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INDO AMERICAN JOURNAL OF

PHARMACEUTICAL SCIENCES
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http://doi.org/10.5281/zenodo.4072577

Available online at: http://www.iajps.com Research Article

COGNITIVE SCHEMES FOR CLINICAL DIAGNOSTIC

REASONING BY MEDICAL STUDENTS
Sadia Chaudhry1, Rehan Ahmed Khan2, Rahila Yasmeen3
1
MBBS, FCPS, MHPE, Dept. of ENT, DHQ Teaching Hospital, Rawalpindi.
2
MBBS, FCPS, FRCS, MHPE, MSC-HPE, PhD-HPE (Scholar), Department of Surgery,
International Islamic Medical College, Islamabad.
3
BDS, DCPS- HPE, MHPE, PhD-HPE (Scholar), Dept. of Medical Education,
International Islamic Medical College, Islamabad.
Article Received: August 2020 Accepted: September 2020 Published: October 2020
Abstract:
Cognitive processes that activate clinical reasoning are complicated. These cognitive processes are either
analytical (slow) or non-analytical (fast). This research focuses on how thinking cultivates and alters over the
course of years spent in medical college and how they are different in high vs borderline medical students.
Objective: The study aims to explore the cognitive schemes, build up by medical students with different achievement
records for clinical diagnostic reasoning, the pathways followed by them for diagnostic reasoning and to explore
neurocognitive factors that influence their clinical diagnostic reasoning. Methodology: The sampling technique was
purposively followed by theoretical sampling. The study was conducted from Dec 2016 to May 2017. This was a
qualitative study based on the Grounded theory of Constructivist design. In-depth interviews were audio-recorded,
transcribed, and analyzed manually. Results: Using thematic analysis, 8 themes surfaced. Students of high
achievement followed pattern recognition (system 1). Hypothetical deductive reasoning (system 2) was followed by
borderline students. However, most strategies of reasoning were uniformly distributed among high achievers and
borderline students. Sleep deprivation and fatigue were the two most important factors which affected the cognitive
schemes of medical students. Conclusion: Clinical reasoning in medical education is of significance in the
development of future doctors. The actual reasoning process includes medical decision-making on one hand and
problem-solving on the other hand. Cognitive schemes of high achiever students are based on pattern recognition
and borderline students follow hypothetical deductive reasoning.
Keywords: Cognitive schemes, clinical diagnostic reasoning, system 1, system 2, pattern recognition, hypothetico-
deductive reasoning.
Corresponding author:
Dr. Sadia Chaudhry, QR code
Associate Professor, Department of ENT, DHQ Teaching Hospital
Rawalpindi Medical University, Rawalpindi.
Email: sadiaaatif@yahoo.com
Cell: +923345295995
Please cite this article in press Sadia Chaudhry et al, Cognitive Schemes For Clinical Diagnostic Reasoning By
Medical Students., Indo Am. J. P. Sci, 2020; 07(10).

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INTRODUCTION: novices use the system 2 approach because they

