When attending physicians are conducting teaching rounds , they rapidly decide what and how much to teach in response to each case presentation . How do they make these instructional decisions ? The author performed a qualitative study of the instructional reasoning and actions of six distinguished clinical teachers in general internal medicine to address this question . Four data sources were used : interviews with teachers and learners , a structured task , transcripts of teaching rounds , and week-long observations of each ward team . The teachers in this study engaged in substantial amounts of planning before rounds and reflected on rounds afterwards . When listening to a case presentation during rounds , they quickly diagnosed the patient's problems and simultaneously diagnosed their learners ' levels of understanding . These diagnostic assessments were used to tailor content-specific curriculum scripts for instruction . Throughout the rounds , the teachers also engaged in interactive thinking , decision making , and improvisation . The author's findings allowed him to hypothesize a model of clinical instructional reasoning and action ; they contribute new insights into the interplay between reasoning in a discipline and pedagogical reasoning . Instructional reasoning and clinical reasoning were found to be closely linked through the use of scripts . The implications of these and other findings for medical faculty development are discussed .