Phenotypes of Management Reasoning Struggle in Postgraduate Medical Education

Andrew S. Parsons; Matthew Kelleher; James Bowen; Karen M. Warburton; Michael S. Ryan; Walther N. K. A. van Mook; Steven J. Durning

doi:10.5334/pme.2960

Phenotypes of Management Reasoning Struggle in Postgraduate Medical Education

Volume 15 (2026): Issue 1

By: Andrew S. Parsons , Matthew Kelleher , James Bowen , Karen M. Warburton , Michael S. Ryan , Walther N. K. A. van Mook and Steven J. Durning

Open Access

|Sep 2026

Cook DA, Sherbino J, Durning SJ. Management Reasoning: Beyond the Diagnosis. JAMA. 2018;319(22):2267–2268. DOI: 10.1001/jama.2018.4385
Open DOI Search in Google Scholar Back to article
Cook DA, Durning SJ, Sherbino J, Gruppen LD. Management Reasoning: Implications for Health Professions Educators and a Research Agenda. Acad Med. 2019;94(9):1310. DOI: 10.1097/ACM.0000000000002768
Open DOI Search in Google Scholar Back to article
Bissessur SW, Geijteman ECT, Al-Dulaimy M, et al. Therapeutic reasoning: from hiatus to hypothetical model. J Eval Clin Pract. 2009;15(6):985–989. DOI: 10.1111/j.1365-2753.2009.01136.x
Open DOI Search in Google Scholar Back to article
Korenstein D, Harris R, Elshaug AG, et al. To Expand the Evidence Base About Harms from Tests and Treatments. J Gen Intern Med. 2021;36(7):2105–2110. DOI: 10.1007/s11606-021-06597-9
Open DOI Search in Google Scholar Back to article
Gram EG, Haas R, Niklasson A, et al. Less is more for patients, practitioners, public and planet: a taxonomy for the harms of too much medicine. BMJ Evid-Based Med. Published online October 5, 2025;bmjebm-2025-113874. DOI: 10.1136/bmjebm-2025-113874
Open DOI Search in Google Scholar Back to article
Guerrasio J, Garrity MJ, Aagaard EM. Learner Deficits and Academic Outcomes of Medical Students, Residents, Fellows, and Attending Physicians Referred to a Remediation Program, 2006–2012. Acad Med. 2014;89(2):352–358. DOI: 10.1097/ACM.0000000000000122
Open DOI Search in Google Scholar Back to article
Warburton KM, Goren E, Dine CJ. Comprehensive Assessment of Struggling Learners Referred to a Graduate Medical Education Remediation Program. J Grad Med Educ. 2017;9(6):763–767. DOI: 10.4300/JGME-D-17-00175.1
Open DOI Search in Google Scholar Back to article
Godschalx-Dekker J, van Mook W. Research on residents’ (re)mediation and dismissal in the interest of society. Soc Impacts. 2025;6:100130. DOI: 10.1016/j.socimp.2025.100130
Open DOI Search in Google Scholar Back to article
Parsons AS, Clancy CB, Rencic JJ, Warburton KM. Targeted Strategies to Remediate Diagnostic Reasoning Deficits. Acad Med. 2022 Apr 1;97(4):616. DOI: 10.1097/ACM.0000000000004244
Open DOI Search in Google Scholar Back to article
Parsons AS, Dreicer JJ, Martindale JR, Young G, Warburton KM. A Targeted Clinical Reasoning Remediation Program for Residents and Fellows in Need. J Grad Med Educ. 2024;16(4):469. DOI: 10.4300/JGME-D-23-00822.1
Open DOI Search in Google Scholar Back to article
Parsons AS, Warburton KM. Clinical Reasoning: Coaching the Struggling Medical Learner. Association for Hospital Medical Education. 2025.
Search in Google Scholar Back to article
Cook DA, Stephenson CR, Gruppen LD, Durning SJ. Management Reasoning: Empirical Determination of Key Features and a Conceptual Model. Acad Med. 2023;98(1):80. DOI: 10.1097/ACM.0000000000004810
Open DOI Search in Google Scholar Back to article
