeutic decision-making activity. A total of 1792 codes were categorized as analytical processes, falling into six major themes: 69% gathering information (1232/1792), 13% processing information (227/1792), 7% making assessments (133/1792), 1% synthesizing information (19/1792), 7% articulating evidence (117/1792), and 4% making a recommendation (64/1792). In comparison to gathering information, a much lower frequency of processing and assessment was observed for students, particularly for those that were unable to resolve the case. Students' movement between major analytical processes co-occurred commonly with metacognitive processes. Of the 918 codes categorized as metacognitive processes, two major themes arose: 28% monitoring for knowledge or emotions (257/918) and 72% controlling the planning of next steps or verification of correct information (661/918). Sequencing the codes and co-occurrences of processes allowed us to propose an integrated cognitive/metacognitive model of therapeutic reasoning for students.Conclusion. This study categorizes the cognitive (analytical) and metacognitive processes engaged during pharmacy students' therapeutic reasoning process. The findings can inform current instructional practices and further research into educational activities that can strengthen pharmacy students' therapeutic reasoning skills.

Reasoning like a doctor or like a nurse? A systematic integrative review

When physicians and nurses are looking at the same patient, they may not see the same picture. If assuming that the clinical reasoning of both professions is alike and ignoring possible differences, aspects essential for care can be overlooked. Understanding the multifaceted concept of clinical reasoning of both professions may provide insight into the nature and purpose of their practices and benefit patient care, education and research. We aimed to identify, compare and contrast the documented features of clinical reasoning of physicians and nurses through the lens of layered analysis and to conduct a simultaneous concept analysis. The protocol of this systematic integrative review was published doi: 10.1136/bmjopen-2021-049862. A comprehensive search was performed in four databases (PubMed, CINAHL, Psychinfo, and Web of Science) from 30th March 2020 to 27th May 2020. A total of 69 Empirical and theoretical journal articles about clinical reasoning of practitioners were included: 27 nursing, 37 medical, and five combining both perspectives. Two reviewers screened the identified papers for eligibility and assessed the quality of the methodologically diverse articles. We used an onion model, based on three layers: Philosophy, Principles, and Techniques to extract and organize the data. Commonalities and differences were identified on professional paradigms, theories, intentions, content, antecedents, attributes, outcomes, and contextual factors. The detected philosophical differences were located on a care-cure and subjective-objective continuum. We observed four principle contrasts: a broad or narrow focus, consideration of the patient as such or of the patient and his relatives, hypotheses to explain or to understand, and argumentation based on causality or association. In the technical layer a difference in the professional concepts of diagnosis and the degree of patient involvement in the reasoning process were perceived. Clinical reasoning can be analysed by breaking it down into layers, and the onion model resulted in detailed features. Subsequently insight was obtained in the differences between nursing and medical reasoning. The origin of these differences is in the philosophical layer (professional paradigms, intentions). This review can be used as a first step toward gaining a better understanding and collaboration in patient care, education and research across the nursing and medical professions.

A GP's clinical reasoning in the context of multimorbidity: beyond the perception of an intuitive approach

INTRODUCTION

GP's clinical reasoning processes in the context of patients suffering from multimorbidity are often a process which remains implicit. Therefore, the goal of this case study analysis is to gain a better understanding of the processes at play in the management of patients suffering from multimorbidity.

METHODS

A case study analysis, using a qualitative thematic analysis was conducted. This case follows a 54-year-old woman who has been under the care of her GP for almost 10 years and suffers from a number of chronic conditions. The clinical reasoning of an experienced GP who can explicitly unfold his processes was chosen for this case analysis.

RESULTS

Four main themes emerged from this case analysis: The different roles that GPs have to manage; the GP's cognitive flexibility and continual adaptation of their clinical reasoning processes, the patient's empowerment, and the challenges related to the collaboration with specialists and healthcare professionals.

CONCLUSION

This could help GPs gain a clearer understanding of their clinical reasoning processes and motivate them to communicate their findings with others during clinical supervision or teaching. Furthermore, this may emphasize the importance of valuing the role of the primary care physician in the management of multimorbid patients.

The future of teaching management reasoning: important questions and potential solutions

Management reasoning is distinct from but inextricably linked to diagnostic reasoning in the iterative process that is clinical reasoning. Complex and situated, management reasoning skills are distinct from diagnostic reasoning skills and must be developed in order to promote cogent clinical decisions. While there is growing interest in teaching management reasoning, key educational questions remain regarding when it should be taught, how it can best be taught in the clinical setting, and how it can be taught in a way that helps mitigate implicit bias. Here, we describe several useful tools to structure teaching of management reasoning across learner levels and educational settings. The management script provides a scaffold for organizing knowledge around management and can serve as a springboard for discussion of uncertainty, thresholds, high-value care, and shared decision-making. The management pause reserves space for management discussions and exploration of a learner's reasoning. Finally, the equity reflection invites learners to examine management decisions from a health equity perspective, promoting the practice of metacognition around implicit bias. These tools are easily deployable, and - when used regularly - foster a learning environment primed for the successful teaching of management reasoning.

