In Support of Meaningful Assessment and Feedback: A Study of Clinical Reasoning Tasks Used in Ambulatory Case Reviews.

Introduction: Assessing clinical reasoning and offering meaningful feedback to residents through workplace-based assessments remains challenging. Part of this challenge lies not only in articulating how well residents perform clinical tasks, but also in having a shared language to describe the underlying reasoning that supports those tasks. This study aimed to explore clinical reasoning tasks in an ambulatory setting and their relationship to clinical expertise. Method: This single-site instrumental case study explored clinical reasoning of junior and senior residents in new and follow-up rheumatology cases. Case reviews, including resident, attending, and patient interactions were audio-recorded and transcribed. Data analysis combined template and content analysis to explore reasoning. Coding was iterative, with regular consensus meetings among researchers. Findings were confirmed through a focus group with clinic faculty and residents. Results: 53 cases were reviewed in ambulatory rheumatology clinics. New consultations focused more on tasks of identifying most likely diagnosis and establishing management plans, whereas follow-up encounters focused on assessing rate of progression, response to treatment, estimating prognosis, and determining follow-up. There were no consistent differences in the number of tasks addressed between junior and senior residents, nor between strong and weak case presentations. However, strong presentations demonstrated selectivity in addressing tasks related to specific patient needs. Discussion: Sharing common patterns of reasoning tasks addressed and omitted can better prepare residents for ambulatory encounters. A shared language around metacognitive tasks can enhance feedback and guide assessment instruments in competency-based training, helping residents broaden their perspectives beyond individual cases.