Parsons AS, Bryan K, Morris C, et al. Learning to manage: a qualitative exploration of how graduate medical trainees develop management reasoning. Acad Med. 2026 Apr 1;101(4):411–421. DOI: 10.1093/acamed/wvaf068
Open DOI Search in Google Scholar Back to article
Parsons AS, Wijesekera TP, Rencic JJ. The Management Script: A Practical Tool for Teaching Management Reasoning. Acad Med. 2020;95(8):1179–1185. DOI: 10.1097/ACM.0000000000003465
Open DOI Search in Google Scholar Back to article
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;95(8):1238. DOI: 10.1097/ACM.0000000000003498
Open DOI Search in Google Scholar Back to article
Cook DA, Stephenson CR, Gruppen LD, Durning SJ. Management reasoning scripts: Qualitative exploration using simulated physician-patient encounters. Perspect Med Educ. 2022;11(4):196–206. DOI: 10.1007/S40037-022-00714-Y
Open DOI Search in Google Scholar Back to article
Custers EJFM. Thirty years of illness scripts: Theoretical origins and practical applications. Med Teach. 2015;37(5):457–462. DOI: 10.3109/0142159X.2014.956052
Open DOI Search in Google Scholar Back to article
Custers EJ, Regehr G, Norman GR. Mental representations of medical diagnostic knowledge: a review. Acad Med. 1996;71(10):S55. DOI: 10.1097/00001888-199610000-00044
Open DOI Search in Google Scholar Back to article
Parsons AS, Morris C, Bryan K, et al. How postgraduate medical trainees conceptualise management reasoning: A qualitative study. Med Educ. 2026;60(6):655–663. DOI: 10.1111/medu.70123
Open DOI Search in Google Scholar Back to article
Mylopoulos M, Kulasegaram K, Woods NN. Developing the experts we need: Fostering adaptive expertise through education. J Eval Clin Pract. 2018;24(3):674–677. DOI: 10.1111/jep.12905
Open DOI Search in Google Scholar Back to article
Bowen JL. Educational Strategies to Promote Clinical Diagnostic Reasoning. N Engl J Med. 2006;355(21):2217–2225. DOI: 10.1056/NEJMra054782
Open DOI Search in Google Scholar Back to article
Abdoler EA, Parsons AS, Wijesekera TP. The future of teaching management reasoning: important questions and potential solutions. Diagnosis. 2022 Nov 23;10(1):19–23. DOI: 10.1515/dx-2022-0048
Open DOI Search in Google Scholar Back to article
Torre D, Durning SJ, Rencic J, Lang V, Holmboe E, Daniel M. Widening the lens on teaching and assessing clinical reasoning: from “in the head” to “out in the world.” Diagnosis. 2020;7(3):181–190. DOI: 10.1515/dx-2019-0098
Open DOI Search in Google Scholar Back to article
Daniel M, Durning SJ, Wilson E, Abdoler E, Torre D. Situated cognition: clinical reasoning and error are context dependent. Diagnosis. 2020;7(3):341–342. DOI: 10.1515/dx-2020-0011
Open DOI Search in Google Scholar Back to article
Rencic J, Schuwirth LWT, Gruppen LD, Durning SJ. A situated cognition model for clinical reasoning performance assessment: a narrative review. Diagnosis. 2020;7(3):227–240. DOI: 10.1515/dx-2019-0106
Open DOI Search in Google Scholar Back to article
Boyle JG, Walters MR, Burton FM, et al. On context specificity and management reasoning: moving beyond diagnosis. Diagnosis. 2025 Jan 8;12(2):217–222. DOI: 10.1515/dx-2024-0122
Open DOI Search in Google Scholar Back to article
Sutton A, Collen J, Durning SJ, Jung E. Does management reasoning display context specificity? An exploration of sleep loss and other distracting situational (contextual) factors in clinical reasoning. Diagnosis. 2025;12(3):372–381. DOI: 10.1515/dx-2025-0007
Open DOI Search in Google Scholar Back to article