"Cephalgia" or "migraine"? Solving the headache of assessing clinical reasoning using natural language processing

In this op-ed, we discuss the advantages of leveraging natural language processing (NLP) in the assessment of clinical reasoning. Clinical reasoning is a complex competency that cannot be easily assessed using multiple-choice questions. Constructed-response assessments can more directly measure important aspects of a learner's clinical reasoning ability, but substantial resources are necessary for their use. We provide an overview of INCITE, the Intelligent Clinical Text Evaluator, a scalable NLP-based computer-assisted scoring system that was developed to measure clinical reasoning ability as assessed in the written documentation portion of the now-discontinued USMLE Step 2 Clinical Skills examination. We provide the rationale for building a computer-assisted scoring system that is aligned with the intended use of an assessment. We show how INCITE's NLP pipeline was designed with transparency and interpretability in mind, so that every score produced by the computer-assisted system could be traced back to the text segment it evaluated. We next suggest that, as a consequence of INCITE's transparency and interpretability features, the system may easily be repurposed for formative assessment of clinical reasoning. Finally, we provide the reader with the resources to consider in building their own NLP-based assessment tools.

Management Reasoning: Empirical Determination of Key Features and a Conceptual Model

PURPOSE

Management reasoning is a critical yet understudied phenomenon in clinical practice and medical education. The authors sought to empirically identify key features of management reasoning and construct a model describing the management reasoning process.

METHOD

In November 2020, 4 investigators each reviewed 10 video clips of simulated outpatient physician-patient encounters and used a coding form to document key features and insights related to management reasoning. The team used a constant comparative approach to distill 120 pages of raw observations into an 18-page list of management tasks, processes, and insights. The team then had a series of discussions to iteratively refine these findings into a parsimonious model of management reasoning.

RESULTS

The investigators empirically identified 12 distinct features of management reasoning: contrasting and selection among multiple solutions; prioritization of patient, clinician, and system preferences and constraints; communication and shared decision making; ongoing monitoring and adjustment of the management plan; dynamic interplay among people, systems, and competing priorities; illness-specific knowledge; process knowledge; management scripts; clinician roles as patient teacher and salesperson; clinician-patient relationship; prognostication; and organization of the clinical encounter (sequencing and time management). Management scripts seemed to play a prominent and critical role. The model of management reasoning comprised 4 steps: instantiation of a management script, identifying (multiple) options and beginning to teach the patient, shared decision making, and ongoing monitoring and adjustment. This model also conceives 2 overarching features: that management reasoning is personalized to the patient and that it occurs between individuals rather than exclusively within the clinician's mind.

CONCLUSIONS

Management scripts constitute a key feature of management reasoning, along with teaching patients about viable options, shared decision making, ongoing monitoring and adjustment, and personalization. Management reasoning seems to be constructed and negotiated between individuals rather than exclusively within the clinician.

Exploring procedure-based management reasoning: a case of tension pneumothorax

OBJECTIVES

Management reasoning has not been widely explored but likely requires broader abilities than diagnostic reasoning. An enhanced understanding of management reasoning could improve medical education and patient care. We conducted a novel exploratory study to gain further insights into procedure-based management reasoning.

METHODS

Participant physicians managed a simulated patient who acutely decompensates in a team-based, time-pressured, live scenario. Immediately following the scenario, physicians perform a think-aloud protocol by watching video recordings of their performance and narrating their reflections in real-time. Verbatim transcripts of the think-aloud protocol were inductively coded using a constant comparative method and evaluated for themes.

RESULTS

We recruited 19 physicians (15 internal medicine, one family medicine, and three general surgery) for this study. Recognizing that diagnostic and management reasoning intertwine, this paper focuses on management reasoning's characteristics. We developed three categories of management reasoning factors with eight subthemes. These are Patient factors: Acuity and Preferences; Physician factors: Recognized Errors, Anxiety, Metacognition, Monitoring, and Threshold to Treat; and one Environment factor: Resources.

CONCLUSIONS

Our findings on procedure-based management reasoning are consistent with Situation Awareness and Situated Cognition models and the extant work on management reasoning, demonstrating that management is inherently complex and contextually bound. Unique to this study, all physicians focused on prognosis, indicating that attaining competency in procedural management may require planning and prediction abilities. Physicians also expressed concerns about making mistakes, potentially resulting from the scenario's emphasis on a procedure and our physicians' having less expertise in the treatment of tension pneumothorax.

