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

Abstract

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.

Management reasoning (MR) is a domain of clinical reasoning distinct from diagnosis.^1,2 It requires the integration of clinical data (e.g., history, physical exam findings, and diagnostic testing results) and situational factors (e.g., patient preferences and environmental and system constraints) to guide decisions about treatment, testing, monitoring, and patient follow-up.^1,2 Despite recent progress in characterizing MR^3–8 and evidence that clinical supervisors routinely assess learners’ management decisions,^9,10 guidance on integrating MR teaching into clinical learning experiences, such as inpatient rounds, remains limited. Practical, theory-informed instructional strategies that support MR teaching can advance clinical reasoning education and practice.

The importance of explicit strategies for teaching MR relates to its prevalence on inpatient rounds.^9,11–14 Recent work of Choi and colleagues, which explored clinical reasoning during inpatient internal medicine rounds, found that conversations about management decisions comprise a substantial portion of team discussions.⁹ In addition, the cognitive processes fundamental to MR are, in some ways, distinct from those of diagnostic reasoning (DR). For example, DR is primarily a classification task (e.g., establishing a diagnosis) reliant on data collection and hypothesis generation.¹⁵ MR is a prioritization exercise that requires clinicians to adapt multiple possible management plans to contextual factors, such as resource availability and patient preferences (e.g., preferred medication dosing frequency or the desire to avoid invasive procedures).^1,3–5 While both DR and MR may overlap during a clinical case (e.g., making diagnostic and management decisions in parallel) and use similar information (e.g., patient history, physical exam, labs, imaging, and advanced studies), the ideal outcome of DR entails identifying a single diagnosis while that of MR entails the specification of a management plan that works best for a particular patient in a particular context.¹ Thus, the frequency with which MR is employed and its differences from DR underscore the need for clinical teachers to possess targeted strategies for teaching MR during active patient care.

Alongside conceptual and empirical work defining MR,^1–5 clinical reasoning education has benefited from several MR teaching tools.^6–8 The management script template supports the development of cognitive structures underlying MR.⁶ Wijesekera and colleagues then published a MR toolbox for educators using a clinical case. Subsequent work proposed the management pause as a reflection tool highlighting key MR concepts and the equity reflection as a strategy to identify and address implicit bias and structural inequities in management decision-making.^7,8 While these teaching tools are designed for easy implementation, frontline clinical teachers could benefit from elaboration of the theories and clinical principles informing the tools and the educational situations most conducive to their use.

Herein, we review two macro theories and three clinical principles most relevant to our understanding of MR in the inpatient clinical environment. Using these theories and principles as a guide, we then incorporate the management script template,^6–8 management pause,⁷ and equity reflection⁷ into a framework for teaching MR during inpatient rounds. These MR teaching strategies complement prior work describing a framework for teaching DR,¹⁶ creating a two-volume set of practical, theory-informed guides for teaching clinical reasoning on inpatient rounds.

THEORETICAL PERSPECTIVES AND CLINICAL PRINCIPLES FOR TEACHING MANAGEMENT REASONING

Clinical reasoning scholars have identified two macro theories of cognition that can inform MR education in the clinical setting: information-processing (IP) and situativity.^17–22 IP theory emphasizes the importance of knowledge organization (e.g., how individuals store information about clinical problems in memory) in MR.^17–19 IP theory suggests that the clinical teacher focuses on the content of a case and the aspects of MR that occur solely in the clinician’s mind. From this perspective, teaching MR entails helping learners analyze clinical information, and organize, retrieve, and apply content knowledge to support management decisions. For example, when supervising trainees managing a patient with an upper gastrointestinal bleed (UGIB), a clinical teacher could help them develop a management script template^6–8 for treating a UGIB, which may include ensuring the patient has adequate intravenous (IV) access, administering volume resuscitation with IV fluids or blood transfusions, ordering an IV proton-pump inhibitor (PPI), and consulting the gastroenterology service (gastrointestinal (GI)) for endoscopy.

Situativity theory provides a complementary perspective to IP theory, arguing that cognitive processes like MR emerge from dynamic interactions between the clinician, the patient, and other aspects of the clinical environment (e.g., interdisciplinary team members, available clinical resources, patient’s family members) (Fig. 1).^20–22 Through this lens, effective MR requires clinicians to understand the content of the case (e.g., the patient’s clinical findings and how to establish and treat diagnoses under consideration) and effectively engage with the context of the case (e.g., patient preferences, interdisciplinary team members, or health-system factors, such as the electronic health record or limitations on interventions in certain levels of care).

