The diagnostic thinking process in medical education and clinical practice : a study of medical students, house officers and registrars with special reference to endocrinology and neurology
Aims: 1. To add clarity, specificity and breadth to current descriptions of the diagnostic thinking process as hypothesis generation and testing. 2. To propose possible pedagogical strategies for efficient and effective development of appropriate diagnostic thinking processes. Subjects and Methods: The study was in two complementary parts: 1. Quantitative data. Structured questionnaires in endocrinology and neurology allowed analysis of the relative contributions of (1) factual knowledge, (ii) interpretation of symptoms and. signs, and (iii) selecting and testing diagnostic possibilities, towards predicting diagnostic ability in 35 final year clinical medical students and 35 registrars per questionnaire. 2. Qualitative data. Introspective account gathering by videotape stimulated recall of clinical interviews yielded data concerning the diagnostic thinking processes of 22 final year medical students, 22 house offloers and 22 registrars. The research design allowed analysis of the development of the diagnostic thinking process, the relative effects of medical education and clinical practice and comparison of these in two specialities. Results: After parametric, non-parametric and content analyses, the results of the two studies were related to yield a unified explanation and description of the diagnostic thinking process in medical education and clinical practice. Its fundamental psychological features are identified as structure and extrapolation. Three stages are Identified and discussed In terms of wider psychological theory. Speciality specific and generalised cognitive processes are identified. Development of the diagnostic thinking process is described in terms of increasing equilibration of the skills measured in the quantitative study. The qualitative study shows that students, house officers and registrars are In command of the same range of cognitive processes although their relative contributions and associated appropriateness and accessibility of content might vary between groups yielding different degrees of diagnostic accuracy. The diagnostic thinking process in all groups of subjects is shown to be considerably more complex than previous descriptions have suggested. Pedagogical implications are discussed.