#3 Management Reasoning: What is it and how do we teach it?

December 28, 2021 | By Molly Heublein

With Drs. Emily Abdoler and Gurpreet Dhaliwal

Summary

Listen as our esteemed guests Dr. Emily Abdoler (@EmilyAbdoler,) and Dr. Gurpreet Dhaliwal (@Gurpreet2015) introduce us to management reasoning and its subset, therapeutic reasoning!  Turns out our learners probably have a lot more to learn about therapeutic reasoning (what we spend most of our time doing in primary care) than the better known cousin, diagnostic reasoning.  Learn easy to implement techniques like the Management Pause- four simple questions that encourage learners to “show their work” and help push reasoning to the next level.  We hope you’ll integrate the Equity Check into your daily practice from here on out!

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Credit

• Hosts/Writers/Producers: Era Kryzhanovskaya, MD; Molly Heublein, MD 
• Infographic, Cover Art: Andrew DeLaat
• Editor: Clair Morgan of nodderly.com
• Guests and Reviewers: Emily Abdoler, MD, MAEd; Gurpreet Dhaliwal, MD

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The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. See info sheet for further directions. Note: A free VCU Health CloudCME account is required in order to seek credit.

Show Segments:  

• Intro, disclaimer, guest bio 
• Guest introductions
• Picks of the Week
• Case #1 from Kashlak 
• Definitions 
• Teaching Therapeutic Reasoning 
• Management Pause
• Case #2 from Kashlak, treatment scripts
• Teaching MgR or TxR at different levels
• Continuing to improve our own management 
• Equity check on management pause 
• Assessing management reasoning
• Outro

Management Reasoning Pearls

1. Clinical reasoning includes diagnostic reasoning and management reasoning with the latter having a subset focused on therapeutics called “therapeutic reasoning.” 
2. The management reasoning process is iterative with further testing, monitoring how a patient does over time, and choices in management (contextual factors) impacting the diagnosis.
3. In teaching learners about management reasoning, consider including the management pause and adding an equity check to see how justice plays into decisions around treatment and monitoring. 
4. Push your learner to “show their work.”

Management Reasoning Notes

Definitions

Clinical reasoning includes both diagnostic and management reasoning.   

 (Abstracted comparison from Cook 2019)

Diagnostic reasoning is a categorization task that involves synthesizing information and assigning a label or prioritized differential diagnosis.   There is usually one right answer that in theory can be verified.  The patient is not usually part of this. This is a classification task.

Management reasoning is establishing the plan to relieve the patient’s symptoms and concerns. It includes choosing appropriate therapies, next steps in testing, follow up/monitoring, and coordinating with other health professionals. It is situated: very context dependent.  There are often multiple logical and reasonable management paths to choose between; priorities and constraints are important, including cost, patient preferences, treatment side effects, and the health system contextual factors.  This is an optimization task! (Parsons 2020, Abdoler 2020)

Therapeutic reasoning is a subset of management reasoning which is focused on treatment selection and considering the specific aspects that make you choose one therapy over another (e.g., surgery versus observation or antibiotic A versus antibiotic B).. 

The whole process is iterative.  Further testing, management decisions, and how a patient fares over time can modify the original working diagnosis.

Teaching Management Reasoning

As a teacher, think about creating an assessment and plan for your learner almost like you would for a patient: What am I trying to focus on teaching today? What aspect of management reasoning will I emphasize? Will I focus on the multiple skills and concepts that underpin the management reasoning process?

To dive into the management reasoning further or the specific therapeutic reasoning a learner did, ask learners to “show their work”.   They may have the “right” answer, but is it just pattern recognition?  A lucky guess? Or was it a result of a robust and nuanced mental map of the treatment options. Look for some artifact of their thinking (verbal, written, action) to start the discussion and the teaching.  Where is the margin of their knowledge?  Try to pick a teaching point that is developmentally appropriate to the learner.  Examples of questions that surface thinking: Could you give me an argument for what you thought the best therapy was?  What is another plausible therapy option in this case?  What would have been a less optimal therapy and why?