Figure 1.

A conceptual representation of the relationships between information processing theory and situativity theory as they relate to management reasoning.

While these theories provide a useful perspective for understanding and teaching MR, their direct application to teaching decisions can be challenging, especially amidst the competing demands and complexity of the inpatient clinical learning environment. To provide additional support to frontline clinical teachers, we highlight three familiar principles of clinical practice likely familiar to frontline educators. These three clinical principles can provide a practical lens for integrating IP and situativity theories when teaching MR on rounds:^7,8

• Shared decision-making, during which clinicians engage the patient and other stakeholders (e.g., family members and multidisciplinary team members) in decisions informed by the patient’s goals and values.

• High-value care, which relies on thoughtful selection of interventions based on quality, service, and cost and encompasses several other key principles of MR, including thresholds and risk/benefit analysis.

• Equity, which promotes consideration of how individual biases and systemic inequity may influence management decisions and exploration of ways to overcome these injustices.

Consider the prior teaching example. While applying stored knowledge about UGIB management is important, clinicians must adapt their management plan to contextual factors. A clinical teacher may focus their MR teaching on the fact that the decision to consult GI for an endoscopy relates to both the presence and severity of a UGIB (i.e., content-related factors) and whether or not endoscopy is within the patient’s goals of care (i.e., a contextual factor related to shared-decision making). Similarly, clinical teachers may highlight that GI consultation requires consideration of contextual factors that can support high-value care. If the patient is admitted on a Friday evening, remains clinically stable overnight, and expresses a desire to not wait in the hospital all weekend for endoscopy on Monday morning, the admitting team may focus their consult question on planning for outpatient endoscopy early the next week, which could reduce unnecessary costs to the patient and align with their preferences. Thus, MR is a dynamic process in which clinicians integrate content knowledge with evolving and emergent contextual factors (Fig. 1).

FRAMEWORK FOR TEACHING MANAGEMENT REASONING ON ROUNDS

Here, we provide a framework for teaching MR on inpatient rounds during discrete moments of a patient’s hospital stay: admission, ongoing uncertainty, and discharge. This framework integrates the aforementioned teaching tools,^6–8 with the underlying theories and clinical principles that support their use.^17–22

Apply Management Scripts on Admission

While clinical cases have varying degrees of diagnostic uncertainty (for which we refer readers to strategies for teaching DR on rounds¹⁶), there is often reasonable clarity around a working diagnosis, which can allow for the prioritization of management decisions during oral presentations and rounding conversations.⁹ Clinical teachers can promote learners’ development and application of MR during new patient presentations by routinizing the explicit use of the management script template.^6–8

The management script template offers a structured approach to organizing and articulating MR on rounds.^6–8 Described previously, a management script^4,6,17,23 is a mental file of specific management strategies that clinicians activate and apply within a given context. During inpatient rounds, clinicians first activate a management script, which includes many illness-specific interventions, not all of which may be necessary or relevant in a given case, and then select from multiple management options to enact a plan.⁶ The management script template^6–8 is a teaching tool that can be used during case presentations on rounds to explicitly consider these two steps, management script activation and option selection, in the context of a given clinical case. In our experience, clearly articulating these steps during inpatient rounds allows for a more nuanced discussion of a patient-centered management plan including consideration of risk and benefit for each intervention in the context of the patient’s goals and any system barriers. This discussion should include reasons for not doing many of the options on the initial management script.

These discrete steps align with IP and situativity theories. In activating a management script, clinicians draw on their stored content knowledge for a specific clinical problem (IP theory). In selecting among multiple options and enacting a management plan, they adapt to contextual factors (situativity theory, see Fig. 1). The accommodation of contextual factors is a more advanced step and requires consideration of shared-decision making, high-value care, and equity, among other clinical principles. Clinical teachers can advance MR instruction on rounds by encouraging learners to elaborate an organized structure for the problem-specific management script they are activating (a task most suitable to early learners still developing their knowledge structures), probing learners to explicitly articulate the content- and context-related factors that influence their management option selection. For more advanced learners, clinical teachers can incorporate counterfactuals and contingency planning (e.g., “What would you do if…”) into case presentations and MR discussions (Table 1, row 2).

Table 1.

