• Elexis McBee, Temple Ratcliffe, Mark Goldszmidt, Lambert Schuwirth, Katherine Picho, Anthony R Artino, Jennifer Masel, and Steven J Durning.
• E. McBee is assistant professor of medicine, Uniformed Services University of the Health Sciences, based at Naval Medical Center San Diego, San Diego, California. T. Ratcliffe is assistant professor of medicine, University of Texas Health Science Center, San Antonio, Texas. M. Goldszmidt is associate professor of medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada. L. Schuwirth is professor of medicine, Flinders University, Adelaide, Australia. K. Picho is assistant professor of medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland. A.R. Artino Jr is associate professor of preventive medicine and biometrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland. J. Masel is third-year resident, Walter Reed National Military Medical Center, Bethesda, Maryland. S.J. Durning is professor of medicine and pathology, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
• Acad Med. 2016 Jul 1; 91 (7): 1022-8.

PurposeA framework of clinical reasoning tasks thought to occur in a clinical encounter was recently developed. It proposes that diagnostic and therapeutic reasoning comprise 24 tasks. The authors of this current study used this framework to investigate what internal medicine residents reason about when they approach straightforward clinical cases.MethodParticipants viewed three video-recorded clinical encounters portraying common diagnoses. After each video, participants completed a post encounter form and think-aloud protocol. Two authors analyzed transcripts from the think-aloud protocols using a constant comparative approach. They conducted iterative coding of the utterances, classifying each according to the framework of clinical reasoning tasks. They evaluated the type, number, and sequence of tasks the residents used.ResultsTen residents participated in the study in 2013-2014. Across all three cases, the residents employed 14 clinical reasoning tasks. Nearly all coded tasks were associated with framing the encounter or diagnosis. The order in which residents used specific tasks varied. The average number of tasks used per case was as follows: Case 1, 4.4 (range 1-10); Case 2, 4.6 (range 1-6); and Case 3, 4.7 (range 1-7). The residents used some tasks repeatedly; the average number of task utterances was 11.6, 13.2, and 14.7 for, respectively, Case 1, 2, and 3.ConclusionsResults suggest that the use of clinical reasoning tasks occurs in a varied, not sequential, process. The authors provide suggestions for strengthening the framework to more fully encompass the spectrum of reasoning tasks that occur in residents' clinical encounters.

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