In considering how we teach the cognitive structures of management reasoning, evaluate if the learner has the treatment scripts (antibiotics vs drainage) and do they have an algorithm (treatment schema) to sort among them. (Abdoler 2020)

Take a management pause! Ask four questions: 

1. Why are we choosing this therapy for this patient? 
2. What are the potential downsides (burdens)? 
3. What are two potential alternatives and why aren’t we choosing them? 
4. How might we include the patient in this decision?  (Parsons, Abdoler et al.  AAME 2021 tweeted by @JenniferSpicer4)

There are many skills and cognitive structures within this management reasoning approach- shared decision making, high value care, communication, monitoring and feedback, and systems knowledge (workplace learning, how things work). These series of skills encircle the core skills of being a clinician.   Explicitly name the skills involved for learners. If you’ve decided, “Today, I’m going to make a decision to teach this learner how to navigate between the different services involved in treating acute cholecystitis and the timing of contacting them,” then name the systems knowledge you are sharing!

It’s always important to emphasize that learners don’t need to memorize all the therapy details, but learners need to know what questions to ask and where to find those answers.

Consider the justice component for management reasoning–what is the best possible plan for the patient? Why are we deviating? How can we mobilize the full interprofessional team to do the best for this patient? Add an EQUITY CHECK on the management pause!  (Abdoler et al.  AAME 2021 tweeted by @JenniferSpicer4; Samson 2018)

Treatment choices can contribute to further diagnosis–that’s where follow up and monitoring comes into play to help edit a diagnosis to clinical situations over time. We should model for our learners, “I’m going to revise the diagnostic or therapeutic reasoning I did,” to highlight the iterative nature of the process. 

How do we evaluate learners based on the strength of their reasoning regarding a particular management decision and the learners “showing their work?” Would separate the ultimate patient outcome (or why a reasonable management plan did not go as well as we hoped) from the strength of the argument the learner made regarding the decision (to give antibiotics or not).

Continue to improve your own Management Reasoning

Get feedback on your management!  Follow up on patients by keeping them on your list or checking in with them later.  Ask colleagues what they would do, why they made a different decision, or how did they come to that therapeutic conclusion. 

References mentioned:

Cook, David A. MD, MHPE; Durning, Steven J. MD, PhD; Sherbino, Jonathan MD, MEd; Gruppen, Larry D. PhD Management Reasoning: Implications for Health Professions Educators and a Research Agenda, Academic Medicine: September 2019 – Volume 94 – Issue 9 – p 1310-1316 doi: 10.1097/ACM.0000000000002768

Cook DA, Sherbino J, Durning SJ. Management Reasoning: Beyond the Diagnosis. JAMA. 2018;319(22):2267–2268. doi:10.1001/jama.2018.4385

Abdoler EA, O’Brien BC, Schwartz BS. Following the Script: An Exploratory Study of the Therapeutic Reasoning Underlying Physicians’ Choice of Antimicrobial Therapy. Acad Med. 2020 Aug;95(8):1238-1247. doi: 10.1097/ACM.0000000000003498. PMID: 32379146.Parsons AS, Wijesekera TP, Rencic JJ. The Management Script: A Practical Tool for Teaching Management Reasoning. Acad Med. 2020 Aug;95(8):1179-1185. doi: 10.1097/ACM.0000000000003465. PMID: 32349018.

Links

1. Emily’s book recommendation How to Survive a Plague by David France
2. Gurpreet’s book recommendation Noise: A Flaw in Human Judgement by Daniel Kahneman
3. Era’s pick of the week: the vegetable beets. How to use them in cooking though no endorsement of this site.  
4. Molly’s pick of the week: The Prophets by Robert Jones Jr

Goals

Listeners will become familiar with the steps and approaches that underlie management reasoning

Learning objectives

After listening to this episode, listeners will be able to…

1. Recall the major categories of clinical reasoning
2. Recognize the distinction between diagnostic vs management reasoning
3. Describe the key elements of the process of reasoning around treatment choice (therapeutic reasoning)

Disclosures

Drs Abdoler and Dhaliwal report no relevant financial disclosures. The Curbsiders Teach report no relevant financial disclosures.

Citation

Abdoler E, Dhaliwal G, Heublein M, Kryzhanovskaya E. “#3 Management Reasoning. The Curbsiders Teach Podcast. http://thecurbsiders.com/teach December 28, 2021.