Response to : Clinical Diagnostic Reasoning

To the Editor: We agree with Bowen that clinical educators need to understand and analyze the varied diagnostic reasoning strategies applied by novices such as medical students to help them improve their performance. However, the diagnostic reasoning schema in Figure 1 of the article appears to oversimplify this process. Because of minimal clinical experience, the novice generally has poorly formed illness scripts and will often generate hypotheses using a pathophysiological, probabilistic, or rule-based representation of the problem (skills acquired during problem- or case-based learning).1,2 Such hypotheses are often more numerous, broader, and less accurate than those of experts and must be refined by the novice during the interview with the patient and during the physical examination, while the novice looks for the specific symptoms, risk factors, and signs that allow for iterative reweighting of the clinical diagnostic possibilities. We believe that acknowledgment of alternative bases for hypothesis generation and of the iterative nature of hypothesis refinement will further assist educators in improving students’ diagnostic reasoning strategies