The Six R's of Management Reasoning for Subintern Education

ABSTRACT

Background

Management reasoning (MR), the component of clinical reasoning concerned with treatment planning, patient preferences and resource considerations, develops later than diagnostic reasoning and remains underemphasised in medical education. Despite calls to explicitly teach MR, instructional strategies remain scarce.

Approach

We developed a mnemonic, the “Six R's of Management Reasoning,” and implemented a 90‐min workshop grounded in social constructivism. Between July 2023 and December 2024, we taught 22 sessions to 119 subinterns. Students used the mnemonic to collaboratively construct management plans and admission orders through case‐based activities and facilitated discussions.

Evaluation

Using three levels of Kirkpatrick's model—reaction, learning and behaviour—we assessed the workshop through IRB‐approved surveys, tests and workplace assessments. Postworkshop and postrotation surveys showed significant increases in students' confidence and ability to apply MR (all p < 0.001). Knowledge test scores improved from 81.7% to 93.3% (p < 0.001, Hedges's g = 1.20). Faculty assessments confirmed students' strengths in risk calculation and shared decision‐making, though some students struggled with applying high‐value care and citing evidence.

Implications

The “Six R's of Management Reasoning” provided a practical tool for MR development, and activities selected based on social constructivism were effective and well received. Mixed performance in clinical settings suggests that MR requires longitudinal reinforcement, repeated patient encounters and continued mentorship beyond a single workshop. This approach is feasible for broader implementation and may serve as a foundation for intentionally integrating MR across the medical education continuum.

1. Background

Clinical reasoning integrates patient information, medical knowledge and situational factors to diagnose and manage illness. Although clinical reasoning encompasses both diagnostic and management reasoning, most medical education research has emphasised diagnostic reasoning, which dominates early medical training [1, 2]. In contrast, management reasoning, the process of determining next steps in evaluation, treatment, follow‐up and aligning plans with patient preferences and available resources, remains comparatively underexplored [3].

Clinical reasoning is iterative, and diagnostic and management reasoning often inform one another. As learners progress, their reasoning evolves. Monajemi and colleagues (2012) found that illness scripts of experienced clinicians incorporated both diagnostic and management features, while early learners focused primarily on diagnostic features [4]. This developmental shift prompted future researchers to distinguish management reasoning education from diagnostic reasoning to better support early‐stage learners [5].

Parsons and colleagues (2020) subsequently introduced “management scripts,” mental schemas clinicians use when creating treatment plans [6]. Management scripts, informed by pathophysiology, must be adapted to individual patient needs, such as transportation, housing stability or treatment preferences. Despite the recognised need to help learners move beyond diagnostic reasoning, students often lack a structured approach for developing and adapting these scripts [5].

Management scripts, informed by pathophysiology, must be adapted to individual patient needs, such as transportation, housing stability, or treatment preferences.

We hypothesised that the subinternship, completed after core clerkships, would be an optimal time to introduce management reasoning. Subinterns are transitioning into the role of an intern and therefore must learn to propose and implement individualised management plans. After reviewing the literature and consulting clinician educators, we developed a management reasoning instructional tool centred on a mnemonic and introduced it through a workshop. The workshop serves as an introduction, providing guidance for students to incorporate management reasoning earlier in training. We acknowledge that true expertise would take years of repeated practice and feedback from mentors in diverse clinical scenarios.

Cook and colleagues (2023) proposed a structured approach for management reasoning involving four steps: recalling a management script, identifying and explaining management options to a patient, engaging in shared decision‐making and monitoring and adjusting the plan [7]. Leveraging our experience working with trainees, we built on this foundation to produce a modified version featuring a memorable mnemonic that captured critical features in management reasoning. Feedback from local and regional meetings led to minor refinements and increased confidence in the instructional tool.

In contrast to the original four‐step model, our approach made risk calculation and resource evaluation explicit steps, emphasising the diagnostic grounding of management script selection and practical realities of available resources. The resulting “Six R's of Management Reasoning” (Figure 1) offers a pedagogical scaffold to help learners incorporate management reasoning more deliberately and systematically.

FIGURE 1.

The Six R's of Management Reasoning. 1. Risk Calculation: consider the risks and implications of various diagnostic possibilities. 2. Recall Management Script: utilise available resources including guidelines and evidence‐based medicine to identify the management script for each diagnostic consideration. 3. Right for the Patient: consider patients' comorbidities, risk tolerance, social, economic and cultural factors and utilise shared decision making. 4. Resource Allocation: examine site‐specific limitations and apply high value care. 5. Recommend: distill the analysis from Steps 1–4 into final recommendations and 6. Re‐evaluation: delineate a follow‐up or monitoring plan for the patient. This cycle should be repeated as necessary as new data emerges during re‐evaluation.

2. Approach

We created a 90‐min Management Reasoning workshop for internal medicine subinterns based on the “Six R's of Management Reasoning.” We used activities grounded in social constructivist theory, which posits that learning depends on interactions between people and that students themselves must personally grapple with problems, incorporating their prior knowledge while identifying solutions [8].