Health care is fragile and is disposed to diagnostic are less experienced and have seen fewer cases,
and management miscalculations1. Doctors are they have fewer disease scripts in their memory
challenged to make clinical judgments that affect the and the clinical presentations could not match the
lives of patients on a daily basis2. Clinical judgment diagnosis of a particular condition17. On the other
is fundamental in the formulation of diagnosis and hand, experienced doctors tend to use the system 1
safe management of patients 3. Clinical reasoning approach, as they have several scripts and clinical
may be well-defined as thinking through the different scenarios in their memories. Pattern recognition
aspects of patient care to choose a rational decision and hypothetico-deduction, which have been
for the prevention, diagnosis, or management of a widely explained in the medical literature – are the
clinical problem in a particular patient 4. foundation of the intuitive system and the
Clinical reasoning emphasizes the clinical analytical system 18. The dual-process theory has
presentation of a patient. This definite reasoning received enormous encouragement from a variety
process comprises decision and problem solving 5. of sources and has surfaced as the chief model for
Training the students with different learning human decision making.
methodologies will help develop cognitive structures
that will enable them to process the patient’s data in a METHODS:
very refined manner6. The characteristic of critical The study duration was from 1st December 2016 to 1st
thinking dates back to the days of Socrates (470–399 May 2017. The study was conducted at Foundation
BC)7. The teacher directs the learner towards critical University Medical College It was a qualitative study
thinking through question and answer procedure 8. based on the Grounded theory of Constructivist
Clinical diagnostic reasoning consists of knowledge, design. This design was used to generate a theory that
cognitive skills, reflective reasoning, contextual expounded a process, interaction or action about a
thinking, and mutual decision making 9. topic at a broader level. The research sets out to
explore the cognitive schemes of medical students for
Cognitive schemes can be defined as questioning the clinical diagnostic reasoning. A research design using
problem, processing information, executing the plan, In-depth Interviews was engaged to discover the
and an estimation of the results10. Earlier research has cognitive schemes of medical students for clinical
documented a range of four consecutive approaches diagnostic reasoning. Students from the 4th and 5th
for problem-solving in medicine: guessing, scheme year were included in the study according to the
induction, hypothetical-deductive reasoning, and sampling criteria. Faculty members of the 4th and 5th
pattern recognition11. Unlike novices, experts are years were interviewed for the triangulation of data.
inclined to use ‘problem solving mental schemes’ 12. The sampling technique adopted was purposive
Clinical reasoning is influenced by more than 40 (maximal variation type) followed by theoretical
cognitive and emotional tendencies13. Researchers sampling. Interviews were conducted in a predefined
have tested the hypothesis that expertise in clinical place in a secure, safe and comfortable environment.
diagnostic reasoning is related to the person’s A total of 20 students of the 4th and 5th year M.B.B.S
knowledge and is captured or interlinked to the class participated in the study. In Phase 1, the 1st
amount of knowledge or the type of knowledge a round of interviews was conducted. Interviews were
person has 14. audio-recorded and then transcribed. For preserving
secrecy and confidentiality, study participants were
The dual-process theory was proposed in 1975 by coded before analysis. In Phase 1, the 2nd round of
Jonathan Evans. In his theory, there were two interviews was conducted once the point of saturation
distinguishing types of processes: analytical reached after 1st round data analysis. Interview
processes and heuristic processes. Stanovich15 questions were changed to get more information in
coined the terms System 1 and System 2 to mark detail. Memo writing was done after each interview.
the two different sets of processes. Daniel In Phase 2, an interview was conducted in which
Kahneman stipulated further understanding by faculty members of the 4th and 5th year were
distinguishing the two processes, intuition and interviewed. This was done to get more info and for
reasoning in 200316. These systems are often the triangulation of data. Thematic analysis was used
signified as "System 1" and "System 2," as created in qualitative research and emphasizes on probing
by Stanovich and West. The non-analytical is themes within data. Coding was the main process for
referred to as system 1 and the analytic as system emerging themes within the raw data by recognizing
2 processing. important moments in the data and encoding it to
interpretation. Triangulation and member checking
Studies have shown that medical students and were the two methods to increase the credibility of

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data. A comprehensive description of the site, in 20 axial codes. Finally, 8 themes appear after
participants, and procedures was used to collect data selective coding.
for other researchers to evaluate whether the results These 8 themes were pattern recognition,
applied in one study is a good match, and makes hypothetico-deductive reasoning, cognitive
sense to generalize. The study described the exact schema building, scheme inductive reasoning,
methods of data collection, analysis, and concept map, memorizing strategies, the role of
interpretation in detail for dependability. intuitive feeling as a diagnostic tool and
neurocognitive factors.
RESULTS:
Out of 20 students, 11 were females and 10 were Figure 1
male students. The mean age was 23 years. 59 A pattern of case-based learning was based on
open codes appeared by analyzing the whole of “illness script” or “pattern recognition”. Pattern
the data manually. In axial coding, categories recognition was the primary clinical reasoning
were interrelated with their subcategories and strategy. High achieving students believed that
tested their associations against data. This resulted cases seen before helped them to recognize the
condition.