Management reasoning scripts: Qualitative exploration using simulated physician-patient encounters

INTRODUCTION

Management reasoning is distinct from diagnostic reasoning and remains incompletely understood. The authors sought to empirically investigate the concept of management scripts.

METHODS

In November 2020, 4 investigators each reviewed 10 video clips of simulated outpatient physician-patient encounters, and used a coding form to document observations about management reasoning. The team used constant comparative analysis to integrate empirically-grounded insights with theories related to cognitive scripts and Type 1/Type 2 thinking.

RESULTS

Management scripts are precompiled conceptual knowledge structures that represent and connect management options and clinician tasks in a temporal or logical sequence. Management scripts appear to differ substantially from illness scripts. Management scripts varied in quality (in content, sequence, flexibility, and fluency) and generality. The authors empirically identified six key features (components) of management scripts: the problem (diagnosis); management options; preferences, values, and constraints; education needs; interactions; and encounter flow. The authors propose a heuristic framework describing script activation, selection, instantiation with case-specific details, and application to guide development of the management plan. They further propose that management reasoning reflects iterative, back-and-forth involvement of both Type 1 (non-analytic, effortless) and Type 2 (analytic, effortful) thinking. Type 1 thinking likely influences initial script activation, selection, and initial instantiation. Type 2 increasingly influences subsequent script revisions, as activation, selection, and instantiation become more deliberate (effortful) and more hypothetical (involving mental simulation).

DISCUSSION

Management scripts constitute a key feature of management reasoning, and could represent a new target for training in clinical reasoning (distinct from illness scripts).

Diagnostic Reasoning of Resident Physicians in the Age of Clinical Pathways

BACKGROUND

Development of skills in diagnostic reasoning is paramount to the transition from novice to expert clinicians. Efforts to standardize approaches to diagnosis and treatment using clinical pathways are increasingly common. The effects of implementing pathways into systems of care during diagnostic education and practice among pediatric residents are not well described.

OBJECTIVE

To characterize pediatric residents' perceptions of the tradeoffs between clinical pathway use and diagnostic reasoning.

METHODS

We conducted a qualitative study from May to December 2019. Senior pediatric residents from a high-volume general pediatric inpatient service at an academic hospital participated in semi-structured interviews. We utilized a basic interpretive qualitative approach informed by a dual process diagnostic reasoning framework.

RESULTS

Nine residents recruited via email were interviewed. Residents reported using pathways when admitting patients and during teaching rounds. All residents described using pathways primarily as management tools for patients with a predetermined diagnosis, rather than as aids in formulating a diagnosis. As such, pathways primed residents to circumvent crucial steps of deliberate diagnostic reasoning. However, residents relied on bedside assessment to identify when patients are "not quite fitting the mold" of the current pathway diagnosis, facilitating recalibration of the diagnostic process.

CONCLUSIONS

This study identifies important educational implications at the intersection of residents' cognitive diagnostic processes and use of clinical pathways. We highlight potential challenges clinical pathways pose for skill development in diagnostic reasoning by pediatric residents. We suggest opportunities for educators to leverage clinical pathways as a framework for development of these skills.

Anatomy of diagnosis in a clinical encounter: how clinicians discuss uncertainty with patients

Background

Studies consider the clinical encounter as linear, comprising six phases (opening, problem presentation, history-taking, physical examination, diagnosis, treatment and closing). This study utilizes formal conversation analysis to explore patient-physician interactions and understanding diagnostic utterances during these phases.

Methods

This study is a qualitative sub-analysis that explores how the diagnosis process, along with diagnostic uncertainty, are addressed during 28 urgent care visits. We analyzed physicians’ hypothesis-generation process by focusing on: location of diagnostic utterances during the encounter; whether certain/uncertain diagnostic utterances were revised throughout the encounter; and how physicians tested their hypothesis-generation and managed uncertainty. We recruited 7 primary care physicians (PCPs) and their 28 patients from Brigham and Women’s Hospital (BWH) in 3 urgent care settings. Encounters were audiotaped, transcribed, and coded using NVivo12 qualitative data analysis software. Data were analyzed inductively and deductively, using formal content and conversation analysis.

Results

We identified 62 diagnostic communication utterances in 12 different clinical situations. In most (24/28, 86%) encounters, the diagnosis process was initiated before the diagnosis phase (57% during history taking and 64% during physical examination). In 17 encounters (61%), a distinct diagnosis phase was not observed. Findings show that the diagnosis process is nonlinear in two ways. First, nonlinearity was observed when diagnostic utterances occurred throughout the encounter, with the six encounter phases overlapping, integrating elements of one phase with another. Second, nonlinearity was noted with respect to the resolution of diagnostic uncertainty, with physicians acknowledging uncertainty when explaining their diagnostic reasoning, even during brief encounters.

