Does management reasoning display context specificity? An exploration of sleep loss and other distracting situational (contextual) factors in clinical reasoning
-
Amanda Sutton
,
Jacob Collen
Abstract
Objectives
Context specificity occurs when a health professional sees two patients with identical signs and symptoms yet arrives at two different diagnoses due to other existing factors. For example, one patient speaks English as a first language, while the other patient has limited English proficiency. It is not known if context specificity extends beyond diagnosis and also affects management reasoning. Our study explored whether reduced sleep and other distracting contextual factors (e.g., limited English proficiency) lead to context specificity, resulting in suboptimal management reasoning.
Methods
Seventeen medical residents participated in a two-month study (consisting of one outpatient and one inpatient rotation), in which their sleep was tracked. After each rotation, participants watched two clinical encounter videos–one with and one without distracting contextual factors–and completed think-aloud interviews for each video discussing their management plans. Interviews were transcribed and assessed for management reasoning themes.
Results
Residents (n=17) on outpatient rotations received more sleep than those on inpatient rotations (450.5 min ± 7.13 vs. 425.6 min ± 10.78, p=0.023). Five management reasoning themes were identified: organized knowledge, disorganized knowledge, uncertainty, addressing non-pharmacologic interventions, and addressing patient needs and concerns. There was essentially no difference in the prevalence of utterances of organized knowledge themes between residents with more or less sleep (25 vs. 27 times, p=0.78) or those exposed to contextual factors vs. not exposed (24 vs. 28 times, p=0.58). However, disorganized knowledge themes were observed significantly more frequently in participants exposed to contextual factors (33 vs. 18 times, p=0.036).
Conclusions
Residents slept more during outpatient rotations. While sleep alone was not associated with the prevalence of management reasoning themes, residents exposed to videos with distracting contextual factors displayed significantly more instances of disorganized knowledge, supporting the phenomenon of context specificity in management reasoning.
-
Research ethics: IRB# MED-83-3824, JAN 19, 2022. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013).
-
Informed consent: Informed consent was obtained from all individuals included in this study, or their legal guardians or wards.
-
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
-
Use of Large Language Models, AI and Machine Learning Tools: None declared.
-
Conflict of interest: The authors state no conflict of interest.
-
Research funding: None declared.
-
Data availability: Not applicable.
-
Disclaimer: The opinions and assertions expressed herein are those of the authors’ and do not necessarily reflect the official policy or position of the Uniformed Services University of the Department of Defense.
References
1. Durning, S, Artino, AR, Pangaro, L, van der Vleuten, CPM, Schuwirth, L. Context and clinical reasoning: understanding the perspective of the expert’s voice. Med Educ 2011;45:927–38. https://doi.org/10.1111/j.1365-2923.2011.04053.x.Suche in Google Scholar PubMed
2. Connor, DM, Durning, SJ, Rencic, JJ. Clinical reasoning as a core competency. Acad Med J Assoc Am Med Coll 2020;95:1166–71. https://doi.org/10.1097/acm.0000000000003027.Suche in Google Scholar PubMed
3. Parsons, AS, Wijesekera, TP, Rencic, JJ. The management script: a practical tool for teaching management reasoning. Acad Med J Assoc Am Med Coll 2020;95:1179–85. https://doi.org/10.1097/acm.0000000000003465.Suche in Google Scholar PubMed
4. Rodziewicz, TL, Houseman, B, Vaqar, S, Hipskind, JE. Medical error reduction and prevention. In: StatPearls, [Internet]. Treasure Island (FL): StatPearls Publishing; 2025. [cited 2025 Jan 11]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK499956/.Suche in Google Scholar
5. Collen, J, Durning, S, Berk, J, Mang, J, Alcover, K, Jung, E. Exploring sleep duration and clinical reasoning process in resident physicians: a thematic analysis. J Clin Sleep Med JCSM Off Publ Am Acad Sleep Med 2024;20:1279–89. https://doi.org/10.5664/jcsm.11134.Suche in Google Scholar PubMed PubMed Central
6. Boyle, JG, Walters, MR, Jamieson, S, Durning, SJ. Reframing context specificity in team diagnosis using the theory of distributed cognition. Diagn Berl Ger 2023;10:235–41. https://doi.org/10.1515/dx-2022-0100.Suche in Google Scholar PubMed
7. Konopasky, A, Artino, AR, Battista, A, Ohmer, M, Hemmer, PA, Torre, D, et al.. Understanding context specificity: the effect of contextual factors on clinical reasoning. Diagn Berl Ger 2020;7:257–64. https://doi.org/10.1515/dx-2020-0016.Suche in Google Scholar PubMed
