Theory at the Bedside: Problems and Phenomena

Before going any further, it helps to say what I mean by theory, because the word does different work in different rooms. On the MedEdMentor theory pages we collect several definitions, and two of them are enough here. The more formal one, from Lara Varpio and colleagues: a theory is "an abstract description of the relationships between concepts that help us to understand the world." The plainer one, from Cianciolo, Eva, and Colliver: "At its most basic level, theory is an explanation. It is an account of a phenomenon: its nature, its causes, its function, and its observable properties." The practical version I give mentees sits between those two: a theory is a framework or approach that helps you to take something really complex and put some parameters on it so you can examine it in a meaningful way.

Then there is the way clinicians use the word, and it is worth separating out, because it is not wrong, it is just a different sense. Georges Bordage puts it well: in scientific terms a theory "embodies an idea or set of ideas that have been confirmed by observations or experiments," while "in lay terms, however, theories are often considered as hypotheses yet to be proven." When I say at the bedside, "my theory is that this is a heart failure exacerbation," I mean a hypothesis about this patient, today. The theory in the scientific sense is the thing underneath that hypothesis: what heart failure is, what sets it off, what it does, and what the exam and the labs should show, which I learned in my second year of medical school and have been refining on every patient ever since. A differential diagnosis is a list of hypotheses, and every one of them is borrowed from a theory of that kind. Hold onto that distinction, because the next post leans on it.

The third thing I say to a mentee who fears using theory is something I have wanted to write about for three or four years, and it is the reason for this series: it is similar to work you already do. Every time you see a patient, you take a messy, specific, local situation, turn it into something general enough to reason about, lay a list of possible explanations over it, and choose one to act on. Clinicians call that clinical reasoning. Scholars refer to the same set of moves as problems, phenomena, theories, and frameworks. This new vocabulary is a big part of what makes it scary, but many of the cognitive processes are ones you may already use every day.

So, over the next few months I am going to follow one patient through an emergency department and one educational problem through a medical school, side by side, and use the first to explain the second. Today is "problems and phenomena." Later posts will take up theories (which is where the differential diagnosis comes in), paradigms (which is where the people around the bed start to disagree), and how to get started on your own problem.

A few notes up front: the clinical scenario is a composite of patients I have cared for in the past. Also, the analogy is not perfect, and I will say where it breaks down, because looking at how clinical reasoning differs from theory use in HPE can teach as much as the places where they're similar.

Mr. R is a 65-year-old man with a 60 pack-year smoking history and known COPD, coming to the ER for the fourth time this year with acute on chronic shortness of breath. His three previous visits were seven months ago, three months ago, and six weeks ago. At each one, he required supplemental oxygen when he arrived, was admitted to the hospital, treated with oral steroids and antibiotics, and discharged within three to four days when he no longer required oxygen. He is coming in today with what he reports are symptoms similar to those from the previous three visits. His daughter is very involved in his care remotely, but is not often able to come with him to the hospital because she lives two hours away. She was not present for the other three hospitalizations. This time she happened to be visiting, did not like how he looked, and insisted that he come in, so she is here with him now.

That is a bit of the pertinent HPI (history of present illness), but not the whole presentation (which would include the past medical history, meds, allergies, exam, imaging, labs, and the assessment and plan), but it is enough to do the thing I want to show you.

Here is my one-liner for Mr. R: a middle-aged man with a long smoking history and known COPD, presenting with acute on chronic dyspnea at rest, with multiple similar presentations in the last seven months.

Notice what happened between the HPI and the one-liner. "Fourth time this year" became "multiple similar presentations." Seven months, three months, and six weeks became "the last seven months." The daughter disappeared entirely. Judith Bowen's piece on clinical reasoning in the New England Journal of Medicine calls the one-liner a problem representation, "a one-sentence summary defining the specific case in abstract terms," and her example is exactly this move: "'Last night' became 'acute onset.'" Georges Bordage spent much of his career on the semantic qualifiers that do the abstracting (acute versus chronic, single versus recurrent, and so on), and he found that the clinicians who reason best are the ones who use them the most.

Now, the educational side. For the last four years, I have been working on a real problem at my institution. It started when I was handed survey data showing that our students were dissatisfied with the formative feedback they received during their clinical years (reach out to me if you know of a medical school where this is not the case, because I haven't seen one). When I started as director of clinical faculty development, I conducted my own needs assessment, and the first thing I had to do was to better understand both sides of the story. I interviewed fourth-year students who could speak to their experience in all their clerkships and had already completed them and received grades, so they could speak freely without fear of retaliation. And I talked to faculty about what makes feedback difficult from their end, what they saw as the problem, and what solutions they could imagine. What I found was that students and faculty agreed on two things: feedback matters, and faculty were not as effective at it as they should be.

