How postgraduate medical trainees conceptualise management reasoning: A qualitative study

Introduction: Management reasoning (MR) remains poorly understood in medical education. Current understanding is largely theoretical or based on studies of physicians in simulated settings or narrow clinical contexts. Little is known about how trainees themselves conceptualise and enact MR during routine care. This study explored how postgraduate trainees conceptualise MR and describe the process, as well as the contextual influences that shape their MR during training. Method: We conducted a qualitative study using a constructivist paradigm and reflexive thematic analysis. Four semi-structured focus groups were held with 28 senior postgraduate trainees in Internal Medicine, Paediatrics, Family Medicine, and Medicine-Paediatrics across two U.S. academic medical centres. Focus groups were transcribed verbatim and coded inductively. Themes were developed through an iterative and reflexive process with attention to both semantic content and underlying meaning. Results: Four themes captured how trainees conceptualise MR: how MR is understood within clinical reasoning, uncertainty and risk characterise the complexity of MR, core and variable components of the MR process, and contextual factors influencing the MR. Trainees viewed MR as linked to diagnostic reasoning but distinct in its pragmatic and action-oriented focus. They described ongoing negotiation of uncertainty and risk, emphasising flexibility and adjustment as conditions changed. The MR process commonly featured four core components—working diagnosis, delineation of management options, contextualisation and monitoring or follow-up—along with variable components that were applied flexibly depending on context. Trainees described a variety of contextual factors that influenced MR. Discussion: Postgraduate trainees viewed MR as a dynamic, complex and flexible process. This study adds to the empirical literature on MR by confirming its patient-centred and context-dependent nature while introducing novel insights from the trainee perspective, especially the centrality of uncertainty and risk. Understanding how trainees conceptualise MR can help educators make MR more visible in clinical practice.