8. Ramani, D, Soh, M, Merkebu, J, Durning, SJ, Battista, A, McBee, E, et al.. Examining the patterns of uncertainty across clinical reasoning tasks: effects of contextual factors on the clinical reasoning process. Diagn Berl Ger 2020;7:299–305. https://doi.org/10.1515/dx-2020-0019.Suche in Google Scholar PubMed
9. Ahmed, N, Sadat, M, Cukor, D. Sleep knowledge and behaviors in medical students: results of a single center survey. Acad Psychiatr J Am Assoc Dir Psychiatr Resid Train Assoc Acad Psychiatr 2017;41:674–8. https://doi.org/10.1007/s40596-016-0655-3.Suche in Google Scholar PubMed PubMed Central
10. Barger, LK, Cade, BE, Ayas, NT, Cronin, JW, Rosner, B, Speizer, FE, et al.. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med 2005;352:125–34. https://doi.org/10.1056/nejmoa041401.Suche in Google Scholar
11. Wali, SO, Qutah, K, Abushanab, L, Basamh, R, Abushanab, J, Krayem, A. Effect of on-call-related sleep deprivation on physicians’ mood and alertness. Ann Thorac Med 2013;8:22–7. https://doi.org/10.4103/1817-1737.105715.Suche in Google Scholar PubMed PubMed Central
12. Cook, DA, Sherbino, J, Durning, SJ. Management reasoning: beyond the diagnosis. JAMA 2018;319:2267–8. https://doi.org/10.1001/jama.2018.4385.Suche in Google Scholar PubMed
13. Brown, JS, Collins, A, Duguid, P. Situated cognition and the culture of learning. Educ Res 1989;18:32–42. https://doi.org/10.2307/1176008.Suche in Google Scholar
14. Artino, AR. It’s not all in your head: viewing graduate medical education through the lens of situated cognition. J Grad Med Educ 2013;5:177–9. https://doi.org/10.4300/jgme-d-13-00059.1.Suche in Google Scholar PubMed PubMed Central
15. Burbach, B, Barnason, S, Thompson, SA. Using “think aloud” to capture clinical reasoning during patient simulation. Int J Nurs Educ Scholarsh 2015;12:1–7. https://doi.org/10.1515/ijnes-2014-0044.Suche in Google Scholar PubMed
16. 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 Theory Pract 2012;17:65–79. https://doi.org/10.1007/s10459-011-9294-3.Suche in Google Scholar PubMed
17. Johnson, WR, Artino, AR, Durning, SJ. Using the think aloud protocol in health professions education: an interview method for exploring thought processes: AMEE Guide No. 151. Med Teach 2023;45:937–48. https://doi.org/10.1080/0142159x.2022.2155123.Suche in Google Scholar
18. Clarke, V, Braun, V. Teaching thematic analysis: overcoming challenges and developing strategies for effective learning. Psychol 2013;26:120–3.Suche in Google Scholar
19. Berge, M, Soh, M, Fahlsing, C, MacKinnon, R, Wetstein, B, Anderson, A, et al.. Semantic competency as a marker of clinical reasoning performance. MedEdPublish 2022;12:1. https://doi.org/10.12688/mep.17438.1.Suche in Google Scholar
20. Ericsson, KA, Simon, HA. How to study thinking in everyday life: contrasting think-aloud protocols with descriptions and explanations of thinking. Mind Cult Act 1998;5:178–86. https://doi.org/10.1207/s15327884mca0503_3.Suche in Google Scholar
21. Fraser, KL, Ayres, P, Sweller, J. Cognitive load theory for the design of medical simulations. Simul Healthc J Soc Simul Healthc 2015;10:295–307. https://doi.org/10.1097/sih.0000000000000097.Suche in Google Scholar
22. Miller, GA. The magical number seven, plus or minus two: some limits on our capacity for processing information. Psychol Rev 1994;101:343–52. https://doi.org/10.1037//0033-295x.101.2.343.Suche in Google Scholar
23. Mizuno, K, Tanaka, M, Yamaguti, K, Kajimoto, O, Kuratsune, H, Watanabe, Y. Mental fatigue caused by prolonged cognitive load associated with sympathetic hyperactivity. Behav Brain Funct BBF 2011;7:17. https://doi.org/10.1186/1744-9081-7-17.Suche in Google Scholar PubMed PubMed Central
24. Taffinder, NJ, McManus, IC, Gul, Y, Russell, RC, Darzi, A. Effect of sleep deprivation on surgeons’ dexterity on laparoscopy simulator. Lancet Lond Engl 1998;352:1191. https://doi.org/10.1016/s0140-6736(98)00034-8.Suche in Google Scholar PubMed
© 2025 Walter de Gruyter GmbH, Berlin/Boston
Artikel in diesem Heft
- Frontmatter
- Reviews
- Accuracy of pulse wave velocity for screening coronary artery disease: a systematic review and meta-analysis
- Prenatal screening for genetic disorders: updated guidelines, proposed counseling, a holistic approach for primary health care providers in developing countries
- A scoping review of fever of unknown origin with normal serum C-reactive protein
- Mini Review
- Overview of dengue diagnostic limitations and potential strategies for improvement
- Opinion Papers
- Demystifying cognitive bias in the diagnostic process for frontline clinicians and educators; new words for old ideas
- Physicians’ prism: illuminating history with structured expertise
- Original Articles
- Implementation of a curriculum on communicating diagnostic uncertainty for clerkship-level medical students: a pseudorandomized and controlled study
- A synthesized differential diagnosis is associated with fewer diagnostic errors compared to an inventorial list
- Equity-Driven Diagnostic Excellence framework: An upstream approach to minimize risk of diagnostic inequity
- Two decades of autopsy-detected diagnostic errors in Japan
