Learning to manage: a qualitative exploration of how graduate medical trainees develop management reasoning

Abstract – Purpose – Management reasoning, the process of making decisions about patient treatment, testing, and resource allocation, remains inadequately addressed in medical education. This qualitative study explored how graduate medical trainees develop management reasoning during medical school and residency.Method – Between February and June 2024, focus groups were conducted with residents representing postgraduate years 2 to 4 from internal medicine, pediatrics, family medicine, and medicine-pediatrics at 2 US academic institutions. Using dual process theory and situated cognition theory as sensitizing concepts, focus groups explored trainees’ experiences and perceptions of management reasoning learning and factors that shape their development. Reflexive thematic analysis was used to identify themes.Results – Four focus groups with 28 residents yielded 4 themes characterizing the development of management reasoning: learning formats, factors supportive of learning, barriers to learning, and developmental trajectories. Residents developed management reasoning through experiential learning activities, such as actively managing patients, observing management practices by senior trainees and faculty clinicians, and interacting with patients, consultants, and peers. In contrast, structured educational activities typically emphasized diagnostic reasoning. Supportive factors contributing to management reasoning included verbalization of reasoning processes, opportunities for ownership, case repetition and variability within the clinical learning environment, individual learner characteristics such as preexisting knowledge base, and practices such as vulnerability and reflection. Barriers included minimized responsibility, lack of patient continuity or follow-up, hierarchy, and extrinsic cognitive load. Trainees described progression from rigid, guideline-dependent approaches toward more nuanced, patient-centered reasoning.Conclusions – This study provides empirical evidence on how graduate medical trainees develop management reasoning along with actionable recommendations for educators to support this development. Findings highlight the need to intentionally design clinical environments to promote graduated autonomy and verbalization of reasoning by senior clinicians. Addressing identified barriers and maximizing supportive factors will help ensure that future clinicians can navigate the complexities of patient-centered management decisions.