Measuring residents' performance of diagnostic reasoning using clinical vignettes: an international collaborative study

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OBJECTIVE : To compare the diagnostic thinking process of medical students in Japan and US.METHODS : Students were presented with three clinical scenarios corresponding to high, low, and intermediate pre-test probability of coronary artery disease. Estimates of pre-test and post-test probability for each scenario were elicited from the students (intuitive estimates) and from the literature (reference estimates). The difference between the reference estimates and the intuitive estimates was used for assessing knowledge of test characteristics, ability of estimating pre-test and post-test probability of disease.RESULTS : One hundred twelve students in US and 224 in Japan were participated. Both US and Japanese students underestimated pre-test and post-test probability of high pre-test scenario, although the estimates are close to reference estimates. There was no significant difference between US and Japan. In the low pre-test probability scenario, both students overestimated the pre-test and post-test probability. The deviation from reference estimate was, however, greater in Japanese students.CONCLUSIONS : US and Japanese students could not rule out disease in low or intermediate pre-test probability settings, mainly because of poor pre-test estimates of disease probability. But, US students performed significantly accurate estimation than Japanese students. This diagnostic thinking pattern account for why medical students or novice physicians end up repeating unnecessary examinations.In medical education in Japan, ruling out disease has been less emphasized than the importance of not overlooking a possible disease. It is presumed that this traditional attitude is associated with the difference in the diagnostic thinking process between US and Japanese medical students.