Clinical Reasoning During Acute Decompensation: A Metacognitive Act

ABSTRACT Introduction Medical errors contribute to preventable morbidity and mortality. Categories of error include diagnostic and management error, to which lack of urgency, understanding, or awareness contribute. While physician reasoning is influenced by medical content, acute clinical situations require rapid metacognitive shifts‐moving from diagnostic hypothesis generation to decisive management action. This study investigated physician clinical reasoning and how it is impacted by emotion and metacognitive reflection during this critical transition from diagnosis to procedural intervention in an acute inpatient encounter. Methods Physicians ( n = 19) diagnosed and managed a live simulation of acute patient decompensation. Clinical reasoning performance was assessed with clinical benchmarks and utilizing a novel video‐stimulated think‐aloud protocol immediately following the encounter; participants reflected aloud while reviewing their recorded performance. Verbatim transcripts were analyzed using Braun and Clarke's reflexive thematic analysis, informed by situated cognition and SchÖn's reflective framework. Results Themes of deliberation, prioritization and fixation, and reflection were identified. Effective clinical reasoning depended on executing timely metacognitive shifts to bridge the gap between diagnostic recognition and management action. Video recall revealed distinctions between real‐time cognitive processing (reflection‐in‐action) and post‐hoc insights (reflection‐on‐action). Environmental cues, such as nurse prompting, functioned as distributed cognitive support. Notably, emotional distress often coexisted with effective prioritization, while procedural hesitation stemmed from both metacognitive regulation and limited procedural familiarity. Conclusion Transitioning from diagnosis to action requires dynamic cognitive flexibility with clinical reasoning. Recognizing missed opportunities post‐hoc represents a substantive finding for reflective learning, though it does not imply identical awareness was active during the event. Educational strategies must separately address real‐time cognitive pivoting during crisis and post‐event debriefing.