Audétat MC, Laurin S, Dory V, Charlin B, Nendaz MR. Diagnosis and management of clinical reasoning difficulties: Part II. Clinical reasoning difficulties: Management and remediation strategies. Med Teach. 2017;39(8):797–801. DOI: 10.1080/0142159X.2017.1331034
Open DOI Search in Google Scholar Back to article
The SAGE Handbook of Qualitative Research. SAGE Publications Inc. March 8, 2026. Accessed March 10, 2026. https://us.sagepub.com/en-us/nam/the-sage-handbook-of-qualitative-research/book242504
Search in Google Scholar Back to article
Patrick J, Scrase G, Ahmed A, Tombs M. Effectiveness of instructor behaviours and their relationship to leadership. J Occup Organ Psychol. 2009;82(3):491–509. DOI: 10.1348/096317908X360693
Open DOI Search in Google Scholar Back to article
Flanagan JC. The critical incident technique. Psychol Bull. 1954;51(4):327–358. DOI: 10.1037/h0061470
Open DOI Search in Google Scholar Back to article
FitzGerald K, Seale NS, Kerins CA, McElvaney R. The critical incident technique: a useful tool for conducting qualitative research. J Dent Educ. 2008;72(3):299–304. DOI: 10.1002/j.0022-0337.2008.72.3.tb04496.x
Open DOI Search in Google Scholar Back to article
The Most Accurate Speech-To-Text API | Rev AI. Accessed February 25, 2026. https://www.rev.ai
Search in Google Scholar Back to article
Miles MB, Huberman AM, Saldaña J. Qualitative Data Analysis: A Methods Sourcebook. Fourth edition. SAGE; 2020.
Search in Google Scholar Back to article
Ayres L, Kavanaugh K, Knafl KA. Within-Case and Across-Case Approaches to Qualitative Data Analysis. Qual Health Res. 2003;13(6):871–883. DOI: 10.1177/1049732303013006008
Open DOI Search in Google Scholar Back to article
Cheek C, Hays R, Smith J, Allen P. Improving case study research in medical education: a systematised review. Med Educ. 2018;52(5):480–487. DOI: 10.1111/medu.13469
Open DOI Search in Google Scholar Back to article
Audétat MC, Laurin S, Sanche G, et al. Clinical reasoning difficulties: A taxonomy for clinical teachers. Med Teach. 2013;35(3):e984–e989. DOI: 10.3109/0142159X.2012.733041
Open DOI Search in Google Scholar Back to article
Coderre S, Jenkins D, Mclaughlin K. Qualitative differences in knowledge structure are associated with diagnostic performance in medical students. Adv Health Sci Educ. 2009;14(5):677–684. DOI: 10.1007/s10459-008-9149-8
Open DOI Search in Google Scholar Back to article
Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S. The Causes of Errors in Clinical Reasoning: Cognitive Biases, Knowledge Deficits, and Dual Process Thinking. Acad Med. 2017;92(1):23–30. DOI: 10.1097/ACM.0000000000001421
Open DOI Search in Google Scholar Back to article
Croskerry P. The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them. Acad Med. 2003 Aug;78(8):775–780. DOI: 10.1097/00001888-200308000-00003
Open DOI Search in Google Scholar Back to article
Marcum JA. An integrated model of clinical reasoning: dual-process theory of cognition and metacognition. J Eval Clin Pract. 2012;18(5):954–961. DOI: 10.1111/j.1365-2753.2012.01900.x
Open DOI Search in Google Scholar Back to article
Croskerry P. From Mindless to Mindful Practice — Cognitive Bias and Clinical Decision Making. N Engl J Med. 2013;368(26):2445–2448. DOI: 10.1056/NEJMp1303712
Open DOI Search in Google Scholar Back to article
Daniel M, Torre D, Durning SJ, Wilson E, Rencic JJ. Ecological psychology: diagnosing and treating patients in complex environments. Diagnosis. 2020;7(3):339–340. DOI: 10.1515/dx-2020-0008
Open DOI Search in Google Scholar Back to article
