David A Cook1, Christopher R Stephenson2, Larry D Gruppen3, Steven J Durning4. 1. D.A. Cook is professor of medicine and professor of medical education; director of education science, Office of Applied Scholarship and Education Science; and consultant, Division of General Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota; ORCID: https://orcid.org/0000-0003-2383-4633. 2. C.R. Stephenson is assistant professor of medicine and consultant, Division of General Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota; ORCID: https://orcid.org/0000-0001-8537-392X. 3. L.D. Gruppen is professor, Department of Learning Health Sciences, and director, Master in Health Professions Education Program, University of Michigan, Ann Arbor, Michigan. ORCID: https://orcid.org/0000-0002-2107-0126. 4. S.J. Durning is professor and vice chair, Department of medicine, and director, Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland. ORCID: https://orcid.org/0000-0001-5223-1597.
Abstract
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.
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.