Conclusions

Diagnosis is often more interactive and nonlinear, and expressions of diagnostic assessments can occur at any point during an encounter, allowing more flexible and potentially more patient-centered communication. These findings are relevant for physicians’ training programs and helping clinicians improve their communication skills in managing uncertain diagnoses.

How to Keep Training-After Residency Training

Lifelong learning in medicine is an important skill and ethical obligation, but many residents do not feel prepared to be effective self-directed learners when training ends. The learning sciences offer evidence to guide self-directed learning, but these insights have not been integrated into a practical and actionable plan for residents to improve their clinical knowledge and reasoning. We encourage residents to establish a self-directed learning plan, just as an athlete employs a training plan in the pursuit of excellence. We highlight four evidence-based learning principles (spaced practice, mixed practice, retrieval practice, and feedback) and four training strategies comprising a weekly training plan: case tracking, simulated cases, quizzing, and new evidence integration. We provide tips for residents to implement and refine their approach and discuss how residency programs can foster these routines and habits. By optimizing their scarce self-directed learning time with a training plan, residents may enhance patient care and their career satisfaction through their pursuit of clinical mastery.

Types of therapeutic errors in the management of osteoporosis made by physicians and medical students

BACKGROUND

Clinical reasoning is of high importance in clinical practice and thus in medical education research. Regarding the clinical reasoning process, the focus has primarily been on diagnostic reasoning and diagnostic errors, but little research has been done on the subsequent management reasoning process, although the therapeutic decision-making process is at least equally important. The aim of this study was to investigate the frequency of therapeutic decision errors and the cognitive factors leading to these errors in the context of osteoporosis, as it is known to be frequently associated with inadequate treatment decisions in clinical practice worldwide.

METHODS

In 2019, 19 medical students and-for comparison-23 physicians worked on ten patient cases with the medical encounter of osteoporosis. A total of 254 cases were processed. The therapeutic decision errors were quantitatively measured, and the participants' cognitive contributions to therapeutic errors and their clinical consequences were qualitatively analysed.

RESULTS

In 26% of the cases, all treatment decisions were correct. In the remaining 74% cases, multiple errors occurred; on average, 3 errors occurred per case. These 644 errors were further classified regarding the cognitive contributions to the error. The most common cognitive contributions that led to errors were faulty context generation and interpretation (57% of students, 57% of physicians) and faulty knowledge (38% of students, 35% of physicians). Errors made due to faulty metacognition (5% of students, 8% of physicians) were less common. Consequences of these errors were false therapy (37% of cases), undertreatment (30% of cases) or overtreatment (2.5% of cases).

CONCLUSION

The study is the first to show that errors in therapy decisions can be distinguished and classified, similar to the already known classification for errors in diagnostic reasoning. Not only the correct diagnosis, but particularly the correct therapy, is critical for the outcome of a patient.

Sharing the Bandwidth in Cognitively Overloaded Teams and Systems: Mechanistic Insights from a Walk on the Wild Side of Clinical Reasoning

IssuePrevious work from the diagnostic error literature has provided indirect evidence that faulty clinical reasoning may be the most frequent cause of error when attaching a diagnostic label. The precise mechanisms underlying diagnostic error are unclear and continue to be subject to considerable theory informed debate in the clinical reasoning literature. Evidence: We take a theoretical approach to merging these two worlds of literature by first zooming out using distributed cognition as a social cognitive lens (macro theory) to develop a view of the process and outcome of clinical reasoning occurring in the wild - defined as the integrated clinical workplace - the natural habitat of clinicians working within teams. We then zoom in using the novel combination of cognitive load theory and distributed cognition to provide additional theoretical insights into the potential mechanisms of error. Implications: Through the lenses of distributed cognition and cognitive load theory, we can begin to prospectively investigate how cognitive overload is represented and shared within interprofessional teams over time and space and how this influences clinical reasoning performance and leads to error. We believe that this work will help teams manage cognitive load and prevent error.

Evaluating the Clinical Reasoning of Student Health Professionals in Placement and Simulation Settings: A Systematic Review

(1) Background: Clinical reasoning is essential to the effective practice of autonomous health professionals and is, therefore, an essential capability to develop as students. This review aimed to systematically identify the tools available to health professional educators to evaluate students' attainment of clinical reasoning capabilities in clinical placement and simulation settings. (2) Methods: A systemic review of seven databases was undertaken. Peer-reviewed, English-language publications reporting studies that developed or tested relevant tools were included. Searches included multiple terms related to clinical reasoning and health disciplines. Data regarding each tool's conceptual basis and evaluated constructs were systematically extracted and analysed. (3) Results: Most of the 61 included papers evaluated students in medical and nursing disciplines, and over half reported on the Script Concordance Test or Lasater Clinical Judgement Rubric. A number of conceptual frameworks were referenced, though many papers did not reference any framework. (4) Conclusions: Overall, key outcomes highlighted an emphasis on diagnostic reasoning, as opposed to management reasoning. Tools were predominantly aligned with individual health disciplines and with limited cross-referencing within the field. Future research into clinical reasoning evaluation tools should build on and refer to existing approaches and consider contributions across professional disciplinary divides.

