Perspectives on Medical Education最新文献

{"title":"\"Can You Hear Me? Can Anybody Pretty Please Validate [Me]?\": The Long Shadow of Separation and Liminality in Military Physicians' Remediation.","authors":"Tasha R Wyatt, Witzard Seide, Emily Scarlett, Rachel Chamberlin, Jessica Bunin","doi":"10.5334/pme.2463","DOIUrl":"10.5334/pme.2463","url":null,"abstract":"<p><strong>Introduction: </strong>Much of the current literature on remediation centers on procedural steps, due process, and the implementation of model programs. However, these studies frequently omit the critical perspective of the learners undergoing the process, which can reveal hidden forces that shape medical students' experiences.</p><p><strong>Methods: </strong>We conducted narrative interviews with 15 practicing physicians who remediated as medical students 5-15 years ago. Data were analyzed by examining plot, characters, and event sequences. Upon identifying a pattern of stages, we applied van Gennep's three-phase framework of rites of passage: <i>separation, liminality, and aggregation</i>.</p><p><strong>Results: </strong>Remediation remained a vivid, salient experience for participants, characterized by disorientation. Separation was marked by strained community interactions and symbolic \"parting.\" The liminal phase involved isolation and ambiguity while awaiting institutional decisions. Notably, aggregation, reintegration into the medical community, was achieved by few; more than half of the participants still feel excluded or marginalized years later.</p><p><strong>Discussion: </strong>Remediation is a harrowing process with long-lasting professional consequences. While all participants experienced separation and liminality, the failure to achieve aggregation highlights the \"long shadow\" remediation casts over a remediated physicians' career. We suggest that remediation committees consider providing a ritual specific to the reintegration phase to ensure learners feel successfully folded back into the professional community.</p>","PeriodicalId":48532,"journal":{"name":"Perspectives on Medical Education","volume":"15 1","pages":"819-829"},"PeriodicalIF":3.5,"publicationDate":"2026-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13565038/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148956991","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Advancing Competency-Based Health Professions Education: Insights for Implementation.","authors":"Daniel J Schumacher, Marije P Hennus, Christy K Boscardin, Aleda M H Chen","doi":"10.5334/pme.3021","DOIUrl":"https://doi.org/10.5334/pme.3021","url":null,"abstract":"<p><p>This Foreword introduces the Advancing Competency-Based Health Professions Education (CBHPE) collection of papers. These articles seek to synthesizing practical guidance for CBHPE implementation at a time when CBHPE is rapidly expanding across the globe. Together, the papers in this series highlight that meaningful CBHPE implementation requires attention to adaptive change, fidelity to core components, relational work among learners and supervisors, responsiveness to local context, and systematic study of implementation processes and outcomes.</p>","PeriodicalId":48532,"journal":{"name":"Perspectives on Medical Education","volume":"15 1","pages":"814-818"},"PeriodicalIF":3.5,"publicationDate":"2026-09-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13629544/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149116874","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Educational Alliance: Essential to Implement Competency-Based Health Professions Education.","authors":"Karen E Hauer, Mary Ellen J Goldhamer, Jonathan Amiel, Denyse Richardson, Alan Schwartz, Adrian P Marty, Laura Molgaard, Severin Pinilla, Jan Breckwoldt","doi":"10.5334/pme.2607","DOIUrl":"https://doi.org/10.5334/pme.2607","url":null,"abstract":"<p><p>The educational alliance describes a framework for the trusting relationship between trainee and supervisor as they engage in meaningful, effective feedback. This framework emphasizes interpersonal relationships, shared goals, and agreement on actionable steps to achieve these goals. In this theory-informed conceptual analysis, the authors propose that the educational alliance logically extends to support and enhance competency-based medical education and health professions education, collectively known as competency-based health professions education (CBHPE). Authors describe how key features of the educational alliance align with the five core components of CBHPE: outcome-based competencies, sequenced progression, tailored learning experiences, competency-focused instruction, and programmatic assessment - by facilitating individualized learning that is centered on the trainee-supervisor relationship. Relevant theories that support the effective implementation of the educational alliance in CBHPE to advance learning include growth mindset and self-regulated learning theories. Authors present specific actionable recommendations regarding trainee and supervisor roles and responsibilities within an educational alliance for creating shared mental models, building relationships, engaging in team training, and attending to ethical considerations, including conflicts of interest and using data for the determination of trainee competency and advancement. Additionally, the authors introduce an Educational Agreement applicable to all training levels, designed to foster, guide, and strengthen the educational alliance. The Agreement is intended to be voluntary, co-constructed, and may be adapted to local contexts. Finally, the authors identify areas for future empirical examination through research on the educational alliance in CBHPE programs.