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J Dent Educ. 68(12): 1235-1244 2004
© 2004 American Dental Education Association
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Educational Methodologies

Reasoning Process Characteristics in the Diagnostic Skills of Beginner, Competent, and Expert Dentists

Kathleen E. Crespo, Ed.D.; José E. Torres, Ph.D.; María E. Recio, D.M.D.

Key words: cognition, clinical diagnosis, reasoning process, dental education, competency

Submitted for publication 01/08/04; accepted 10/13/04


   Abstract
Top
 Abstract
Method
 Data analysis
 Results
 Discussion
 References
 
The purpose of this study was to evaluate qualitative differences in the diagnostic reasoning process at different developmental stages of expertise. A qualitative design was used to study cognitive processes that characterize the diagnosis of oral disease at the stages of beginner (five junior students who had passed the NBDE I), competent (five GPR first-year residents), and expert dentists (five general dentists with ten or more years of experience). Individually, each participant was asked to determine the diagnosis of an oral condition based on a written clinical case, using the think aloud technique and retrospective reports. A subsequent interview was conducted to obtain the participants’ diagnostic process model and pathophysiology of the case. The analysis of the verbal protocols indicated that experts referred to the patient’s sociomedical context more frequently, demonstrated better organization of ideas, could determine key clinical findings, and had an ability to plan for the search of pertinent information. Fewer diagnostic hypotheses were formulated by participants who used forward reasoning, independent of the stage of development. Beginners requested additional diagnostic aids (radiographs, laboratory tests) more frequently than the competent/expert dentists. Experts recalled typical experiences with patients, while competent/beginner dentists recalled information from didactic courses. Experts evidenced cognitive diagnostic schemas that integrate pathophysiology of disease, while competent and beginner participants had not achieved this integration. We conclude that expert performance is a combination of a knowledge base, reasoning skills, and an accumulation of experiences with patients that is qualitatively different from that of competent and beginner dentists. It is important for dental education to emphasize the teaching of cognitive processes and to incorporate a wide variety of clinical experiences in addition to the teaching of disciplinary content.

Research in cognitive science has generated interest in studying the differences in the performance and cognitive processes of novices and experts. The goal of dental education is to guide students’ development through different stages from novice to competent, eventually resulting in an expert clinician.1 What characterizes the cognitive processes of expert dentists is an issue that educators are attempting to understand.

Theories on the novice-expert continuum are based on the cognitive model of information processing. This cognitive model is used to analyze the differences in the way that the knowledge base and the production rules (ways and circumstances under which actions are performed) of a particular field are processed, represented, and used in the different stages of the development of a skill. Differences between novices and experts demonstrate that cognitive learning involves not only quantitative but also qualitative changes; thus, it is important to study the transition from novice to expert in order to improve learning processes.2,3 Being an expert has been conceived of as a matter of knowledge, reasoning processes, development (from novice to expert, lifelong development), intelligence (individual differences in abilities and creativity), practice, and expert performance.4–8

In the field of medicine it is theorized that, to become an expert, students progress through various stages of transition characterized by distinctive cognitive structures. According to Schmidt et al.,9 when physicians with experience are diagnosing routine cases, they operate using knowledge structures called illness scripts. These scripts develop from the continuous exposure to patients and are a result of experience. They contain limited knowledge concerning the pathophysiology of the causes of symptoms and complaints, but at the same time contain a richness of clinical information on the illness, its consequences, and the context of its development. Illness scripts contain physicians’ memories of previous patients that aid in the diagnosis of new cases.

Schmidt et al. propose that there are four stages in the development of causal elaborated networks of memory derived from clinical experiences.9 The first stage is based on textbook knowledge. The second stage is the development of simplified cognitive models that are categorized by diagnostic classifications. These are developed through extensive and repeated exposure to patients. The third stage is termed the emergence of illness scripts. After extensive contact with multiple patients with the same or similar symptoms, more compilations are produced, enabling the development of the fourth stage: the storage of patient encounters as illness scripts. These scripts contain enabling conditions, the fault (a description of what is not functioning properly), and the consequences (signs and symptoms that arise due to the fault).

According to Kushniruk et al.,10 experts make extensive use of the context (social, behavioral, medical characteristics) in their approach to patients, with the memories of previous patients retained as individual entities rather than as prototypes. The clinical reasoning of experts is based on the similarities between present situations and some patient in his or her memory. The recognition of patterns is not a shortcut but an essential skill for expert performance. These authors characterize the process of diagnostic reasoning as a succession of limited comparisons that produce related diagnostic hypotheses.

