What physicians reason about during admission case review

Research suggests that physicians perform multiple reasoning tasks beyond diagnosis during patient review. However, these remain largely theoretical. The purpose of this study was to explore reasoning tasks in clinical practice during patient admission review. The authors used a constant comparative approach—an iterative and inductive process of coding and recoding—to analyze transcripts from 38 audio-recorded case reviews between junior trainees and their senior residents or attendings. Using a previous list of reasoning tasks, analysis focused on what tasks were performed, when they occurred, and how they related to the other tasks. All 24 tasks were observed in at least one review with a mean of 17.9 (Min = 15, Max = 22) distinct tasks per review. Two new tasks—assess illness severity and patient decision-making capacity—were identified, thus 26 tasks were examined. Three overarching tasks were identified—assess priorities, determine and refine the most likely diagnosis and establish and refine management plans—that occurred throughout all stages of the case review starting from patient identification and continuing through to assessment and plan. A fourth possible overarching task—reflection—was also identified but only observed in four instances across three cases. The other 22 tasks appeared to be context dependent serving to support, expand, and refine one or more overarching tasks. Tasks were non-sequential and the same supporting task could serve more than one overarching task. The authors conclude that these findings provide insight into the ‘what’ and ‘when’ of physician reasoning during case review that can be used to support professional development, clinical training and patient care. In particular, they draw attention to the iterative way in which each task is addressed during a case review and how this finding may challenge conventional ways of teaching and assessing clinical communication and reasoning. They also suggest that further research is needed to explore how physicians decide why a supporting task is required in a particular context.