</p>","PeriodicalId":48532,"journal":{"name":"Perspectives on Medical Education","volume":"15 1","pages":"799-813"},"PeriodicalIF":3.5,"publicationDate":"2026-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13629524/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149116974","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Pedagogical Efficacy of LLM-Generated Synthetic Data Versus Real-World Clinical Records: A Randomized Controlled Non-Inferiority Trial.","authors":"Zhongkun Zuo, Jianyu Fang, Muyao Ye, Zedong Li","doi":"10.5334/pme.2535","DOIUrl":"10.5334/pme.2535","url":null,"abstract":"<p><strong>Background: </strong>Expert-reviewed clinical cases generated by large language models (LLMs) may supplement case resources in medical education, but their short-term educational performance relative to real-case-derived teaching materials remains uncertain. We compared immediate post-training test performance after teaching with the two types of case materials and assessed non-inferiority against a prespecified margin.</p><p><strong>Methods: </strong>We conducted a prospective, parallel-group, randomized non-inferiority trial. Through the Wenjuanxing online platform, participants were randomized 1:1 to learn with either real-case-derived teaching cases compiled by clinicians and reviewed by experts or AI-generated clinical cases produced by Gemini 3.0 Pro from fully de-identified matched real cases and reviewed by three senior general surgery specialists with full-professor rank. The primary outcome was the total score on an independent 10-item immediate post-training test (0-10 points), with a prespecified non-inferiority margin of -0.5 points. Secondary outcomes included the training-phase performance score, learning efficiency index, single-item mental effort rating, case realism, and case-source judgment.</p><p><strong>Results: </strong>A total of 403 participants were randomized, of whom 386 were included in the modified intention-to-treat analysis: 192 in the real-case group and 194 in the AI-generated case group. The mean post-training test score was 4.95 (SD, 3.35) in the real-case group and 4.61 (SD, 3.35) in the AI-generated case group. The mean difference (AI-generated minus real-case group) was -0.335 points (95% CI, -1.006 to 0.337). Because the lower bound of the confidence interval was below the prespecified non-inferiority margin of -0.5 points, non-inferiority was not demonstrated (one-sided P = 0.314). No significant between-group differences were observed in the training-phase performance score, learning efficiency index, or single-item mental effort rating. AI-generated cases received lower realism ratings for Level 3 cases. The proportion of participants with at least one high-confidence completely incorrect response was 1.6% in the real-case group and 2.1% in the AI-generated case group.</p><p><strong>Conclusions: </strong>In this short-term, text-based online case-learning setting, no statistically significant between-group difference was observed in immediate post-training test performance; however, non-inferiority of AI-generated clinical cases relative to real-case-derived teaching materials was not demonstrated.</p>","PeriodicalId":48532,"journal":{"name":"Perspectives on Medical Education","volume":"15 1","pages":"759-770"},"PeriodicalIF":3.5,"publicationDate":"2026-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13564930/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148956989","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"No Free Lunch in Competency-Based Health Professions Education: Exploring Trade-Offs, Value, and Shared Investment in Health Professions Education.","authors":"Denise H Rhoney, Michael A Barone, Holly Caretta-Weyer, Laura Edgar, Daniel J Schumacher, John Q Young, Roberta Ladenheim, Kelly J Caverzagie","doi":"10.5334/pme.2574","DOIUrl":"https://doi.org/10.5334/pme.2574","url":null,"abstract":"<p><strong>Background/problem: </strong>Competency-Based Health Professions Education (CBHPE) aims to improve workforce readiness, patient safety, and equity, but achieving these outcomes requires sustained investment. The \"No Free Lunch\" (NFL) rule underscores that value cannot be realized without visible costs, which can be financial, cultural, temporal, and structural. Although costs are ideally shared across the health professions education and health care ecosystem, interest holders often invest unevenly despite broad benefits. As a result, many programs and institutions struggle to implement and sustain CBHPE, even as adoption grows globally.