Diagnostic reasoning in cardiovascular medicine

Research in cognitive psychology shows that expert clinicians make a medical diagnosis through a two step process of hypothesis generation and hypothesis testing. Experts generate a list of possible diagnoses quickly and intuitively, drawing on previous experience. Experts remember specific examples of various disease categories as exemplars, which enables rapid access to diagnostic possibilities and gives them an intuitive sense of the base rates of various diagnoses. After generating diagnostic hypotheses, clinicians then test the hypotheses and subjectively estimate the probability of each diagnostic possibility by using a heuristic called anchoring and adjusting. Although both novices and experts use this two step diagnostic process, experts distinguish themselves as better diagnosticians through their ability to mobilize experiential knowledge in a manner that is content specific. Experience is clearly the best teacher, but some educational strategies have been shown to modestly improve diagnostic accuracy. Increased knowledge about the cognitive psychology of the diagnostic process and the pitfalls inherent in the process may inform clinical teachers and help learners and clinicians to improve the accuracy of diagnostic reasoning. This article reviews the literature on the cognitive psychology of diagnostic reasoning in the context of cardiovascular disease.

Virtual Wards: A Rapid Adaptation to Clinical Attachments in MBChB During the COVID-19 Pandemic

When the COVID-19 pandemic suddenly prevented medical students from attending their clinical attachments, the faculty involved in the third year of medical school (MBChB3) at the University of Glasgow created Virtual Wards. The focus of the Virtual Wards was to continue teaching of clinical reasoning remotely whilst COVID-19 restrictions were in place. Virtual Wards were mapped to the common and important presentations and conditions and provided opportunity for history-taking, clinical examination skills, requesting investigations, interpreting results, diagnosis and management. The Virtual Wards were successful, and further wards were developed the following academic year for MBChB4 students. This chapter describes the theoretical underpinnings of the Virtual Wards and the technological considerations, followed by a description of the Wards themselves. We then analyse an evaluation of the Virtual Wards and provide both a faculty and student perspective. Throughout the chapter, we provide tips for educators developing Virtual Ward environments.

Context and general practitioner decision-making - a scoping review of contextual influence on antibiotic prescribing

BACKGROUND

How contextual factors may influence GP decisions in real life practice is poorly understood. The authors have undertaken a scoping review of antibiotic prescribing in primary care, with a focus on the interaction between context and GP decision-making, and what it means for the decisions made.

METHOD

The authors searched Medline, Embase and Cinahl databases for English language articles published between 1946 and 2019, focusing on general practitioner prescribing of antibiotics. Articles discussing decision-making, reasoning, judgement, or uncertainty in relation to antibiotic prescribing were assessed. As no universal definition of context has been agreed, any papers discussing terms synonymous with context were reviewed. Terms encountered included contextual factors, non-medical factors, and non-clinical factors.

RESULTS

Three hundred seventy-seven full text articles were assessed for eligibility, resulting in the inclusion of 47. This article documented the experiences of general practitioners from over 18 countries, collected in 47 papers, over the course of 3 decades. Contextual factors fell under 7 themes that emerged in the process of analysis. These were space and place, time, stress and emotion, patient characteristics, therapeutic relationship, negotiating decisions and practice style, managing uncertainty, and clinical experience. Contextual presence was in every part of the consultation process, was vital to management, and often resulted in prescribing.

CONCLUSION

Context is essential in real life decision-making, and yet it does not feature in current representations of clinical decision-making. With an incomplete picture of how doctors make decisions in real life practice, we risk missing important opportunities to improve decision-making, such as antibiotic prescribing.

Differential effects of team-based learning on clinical reasoning

BACKGROUND

Clinical reasoning (CR) is the ability to integrate information, knowledge and contextual factors for patient care. Few studies have explored effects of team-based learning (TBL) on neurological CR. This study compared simplified TBL (sTBL) against interactive lectures (IL) for teaching CR in neuroanatomical localisation (NL) and neurological emergencies (NE), assessed using a validated Script Concordance Test (SCT).

METHODS

A crossover study was conducted with third- and fifth-year undergraduates, randomly assigned to two groups, from the Yong Loo Lin School of Medicine in Singapore. Group 1 was taught NE with sTBL and NL with IL, whereas Group 2 was taught NL with sTBL and NE with IL. Teaching was conducted sequentially over 3 h followed immediately by the SCT. The primary outcome was the difference in mean SCT scores of NE and NL taught with sTBL versus IL.