Figure 1: Themes of students

Table 1
A significant difference between high achievers and borderline students had been seen while asking about the
diagnostic strategy they used on encountering a patient.
• Respondent H. A 2 5th said” you become brisker if you have seen such case before”
The borderline respondent didn’t feel confident while reasoning the patient with a pattern recognition strategy.
They believed in reasoning protocols to be followed.
Hypothetico-deductive reasoning helped in history taking and physical examination to form detailed knowledge
structures of basic scientific understanding and mechanisms.

Table 1: Theme of Pattern recognition

Theme Axial code Open code Frequency (f) %

Pattern recognition Confident on Cases seen before 9 45%
seeing cases
before
Quick at diagnosis 6 30%
Independent to 3 15%
diagnose
Confident to diagnose 7 35%
Pattern Register in mind 8 40%
recognition

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Figure 2 knowledge is linked to the new one that

Mostly borderline students tried to reason out the helps to create a better diagnosis”.
cases with help of history, examination, and
investigation. Both groups believed that long-term memory
• Respondent B.L 3 5th said,” I concentrate played a major role in the retrieval of old
more on history and examination as each knowledge which has been stored in the form of
of them will help me customize the schemas for clinical diagnostic reasoning.
investigations and treatment plan
according to the patient”. Students related new technology with old
databases already formed in long term memory.
However, if high achiever students came up with Both groups believed the effectiveness of
the wrong diagnosis via the case-based reasoning technology for updating knowledge and relating
method switched over to hypothetico deductive new knowledge to the older one.
reasoning. Borderline students felt more confident
when they reasoned out with hypothetico Both the student groups believed that greeting
deductive reasoning. patients helped them to build repo with patients so
that it increased the patient’s confidence in them
Learners elaborated on their cognitive schemas by for future inquiry. The patient became more
linking newly presented information to the things acquainted and gave all the information regarding
they already knew. The responses of interviewees their disease in detail. This helped the students to
explained their schema building and retrieval of diagnose the patient.
these schemas when and where required. They
consider long-term memory as an important Surprisingly students had no idea about concept
element for retrieval of these schemas. Both high maps and those who heard about it never saw and
achievers and borderline believed that new draw it. Though the concept map was one of the
knowledge was built upon previous knowledge older tools which had been in use for the last 25
base. years, it had not been implemented in
• Respondent B. L 1 4th said,” From history undergraduate teachings.
to examination, in every step, prior

