Karen M. Warburton

Purpose: 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.Methods: 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.Results: 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.Conclusion: 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.

Background Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition that often results in poor academic performance. Little is known about how ADHD manifests in residents and fellows. Objective To describe the prevalence and phenotype of ADHD among residents and fellows referred to a centralized remediation program. Methods We conducted a retrospective review of data obtained from referrals to a single-center centralized graduate medical education remediation program from 2017 to 2023. Data included demographic variables, ADHD and mental health history, and training performance characteristics. ADHD was determined by self-report, clinical diagnosis by mental health provider, or neuropsychological testing. Results A total of 173 trainees were referred in the study period. The prevalence of ADHD was 20% (35 of 173). ADHD was most commonly diagnosed in childhood (57%, 20 of 35); however, 26% (9 of 35) were diagnosed during or after medical school. Only 37% (13 of 35) were on medication, and 69% (24 of 35) disclosed at least one concomitant mental health diagnosis. Performance deficits were common in professionalism (69%, 24 of 35), organization/efficiency (O/E; 63%, 22 of 35), and medical knowledge (46%, 16 of 35). Repeated errors in patient care were made by 34% (12 of 35); 29% (10 of 35) failed at least one board examination, and 20% (7 of 35) required extension of residency or fellowship training. When compared to referrals without ADHD, residents and fellows with ADHD were more likely to struggle with O/E, failure to engage, and repeated errors. Conclusions One in 5 trainees referred to a GME remediation program had ADHD, and most were not being treated for ADHD when referred. The deficits identified suggest an ADHD phenotype in GME which may be considered for struggling residents and fellows.

Background There is no standardized, widely accepted process for individualized clinical reasoning remediation. Objective We describe a novel, targeted assessment and coaching process that allows for individualized intervention for residents and fellows struggling with clinical reasoning. Methods Residents and fellows at the University of Virginia with performance concerns are referred to COACH (Committee on Achieving Competence Through Help) and assessed by a remediation expert. A subset is referred to a clinical reasoning remediation coach who performs an additional assessment and cocreates an individualized remediation plan. Following remediation, residents and fellows are reassessed by their respective programs. We report the frequency of struggle, remediation time invested, and academic outcomes. Results From 2017 to 2022, 114 residents and fellows referred to COACH met inclusion criteria, of which 38 (33%) had a deficiency in clinical reasoning. Targeted assessment revealed the following microskill deficits: hypothesis generation (16 of 38, 42%); data gathering (6 of 38, 16%); problem representation (7 of 38, 18%); hypothesis refinement (3 of 38, 8%); and management (6 of 38, 16%). Remediation required a mean of nearly 23 hours per trainee. Of the 38 trainees, 33 (87%) are in good standing at the time of writing. Conclusions Our unique program offers a feasible, targeted approach to clinical reasoning remediation based on our current understanding of the clinical reasoning process. Early hypothesis generation was the most common microskill deficit identified.