In 2010, JGIM introduced the Exercises in Clinical Reasoning (ECR) series to provide insight into how expert clinicians navigate the process of diagnostic reasoning. The ECR series expands on a typical clinical problem-solving case presentation format through a unique metacognitive commentary. This addition sought to help the reader gain insight into how expert clinicians reason through clinical cases. The series helped bring foundational reasoning concepts such as problem representation, illness scripts, and diagnostic frameworks to the forefront of medical education. Over a decade later, an expanding body of literature on the diagnostic process paired with the rapid growth of teaching tools through digital and social media has cemented diagnostic reasoning as a core component of the internists’ skill set [1,2,3,4,5].

However, the ever-evolving healthcare landscape has highlighted factors that affect the teaching and practice of clinical reasoning, creating the need to expand the scope of the ECR series. Clinicians are more aware of variables that influence the diagnostic process such as practice setting, resource availability, social determinants of health, and cognitive biases. There is a renewed interest in exploring the typical and the atypical presentations of common diseases [6]. An emerging body of literature on management reasoning and handling uncertainty in medicine showcases how clinicians navigate the theoretical and practical complexity of treatment decisions [7, 8]. Additionally, recognition of the growing diversity of experts in clinical reasoning presents both a need and opportunity to be more inclusive [9]. This evolution requires the ECR series to expand its horizons as we strive to deliver more equitable and more effective patient care.

As the new editors of the ECR series, we aim to push the boundaries of how clinical reasoning is conceived, discussed, and taught in four main ways:

  1. 1.

    Expand the pool of cases to reflect diversity in authorship and clinical practice environments (e.g., outpatient, virtual care, resource-limited, and international settings).

    Clinical practice environments are highly diverse and an important contextual factor that influences a clinician’s reasoning process. Currently, most case-based clinical reasoning publications are authored by a narrow demographic of clinicians at academic institutions in the United States [9]. In recent years, digital media platforms such as the Clinical Problem Solvers have shed light on the wealth of learning cases from non-academic and community centers in the US and institutions around the world. There is a significant opportunity to increase the diversity in cases and mitigate gender and racial biases in clinical problem-solving publications. By harnessing the reach of digital media, we hope to actively recruit diverse voices from across the world.

  2. 2.

    Broaden the focus of clinical reasoning beyond diagnosis to include management and therapeutic reasoning.

    Diagnosis features prominently in clinical reasoning discussions. However, patient care is characterized by a real-time interplay between diagnosis and management decisions that does not necessarily follow the chronological presentation of thoughtfully packaged aliquots seen in traditional clinical problem-solving manuscripts. There is a need to address the process of management and therapeutic reasoning through clinical cases. This offers an opportunity to offer theory-informed commentary that highlights how expert clinicians navigate the parallel processing of diagnosis and treatment decisions [10, 11].

  3. 3.

    Renew focus on the conditions and presentations most commonly encountered by internists.

    Rare diagnoses are disproportionately discussed in clinical problem-solving manuscripts. However, the path to a rare diagnosis runs through typical and atypical presentations of common diseases. Outstanding clinicians master these varied presentations of common diseases. Showcasing how clinicians navigate these presentations warrants attention in the ECR series [6].

  4. 4.

    Showcase uncertainty in reasoning.

    Uncertainty in diagnosis and management decision-making can be helped or hindered by cognitive tools such as heuristics and biases. The advent of artificial intelligence and other diagnostic aids brings potential solutions and challenges in handling uncertainty. By featuring cases where expert clinicians navigate uncertainty, with or without adjunct tools, readers may gain insights into how they might change their practice and lower their thresholds to talk and teach about this important topic [11].

We invite clinicians to submit cases to the JGIM ECR series with the aim that this new direction will expand and showcase the collective knowledge and understanding of clinical reasoning, further evolving and enriching this quintessential skill set.