title: Diagnostic Reasoning across the Medical Education Continuum.
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.
authors.affiliation: Department of Medicine, VA Medical Center, Boise, ID 83702, USA. scott.smith2@va.gov.|Behavioral Informatics and Medical Education, University of Washington, Seattle, WA 98195, USA. scott.smith2@va.gov.
authors.forename: C Scott
authors.initials: CS
authors.lastname: Smith
authors.affiliation: Department of Medicine, VA Medical Center, Boise, ID 83702, USA. tatlnd@aol.com.
authors.forename: William
authors.initials: W
authors.lastname: Hill
authors.affiliation: Department of Medicine, VA Medical Center, Boise, ID 83702, USA. francovich@gonzaga.edu.|Leadership Studies, Gonzaga University, Spokane, WA 99258, USA. francovich@gonzaga.edu.
authors.forename: Chris
authors.initials: C
authors.lastname: Francovich
authors.affiliation: Department of Medicine, VA Medical Center, Boise, ID 83702, USA. magnan@spro.net.|Department of Nursing, Eagle Gate College, Murray, UT 84123, USA. magnan@spro.net.
authors.forename: Magdalena
authors.initials: M
authors.lastname: Morris
authors.affiliation: English Department, Boise State University, Boise, ID 83725, USA. brobbins@boisestate.edu.
authors.forename: Bruce
authors.initials: B
authors.lastname: Robbins
authors.affiliation: Behavioral Informatics and Medical Education, University of Washington, Seattle, WA 98195, USA. lynner@u.washington.edu.
authors.forename: Lynne
authors.initials: L
authors.lastname: Robins
authors.affiliation: Santa Rosa Community-based Outreach Clinic, VA Medical Center, San Francisco, CA 95403, USA. Andrew.Turner2@va.gov.
authors.forename: Andrew
authors.initials: A
authors.lastname: Turner
keywords: curriculum; diagnostic reasoning; emotional stress; graduate medical education; narrative medicine; personal narratives; professional competence; undergraduate medical education