Open Access Research article

Physician clinical management strategies and reasoning: a cross-sectional survey using clinical vignettes of eight common medical admissions

Kristofer L Smith1, Sarah Ashburn2, Jenerius A Aminawung3, Micah Mann4 and Joseph S Ross35*

Author Affiliations

1 Department of Medicine, North Shore-Long Island Jewish Health System, New Hyde Park, NY, USA

2 Hofstra-North Shore School of Medicine, Rego Park, NY, USA

3 Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, P.O. Box 208093, 06520 New Haven, CT, USA

4 Division of Hospital Medicine, The Samuel Bronfman Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA

5 Section of General Internal Medicine and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine and Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA

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BMC Health Services Research 2014, 14:176  doi:10.1186/1472-6963-14-176

Published: 17 April 2014



Physicians often select clinical management strategies not strongly supported by evidence or guidelines. Our objective was to examine the likelihood of selecting, and rationale for pursuing, clinical management strategies with more or less guideline support among physicians using clinical vignettes of eight common medical admissions.


We conducted a cross-sectional survey using clinical vignettes of attending physicians and housestaff at one internal medicine program in New York City. Each clinical vignette included a brief clinical scenario and a varying number of clinical management strategies: diagnostic tests, consultations, and treatments, some of which had strong evidence or guideline support (Level 1 strategies) while others had limited evidence or guideline support (Level 3 strategies). Likelihood of selecting a given management strategy was assessed using Likert scales and multiple response options were used to indicate rationale(s) for selections.


Our sample included 79 physicians; 68 (86%) were younger than 40 years of age, 34 (43%) were female. There were 31 attending physicians (39%) and 48 housestaff (61%) and 39 (49%) had or planned to have primarily primary care internal medicine clinical responsibilities. Overall, physicians were more likely to select Level 1 strategies “always” or “most of the time” when compared with Level 3 strategies (82% vs. 43%; p < 0.001), with wide variation across the eight medical admissions. There were no differences between attending and housestaff physician likelihood of selecting Level 3 strategies (47% vs. 45%, p = 0.36). Supportive evidence and local practice patterns were the two most common rationales behind selections; supportive evidence was cited as the most common rationale for selecting Level 1 when compared with Level 3 strategies (63% versus 30%; p < 0.001), whereas ruling out other severe conditions was cited most often for Level 3 strategies.


For eight common medical admissions, physicians selected more than 80% of management strategies with strong evidence or guideline support, but also selected more than 40% of strategies for which there was limited evidence or guideline support. The promotion of evidence-based care, including the avoidance of care that is not strongly supported by evidence or guidelines, may require better evidence dissemination and educational outreach to physicians.