Here is my one-liner for that problem: student dissatisfaction with the quality and quantity of formative feedback during clinical rotations, with faculty echoing the students' sentiments.

In the paper that Greg Ow, Bridget O'Brien, and I published this spring on how experienced mentors help people use theory (the Abstracting-Contextualizing Model, which I wrote about here in May), the mentors we interviewed kept drawing the same distinction. A problem is local. It is situated in your context, it belongs to you, and it is usually the thing that you care about changing. A phenomenon is what you get when you abstract that problem into something general enough that other people, in other places, would recognize it and might already have studied it. The mentors described phenomena as the mid-level point between problems and theories, and they described understanding phenomena as the central goal of scholarship.

Mr. R's story is a problem, and the one-liner is a phenomenon. In the same way, the students' survey comments and what I learned through my data gathering are a problem, and "dissatisfaction with the quality and quantity of formative feedback on clinical rotations" is a phenomenon. The moment I wrote it that way I could go and read what people at other schools had learned about it, which is more or less what a differential diagnosis is for. I will get to the differential in the next post.

Bordage has a lovely image for conceptual frameworks that works just as well for one-liners: they are lighthouses and magnifying glasses. A lighthouse lights up part of the ocean and leaves the rest dark. My one-liner for Mr. R lights up his lungs and his history and leaves his daughter in the dark, and his daughter, who missed three admissions and is standing in the room for this one, might turn out to be the most important new piece of information we have. Something similar is true on the education side. "Quality and quantity of feedback" lights up what faculty do and leaves in the dark what the students were doing, which, as it happens, is where I ended up some years later.

Because my first approach to the feedback problem focused on faculty. I taught the educational alliance and coaching. I borrowed the growth mindset. I told faculty that much of the teeth-grinding over the exact words to say in a feedback conversation gets easier inside a trusting relationship. I explained that making the plan for feedback explicit to learners increases transparency and accountability. I made clear that feedback is a conversation rather than information delivery (there are two sides to every story and the truth is usually somewhere in between). I stressed that objective observations of behaviors need to be recorded and judgment statements will cause disagreement. I even made up a mnemonic (ARTIST, which I will subject you to in a later post, with apologies in advance). Only later did I add sessions for the students themselves, to build their agency and give them tools to solicit, interpret, and receive feedback, as they are at least half of the equation.

Which is the cost of abstraction I promised to come back to. Mr. R was treated for a COPD exacerbation three times, and three times he got better and came back, and I spent three years treating a faculty skills problem before I addressed the other half of the room. Neither one-liner was wrong. Both of them were bets about where the answer would be found, and when the same treatment keeps producing the same result, the thing to revisit is not the treatment but the one-liner.

This week, try to write the "one-liner" for an education problem you are working on. Take that thing that you are dealing with in your day-to-day work, and extrapolate it to a general phenomenon that your peer at another institution, or in another country, would recognize. If you're willing, I'd love to hear what you come up with!

Also, I would love to hear where this analogy already strains for you, especially if you are a nurse, a pharmacist, a respiratory therapist, a social worker, or anyone else whose bedside looks different from an internist's, because the next post puts a whole team around Mr. R's bed and not just doctors. As always, geoffstetson@mededmentor.org.

Next week, I will be at the Association of American Medical Colleges (AAMC) meeting, so I won't be posting. But I'll be back on November 16th. Thanks for reading!

1. Bowen JL. Educational strategies to promote clinical diagnostic reasoning. N Engl J Med. 2006;355(21):2217-2225.
2. Bordage G. Conceptual frameworks to illuminate and magnify. Med Educ. 2009;43(4):312-319.
3. Bordage G. Prototypes and semantic qualifiers: from past to present. Med Educ. 2007;41(12):1117-1121.
4. Varpio L, Paradis E, Uijtdehaage S, Young M. The distinctions between theory, theoretical framework, and conceptual framework. Acad Med. 2020;95(7):989-994.
5. Cianciolo AT, Eva KW, Colliver JA. Theory development and application in medical education. Teach Learn Med. 2013;25(Suppl 1):S75-S80.
6. Stetson GV, Ow GM, O'Brien B. Navigating problems, phenomena, and theories: the Abstracting-Contextualizing Model of Mentoring for theory use in medical education. Acad Med. 2026. https://doi.org/10.1093/acamed/wvag103
7. Stetson G. The Abstracting-Contextualizing Model of Mentorship. MedEdMentor blog. May 2026. https://mededmentor.org/blog/the-abstracting-contextualizing-model-of-mentorship/
8. MedEdMentor guide: The Difference Between Theory, Theoretical, and Conceptual Frameworks. https://mededmentor.org/guides/medical-education-research-beginners-guide/difference-between-theory-theoretical-conceptual-frameworks/
9. MedEdMentor glossary: Theory. https://mededmentor.org/glossary/theory/