Diagnostic Reasoning across the Medical Education Continuum.

C Smith,Magdalena Morris,Bruce Robbins,Chris Francovich,William Hill,Lynne Robins,Andrew Turner

doi:10.3390/healthcare2030253

Abstract

We aimed to study linguistic and non-linguistic elements of diagnostic reasoning across the continuum of medical education. We performed semi-structured interviews of premedical students, first year medical students, third year medical students, second year internal medicine residents, and experienced faculty (ten each) as they diagnosed three common causes of dyspnea. A second observer recorded emotional tone. All interviews were digitally recorded and blinded transcripts were created. Propositional analysis and concept mapping were performed. Grounded theory was used to identify salient categories and transcripts were scored with these categories. Transcripts were then unblinded. Systematic differences in propositional structure, number of concept connections, distribution of grounded theory categories, episodic and semantic memories, and emotional tone were identified. Summary concept maps were created and grounded theory concepts were explored for each learning level. We identified three major findings: (1) The “apprentice effect” in novices (high stress and low narrative competence); (2) logistic concept growth in intermediates; and (3) a cognitive state transition (between analytical and intuitive approaches) in experts. These findings warrant further study and comparison.

Highlights

Our study aimed to explore differences in diagnostic reasoning over the continuum from premedical students to experienced faculty
We identified an apparent discontinuity for MS1s in the expected development of diagnostic expertise, which we call the “apprentice effect”
This appears to be due to barriers to accessing knowledge due to anxiety and embarrassment. This is manifested by emotional stress, cognitive overload, mistrust of experience, narrative sparseness, and misplaced concreteness compared with premeds, MS3s, or residents

Summary

Introduction

Our study aimed to explore differences in diagnostic reasoning over the continuum from premedical students to experienced faculty. Ecological decision making (described below) were expected to be critical for expert diagnostic reasoning. Our interest began with several puzzling phenomena that have been identified in studies of clinical reasoning. Researchers have discovered that residents (intermediate level learners) generate more facts and rules than students or faculty when explaining their approach to clinical problems, despite the fact that faculty have more experience [1,2]. Clinical reasoning has been shown to be highly context dependent; that is, diagnostic decision making is better when the context resembles that in which the knowledge will be used [3,6]

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Conclusion