Diagnostic reasoning in primary care
: experiences of medical students and foundation trainees in real and simulated environments

  • Annamaria Witheridge

Student thesis: Doctoral Thesis


Sound diagnostic reasoning is essential for safe clinical practice. However, specific training in diagnostic reasoning has yet to be systematically integrated into the medical curricula across the
UK. The development of appropriate training requires an understanding of the diagnostic process from the learners’ perspective. The aim of this four-phase, mixed method study was to explore the diagnostic reasoning skills of senior medical students and Foundation doctors within the context of primary care, in order to enhance undergraduate training towards the point of graduation.

Phase 1, the main study, involved the filming of twelve 4th year medical students across 21 simulated primary care consultations. The students subsequently reviewed their filmed consultations and through semi-structured interviews with the researcher, reflected upon their diagnostic reasoning. Interpretative phenomenological analysis (IPA) was used to analyse the interview transcripts.

Phase 2 followed the same cohort of medical students into real primary care settings in their final year. Two participants were filmed across four consultations followed by video-stimulated,
reflective interviews, and this was again analysed using the IPA method.

Phase 3 explored the diagnostic reasoning of qualified doctors in their foundation training. Two participants were filmed across six consultations using the same method and analysis as before.

Phase 4 consisted of an online survey sent to all medical schools in the UK to enquire whether medical students in their penultimate and final years have views that are consistent with the main findings from Phase 1.

The findings of this study suggest that it is unlikely that Objective Structured Clinical Examinations (OSCEs) with standardized patients and checklist-style assessment could effectively test the diagnostic reasoning skill of senior medical students. Based on the data, the ‘OSCE effect’ model has been proposed that could provide new insight into why previous studies have not found a strong correlation between OSCE performance and diagnostic
reasoning ability. The present findings also suggest that it is time to revise the current conceptual framework for assessing clinical competencies in medical education by emphasizing the importance of cognitive skills. Finally, this study has identified a major challenge that medical students face during their penultimate year: for the first time in their training, students are
expected to make explicit links between history taking, diagnosis and management by engaging in diagnostic reasoning. This transitional period could be the ideal time to integrate diagnostic
reasoning training into their curriculum to better prepare students for future practice.
Date of AwardOct 2018
Original languageEnglish
Awarding Institution
  • University of Brighton
SupervisorG.A.A. Ferns (Supervisor)

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