</p><p><strong>Purpose/approach: </strong>This paper examines how \"value\" and return on investment (ROI) in CBHPE are conceptualized across learners, faculty, institutional leaders, governments/funders, clinical systems, accreditors/regulators, professional organizations, and patients/communities. The authors describe tensions regarding who invests and who benefits, identify practical trade-offs, and highlight opportunities for alignment across settings, including low-resource contexts. We propose an interest-holder-informed framework that links typical investments to forms of value/ROI to support explicit, context-sensitive cost-sharing.</p><p><strong>Key insight: </strong>Value in CBHPE is contextual, shaped by the mission of the interest holder, the time horizon for returns, and available resources. Because benefits are often diffuse or delayed, ROI may be difficult to demonstrate, reinforcing underinvestment. Value must ultimately be judged by benefit to patients and communities.</p><p><strong>Conclusion: </strong>CBHPE cannot rely on the goodwill of those closest to implementation. Sustainability requires clear articulation of value, shared responsibility for costs that are proportional to benefits, and alignment between goals and resources among interest holders. CBHPE should be treated as long-term infrastructure for better care, not a temporary reform.</p>","PeriodicalId":48532,"journal":{"name":"Perspectives on Medical Education","volume":"15 1","pages":"783-798"},"PeriodicalIF":3.5,"publicationDate":"2026-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13629545/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149116943","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"No Environment, No Education: Honoring the Clinical Learning Environment as the Engine of Competency-Based Education - A Call to Action.","authors":"Eusang Ahn, Kelly J Caverzagie, Arvin Damodaran, Soeren Huwendiek, Kimberly Lomis, Adrian P Marty, David A Turner, Teri Turner, Adelle Atkinson","doi":"10.5334/pme.2548","DOIUrl":"https://doi.org/10.5334/pme.2548","url":null,"abstract":"<p><p>Competency-Based Health Professions Education (CBHPE) has transformed health professions training by emphasizing demonstrated competence over time-based progression. Yet the clinical learning environment (CLE), the social, cultural, and organizational ecosystem in which learning occurs, has not evolved in parallel. Persistent hierarchies, workload pressures, and inadequate faculty development limit CBHPE's full potential. Thus, the authors sought to identify priorities for CLE reform. A structured consensus process was conducted at the International Competency-Based Education Collaborators Summit in February 2025, where interdisciplinary health professions educators identified CLE reform priorities. Findings were refined through virtual meetings over three months. Five interdependent priorities were identified as essential for transforming the CLE: <b>Psychological safety:</b> enabling vulnerability, feedback, coaching, and growth through faculty and learner development<b>Teaching environment:</b> prioritizing faculty well-being, recognition, and sustainable teaching capacity<b>Desirable difficulty and productive struggle:</b> balancing challenge and safety to promote adaptive expertise and resilience<b>Interdependence and collectivism:</b> reframing education from individual performance to team-based competence and shared accountability<b>Partner alignment:</b> integrating educational and healthcare system goals to advance patient care and workforce well-being Together, these domains outline the CLE as both a developmental and operational engine for CBHPE. Realizing the promise of CBHPE depends on transforming the CLE into a psychologically safe, appropriately challenging, interdependent, and system-aligned ecosystem. Reform demands cultural change that values coaching, feedback, vulnerability, and collective responsibility as professional imperatives. By aligning structures and empowering adaptive educators, the CLE can evolve from a passive setting to an active driver of successful competency-based transformation.</p>","PeriodicalId":48532,"journal":{"name":"Perspectives on Medical Education","volume":"15 1","pages":"771-782"},"PeriodicalIF":3.5,"publicationDate":"2026-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13629532/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149116940","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Beyond Online Course Evaluations: Student-Led Focus Groups for Curricular Feedback.","authors":"David Rekhtman, Jessica Campanile, Alex F Nisbet, Abigail Kohler, Jennifer Hong, Ish Sethi, Suzanne Rose, C Jessica Dine","doi":"10.5334/pme.1786","DOIUrl":"10.5334/pme.1786","url":null,"abstract":"<p><strong>Purpose: </strong>Medical student curricular evaluation is both beneficial and required. Most medical schools rely on online questionnaires for evaluations, but these are often overlooked or completed haphazardly. We describe the implementation of focus groups as a supplemental form of curricular assessment and evaluate students' and faculty members' attitudes towards this novel approach.