FINDINGS

A total of 179 students (Group 1, n = 81; Group 2, n = 98) participated. Mean NL SCT scores for students taught with sTBL were significantly higher compared with IL (64.8% vs. 61.7%, mean difference 3.1%, 95% confidence interval [CI] 0.6%-5.5%, p = 0.013); effect size was 0.38. Mean NE SCT scores were similar between students taught with sTBL or IL (66.6% vs. 67.0%, mean difference -0.4%, 95% CI -2.2% to 3.1%, p = 0.75).

CONCLUSIONS

sTBL was superior to IL for teaching NL, whereas both methods were comparable for teaching NE. TBL may be suitable for teaching more complex neurological topics involving diagnostic reasoning through development of problem representation, hypothesis generation and illness script selection.

Differential diagnosis checklists reduce diagnostic error differentially: A randomised experiment

INTRODUCTION

Wrong and missed diagnoses contribute substantially to medical error. Can a prompt to generate alternative diagnoses (prompt) or a differential diagnosis checklist (DDXC) increase diagnostic accuracy? How do these interventions affect the diagnostic process and self-monitoring?

METHODS

Advanced medical students (N = 90) were randomly assigned to one of four conditions to complete six computer-based patient cases: group 1 (prompt) was instructed to write down all diagnoses they considered while acquiring diagnostic test results and to finally rank them. Groups 2 and 3 received the same instruction plus a list of 17 differential diagnoses for the chief complaint of the patient. For half of the cases, the DDXC contained the correct diagnosis (DDXC+), and for the other half, it did not (DDXC-; counterbalanced). Group 4 (control) was only instructed to indicate their final diagnosis. Mixed-effects models were used to analyse results.

RESULTS

Students using a DDXC that contained the correct diagnosis had better diagnostic accuracy, mean (standard deviation), 0.75 (0.44), compared to controls without a checklist, 0.49 (0.50), P < 0.001, but those using a DDXC that did not contain the correct diagnosis did slightly worse, 0.43 (0.50), P = 0.602. The number and relevance of diagnostic tests acquired were not affected by condition, nor was self-monitoring. However, participants spent more time on a case in the DDXC-, 4:20 min (2:36), P ≤ 0.001, and DDXC+ condition, 3:52 min (2:09), than in the control condition, 2:59 min (1:44), P ≤ 0.001.

DISCUSSION

Being provided a list of possible diagnoses improves diagnostic accuracy compared with a prompt to create a differential diagnosis list, if the provided list contains the correct diagnosis. However, being provided a diagnosis list without the correct diagnosis did not improve and might have slightly reduced diagnostic accuracy. Interventions neither affected information gathering nor self-monitoring.

Multimorbidity and clinical reasoning through the eyes of GPs: a qualitative study

Objectives

Despite the high prevalence of patients suffering from multimorbidity, the clinical reasoning processes involved during the longitudinal management are still sparse.

This study aimed to investigate what are the different characteristics of the clinical reasoning process clinicians use with patients suffering from multimorbidity, and to what extent this clinical reasoning differs from diagnostic reasoning.

Design

Given the exploratory nature of this study and the difficulty general practitioners (GPs) have in expressing their reasoning, a qualitative methodology was therefore, chosen. The Clinical reasoning Model described by Charlin et al was used as a framework to describe the multifaceted processes of the clinical reasoning.

Setting

Semistructured interviews were conducted with nine GPs working in an ambulatory setting in June to September 2018, in Geneva, Switzerland.

Participants

Participants were GPs who came from public hospital or private practice. The interviews were transcribed verbatim and a thematic analysis was conducted.

Results

The results highlighted how some cognitive processes seem to be more specific to the management reasoning.

Thus, the main goal is not to reach a diagnosis, but rather to consider several possibilities in order to maintain a balance between the evidence-based care options, patient’s priorities and maintaining quality of life. The initial representation of the current problem seems to be more related to the importance of establishing links between the different pre-existing diseases, identifying opportunities for actions and trying to integrate the new elements from the patient’s context, rather than identifying the signs and symptoms that can lead to generating new clinical hypotheses. The multiplicity of options to resolve problems is often perceived as difficult by GPs. Furthermore, longitudinal management does not allow them to achieve a final resolution of problems and that requires continuous review and an ongoing prioritisation process.

Conclusion

This study contributes to a better understanding of the clinical reasoning processes of GPs in the longitudinal management of patients suffering from multimorbidity. Through a practical and accessible model, this qualitative study offers new perspectives for identifying the components of management reasoning. These results open the path to new research projects.