- Does management reasoning display context specificity? An exploration of sleep loss and other distracting situational (contextual) factors in clinical reasoning
- Cognitive biases in osteopathic diagnosis: a mixed study among French osteopaths
- Racial and ethnic disparities in pediatric emergency department patients with missed opportunities for diagnostic excellence
- Diagnostic accuracy of non-mydriatic fundus photography as a triage and telemedicine tool for patients with vision loss
- “Innumerable” lesion burden on brain MRI ‒ a diagnostic approach
- Factors associated with positive findings of deep infection on computed tomography among patients with extremity cellulitis
- Exploring emergency department providers’ uncertainty in neurological clinical reasoning
- Analytical performance and user-friendliness of four point-of-care measuring systems for monitoring prothrombin time international normalized ratio in the hands of the intended users
- Fetal hematological phenotypes of various hemoglobinopathies and demonstration of embryonic hemoglobins on capillary electrophoresis: a large cohort data from prenatal screening program
- Development and assessment of autoverification system for routine coagulation assays in inpatient and outpatient settings of tertiary care hospital: algorithm performance and impact on laboratory efficiency
- Validation of new, circulating biomarkers for gliomas
- Short Communications
- Using language to evaluate curricular impact: a novel approach in assessing clinical reasoning curricula
- Comparative evaluation of routine coagulation testing on Stago sthemO 301 and Werfen ACL TOP 750
- Letters to the Editor
- Reversible systemic vasoconstriction syndrome: a new diagnostic family of generalized vasospasm in multiple organs
- The value of designating symptoms as “vague” in diagnosis
- Immunoglobulin E in an inverted skin-prick test for rapid detection of cutaneous antigens
Artikel in diesem Heft
- Frontmatter
- Reviews
- Accuracy of pulse wave velocity for screening coronary artery disease: a systematic review and meta-analysis
- Prenatal screening for genetic disorders: updated guidelines, proposed counseling, a holistic approach for primary health care providers in developing countries
- A scoping review of fever of unknown origin with normal serum C-reactive protein
- Mini Review
- Overview of dengue diagnostic limitations and potential strategies for improvement
- Opinion Papers
- Demystifying cognitive bias in the diagnostic process for frontline clinicians and educators; new words for old ideas
- Physicians’ prism: illuminating history with structured expertise
- Original Articles
- Implementation of a curriculum on communicating diagnostic uncertainty for clerkship-level medical students: a pseudorandomized and controlled study
- A synthesized differential diagnosis is associated with fewer diagnostic errors compared to an inventorial list
- Equity-Driven Diagnostic Excellence framework: An upstream approach to minimize risk of diagnostic inequity
- Two decades of autopsy-detected diagnostic errors in Japan
- Does management reasoning display context specificity? An exploration of sleep loss and other distracting situational (contextual) factors in clinical reasoning
- Cognitive biases in osteopathic diagnosis: a mixed study among French osteopaths
- Racial and ethnic disparities in pediatric emergency department patients with missed opportunities for diagnostic excellence
- Diagnostic accuracy of non-mydriatic fundus photography as a triage and telemedicine tool for patients with vision loss
- “Innumerable” lesion burden on brain MRI ‒ a diagnostic approach
- Factors associated with positive findings of deep infection on computed tomography among patients with extremity cellulitis
- Exploring emergency department providers’ uncertainty in neurological clinical reasoning
- Analytical performance and user-friendliness of four point-of-care measuring systems for monitoring prothrombin time international normalized ratio in the hands of the intended users
- Fetal hematological phenotypes of various hemoglobinopathies and demonstration of embryonic hemoglobins on capillary electrophoresis: a large cohort data from prenatal screening program
- Development and assessment of autoverification system for routine coagulation assays in inpatient and outpatient settings of tertiary care hospital: algorithm performance and impact on laboratory efficiency
- Validation of new, circulating biomarkers for gliomas
- Short Communications
- Using language to evaluate curricular impact: a novel approach in assessing clinical reasoning curricula
- Comparative evaluation of routine coagulation testing on Stago sthemO 301 and Werfen ACL TOP 750
- Letters to the Editor
- Reversible systemic vasoconstriction syndrome: a new diagnostic family of generalized vasospasm in multiple organs
- The value of designating symptoms as “vague” in diagnosis
- Immunoglobulin E in an inverted skin-prick test for rapid detection of cutaneous antigens
