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

Cook, David A. MD, MHPE; Durning, Steven J. MD, PhD; Sherbino, Jonathan MD, MEd; Gruppen, Larry D. PhD

doi: 10.1097/ACM.0000000000002768
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Substantial research has illuminated the clinical reasoning processes involved in diagnosis (diagnostic reasoning). Far less is known about the processes entailed in patient management (management reasoning), including decisions about treatment, further testing, follow-up visits, and allocation of limited resources. The authors’ purpose is to articulate key differences between diagnostic and management reasoning, implications for health professions education, and areas of needed research.

Diagnostic reasoning focuses primarily on classification (i.e., assigning meaningful labels to a pattern of symptoms, signs, and test results). Management reasoning involves negotiation of a plan and ongoing monitoring/adjustment of that plan. A diagnosis can usually be established as correct or incorrect, whereas there are typically multiple reasonable management approaches. Patient preferences, clinician attitudes, clinical contexts, and logistical constraints should not influence diagnosis, whereas management nearly always involves prioritization among such factors. Diagnostic classifications do not necessarily require direct patient interaction, whereas management prioritizations require communication and negotiation. Diagnoses can be defined at a single time point (given enough information), whereas management decisions are expected to evolve over time. Finally, management is typically more complex than diagnosis.

Management reasoning may require educational approaches distinct from those used for diagnostic reasoning, including teaching distinct skills (e.g., negotiating with patients, tolerating uncertainty, and monitoring treatment) and developing assessments that account for underlying reasoning processes and multiple acceptable solutions.

Areas of needed research include if and how cognitive processes differ for management and diagnostic reasoning, how and when management reasoning abilities develop, and how to support management reasoning in clinical practice.

D.A. Cook is professor of medicine and 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: http://orcid.org/0000-0003-2383-4633.

S.J. Durning is professor of medicine and director, Division of Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland.

J. Sherbino is assistant dean, Health Professions Education Research, Faculty of Health Sciences, and professor, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.

L.D. Gruppen is professor, Department of Learning Health Sciences, and director, Master of Health Professions Education Program, University of Michigan Medical School, Ann Arbor, Michigan.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Disclaimer: The views expressed herein are those of the authors and not necessarily those of the U.S. Department of Defense or other federal agencies.

Correspondence should be addressed to David A. Cook, Division of General Internal Medicine, Mayo Clinic College of Medicine and Science, Mayo 17-W, 200 First St. S.W., Rochester, MN 55905; telephone: (507) 284-2269; email: cook.david33@mayo.edu.

Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.