Application of the Framework for Teaching MR on Inpatient Rounds

Setting	Tool	Example questions
Admission	Management script template6	• “What are the components of your upper GI bleed management script?”       Instructional aim: articulate a general management script for an upper GI bleed      Target learner: predominantly for early learners (e.g., medical students)     Theory: IP (content) > situativity (context) • “What influenced your decision to wait to consult the GI service until tomorrow morning?”     Instructional aim: explore the extent to which the learner is integrating content-related (e.g., clinical stability) and context-related (e.g., patient preferences, time of day/week) factors into their management plan     Target learner: senior medical students through residents     Theory: both IP (content) and situativity (context) • “How would your management differ if…the patient had cirrhosis? …endoscopy was not within his goals of care?…he had been admitted early Friday morning, instead of Friday evening; would you have consulted GI to try to get a same endoscopy?”     Instructional aim: use counterfactuals to challenge and expand learner’s repertoire of possible management strategies by varying content-related and context-related factors     Target learner: experienced residents     Theory: question 1 (cirrhosis) draws on IP (exploring how changing the content may change management). Questions 2 and 3 draw on situativity (how changing the context may change management) and integrate the values of shared-decision making and high-value care
Uncertainty during/after initial management selection	Management pause7	• “What influenced your decision to hold the patient’s oral anti-coagulation on admission?”     Instructional aim: prompt learner to make explicit the factors (content- and/or context-related) that influenced management decisions     Target learner: all levels     Theory: both IP (content) and situativity (context) • “What are the potential downsides of holding anticoagulation for this patient with a recently diagnosed, large, deep vein thrombosis (DVT)?” • “What are the potential alternatives to only holding oral anticoagulation and why are we not choosing them?”     Instructional aim: ensure deliberate consideration of risks of and alternatives to proposed management plans, which can expand learner’s repertoire of management options, engage system 2 thinking, and help overcome cognitive biases6     Target learner: all levels     Theory: both IP (content) and situativity (context). Risks and alternatives may be related to content of the case (e.g., the presence of a DVT increases the risks of holding anti-coagulation) or context (e.g., the ability to have an in inferior vena cava filter placed may vary from hospital to hospital) • “Have you discussed our management options with the patient and gotten their perspective?”     Instructional aim: ensure incorporation of patient perspectives into management decisions during moments of uncertainty     Target learner: all levels     Theory: focuses on situativity (context), drawing on the value of shared-decision making
Discharge	Equity reflection7	• “Does your discharge plan of deferring an endoscopy deviate from standard of care for this patient? If so, in what ways are we deviating and why?” • “Are there things you could do differently to ensure we are providing the highest value care?”     Instructional aim: encourage learners to explicitly discuss how, if at all, the team’s management plans differ from the standard of care, and whether that discrepancy can and should be addressed     Target level: may be more suitable for advanced learners who have a more robust understanding of standard of care; however, all learners can participate     Theory: focuses primarily on situativity (context), drawing on the values of patient preferences, high-value care, and equity • “Would you choose this plan for ourselves or family members if you were in the same situation? If not, what would you want done differently and why aren’t we doing that here?” • “Are there systems (e.g., endoscopy availability) or patient factors (e.g., preference) that led to this decision? If so, are there ways you could address these factors?”     Instructional aim: provide a personal lens through which learners can reflect on management decisions, health-systems barriers, and patient preferences     Target level: may be more suitable for advanced learners who have a more robust understanding of standard of care and health-system factors; however, all learners can participate     Theory: focuses primarily on situativity (context), drawing on patient preferences, high-value care, and equity

Use the Management Pause During Moments of Uncertainty

Ideally, enacting an initial management plan for a hospitalized patient would be a relatively straightforward process and lead to a patient’s clinical improvement. However, clinicians may need to contend with uncertainty during inpatient rounds, such as when a patient does not respond as expected to an initial management plan, requiring reconsideration of the working diagnosis and/or the previously established management decisions. The management pause⁷ offers a practical tool for clinical teachers to promote deliberate engagement with this uncertainty, whether it be their own uncertainty or that of the learners they work with, during authentic case discussions on rounds. The management pause also explicitly centers patient preferences and shared decision-making during these challenging moments of clinical practice.

