Management reasoning scripts: Qualitative exploration using simulated physician-patient encounters

Abstract

Introduction: Management reasoning is distinct from diagnostic reasoning and remains incompletely understood. The authors sought to empirically investigate the concept of management scripts.

Methods: In November 2020, 4 investigators each reviewed 10 video clips of simulated outpatient physician-patient encounters, and used a coding form to document observations about management reasoning. The team used constant comparative analysis to integrate empirically-grounded insights with theories related to cognitive scripts and Type 1/Type 2 thinking.

Results: Management scripts are precompiled conceptual knowledge structures that represent and connect management options and clinician tasks in a temporal or logical sequence. Management scripts appear to differ substantially from illness scripts. Management scripts varied in quality (in content, sequence, flexibility, and fluency) and generality. The authors empirically identified six key features (components) of management scripts: the problem (diagnosis); management options; preferences, values, and constraints; education needs; interactions; and encounter flow. The authors propose a heuristic framework describing script activation, selection, instantiation with case-specific details, and application to guide development of the management plan. They further propose that management reasoning reflects iterative, back-and-forth involvement of both Type 1 (non-analytic, effortless) and Type 2 (analytic, effortful) thinking. Type 1 thinking likely influences initial script activation, selection, and initial instantiation. Type 2 increasingly influences subsequent script revisions, as activation, selection, and instantiation become more deliberate (effortful) and more hypothetical (involving mental simulation).

Discussion: Management scripts constitute a key feature of management reasoning, and could represent a new target for training in clinical reasoning (distinct from illness scripts).

Keywords: Clinical decision-making; Diagnostic errors; Diagnostic reasoning; Education, medical; Therapeutic reasoning.

Fig. 1

Model of management reasoning script. Management scripts are “precompiled conceptual knowledge structures that represent and connect management options and clinician tasks in a temporal or logical sequence to facilitate development of a rational management plan” [14]. Although initial script activation, selection, and instantiation are likely (usually) predominantly Type 1 thinking, with each iteration the script and associated management tasks (usually) employ more Type 2 thinking. The list of management tasks is illustrative, not comprehensive. EHR electronic health record