</p><p><strong>Method: </strong>Ten randomly selected students were assigned to eight focus groups regarding three different preclerkship courses. Following the completion of focus groups, interviews were conducted with students who participated in them, course directors who received the focus group reports, and administrators who oversaw the preclerkship curriculum and the implementation of the focus group program. The semi-structured interviews were then analyzed using inductive thematic analysis, with initial codes generated from the data and subsequent interpretation informed by prior literature on feedback relationships and curricular program evaluation.</p><p><strong>Results: </strong>Interviews were conducted with 17 students, 5 faculty members, and 3 administrators. Participants highlighted key themes related to trust, engagement, collaboration, and the learning environment. Students described the focus groups as a safe space and said they enjoyed thinking critically about improvements. Faculty perceived the thematic content of focus group reports to be comparable to course evaluation summaries from established online forms despite concerns for a smaller sample size.</p><p><strong>Conclusions: </strong>Focus groups are a novel supplemental tool that can complement existing evaluation mechanisms. Engaging students through focus groups can improve feedback and advance medical school curricula, resulting in a more responsive and adaptive approach to education.</p>","PeriodicalId":48532,"journal":{"name":"Perspectives on Medical Education","volume":"15 1","pages":"748-758"},"PeriodicalIF":3.5,"publicationDate":"2026-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13564938/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148957002","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The CBHPE Outcomes Theory of Change: An International Consensus Statement on the Mechanisms and Outcomes of Competency-Based Education in the Health Professions.","authors":"Aleda M H Chen, Denise H Rhoney, Mary Ellen J Goldhamer, Andem Ekpenyong, Susan Humphrey-Murto, Holly Caretta-Weyer, Linda Snell, Arvin Damodaran, Robert Englander, Andrew K Hall, Soeren Huwendiek, Laura Molgaard, Anna Oswald, Daniel J Schumacher, Fremen Chihchen Chou, Pedro Tanaka, Jason R Frank","doi":"10.5334/pme.2553","DOIUrl":"10.5334/pme.2553","url":null,"abstract":"<p><strong>Introduction: </strong>Competency-Based Health Professions Education (CBHPE) is an outcomes-based approach to planning and conceptualizing the training of health professionals to serve population needs. Despite its uptake, ongoing debate persists regarding the assumptions underpinning CBHPE, its intended purposes, and how success should be defined and evaluated. This contributes to variable implementation and difficulty aligning core features with meaningful outcomes. To date, no published theory of change has articulated how CBHPE's core components provide a framework for later evaluation of intended outcomes.</p><p><strong>Methods: </strong>Using Funnell and Rogers' purposeful program theory, the authors, all members of the International Competency-based Education Health Professions Educators Collaborative (ICBHPE), developed a model theory of change. The authors conducted a broad review of CBHPE literature, supplemented by CBE frameworks from adjacent educational contexts to strengthen underdeveloped constructs in implementation and evaluation. Findings were iteratively synthesized into a program theory and refined through repeated cycles of large-group feedback, consensus building, and member checking within ICBHPE.</p><p><strong>Results: </strong>The authors developed a CBHPE Outcomes Theory of Change that articulates key assumptions, mechanisms of impact, and expected outcomes associated with CBHPE implementation. The framework specifies how van Melle's CBHPE core components are theorized to function across phases of implementation and identifies proximal and distal outcomes that can reasonably be expected, based on intentional, deliberate program evaluation at each implementation and evaluation stage.</p><p><strong>Discussion: </strong>The CBHPE Outcomes Theory of Change offers scholars and implementers a practical guide to enhance the quality and fidelity of implementation, evaluation, and research efforts related to CBHPE worldwide. Using this guide as a framework, programs can plan, implement, and then examine whether the intended outcomes of CBHPE have been realized.