Teaching diagnostic reasoning to surgical residents: early evaluation of a real-patient intervention in an LMIC

Diagnostic reasoning remains insufficiently prioritised within medical education and clinical practice in Pakistan. We implemented a real-patient programme at a tertiary teaching hospital in Karachi to train junior surgical residents, followed by early implementation evaluation. We used real patients with complex, undiagnosed conditions for teaching. In small groups, faculty directly observed residents and provided feedback on clinical methods and data analysis, which used concept mapping to structure problem representation and differential diagnosis. Residents refined their analysis through self-directed study, and once a definitive diagnosis was available, reflected on performance and updated their mental models of disease. We evaluated the process by assessing residents’ perceptions of acceptability, relevance, and impact via questionnaires and focus groups. Early outcomes were measured through performance in problem representation and differential diagnosis. To examine learning attribution to the intervention, we compared Diagnostic Thinking Inventory (DTI) scores with non-equivalent controls using a quasi‑experimental design. Over 60 weeks, 11 residents encountered 51 patients with complex, undiagnosed conditions (median 20 per resident; range 12-40). Surveys and focus groups indicated the program was acceptable, relevant, and supported professional growth. Residents’ problem representations and differential diagnoses frequently aligned with the definitive diagnosis achieved in 39 of 51 cases (76.5%). Comparisons of Diagnostic Thinking Inventory scores with non‑equivalent controls provided modest evidence that learning gains were attributable to the intervention. However, residents reported anxiety related to knowledge gaps, exhibited persistent deficiencies in data gathering and analysis, and pointed to limited faculty support amid heavy service demands that hindered consolidation of learning in the workplace. This intervention offers an innovative real-patient approach to teaching diagnostic reasoning among junior surgical residents in a lower – middle – income country (LMIC) context. Early evaluation suggests potential effectiveness, although important gaps remain. Future efforts should emphasize structured illness script development, greater integration of supervised learning in the workplace, and the introduction of formal assessment with targeted feedback.