Phenotypes of Management Reasoning Struggle in Postgraduate Medical Education

Clinical reasoning struggles are a leading cause of remediation referrals in postgraduate medical education. Most remediation efforts, like much of the clinical reasoning literature, focus on diagnostic reasoning. Errors in management reasoning can have serious consequences for patients, yet no framework exists for recognizing how learners struggle in this domain or for guiding remediation when they do.

We conducted a multi-institutional qualitative interview study within a constructivist paradigm using the critical incident technique to explore how postgraduate medical trainees struggle with management reasoning in clinical practice, how those struggles are recognized, and how programs respond. Participants were residency program directors and clinical competency committee chairs from U.S. internal medicine and pediatrics programs. Data were analyzed using a systematic cross-case approach to identify phenotypes of management reasoning struggle.

We interviewed 20 program directors and clinical competency committee chairs from 15 programs about 15 trainees remediated for management reasoning difficulties. Cross-case analysis identified four phenotypes: (1) limited management scripts (inability to generate or contextualize a plan despite reaching a diagnosis), (2) can't change course (inability to integrate new clinical information into an existing management plan), (3) impaired task triage and execution (difficulty prioritizing and coordinating management within a complex clinical environment), and (4) failure to calibrate (misjudgment of how much intervention a situation warrants). Contextual (i.e., situational) factors including clinical complexity, patient acuity, diagnostic uncertainty, and reduced supervision increased the likelihood of these phenotypes, and team structures often compensated for struggles before they were recognized. Struggles were frequently misattributed to problems with time management, organization, or communication, and remediation strategies were largely nonspecific across phenotypes.

These four phenotypes offer program leaders and frontline educators an empirically grounded vocabulary for recognizing patterns of management reasoning struggle earlier and designing more targeted support.