Management reasoning is primarily a task of shared decision-making and monitoring, and is inherently more complex than diagnostic reasoning. A better understanding of management reasoning will offer insights into the causes and avoidance of medical error, clinical practice quality improvement, and training and assessment of health professionals.
When we think of clinical reasoning, we usually think of coming up with a diagnosis. Yet decisions about management may actually be more important, especially since management decisions often precede the diagnosis or influence the diagnostic approach. Diagnosis is primarily a classification activity – the assignment of a label to a constellation of symptoms, exam findings, and test results. This label should (hopefully) have implications for treatment and prognosis, and facilitates meaningful communication with patients and other members of the healthcare team. Management, by contrast, is primarily a task of shared decision-making and monitoring.
While diagnostic reasoning is certainly not easy, management reasoning is inherently more complex for several reasons:
1.) There is rarely a single correct answer for any management problem – the solution is usually, “It depends.” Management decisions should, of course, be grounded in evidence and other best practices – but these must be integrated with patient preferences and contextual factors such as healthcare team capacity, locally available resources, insurance coverage, and more.
2.) Management requires communication, negotiation, and shared decision-making with the patient and often with others stakeholders. Diagnosis, by contrast, can sometimes be done in isolation of the patient (for example, interpreting the data in a clinical vignette).
3.) Management decisions are rarely final – they nearly always involve ongoing monitoring and adjustment based on response, side effects, disease progression, and ever-changing contextual issues. Diagnoses also evolve over time (an illness might resolve, progress, or become complicated) but this does not invalidate the correctness of the original diagnosis.
4.) Management reasoning must consider more “moving parts” than diagnosis – including the dynamic interplay among people, systems, contexts, and contingency plans. In the absence of sufficient information, a diagnosis can be stated in less specific or provisional terms or sometimes even deferred – management, however, often cannot be postponed.
So what do we do?
1.) As clinicians and educators we must recognize that there is more to clinical reasoning than just making the diagnosis. At the end of the day, diagnosis really just a means to an end – namely, the enabling of effective communication with patients and other providers, and the formulation of appropriate management plans. Is it possible that the true master clinician is not the elite diagnostician but rather the master shared-decision-maker or skilled contingency planner?
2.) We need to extend our understanding of management reasoning: What are the component parts of effective management? Are there specific cognitive processes, competencies, or attitudes that facilitate or impair management reasoning? Given the multiplicity of correct management solutions, how do we define management error, especially since bad (or good) patient outcomes do not always represent bad (or good) management decisions? How can we teach and assess management reasoning?
3.) We need to support management reasoning in clinical practice. Many electronic tools support making a diagnosis or identifying guideline-recommended treatment options. By contrast, relatively few tools to-date support eliciting and integrating patient preferences, educating patients, or monitoring and adjusting treatments plans.
In sum, diagnostic reasoning is just as important as ever. But greater appreciation of management reasoning as a distinct cognitive and clinical activity will allow for practice innovation, education, and research that will ultimately result in safer, more effective, and more humane patient care.