In our recent Academic Medicine Perspective, we proposed the term “management script” as a concept for teaching management reasoning. Analogous to the illness script, an essential component of diagnostic reasoning, management scripts are high-level, precompiled, conceptual knowledge structures of the courses of action that a clinician might undertake to address a patient’s health care problem(s). Not to be confused with a checklist, where specific interventions are mandated in a sequence, management scripts are more like a menu: a collection of options in various categories (e.g., appetizers, courses, desserts versus tests and treatments) for the provider to choose from depending on the situation.
In our experience, teaching management scripts can be most helpful for learners early in their clinical training, which is hardly surprising. Creating management plans is hard! Even the most straightforward chief concern could invoke many diagnoses, each of which informs numerous management options that have their own specific harms and benefits. Providing a management script template, an educational scaffold of potential types of interventions, can augment that first, challenging step of identifying what a clinician could do. Our favorite management script template is laboratory studies, imaging studies, procedures, specialists, medications, and monitoring (LIPS M&M).
Consider this familiar scenario of a new intern presenting their assessment and plan for a patient admitted to the hospital with acute kidney injury:
Intern: In summary, we have a 75-year-old librarian with a past medical history of hypertension and benign prostatic hyperplasia who presents with acute kidney injury most likely secondary to hypovolemia and concomitant urinary obstruction. For his acute kidney injury, I think we should give intravenous fluids, place a foley, and check a basic metabolic panel.
Educator: That’s a great start. Can you think of anything else?
Educator: What else is in our management script for acute kidney injury? Can you think of any other labs, imaging, procedures, specialists, medications, or monitoring we could do?
Intern: Hmm. We could consider some urine electrolytes and a renal ultrasound to help differentiate between prerenal and postrenal etiologies. Maybe if the patient gets worse, we could consult Nephrology who might want a renal biopsy, but I don’t think we’re quite there yet. It might also be worth starting tamsulosin if his BPH is playing a role in an obstruction.
Educator: Excellent! What about monitoring? Is there any way we could keep track of how he’s responding to our plan?
Intern: Well, we could check his intake, output, and weights, which could give us a better idea of his kidney function and volume status.
In this case example, the intern first generates a reasonable, but limited plan. By using a management script template, the intern is forced to recall standard laboratory and radiological testing in addition to possible procedures, consultants, medications, and monitoring associated with the diagnosis, ultimately yielding a more nuanced management plan. Then comes the “hard” step (or arguably the fun step of management reasoning). The intern must next navigate the uncertainty inherent to management decision-making, choosing which of those interventions to perform (i.e., management option selection) based on patient-specific characteristics (e.g., goals of care, values, comorbidities, etc.). We routinely focus such discussions around high-value care, shared decision-making, and testing and treatment thresholds. For additional educational strategies using a management script, please see Table 3 of our Perspective.
Building management scripts can start at any time, though. Based on our experience, learners can and should begin explicitly building management scripts early in health professions training by considering all possible tests and treatments for a health care problem, whether a general chief concern or specific diagnosis. Once in the clinical environment, learners can develop more nuanced management scripts with every patient encounter, utilizing targeted reading and discussions with their supervisors. For more senior learners, educators can present challenges to familiar interventions and ask them to propose a secondary plan (e.g., what if fluids were contraindicated because the patient had pulmonary edema?).
The idea of management scripts is hardly new, likely being informally taught to students and trainees for years. Our hope, however, is that by using a shared mental model of management scripts and templates, the initial step of generating a plan can be less intimidating. We hope that you find this practical tool for teaching management reasoning as effective as we have.
By: Andrew S. Parsons, MD, MPH, and Thilan P. Wijesekera, MD, MHS
A.S. Parsons is assistant professor of medicine and public health sciences, Department of Medicine; associate program director, Internal Medicine Residency Program; and director, Clinical Skills Course and Pre-clerkship Coaching, University of Virginia School of Medicine, Charlottesville, Virginia.
T.P. Wijesekera is assistant professor of medicine, Department of Medicine; director, Clinical Reasoning; associate director, Educator Development in Clinical Reasoning, Teaching and Learning Center, Yale University School of Medicine, New Haven, Connecticut.
1. Parsons AS, Wijesekera TP, Rencic JJ. The management script: A practical tool for teaching management reasoning [published online ahead-of-print April 28, 2020]. Acad Med. doi: 10.1097/ACM.0000000000003465