It has been proposed by Patel and Groen11 that the development from novice to expert can be divided into three stages: first, development of adequate structures of knowledge representation; second, development of ways to discriminate between pertinent and nonpertinent information; and third, learning how to use pertinent representations in an efficient manner. Some of the most important empirical findings in the comparison of expert and novice performance have been enhanced recall and a forward reasoning process. Enhanced recall refers to the superiority of experts in memory skills to identify patterns in their field of knowledge. Forward reasoning refers to the finding that, in routine problems, experts work with the available data to reach a conclusion about the unknown—that is, they analyze available data to generate a hypothesis (forward reasoning = starting with data analysis). When a less extensive knowledge base is available, deductive reasoning (backward reasoning) is used in which a problem is solved by formulating a hypothesis and then looking for the data to sustain it (backward reasoning = starting with a hypothesis). Forward reasoning has been associated with expert physicians’ diagnostic precision.11,12 Research also suggests that experts can discriminate between pertinent and nonpertinent information, contrary to intermediates and beginners who are distracted by less relevant information.11–16 Beginners formulate unnecessary goals and utilize parts of their data base that are not related to the solution of a medical diagnosis problem. Studies in the discipline of dentistry have yielded findings similar to those in medicine.17,18

The purpose of our study was to characterize the cognitive processes at different stages of the development of diagnostic competency in dentistry, in order to gain a better understanding of this process. The specific aims of this study were to 1) determine the factors of the cognitive process that distinguish the performance of dental students in two different stages of development (beginners and competent) from that of expert dentists, and 2) compare the differences in performance of diagnostic skills at the three stages of development previously mentioned.


   Method
Top
 Abstract
 Method
Data analysis
 Results
 Discussion
 References
 
This investigation utilized a qualitative methodology. The cognitive processes that characterize beginner, competent, and expert dentists while reaching a diagnostic decision were analyzed. Participants at the three competency levels were asked to reach a diagnostic decision after reading a clinical case. The think aloud technique, as suggested by Ericsson and Simon,19 was used to study the cognitive process. This technique consisted of having participants verbalize their thinking while performing a task. Participants did not offer an explanation of what they were doing; they verbalized the information that was the focus of their attention while they generated an answer to a problem. The think aloud technique was complemented by retrospective reports; that is, participants were prompted to reflect upon the thinking process that occurred while they were reaching a diagnosis in the case. Subsequently, an interview was conducted to obtain additional information concerning participants’ views on their diagnostic model and a description of the pathophysiology of the case. A pilot study was conducted to test all procedures, and modifications were made to improve their validity prior to conducting this study.

Subjects were asked to determine the diagnosis of an oral condition based on a written clinical case (see Figure 1Go). The case was segmented into three parts. The first part described the patient’s chief complaint and provided background information, the second included clinical and radiographic findings, and the third contained the additional information needed to reach a diagnosis. Each participant received instruction on the think aloud technique and procedures to be followed. Subjects were asked to read the first segment of the case and express their thoughts out loud. They were also asked to indicate the information needed to reach a diagnosis. The subjects then proceeded to read the second segment and express their thoughts out loud while they reached a preliminary diagnosis of the case. They repeated the procedure for the last segment, expressing their thoughts out loud until they reached a final diagnosis. The entire process of analysis of the case was recorded on audiocassette.



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  		Figure 1. Clinical case

 
To obtain more precise information on the participants’ thinking processes, after solving the clinical case subjects were asked to reflect upon the way they approached the case and reached a diagnosis (retrospective reports). They were also asked to explain the necessary steps to reach a diagnosis and the pathophysiology involved in the case. These procedures were also recorded on audiocassette.

The research reported here was conducted at the School of Dentistry of the University of Puerto Rico (UPR) during the year 2000. Typical sampling was employed according to the following pre-established criteria: 1) beginners were junior students who had demonstrated the mastery of foundation knowledge by passing Part I of the National Boards Dental Examination (NBDE); 2) participants classified as competent were recent graduates from the dental school who were enrolled in a graduate program; and 3) experts were dentists who had clinically practiced at least ten years as a general dentist. Experts were selected by consensus of a panel of three professors from the dental school using a modified Delphi approach. Five subjects from each level were invited to participate among volunteers who satisfied the established criteria. Only the above-mentioned criteria were considered to select the participants.

Beginners were five women in their first semester of their third year at dental school. The competent participants were four men and one woman who graduated from the UPR dental school in 2000 and enrolled in the UPR general practice residency. Expert participants were males with more than ten years in the private practice of dentistry and professors at the UPR dental school.