We used activities grounded in social constructivist theory, which posits that learning depends on interactions between people and that students themselves must personally grapple with problems, incorporating their prior knowledge while identifying solutions.

Between July 2023 and December 2024, we delivered 22 in‐person workshops to 119 third‐ and fourth‐year medical students. Sessions, led by two board‐certified Internal Medicine subinternship co‐directors, ranged from 1 to 15 learners and took place in classrooms equipped for didactic instruction. Students used their personal laptops for small group activities. All students had completed the Medicine Clerkship and most other core clerkships and had foundational skills in history‐taking, physical exams, clinical documentation and presentations.

The workshop began with a case discussion introducing clinical, diagnostic and management reasoning along with the concept of threshold. We demonstrated the “Six R's of Management Reasoning” with a second case that incorporated social context, such as financial constraints and travel plans. Students then collaborated in small groups on additional cases involving medical and social complexity, including scenarios with incarcerated or uninsured patients. Group work fostered peer learning and discussions of clinical rationale.

Finally, we discussed the components of admission orders. Students then worked in groups to implement their management plans in a shared document, and the facilitator provided real‐time feedback. In the session with a single student, the student completed the tasks independently while the facilitator explored their reasoning and offered suggestions to improve their management plan and admission orders.

We provided all students with a badge card with the “Six R's of Management Reasoning” and a quick‐reference tool for admission orders. We encouraged students to use these tools during the subinternship.

3. Evaluation

We collected quantitative and qualitative data to assess curricular objectives and inform quality improvement. Evaluation followed three levels of Kirkpatrick's model: reaction, learning and behaviour [9]. The Baylor College of Medicine IRB approved the study.

3.1. Reaction

We administered surveys immediately postworkshop and 4 weeks later, postrotation. These surveys included Likert‐scale agreement items assessing students' confidence in the workshop's learning objectives and general feedback. We used the Wilcoxon signed‐rank tests to analyse preworkshop to postworkshop changes in confidence.

Postworkshop surveys indicated that all students agreed or strongly agreed that the workshop provided them with knowledge and skills relevant to their patient care activities and was beneficial preparation for their role as a subintern. Students' self‐assessed ability to perform workshop skills increased significantly (all p < 0.001, r effect size values between 0.79 and 0.83; Figure 2). This improvement persisted through the 4‐week rotation, and students reported additional improvement in their ability to use a standardised approach to develop a management plan and in their ability to draft admission orders.

FIGURE 2.

Mean student agreement with their ability to perform each task, July 2023 to December 2024. Scale: 5 = strongly agree, 4 = agree, 3 = neutral, 2 = disagree, 1 = strongly disagree. Q1. Definitions of DR and MR: I can explain the difference between diagnostic reasoning and management reasoning. Q2. Threshold: I can explain the concept of threshold in medical decision‐making. Q3. Standardised approach: I can utilise a standardised approach to developing a management plan that incorporates evidence‐based medicine, high value care and shared decision making. Q4. Admission orders: I can draft admission orders for a patient being admitted to the hospital.

3.2. Learning

We used an eight‐item multiple‐choice test on diagnostic reasoning, management reasoning and threshold. We matched questions across tests for consistent difficulty without repetition. Prior to implementation, we piloted the questions with six individuals (faculty, residents and students) to ensure clarity. We used two‐sample t‐tests to ascertain differences in knowledge acquisition. For all statistical tests, statistical significance is evaluated at a threshold of 0.05, and effect sizes for each test are reported.

Students showed a statistically significant improvement in relevant knowledge from the preworkshop to postworkshop tests, where the average score improved from 81.7% to 93.3% (p < 0.001, Hedges's g = 1.20).

3.3. Behaviour

We developed a workplace‐based assessment form that we piloted during night shift admissions at one clinical site to evaluate students' management reasoning. The form contained eight items assessing students' rationale for differential diagnosis, use of risk calculators, incorporation of high‐value care and evidence‐based medicine and engagement in shared decision‐making, along with space for narrative constructive feedback. We emailed a short video explaining the purpose and use of the form to the nocturnists each month. Assessments required on average less than 5 min. We analysed faculty feedback to students to assess the efficacy of our workshop and alignment with the “6 R's of Management Reasoning.”

Eight nocturnists provided 21 assessments of 15 students (1–2 observations per student; see Table 1). All students received “done correctly” for providing differential diagnosis rationale and “done” for using a clinical risk calculator and referencing shared decision‐making. Two presentations were rated “not done” for incorporating high‐value care, and five presentations were rated “not done” for citing evidence from the medical literature (a component of Recall Management Script). Most nocturnist comments highlighted opportunities for improvement that aligned with more consistent application of the “Six R's of Management Reasoning.”

TABLE 1.