Figure 2: Hypothetico-deductive reasoning

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Most of the high achiever students stress upon the is slow. It is related to system 2 of the dual-process
importance of memorizing strategies, very few of model which is analytical. In this study, the
borderline students mention these strategies. The borderline medical students followed system 2. They
most important memorizing strategy used by reasoned out the diagnosis of cases by asking
students was reading out loud and making a questions regarding history, examination findings,
checklist. and finally by various investigations. Literature20
showed that generally an expert in his field does not
It appeared evident that high achiever and use the hypothetico-deductive reasoning approach,
borderline students relied on gut feeling but they but a novice who is struggling to develop a structured
thought it might mislead them to reach a correct knowledge base does rely on analytical approaches 21.
diagnosis. Students didn’t want to support the gut However, high achieving students tried to reason out
feeling much as they had apprehensions about when their diagnosis came up to be incorrect.
reaching the wrong diagnosis. One of the high
achiever students believed that gut feeling came In this study students of both categories believed in
with experience and with a strong knowledge base. schema building but only high achieving students
There is no discrepancy between a high achiever retrieve their schemas to diagnose correctly.
and a borderline student’s clinical diagnostic Literature showed that experts are likely better at
reasoning skills due to sleep deprivation and formulating and applying schemas in situations with
fatigue. Both the groups were affected by it and which they are familiar. Thus, in this study, high
they consider these responsible for the loss of achiever students displayed greater skill with regards
concentration and diagnosing skills. to knowledge retrieval and application. On the
contrary, borderline students had schemas but they
Most of the teachers said that high achievers were not able to retrieve those schemas.
mostly interacted with patients more than
borderline. Mostly borderline students were not In this study, both groups believed that long-term
interested in patients at all. They believed high memory played a great part in the retrieval of
achievers read a lot, study a lot from books, and schemas which was consistent with the literature.
are regular in attendance which is why they fell in
the category of high achievers. Scheme inductive reasoning or forward reasoning is
So, to conclude teachers of 4th and 5th year were characteristic of experts. Brett K Hayes and E Heit 22
also of the opinion that high achiever students showed that although not all of the experts solely
were quicker in diagnosis and borderline were used forward reasoning. However, those whose
slow. This was consistent with what this study reasoning process was mostly in a forward manner
stated. attained an accurate diagnosis more rapidly than
those using a mixture of forward and backward
DISCUSSION: reasoning. Forward reasoning is used by experts and
The objective of this study was to explore the novices in many situations. In this study, both high
cognitive schemes of medical students with different achievers and borderline students tried to reason out
achievement records for clinical diagnostic reasoning. via the forward reasoning in daily routine either in
In this study students with high achieving records wards or in the OPD which is also consistent with the
followed the pattern of system 1 that is intuitive and literature.
is based on pattern recognition or illness scripts.
These illness scripts were already stored in their mind There are very few learning strategies used by
as they already had seen many similar cases before. students to memorize and retrieve important
Timings of diagnosis were immediate and they used information to achieve good grades in their medical
significant case features to reach the diagnosis. colleges23. However, chunking, recalling, revising,
According to Edward et al.19, an extremely structured enlisting has been mentioned in the literature. In this
knowledge structure is considered as a core of pattern study, high achievers mentioned strategies like
recognition. In this study, most of the high achieving recalling, enlisting, and revising for memorizing the
students follow prototype patterns which are like information. Borderline students didn’t mention
expert practitioners who have dealt with a lot of cases about memorizing strategies except writing.
to diagnose with system 1.
Erik Stolper24 mentioned that practitioners recognize
When students enter a medical college, they are the feeling of agitation that sometimes appears during
encouraged to follow a hypothetico-deductive a consultation. In the case of medical students, this
approach to reason. Hypothetico-deductive reasoning gut feeling comes up with good baseline knowledge

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and experience. Deborah25 emphasizes that there is a According to Norman and Eva28, non-analytic
95 percent chance of reaching the correct diagnosis reasoning is responsible for diagnostic errors and
when a correct hypothesis is considered in the first analytic reasoning strategy is superior in decision-
five minutes. In this study high achiever medical making. Researchers were interested to explore the
students believed in the gut feeling while diagnosing cognitive schemes of students and the system they
patients and they believed that these feelings come follow to reach the diagnosis.
with experience. However, borderline believe in gut
feelings but not for the patient’s clinical diagnosis. However, this study concluded that high achiever
They reason out the diagnosis with hypothetico- students reached their diagnosis by system 1 mostly.
deductive reasoning. This was due to pattern recognition. At end of the
study, a framework was developed on basis of
Sleep deprivation results in negative mood situations, findings of the study. This framework explained the
especially reduced orientation, fatigue, confusion and cognitive schemes of both groups of medical
sleepiness 26. In this study, both high achievers and students, neurocognitive factors which affected the
borderline students considered sleep deprivation and pathways and role of gut feeling and memory. The
fatigue as factors that influenced them framework clearly defined the pathways followed by
both of the groups.
Figure 3

Figure 3: Cognitive framework of diagnostic reasoning

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CONCLUSION:
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