Boyle JG, Walters MR, Jamieson S, Durning SJ. Distributed cognition: Theoretical insights and practical applications to health professions education: AMEE Guide No. 159. Med Teach. 2023 Dec;45(12):1323–1333. DOI: 10.1080/0142159X.2023.2190479.
Open DOI Search in Google Scholar Back to article
Pimmer C, Pachler N, Genewein U. Reframing Clinical Workplace Learning Using the Theory of Distributed Cognition. Acad Med. 2013;88(9):1239. DOI: 10.1097/ACM.0b013e31829eec0a
Open DOI Search in Google Scholar Back to article
Watsjold BK, Ilgen JS, Regehr G. An Ecological Account of Clinical Reasoning. Acad Med. 2022 Nov 1;97(11S):S80–S86. DOI: 10.1097/ACM.0000000000004899
Open DOI Search in Google Scholar Back to article
Pauker SG, Kassirer JP. The threshold approach to clinical decision making. N Engl J Med. 1980;302(20):1109–1117. DOI: 10.1056/NEJM198005153022003
Open DOI Search in Google Scholar Back to article
Stojan JN, Daniel M, Hartley S, Gruppen L. Dealing with uncertainty in clinical reasoning: A threshold model and the roles of experience and task framing. Med Educ. 2022;56(2):195–201. DOI: 10.1111/medu.14673
Open DOI Search in Google Scholar Back to article
Stojan JN, Daniel M, Morgan HK, Whitman L, Gruppen LD. A Randomized Cohort Study of Diagnostic and Therapeutic Thresholds in Medical Student Clinical Reasoning. Acad Med. 2017;92(11S):S43. DOI: 10.1097/ACM.0000000000001909
Open DOI Search in Google Scholar Back to article
Kaplan S, Garrick BJ. On The Quantitative Definition of Risk. Risk Anal. 1981;1(1):11–27. DOI: 10.1111/j.1539-6924.1981.tb01350.x
Open DOI Search in Google Scholar Back to article
Kahneman D, Tversky A. Prospect Theory: An Analysis of Decision under Risk. Cambridge University Press; 1988:214. DOI: 10.1017/CBO9780511609220.014
Open DOI Search in Google Scholar Back to article
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(9):927–938. DOI: 10.1111/j.1365-2923.2011.04053.x
Open DOI Search in Google Scholar Back to article
McBee E, Ratcliffe T, Picho K, et al. Consequences of contextual factors on clinical reasoning in resident physicians. Adv Health Sci Educ. 2015;20(5):1225–1236. DOI: 10.1007/s10459-015-9597-x
Open DOI Search in Google Scholar Back to article
Guerrasio J, Aagaard EM. Methods and Outcomes for the Remediation of Clinical Reasoning. J Gen Intern Med. 2014;29(12):1607–1614. DOI: 10.1007/s11606-014-2955-1
Open DOI Search in Google Scholar Back to article
Dupras DM, Edson RS, Halvorsen AJ, Hopkins RH, McDonald FS. “Problem Residents”: Prevalence, Problems and Remediation in the Era of Core Competencies. Am J Med. 2012;125(4):421–425. DOI: 10.1016/j.amjmed.2011.12.008
Open DOI Search in Google Scholar Back to article
Chou CL, Kalet A, Costa MJ, Cleland J, Winston K. Guidelines: The dos, don’ts and don’t knows of remediation in medical education. Perspect Med Educ. 2019;8(6):322–338. DOI: 10.1007/S40037-019-00544-5
Open DOI Search in Google Scholar Back to article

Authors

Additional files

Metrics

Articles in this issue

DOI: https://doi.org/10.5334/pme.2960 | Journal eISSN: 2212-277X

Journal RSS Feed

Language: English

Page range: 718 - 731

Submitted on: Jul 1, 2026

Accepted on: Jul 24, 2026

Published on: Sep 4, 2026

Published by: Ubiquity Press

In partnership with: Paradigm Publishing Services

© 2026 Andrew S. Parsons, Matthew Kelleher, James Bowen, Karen M. Warburton, Michael S. Ryan, Walther N. K. A. van Mook, Steven J. Durning, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.

Volume 15 (2026): Issue 1