   Data Analysis
Top
 Abstract
 Method
 Data analysis
Results
 Discussion
 References
 
A verbatim transcription of audiotapes was performed by one of the researchers. The following categories were employed to conduct a qualitative analysis of the transcripts of each participant’s think aloud process, retrospective report, and interview: 1) use of contextual and background information; 2) sequence of the reasoning process (backward or forward); 3) number of propositions; 4) strategies used for problem-solving; 5) organization of ideas; 6) number of hypotheses formulated; 7) use of external aids (such as referrals or additional information); and 8) references either to typical cases or to textbooks. All analyses and categorization of verbal reports were performed by consensus of the three researchers. Each participant’s reasoning process was diagrammed, illustrating the processes of data collection, revision of information, and hypothesis formulation. A map of concepts and hypotheses was constructed that illustrated the way in which each portion of information was used to generate a diagnostic hypothesis. The three researchers constructed these maps after a discussion of each participant’s thought process as reflected in their analysis of the case, as well as the retrospective report that each participant provided of his or her thought process. To determine a diagnostic hypothesis, the researchers summarized general characteristics of the participants’ behavior in the process of information-gathering according to the three levels of development: expert, competent, and beginner. The responses to the interview questions were also categorized according to the three levels of development.


   Results
Top
 Abstract
 Method
 Data analysis
 Results
Discussion
 References
 
Sequence of the Reasoning Process
Three sequences of the reasoning process were observed in this study: backward, forward, and a combination of both backward and forward. Table 1Go presents a summary of the sequence of reasoning process used by the participants in this study. The analysis of the diagrams prepared for each participant indicated that the reasoning process of three of the five beginners and three of the five competent students was characterized by backward reasoning. Participants who used backward reasoning tried to relate the data presented in the case to previously formulated hypothesis, and three out of six were not able to reach a correct diagnosis. Figure 2Go illustrates an example of backward reasoning. This participant formulated the hypothesis of cancer and searched for the data to support it. After obtaining more data, this subject considered the hypothesis of periodontitis and then searched for additional information to support this diagnosis. The participant was not able to connect the different pieces of information and reached an incorrect diagnostic conclusion.


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  		Table 1. Sequence of reasoning used by participants
 


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  		Figure 2. Example of backward reasoning

 
The reasoning process of two of the five expert dentists was characterized by forward reasoning. Figure 3Go is an example of this type of reasoning. This participant collected key data and formulated a preliminary hypothesis of the cause of infection (trauma in the cheek). Then he proceeded to collect information presented in the second segment of the case and formulated the diagnostic hypothesis. The participant collected information in a forward manner—that is, he collected key data to formulate a possible diagnosis, then corroborated and refined the hypothesis with the information offered in the case and reached a final diagnosis. The two experts who used forward reasoning were able to formulate a hypothesis with less information than other experts and only formulated one diagnostic hypothesis.



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  		Figure 3. Example of forward reasoning

 
Three experts used a combination of backward and forward reasoning, as did two beginner and two competent participants. Figure 4Go illustrates this sequence of reasoning. When presented with the first segment of the case, the participant immediately formulated the hypothesis of a retained tooth. After having access to additional data, he formulated a new hypothesis (laceration by the upper partial denture), reaching the correct diagnosis without the last segment of the case. Participants who used both backward and forward reasoning formulated a diagnostic hypothesis when reading the first segment of the case, considered one or various hypotheses on the cause of the infection, and discarded and formulated new hypotheses as they continued with their reading of the case. These participants exhibited backward reasoning in the sense that they were focused on the idea that the patient’s problem was of dental origin, even though the patient’s complaint was about a growth in his cheek. Notwithstanding, all experts were able to reach a quite precise diagnosis without the last segment of the case. On the other hand, the two beginner and two competent dentists who used both backward and forward reasoning differed from experts in that they required more information to determine the diagnosis and did not anticipate the information needed to confirm the correct diagnosis.



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  		Figure 4. Example of a combination of forward and backward reasoning

 
Characteristics of the Reasoning Process
Beginner students presented characteristics such as focusing their attention on nonpertinent data (mobility in all the patient’s teeth, for example) (see Table 2Go); need for additional diagnostic aids (panoramic radiographs, dental models, biopsy); lack of organization of ideas (change of focus of attention each time new information was offered); difficulty in determining key clinical findings (they related clinical findings to nonplausible hypotheses); and inability to anticipate required information. Competent dentists exhibited organization of their ideas (order in the information gathering); capacity to identify key clinical findings; reference to facts learned in didactic courses (for example, the time of the duration of the lesion could indicate cancer); and need for additional diagnostic aids (laboratory tests, more information on the color and texture of the lesion). On the other hand, expert dentists alluded to the patient’s contextual information ("he has behavioral and compliance problems" [translation]); demonstrated the ability to discriminate between pertinent and nonpertinent data; showed organization of ideas and capacity to determine key clinical findings; planned for the search of information; and made reference to typical cases ("this is typical, I have seen similar cases many times at my dental office" [translation]).


