Table.

Additional Illustrative Quotes From Residents Regarding the Role of Pathways in Formulating Diagnoses

Theme	Quote
Pathways Were Used as Information References to Guide Management and Treatment, Not Diagnostic Decision-Making Aids
Pathways as resources	“The pathways were very new for the oncoming interns, and it was a helpful way to start to frame particular cases for them and also help teach about available resources. [For instance] if you have a [patient] who's coming in with febrile UTI, where do you go to find out which antibiotics? For how long [would you treat]? When would you do IV, when would you do PO?... it was nice to give them a resource to then turn back to again and again as these cases come. I don't think it's quite as helpful in the stage before that when you're really trying to develop your differential or in an undifferentiated patient.” (R4)
Pathways, as Tools for Efficient Treatment, Are Applied Even When the Patient Is Not Believed to Fit the Diagnostic Criteria
Management reasoning	“Nobody was particularly comfortable with a definitive diagnosis of asthma when she arrived on the floor because her story was atypical, but I think you could still put someone on a pathway even in the setting of that uncertainty because that's the therapy that you're pursuing at that point in time.” (R4)
Clinical Pathways Can Negatively Impact Development of Diagnostic Reasoning Skills by Distancing Residents From the Diagnostic Process and May Introduce Cognitive Bias
Premature closure	“I had one patient who came in and was triaged in the emergency department as a kid who had a focal weakness, a focal deficit, and everybody got really nervous that this was stroke. And so, we had this discussion outside of the room before ever seeing the patient like, “Who do we need to call” and “Where do they fall in the pathway,” and we hadn't even seen the patient yet…it just wasn't a natural thing for someone to just step in the room and do the neurologic examination and verify that there was a focal weakness and then move from there. And so, I think we are—I think we just are really quick to jump to pathways.” (R3)
	“The downsides are that I do worry that people become dependent on it, um, and not every case sort of fits into a pathway, but when you're used to using a pathway for 60%+ of what we see in pediatrics, you worry a little bit that you will be accustomed to that and try to fit things into a pathway that they're not, and I think I've seen cases of that taking care of patients.” (R7)
Diagnostic momentum	“You just kind of—you get kind of lodged in one way of thinking about things, like ‘This is asthma, this is only asthma so we're gonna treat it like asthma.'” (R8)
	“These kids are put on autopilot on these pathways, and it really—I find it to be very frustrating because we forget to think about what we're doing.” (R1)
Clinical Pathways Can Positively Impact Diagnostic Reasoning Skills by Providing Opportunity and Scaffolding for Diagnostic Calibration
Forward planning (knowing what to expect)	“We only really start talking about pathway fit when it's not going according to plan, and you start to have setbacks or start to you know, need more escalation, more support than you're used to, or you know, you're not getting to a point of success that you otherwise would have thought you'd be getting to. And so, I think that that's one of the most common spots where we start to say, ‘Is this the right approach for this kid?'” (R3)
Monitoring	“But I would say that, more often than not, I've continued the pathway for the first 24 or 36 hours, and it's only as you're kind of pushing into their course and realizing they actually need something a little bit different at this stage, that I've taken kids off [pathway].” (R4)