Initially adapted from the diagnostic pause,²⁴ the management pause slows MR down, prompts intentional consideration of management options, and assures integration of the patients’ perspective.⁷ This intentional discussion of risks, benefits, and alternatives supports the important engagement of system 2 thinking (i.e., “deliberative mind”²⁵), consistent with IP theory. Effective MR during inpatient rounds, especially in moments of uncertainty, also requires alignment with patients’ values and preferences (e.g., contextual factors), of which clinicians are often unaware.^26–30 In helping clinicians incorporate the patient’s perspective into moments of uncertainty, the management pause forces consideration of contextual factors and aligns with evidence that patients prefer direct and explicit discussion of uncertainty.^29,30

While the astute clinical teacher can apply the management pause in various educational situations on rounds, we propose moments of uncertainty as a fruitful opportunity for use. In these moments, the management pause can help faculty and trainees alike manage uncertainty by facilitating exploration of proposed management decisions, prompting learners to reflect on clinical and contextual factors influencing their decisions, preparing them for bedside conversations that facilitate the integration of shared decision-making into MR, and helping them collaborate with patients to clarify next steps, contingency plans, and thresholds for adjustment (e.g., “if X happens, we will get Y test or change Z treatment.”).³¹ Table 1 (row 3) uses the sample UGIB case to apply the management pause to a moment of uncertainty about how to best manage the patient’s anticoagulation.

Engage in an Equity Reflection on Discharge

Systemic and individual factors—including implicit bias in clinical decision-making—propagate healthcare inequities, promote further oppression of marginalized groups, and thus require attention when teaching MR.^32,33 Associations between outcomes after hospital discharge and patient’s socioeconomic and housing status, race, and language barriers highlight this transition of care as an opportune moment to consider (in)equity in MR when making discharge and follow-up plans during inpatient rounds.^34–36

Similar to the management pause, the equity reflection⁷ equips clinical teachers with questions they can ask learners during discharge case presentations, when care plans, follow-up appointments, and system barriers are a frequent consideration (Table 1, row 4) applies the equity reflection to the sample UGIB case). Through the lens of situativity theories, these questions prompt learners to move beyond preconceived knowledge structures and consider contextual factors during discharge. As a result, they help make explicit the often-implicit ways that healthcare systems and clinicians may promote inequity (e.g., by limiting access to certain medications, enacting follow-up plans that require social or financial resources unavailable to marginalized groups, or failing to provide patient education materials in patients’ primary language). The equity reflection also enables consideration of high-value care by asking learners to consider whether individual decisions are right for this patient at this time in this specific context. In addition, by asking trainees to explore ways to leverage the multidisciplinary team to overcome barriers to providing the standard of care, the equity reflection can support trainees in developing the critical consciousness necessary to deconstruct inequitable systems.⁷

The originators of the equity reflection developed the tool in hopes that regular use will not only prevent further injustices in clinical practice, but also empower learners to develop reflective skills that enable action (rather than self-blame) when they identify bias in their MR.^7,37 Structured support for reflective practice can help learners build the metacognitive capacity to recognize and act on implicit bias^37,38 and support their self-monitoring during high-stakes clinical decisions.^39,40 Discharge discussions offer an important opportunity to explicitly consider unintentional promotion of inequity by employing this teaching tool.

Finally, using the equity reflection requires a foundation of psychological safety. Teachers can build trust with and among team members by embracing vulnerability (e.g., disclosing one’s own moments of bias and lessons learned) and promoting identity safety on clinical teams. In doing so, they can help establish a learning climate that supports learners as they grapple with the charged emotions and the personal and professional identity tensions that can arise when discussing bias and inequity.^37,41,42

CONCLUSION

Effectively teaching MR is not only essential for advancing clinical reasoning education and practice, but is also well within reach for frontline clinician educators. By considering the theories and principles underlying MR, we propose the use of an explicit framework using established tools that provides clinical teachers with practical, theory-informed strategies for enhancing the quality and quantity of reasoning on rounds.

Data Availability

There is no data relevant for this article as it is a perspective piece.

Declarations:

Conflict of Interest:

Emily A. Abdoler has received grant funding to her institution from the Southern Group on Educational affairs for the study of management reasoning and consulting fees from the National Board of Medical Examiners for research projects related to the assessment of management reasoning. Andrew S. Parsons has received grant funding from the American Medical Association and consulting fees for clinical reasoning and clinical reasoning assessment from the New England Journal of Medicine Education Group/Massachusetts Medical Society and the National Board of Medical Examiners. The other authors declare that they do not have a conflict of interest.