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  		Table 2. References of beginners to nonpertinent information
 
Diagnostic Model
After completing the clinical case, subjects were asked to reflect upon the way they approached the case and reached a diagnosis. The diagnostic models described by the three groups of participants had the following characteristics. Beginner students mentioned elements of the process that lacked a sequence or specific order (see Table 3Go). Competent dentists indicated order in the process followed and mentioned diagnosis as a process of searching for information, decision making, and formulation of hypotheses. Experts described diagnosis as a critical thinking process in which the context and the patient’s history are integrated with clinical observation. Their description of the process was fluid, as if they were actually performing it.


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  		Table 3. Steps of the diagnostic process mentioned by participants
 
When asked to explain the pathophysiology involved in the clinical case, beginner and competent dentists were confused and showed difficulty in explaining the factors. They only mentioned some factors in a fragmented way but not as a disease process. Experts, on the contrary, explained the process without difficulty, presenting the way in which the different systems of the body were involved in the patient’s condition.

The following are excerpts from the participants’ explanations:

Beginner: "The first thing that came to my mind was an elderly patient, although that may be irrelevant, but he is diabetic, has hypertension, and has not visited his physician lately. I think he had uncontrolled systemic conditions, I know that his systemic conditions contributed to the processes the patient was developing" [translation].

Competent: "The patient had problems of high blood pressure; it did not say if he was diabetic, but he had high sugar levels. Obviously he did not take good care of himself. He also showed signs that he had a systemic infection because he presented signs of fever and inflammation of sub-mandible and upper cervical nodules, so something pathological was involved in the case" [translation].

Expert: "When a sixty-eight-year-old patient is mentioned, one makes an image of the structures in the mouth one will find and the condition in which they will be found. This will give you an idea because there is a physiological deterioration in patients . . . physiologically how a diabetic patient responds to treatment. . . . When you encounter swelling, you think about what swelling is, a response of the body to an injury, and there are nodules. . . . These are filters, so the infected cells go there, they are like a filtering system. If there is swelling there is an infection somewhere" [translation].


   Discussion
Top
 Abstract
 Method
 Data analysis
 Results
 Discussion
References
 
Our findings of forward reasoning by expert dentists are similar to those reported concerning clinical diagnosis in medicine.7,11 Although not all of the expert dentists exclusively used forward reasoning, those whose reasoning process was mostly in a forward manner obtained a precise diagnosis more rapidly than those employing a combination of forward and backward reasoning to the problem-solving. The competent and beginner dentists who exhibited some degree of forward reasoning were also more precise in their diagnosis than their counterparts who did not use forward reasoning. According to Groen and Patel,20 an individual develops rules of a situation model and applies them in a forward manner until he or she confronts an incomplete or imprecise situation model, which explains the forward reasoning of experts, but does not exclude nonexperts’ use of forward reasoning. Forward reasoning is explained by an individual’s thorough knowledge of the pertinent discipline and is related to a vast experience with similar patients. This clinical experience is stored in memory as illness scripts of previous patients.9

The role of experience is also evident in the development of a diagnostic model. Experts demonstrated elaborate schemas about the diagnostic process, while competent dentists demonstrated superior schemas to beginner dentists. This is obviously related to the minimum exposure that beginner dentists have had to clinical experiences. This finding is consistent with the critical role of experience in the development of meaning and construction of schemas in memory, according to information-processing theory.9,21,22 This is of importance for education in that knowledge is acquired through both theory and practice. The integration of theory and practice promotes the development of schemas in the long-term memory, a distinguishing feature of the expert clinician’s development.