Understanding GPs' clinical reasoning processes involved in managing patients suffering from multimorbidity: A systematic review of qualitative and quantitative research

BACKGROUND

Most consultations in primary care involve patients suffering from multimorbidity. Nevertheless, few studies exist on the clinical reasoning processes of general practitioners (GPs) during the follow-up of these patients. The aim of this systematic review is to summarise published evidence on how GPs reason and make decisions when managing patients with multimorbidity in the long term.

METHODS

A search of the relevant literature from Medline, Embase, PsycINFO, and ERIC databases was conducted in June 2019. The search terms were selected from five domains: primary care, clinical reasoning, chronic disease, multimorbidity, and issues of multimorbidity. Qualitative, quantitative, and mixed-methods studies published in English and French were included. Quality assessment was performed using the Mixed Methods Appraisal Tool.

RESULTS

A total of 2 165 abstracts and 362 full-text articles were assessed. Thirty-two studies met the inclusion criteria. Results showcased that GPs' clinical reasoning during the long-term management of multimorbidity is about setting intermediate goals of care in an ongoing process that adapts to the patients' constant evolution and contributes to preserve their quality of life. In the absence of guidelines adapted to multimorbidity, there is no single correct plan, but competing priorities and unavoidable uncertainties. Thus, GPs have to consider and weigh multiple factors simultaneously. In the context of multimorbidity, GPs describe their reasoning as essentially intuitive and seem to perceive it as less accurate. These clinical reasoning processes are nevertheless more analytical as they might think and rooted in deep knowledge of the individual patient.

CONCLUSIONS

Although the challenges GPs are facing in the long-term follow-up of patients suffering from multimorbidity are increasingly known, the literature currently offers limited information about GPs' clinical reasoning processes at play. GPs tend to underestimate the complexity and richness of their clinical reasoning, which may negatively impact their practice and their teaching.

Unravelling the polyphony in clinical reasoning research in medical education

RATIONALE

Clinical reasoning lies at the heart of medical practice and has a long research tradition. Nevertheless, research is scattered across diverse academic disciplines with different research traditions in a wide range of scientific journals. This polyphony is a source of conceptual confusion.

AIMS AND OBJECTIVES

We sought to explore the underlying theoretical assumptions of clinical reasoning aiming to promote a comprehensive conceptual and theoretical understanding of the subject area. In particular, we asked how clinical reasoning is defined and researched and what conceptualizations are relevant to such uses.

METHODS

A scoping review of the clinical reasoning literature was undertaken. Using a "snowball" search strategy, the wider scientific literature on clinical reasoning was reviewed in order to clarify the different underlying conceptual assumptions underlying research in clinical reasoning, particularly to the field of medical education. This literature included both medical education, as well as reasoning research in other academic disciplines outside medical education, that is relevant to clinical reasoning. A total of 124 publications were included in the review.

RESULTS

A detailed account of the research traditions in clinical reasoning research is presented. In reviewing this research, we identified three main conceptualisations of clinical reasoning: "reasoning as cognitive activity," "reasoning as contextually situated activity," and "reasoning as socially mediated activity." These conceptualisations reflected different theoretical understandings of clinical reasoning. Each conceptualisation was defined by its own set of epistemological assumptions, which we have identified and described.

CONCLUSIONS

Our work seeks to bring into awareness implicit assumptions of the ongoing clinical reasoning research and to hopefully open much needed channels of communication between the different research communities involved in clinical reasoning research in the field.

Warning bells: How clinicians leverage their discomfort to manage moments of uncertainty

OBJECTIVES

It remains unclear how medical educators can more effectively bridge the gap between trainees' intolerance of uncertainty and the tolerance that experienced physicians demonstrate in practice. Exploring how experienced clinicians experience, appraise and respond to discomfort arising from uncertainty could provide new insights regarding the kinds of behaviours we are trying to help trainees achieve.

METHODS

We used a constructivist grounded theory approach to explore how emergency medicine faculty experienced, managed and responded to discomfort in settings of uncertainty. Using a critical incident technique, we asked participants to describe case-based experiences of uncertainty immediately following a clinical shift. We used probing questions to explore cognitive, emotional and somatic manifestations of discomfort, how participants had appraised and responded to these cues, and how they had used available resources to act in these moments of uncertainty. Two investigators coded the data line by line using constant comparative analysis and organised transcripts into focused codes. The entire research team discussed relationships between codes and categories, and developed a conceptual framework that reflected the possible relationships between themes.

RESULTS

Participants identified varying levels of discomfort in their case descriptions. They described multiple cues alerting them to problems that were evolving in unexpected ways or problems with aspects of management that were beyond their abilities. Discomfort served as a trigger for participants to monitor a situation with greater attention and to proceed more intentionally. It also served as a prompt for participants to think deliberately about the types of human and material resources they might call upon strategically to manage these uncertain situations.

