Exploring procedure-based management reasoning: a case of tension pneumothorax

Raj C. Singaraju; Steven J. Durning; Alexis Battista; Abigail Konopasky

doi:10.1515/dx-2022-0028

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Article

Exploring procedure-based management reasoning: a case of tension pneumothorax

Raj C. Singaraju , Steven J. Durning , Alexis Battista and Abigail Konopasky

Published/Copyright: August 4, 2022

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From the journal Diagnosis Volume 9 Issue 4

Abstract

Objectives

Management reasoning has not been widely explored but likely requires broader abilities than diagnostic reasoning. An enhanced understanding of management reasoning could improve medical education and patient care. We conducted a novel exploratory study to gain further insights into procedure-based management reasoning.

Methods

Participant physicians managed a simulated patient who acutely decompensates in a team-based, time-pressured, live scenario. Immediately following the scenario, physicians perform a think-aloud protocol by watching video recordings of their performance and narrating their reflections in real-time. Verbatim transcripts of the think-aloud protocol were inductively coded using a constant comparative method and evaluated for themes.

Results

We recruited 19 physicians (15 internal medicine, one family medicine, and three general surgery) for this study. Recognizing that diagnostic and management reasoning intertwine, this paper focuses on management reasoning’s characteristics. We developed three categories of management reasoning factors with eight subthemes. These are Patient factors: Acuity and Preferences; Physician factors: Recognized Errors, Anxiety, Metacognition, Monitoring, and Threshold to Treat; and one Environment factor: Resources.

Conclusions

Our findings on procedure-based management reasoning are consistent with Situation Awareness and Situated Cognition models and the extant work on management reasoning, demonstrating that management is inherently complex and contextually bound. Unique to this study, all physicians focused on prognosis, indicating that attaining competency in procedural management may require planning and prediction abilities. Physicians also expressed concerns about making mistakes, potentially resulting from the scenario’s emphasis on a procedure and our physicians’ having less expertise in the treatment of tension pneumothorax.

Keywords: clinical reasoning; management reasoning; procedure

Corresponding author: Raj C. Singaraju, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA, E-mail: raj.singaraju@usuhs.edu

Research funding: None declared.
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interests: Authors state no conflict of interest.
Informed consent: Informed consent was obtained from all individuals included in this study.
Ethical approval: The local Institutional Review Board approved this study.
Disclaimer: The opinions and assertions expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Uniformed Services University or the Department of Defense.

References

1. McBee, E, Ratcliffe, T, Goldszmidt, M, Schuwirth, L, Picho, K, Artino, ARJ, et al.. Clinical reasoning tasks and resident physicians: what do they reason about? Acad Med 2016;91:1022–8. https://doi.org/10.1097/acm.0000000000001024.Search in Google Scholar PubMed

2. Juma, S, Goldszmidt, M. What physicians reason about during admission case review. Adv Health Sci Educ 2017;22:691–711. https://doi.org/10.1007/s10459-016-9701-x.Search in Google Scholar PubMed PubMed Central

3. Ilgen, JS, Eva, KW, Regehr, G. What’s in a label? Is diagnosis the start or the end of clinical reasoning? J Gen Intern Med 2016;31:435–7. https://doi.org/10.1007/s11606-016-3592-7.Search in Google Scholar PubMed PubMed Central

4. Cook, DA, Sherbino, J, Durning, SJ. Management reasoning: beyond the diagnosis. JAMA 2018;319:2267–8. https://doi.org/10.1001/jama.2018.4385.Search in Google Scholar PubMed

5. Wright, DFB, Duffull, SB, Wilby, KJ, Peterson, AK, Anakin, MG. Measuring the development of therapeutic-decision-making skills by practicing pharmacists undertaking a university-based postgraduate clinical qualification at distance. Pharmacy 2020;8:1–9. https://doi.org/10.3390/pharmacy8020083.Search in Google Scholar PubMed PubMed Central

6. Rodziewicz, TL, Houseman, B, Hipskind, JE. Medical error reduction and prevention. StatPearls. Treasure Island (FL): StatPearls Publishing.Search in Google Scholar

7. Institute of Medicine Committee on Quality of Health Care in A. In: Kohn, LT, Corrigan, JM, Donaldson, MS, editors. Washington (DC): National Academies Press (US); 2000.Search in Google Scholar

8. Committee on Diagnostic Error in Health C, Board on Health Care S, Institute of M, The National Academies of Sciences E, Medicine. In: Balogh, EP, Miller, BT, Ball, JR, editors. Improving diagnosis in health care. Washington (DC): National Academies Press (US); 2015.Search in Google Scholar