Nocturnist faculty feedback on workplace‐based assessment of subinterns' management reasoning, July 2023 to December 2024.

“Six R's” component	Theme	Comments
Risk calculation	Stating and rationalising the differential diagnosis	Broadening differential diagnosis for chest pain to include oesophageal pathology Separate problems in the plan and add a mini‐differential for each We discussed adding rationale for why each treatment was chosen State your assessment and plan more clear, do not include things from your HPI (History of Present Illness). Clearly state your differential and things you have ruled in or out on your differential No suggestions for improvement. Did a great job making a broad differential diagnosis and a detailed plan Recommend continuing to integrate your objective findings into the assessment/plan.
	Prioritisation	Discussed importance of recognising urgent vs. nonurgent needs for patients Prioritise the top items for patients, such as their chief complaint, and focus on that for the presentation. Discussed importance of looking into complex or unusual conditions patients may present with and prioritising their management
	Cognitive biases	Be wary of anchoring bias, it can be easy to focus on 1 diagnosis Avoid anchoring on the diagnosis handed to you
Recall management script	Diagnostic testing	Secondary cirrhosis workup for presumed alcoholic cirrhosis
	Evidence‐based medicine	We talked about using clinical reasoning with evidence‐based research
	Medical knowledge	Discussed areas of medical knowledge foundation review
Right for the patient	Patient experience	Do not be afraid to ask about a patient's experience and perception as it can keep your work interesting and help you to connect with the patient.
Resource allocation	High value care	Discussed thinking through if diagnostics will change management
Recommend	Details and organisation	Consider grouping prophylactic treatments together. For example, “for ascites, continue Lasix 40 mg and spironolactone 100 mg daily” instead of having them as separate lines in your plan. Continue presenting in a structured H&P format, especially the assessment and plan Be as systematic and thorough as possible early in your career
Re‐evaluation	Continuity of care	Having clinical data points to follow and plan for continuity of care on discharge We discussed follow‐up on clinical data, radiological and microbiology data after seeing a patient to ensure continuity of care Add details about prior untreated infections and surgical consult notes in plan so others are aware.

4. Implications

Despite calls for research on how to teach management, best practices remain unclear [5]. Many proposed pedagogical strategies lack rigorous evaluation [10]. Implementing the “Six R's of Management Reasoning” in an active‐learning workshop helps to address this gap and grounding the session in social constructivism align it with evidence‐based teaching practices [11].

The workshop effectively introduced management reasoning and increased learner confidence. Nocturnist feedback supported the utility of the mnemonic and also revealed that learners struggled to effectively apply the tool in clinical settings. Management reasoning requires repeated patient encounters, longitudinal mentorship and time—far more than a single 90‐min session can provide. The workshop provides an introductory scaffold; durable skill development likely requires longitudinal reinforcement, spaced practice and integration across clinical rotations.

The workshop provides an introductory scaffold; durable skill development likely requires longitudinal reinforcement, spaced practice and integration across clinical rotations.

Our study focused on subinterns—senior medical students transitioning from recorder and interpreter to manager. This stage is a natural point to introduce and strengthen management reasoning skills, which will continue to develop throughout residency and beyond. Earlier integration may offer long‐term benefits, though prior work shows that late‐stage learners naturally emphasise management more than early learners [4]. Teaching management reasoning alongside diagnostic reasoning may accelerate development, but this remains unexplored.

Future research should develop validated instruments for assessing management reasoning, as current tools such as the Assessment of Reasoning Tool fail to fully address evidence‐based medicine, high‐value care and shared decision‐making [12]. Evaluations should extend beyond the rotation and compare teaching modalities using rigorous design to identify what works best when attempting to develop management reasoning.

Students found the curriculum valuable, with one calling it “the most helpful hour experience I have had in my training.” Building on this success, we plan to expand the workshop to subinterns in other specialties and explore its utility for interns and residents. As a structured approach to management reasoning, the “Six R's of Management Reasoning” may support broader initiatives to strengthen clinical decision‐making across training stages.

Author Contributions

Maria Maldonado: conceptualization, investigation, writing – original draft, methodology, validation, visualization, writing – review and editing, formal analysis, project administration, data curation, software, supervision, resources. Peter Boedeker: methodology, visualization, validation, writing – review and editing, formal analysis, data curation, writing – original draft. Anita V. Kusnoor: conceptualization, investigation, writing – original draft, resources, supervision, data curation, project administration, formal analysis, writing – review and editing, visualization, validation, methodology, software.

Funding

The authors have nothing to report.

Disclosure

The authors have nothing to report.

Ethics Statement

This study was approved by the Baylor College of Medicine IRB.

Conflicts of Interest

The authors declare no conflicts of interest.

Disclaimers

The author has nothing to report.

Previous Presentations

Southern Group of Educational Affairs (SGEA), Association of American Medical Colleges (AAMC) Conference, April 2024, Houston, TX.

Data Availability Statement

No data were obtained from outside sources.