CONCLUSIONS

Discomfort served as a dynamic means to manage and respond to uncertainty. To be 'tolerant' of uncertainty thus requires clinicians to embrace discomfort as a powerful tool with which to grapple with the complex problems pervasive in clinical practice.

Understanding the clinical reasoning processes involved in the management of multimorbidity in an ambulatory setting: study protocol of a stimulated recall research

BACKGROUND

Primary care physicians are at the very heart of managing patients suffering from multimorbidity. However, several studies have highlighted that some physicians feel ill-equipped to manage these kinds of complex clinical situations. Few studies are available on the clinical reasoning processes at play during the long-term management and follow-up of patients suffering from multimorbidity. This study aims to contribute to a better understanding on how the clinical reasoning of primary care physicians is affected during follow-up consultations with these patients.

METHODS

A qualitative research project based on semi-structured interviews with primary care physicians in an ambulatory setting will be carried out, using the video stimulated recall interview method. Participants will be filmed in their work environment during a standard consultation with a patient suffering from multimorbidity using a "button camera" (small camera) which will be pinned to their white coat. The recording will be used in a following semi-structured interview with physicians and the research team to instigate a stimulated recall. Stimulated recall is a research method that allows the investigation of cognitive processes by inviting participants to recall their concurrent thinking during an event when prompted by a video sequence recall. During this interview, participants will be prompted by different video sequence and asked to discuss them; the aim will be to encourage them to make their clinical reasoning processes explicit. Fifteen to twenty interviews are planned to reach data saturation. The interviews will be transcribed verbatim and data will be analysed according to a standard content analysis, using deductive and inductive approaches.

CONCLUSION

Study results will contribute to the scientific community's overall understanding of clinical reasoning. This will subsequently allow future generation of primary care physicians to have access to more adequate trainings to manage patients suffering from multimorbidity in their practice. As a result, this will improve the quality of the patient's care and treatments.

"I Was Worried About the Patient, but I Wasn't Feeling Worried": How Physicians Judge Their Comfort in Settings of Uncertainty

PURPOSE

Clinical educators often raise concerns that learners are not comfortable with uncertainty in clinical work, yet existing literature provides little insight into practicing clinicians' experiences of comfort when navigating the complex, ill-defined problems pervasive in practice. Exploring clinicians' comfort as they identify and manage uncertainty in practice could help us better support learners through their discomfort.

METHOD

Between December 2018 and April 2019, the authors employed a constructivist grounded theory approach to explore experiences of uncertainty in emergency medicine faculty. The authors used a critical incident technique to elicit narratives about decision making immediately following participants' clinical shifts, exploring how they experienced uncertainty and made real-time judgments regarding their comfort to manage a given problem. Two investigators analyzed the transcripts, coding data line-by-line using constant comparative analysis to organize narratives into focused codes. These codes informed the development of conceptual categories that formed a framework for understanding comfort with uncertainty.

RESULTS

Participants identified multiple forms of uncertainty, organized around their understanding of the problems they were facing and the potential actions they could take. When discussing their comfort in these situations, they described a fluid, actively negotiated state. This state was informed by their efforts to project forward and imagine how a problem might evolve, with boundary conditions signaling the borders of their expertise. It was also informed by ongoing monitoring activities pertaining to patients, their own metacognitions, and their environment.

CONCLUSIONS

The authors' findings offer nuances to current notions of comfort with uncertainty. Uncertainty involved clinical, environmental, and social aspects, and comfort dynamically evolved through iterative cycles of forward planning and monitoring.

The Management Script: A Practical Tool for Teaching Management Reasoning

Management reasoning, a component of clinical reasoning, has become an important area for medical education research given its inherent complexity, role in medical decision making, and association with high-value care. Teaching management reasoning requires characterizing its core concepts and identifying strategies to teach them. In this Perspective, the authors propose the term "management script" to describe the mental schema that clinicians develop and use in medical decision making. Management scripts are high-level, precompiled, conceptual knowledge structures of the courses of action that a clinician may undertake to address a patient's health care problem(s). Like illness scripts, management scripts have foundational elements that are shared by most clinicians but are ultimately idiosyncratic based on each clinician's unique history of learning and experience. Applying management scripts includes 2 steps-(1) management script activation and (2) management option selection-which can occur reflexively (unconsciously) or deliberately (consciously), similar to, respectively, the System 1 thinking and System 2 thinking of dual process theory. Management scripts can be taught for different conditions by using management script templates, educational scaffolds that provide possible courses of action to address a health care problem at any stage. Just as learners use system-based or organ-based frameworks to generate a differential diagnosis, students can use a generic management script template early in training to develop management scripts for specific problems. Future research directions include exploring the role of management scripts in medical education and quality improvement practices.