9. Cook, DA, Durning, SJ, Sherbino, J, Gruppen, LD. Management reasoning: implications for health professions educators and a research agenda. Acad Med 2019;94:1310–6. https://doi.org/10.1097/acm.0000000000002768.Search in Google Scholar PubMed

10. Chan, TM, Mercuri, M, Turcotte, M, Gardiner, E, Sherbino, J, de Wit, K. Making decisions in the era of the clinical decision rule: How emergency physicians use clinical decision rules. Acad Med 2020;95:1230–7. https://doi.org/10.1097/acm.0000000000003098.Search in Google Scholar

11. Goldszmidt, M, Minda, JP, Bordage, G. Developing a unified list of physicians’ reasoning tasks during clinical encounters. Acad Med 2013;88:390–7. https://doi.org/10.1097/acm.0b013e31827fc58d.Search in Google Scholar

12. American College of Surgeons Committee on Trauma. ATLS Student course manual, 10th ed. Chicago, IL: American College of Surgeons; 2018.Search in Google Scholar

13. Ohmer, M, Durning, SJ, Kucera, W, Nealeigh, M, Ordway, S, Mellor, T, et al.. Clinical reasoning in the ward setting: a rapid response scenario for residents and attendings. MedEdPORTAL 2019;15: 10834. https://doi.org/10.15766/mep_2374-8265.10834.Search in Google Scholar PubMed PubMed Central

14. Pinnock, R, Young, L, Spence, F, Henning, M, Hazell, W. Can think aloud be used to teach and assess clinical reasoning in graduate medical education? J Grad Med Educ 2015;7:334–7. https://doi.org/10.4300/jgme-d-14-00601.1.Search in Google Scholar

15. Banning, M. Clinical reasoning and its application to nursing: concepts and research studies. Nurse Educ Pract 2008;8:177–83. https://doi.org/10.1016/j.nepr.2007.06.004.Search in Google Scholar PubMed

16. Endsley, MR. Expertise and situation awareness. In: Ericsson, KA, Hoffman, RR, Kozbelt, A, Williams, AM, editors. The Cambridge handbook of expertise and expert performance. Cambridge: Cambridge University Press; 2018.Search in Google Scholar

17. Durning, SJ, Artino, AR, Boulet, JR, Dorrance, K, van der Vleuten, C, Schuwirth, L. The impact of selected contextual factors on experts’ clinical reasoning performance (does context impact clinical reasoning performance in experts?). Adv Health Sci Educ 2012;17:65–79. https://doi.org/10.1007/s10459-011-9294-3.Search in Google Scholar PubMed

18. Abernethy, B, Farrow, D, Mann, DL. Superior anticipation. In: Ericsson, KA, Hoffman, RR, Kozbelt, A, Williams, AM, editors. The Cambridge handbook of expertise and expert performance. Cambridge: Cambridge University Press; 2018.Search in Google Scholar

19. Holmboe, ES, Ward, DS, Reznick, RK, Katsufrakis, PJ, Leslie, KM, Patel, VL, et al.. Faculty development in assessment: the missing link in competency-based medical education. Acad Med 2011;86:460–7. https://doi.org/10.1097/acm.0b013e31820cb2a7.Search in Google Scholar PubMed

20. Ericsson, KA. Superior working memory in experts. In: Ericsson, K, Hoffman, R, Kozbelt, A, Williams, A, editors. The Cambridge handbook of expertise and expert performance. Cambridge: Cambridge University Press; 2018.10.1017/9781316480748Search in Google Scholar

21. Durning, SJ, Artino, ARJr., Pangaro, LN, van der Vleuten, C, Schuwirth, L. Perspective: redefining context in the clinical encounter: implications for research and training in medical education. Acad Med 2010;85:894–901. https://doi.org/10.1097/acm.0b013e3181d7427c.Search in Google Scholar

22. Schulz, CM, Endsley, MR, Kochs, EF, Gelb, AW, Wagner, KJ. Situation awareness in anesthesia: concept and research. Anesthesiology 2013;118:729–42. https://doi.org/10.1097/aln.0b013e318280a40f.Search in Google Scholar PubMed

23. Gruppen, LD, Frohna, AZ, Norman, G, van der Vleuten, C, Newble, D. International handbook of research in medical education. Great Britain: Kluwer Academic Publishers; 2002.Search in Google Scholar

Received: 2022-03-06

Accepted: 2022-07-10

Published Online: 2022-08-04

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Articles in the same Issue

https://doi.org/10.1515/dx-2022-0028

Keywords for this article

clinical reasoning; management reasoning; procedure