</p>","PeriodicalId":48532,"journal":{"name":"Perspectives on Medical Education","volume":"15 1","pages":"732-747"},"PeriodicalIF":3.5,"publicationDate":"2026-09-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13629535/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149116999","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Gordian Knot That Is Patient and Public Involvement in Interprofessional Education.","authors":"Matthijs H Bosveld, Dante N Mulder, Lucija Gosak, Isabelle Huys, Cathy C Kline, Matilde R P F Leal, Mateja Lorber, Elsa F Mateus, Pedro Morgado, Catarina Raposo-Lima, Adrijana Svenšek, Charlotte Verbeke, Marloes A van Bokhoven, Ricardo J O Ferreira","doi":"10.5334/pme.2261","DOIUrl":"10.5334/pme.2261","url":null,"abstract":"<p><strong>Introduction: </strong>The combination of patient and public involvement (PPI) and interprofessional education (IPE) is promising to help students delineate roles based on real patients' needs; however, their integration in practice remains limited. Although the individual concepts have been studied, little is known about how stakeholders perceive PPI in IPE, leaving gaps in designing effective educational strategies. Therefore, this study aims to explore the experiences and perspectives of key stakeholders - students, academic staff members, and patient representatives - on the feasibility, (intended) learning outcomes, and requirements for the successful implementation of PPI in IPE in undergraduate healthcare education.</p><p><strong>Methods: </strong>We qualitatively explored the experiences and perspectives of each stakeholder group in separate focus groups. In total, 15 focus groups were conducted across four European countries, involving 27 academic staff members, 27 students, and 24 patient representatives, all with diverse backgrounds. Data were analyzed using thematic analysis.</p><p><strong>Results: </strong>Themes were structured by organizational levels within educational institutions to optimize uptake in practice. As for strategic considerations (<i>align</i>), participants noted compounded organizational complexity, which may lead to inertia - especially without institutional support. At the same time, PPI in IPE should be valued equally compared to biomedical subjects. With respect to educational <i>design</i> considerations, PPI in IPE helped students bridge theory and practice and decreased hierarchy. Lastly, regarding operational considerations (<i>execute</i>), the compounding complexity of organizing patient involvement in interprofessional education also holds true for facilitating it, as facilitators must role-model both person-centered communication and interprofessional collaboration. According to participants, learning from PPI in IPE is about unifying what cannot be separated.</p><p><strong>Discussion: </strong>Despite strong rhetorical endorsement, a lack of institutional support persists. Our findings suggest PPI in IPE as a powerful means of addressing epistemic injustice by promoting epistemic symmetry between future professionals and patients, reducing interprofessional hierarchies, and grounding interprofessional learning in real-world experiences. Strategic use of these levers may unlock the necessary institutional resources, acting as Alexander's sword to overcome barriers and ultimately slice through the Gordian knot.</p>","PeriodicalId":48532,"journal":{"name":"Perspectives on Medical Education","volume":"15 1","pages":"705-717"},"PeriodicalIF":3.5,"publicationDate":"2026-09-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13544041/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148898119","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Phenotypes of Management Reasoning Struggle in Postgraduate Medical Education.","authors":"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","DOIUrl":"10.5334/pme.2960","url":null,"abstract":"<p><strong>Purpose: </strong>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.</p><p><strong>Methods: </strong>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.</p><p><strong>Results: </strong>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) <i>limited management scripts</i> (inability to generate or contextualize a plan despite reaching a diagnosis), (2) <i>can't change course</i> (inability to integrate new clinical information into an existing management plan), (3) <i>impaired task triage and execution</i> (difficulty prioritizing and coordinating management within a complex clinical environment), and (4) <i>failure to calibrate</i> (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.</p><p><strong>Conclusion: </strong>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.</p>","PeriodicalId":48532,"journal":{"name":"Perspectives on Medical Education","volume":"15 1","pages":"718-731"},"PeriodicalIF":3.5,"publicationDate":"2026-09-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13544060/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148898054","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}