The consideration of the patient’s contextual and background information also distinguishes the performance of expert dentists. Expert subjects in this project demonstrated greater consideration to the patient’s context, giving more importance to background information as they explained their diagnostic model. This finding is consistent with Custers et al.12 and Hobus et al.23 who pointed out that experts exhibit greater sensibility towards the patient’s contextual and background information, which is a critical factor in the development of their diagnostic skills, and the integration of contextual factors is essential in the development of illness scripts.9

Additionally, the capacity of experts to discriminate between pertinent and nonpertinent information was evident in this study. Characteristics such as distraction by nonpertinent data, formulating unnecessary goals, and making use of parts of their knowledge base that were not relevant were exhibited principally by beginner and to a lesser degree by the competent dentists. The organization of ideas demonstrated by expert dentists has also been reported for physicians.10 Experts use key clinical findings to discern between possible hypotheses. The analysis of the subject’s diagnostic solution protocols in this project demonstrated that expert dentists exhibited these characteristics and competent dentists were superior to beginner dentists in their capacity to determine key clinical findings. The maps of concepts and hypothesis of participants in this research also reflect the superior capacity of experts to identify the clinical findings that enable them to discern among possible diagnostic hypotheses.

The need for more external aids to solve the diagnostic problem exhibited by beginner and competent dentists may be explained by their limited clinical experience. Beginner and competent dentists require more explanations of phenomena because they do not possess simplified high level models of reasoning, developed through an extensive exposure to patients’ signs and symptoms.9

The superiority demonstrated by experts in their explanations of the pathophysiology involved in the clinical case presented here are similar to findings in other disciplines as well as dentistry.18,24 These authors also report that experts present coherent explanations based on the concepts and principles involved in the solution of a problem and offer explanations based on principles more than on superficial elements presented in the problem.

This research has significance for dental education. The importance of the integration of theory and practice has been extensively discussed in the literature and demonstrated in this study as pertinent to dental education. The need for multiple and varied clinical experiences for the development of the reasoning process in clinical diagnosis is suggested in this study and appears to be fundamental for the development of illness scripts, as well as for the development of analogical thinking.

The traditional curriculum has given greater emphasis to repetitive treatment techniques than to diagnostic skills and treatment in a comprehensive care model.25 Competency-based education promotes the integration of theory and practice, as well as the integration between disciplines.26 Chickering and Claxton27 indicate that students’ competency will be conditioned by their ability to order stimuli and reorder, apply, and censor their previous ordering according to new information received. This demonstrates the importance of students’ learning to organize and plan their search for data, so as to lead to an accurate diagnosis. It is also necessary that students learn to evaluate signs and symptoms in order to develop the capacity to discriminate between pertinent and nonpertinent information. Therefore, it is important for dental education to give equal emphasis to diagnostic and treatment skills. Experience can not be taught, but should be offered by exposing students to a wide variety of patients by means of strategies such as case-based learning and clinical simulations in addition to direct contact with patients.

This study suggests a distinction among beginner, competent, and expert participants in their ability to consider the patient’s contextual and background information, which has been reported by other investigations. The ability to consider the broader context of the patient’s overall health problems can be achieved by the integration of clinical, biomedical, and behavioral disciplines through clinical cases and a comprehensive treatment of the patient.

Through an analysis of the reasoning process in the solution of a clinical case, evidence suggests that differences exist not only in the product, which was the solution of the diagnostic problem, but also in the process employed to reach the solution by individuals of differing levels of dental experience. This implies that it is necessary to teach not only the content of the disciplines but also the reasoning processes and production rules (ways and circumstances under which actions are performed) inherent to clinical practice. Traditionally, the progress of students in reaching competence has been based on the evaluation of products rather than processes.1 This study found differences among expert, beginner, and competent individuals in the processes of data collection, hypothesis generation, interpretation of information, and evaluation of hypotheses, although the use of forward and backward reasoning did not seem related to level of expertise. These findings suggest the importance of evaluation strategies in dental education to examine not only the performance of students in offering treatment, but also the steps that are taken to reach the decisions for the most effective treatment.

These findings are tempered by two study limitations. First, the primary researcher was not blinded in the analysis of the protocols. However, the use of three researchers who developed consensus and reached agreements suggests a limited bias. Second, the small sample size, though consistent with similar studies, may have produced spurious findings—although internal consistency of the study supports the findings. Given these limitations, further research is warranted to understand the difference in performance among expert, competent, and beginner dentists in diagnostic skills and confirm the results of this investigation.


   Footnotes
 
Dr. Crespo is Professor at the Ecological Sciences Department and Assistant Dean for Institutional Development; Dr. Torres is Professor and Director of the Academic Affairs Office; and Dr. Recio is Professor at the School of Dentistry—all at the Medical Sciences Campus, University of Puerto Rico. Direct correspondence and requests for reprints to Dr. Kathleen Crespo, School of Dentistry, Medical Sciences Campus, University of Puerto Rico, P.O. Box 365067, San Juan, Puerto Rico 00936-5067; 787-751-5279 phone and fax; kcrespo{at}rcm.upr.edu.


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