{"paper_id":"2e38562b-14df-441e-b7a5-e1976433150e","body_text":"Collaborative engagement with diagnostic uncertainty across sequential molecular diagnostic cases: an interpretive thematic analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Collaborative engagement with diagnostic uncertainty across sequential molecular diagnostic cases: an interpretive thematic analysis Li Chen, Yiming Tao, Hua Zhu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8966520/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 9 You are reading this latest preprint version Abstract Introduction Preparing health professions students to work collaboratively under conditions of diagnostic uncertainty is an important goal in contemporary medical education. While problem-based and inquiry-based approaches are widely used, less is known about how collaborative practices unfold over time when students encounter uncertainty in authentic diagnostic tasks. This study examined how collaborative engagement with diagnostic uncertainty developed across a sequence of case-based molecular diagnostic activities. Methods An interpretive qualitative study was conducted within a five-week molecular diagnostics elective for undergraduate biotechnology students (n = 42) at a medical university in China. Students worked in fixed small groups across four progressively complex diagnostic cases. Data included group diagnostic worksheets, mechanism-based diagrams, peer evaluation records, and individual reflective writings collected longitudinally. Data were analyzed using an interpretive thematic approach to identify patterns in how collaboration was organized in response to diagnostic uncertainty over time. Results Three recurring configurations of collaborative engagement with diagnostic uncertainty were identified: procedural containment, intermittent interpretive engagement, and collective interpretive engagement. Groups shifted among these configurations rather than progressing linearly. Procedural containment and intermittent interpretive engagement were commonly observed across groups and cases, whereas collective interpretive engagement appeared only episodically and did not stabilize as a sustained collaborative pattern. Changes in how interpretive responsibility was distributed and how artifacts were used as shared reasoning spaces appeared to shape these shifts. Conclusions Collaborative diagnostic learning under uncertainty does not develop uniformly, even within the same instructional design. Rather, engagement fluctuates depending on how uncertainty is recognized, negotiated, and supported within group activity. Designing learning environments that position uncertainty as a shared object of inquiry and support the use of artifacts for collective reasoning may help sustain collaborative interpretation in diagnostic learning. Diagnostic uncertainty Collaborative learning Qualitative research Thematic analysis Medical education Collaborative reasoning Figures Figure 1 Introduction Contemporary medical and biomedical education increasingly emphasizes preparing learners to engage with complex problems and collaborate effectively in uncertain and evolving professional contexts [ 1 – 3 ]. However, traditional content-centered instructional approaches often provide limited opportunities for students to experience how such processes unfold in practice, particularly in authentic problem-solving situations where knowledge and interpretations remain provisional [ 4 – 6 ]. In response to these challenges, instructional approaches such as problem-based learning, inquiry-based learning, and gamified designs have been introduced to enhance student engagement and learning outcomes [ 4 – 5 , 7 ]. Empirical studies have shown that such approaches can positively influence students’ motivation, participation, and perceived competence development [ 7 – 8 ]. However, much of this literature remains outcome-oriented, focusing primarily on performance indicators, satisfaction measures, or self-reported gains [ 4 – 5 ]. As a result, we still have limited insight into how collaborative learning processes unfold over time within these instructional environments [ 9 ]. Despite growing interest in collaborative and inquiry-based learning in medical education, we know relatively little about how collaborative practices are reorganized when students encounter diagnostic uncertainty, particularly over successive learning tasks in authentic settings where evidence and interpretations remain provisional [ 9 ]. The aim of this study is to examine how collaborative engagement with diagnostic uncertainty takes different forms and evolves over time in a case-based molecular diagnostics course. Methods Study design and methodological approach This study adopted an interpretive, process-oriented qualitative approach to examine how collaborative practices unfolded over time in an authentic educational setting[ 10 – 11 ]. Rather than seeking to evaluate instructional effectiveness or learning outcomes, the analysis focused on how learning-related practices were enacted, reorganized, and inferred from students’ documented collaborative artifacts and reflections as students engaged with increasing diagnostic uncertainty[ 9 ]. Data analysis followed an interpretive thematic approach to identify and compare patterns of collaborative work under diagnostic uncertainty across cases, without aiming to generate a formal theory[ 12 ]. Educational context and participants The study was conducted at a medical university in China within a Molecular Diagnostics elective course for undergraduate biotechnology students in their fourth semester. A total of 42 students participated and were organized into 12 small groups of three to four members. The course lasted five weeks. The same cohort of students and fixed group compositions were maintained throughout the course. The course was organized around a sequence of four case-based diagnostic tasks of increasing complexity[ 8 ]. In each task, students were required to propose diagnostic hypotheses, select molecular targets, design appropriate diagnostic strategies, and interpret results to reach a diagnostic conclusion. Each case lasted one week and engaged the same student groups in longitudinal collaborative work. Uncertainty was an inherent feature of the course design. As tasks progressed, students encountered increasingly incomplete information, alternative explanations, and multiple plausible diagnostic pathways—conditions aligned with established taxonomies and frameworks of medical uncertainty[ 6 , 13 ]. These conditions prompted students to revisit earlier assumptions, coordinate disciplinary knowledge, and discuss and revise their interpretations collaboratively over time. Data sources and analytic stance This study drew on multiple qualitative data sources collected across four sequential case-based diagnostic tasks to examine how collaborative engagement with diagnostic uncertainty unfolded over time[ 10 , 14 ]. These sources included: (1)Group diagnostic worksheets completed through role-differentiated sections. (2)Mechanism-based diagrams linking molecular, protein, clinical, and diagnostic reasoning. (3)Within-group peer evaluation records following each case. (4)Individual reflective writings submitted after each case and at the end of the course. Importantly, these data sources served distinct analytic functions rather than being treated as parallel outcome measures. Diagnostic worksheets and mechanism maps were mandatory course artifacts generated under shared task constraints. In this study, they were not analyzed as indicators of performance quality or learning outcomes. Instead, they were used as material traces of diagnostic reasoning-in-practice, anchoring the analysis of when and how uncertainty emerged, was operationalized, and revised during collaborative work, particularly as evidential ambiguity increased in later cases. Peer evaluation records provided complementary insight into the social positioning of interpretive contributions within groups, capturing how students recognized and attributed roles, influence, and responsibility as diagnostic challenges unfolded. These records were used to contextualize shifts in collaborative organization rather than to evaluate individual competence. Individual reflective writings constituted the primary analytic lens for examining engagement with diagnostic uncertainty. Rather than being treated as measures of reflective ability or learning gain, reflections were analyzed as sense-making accounts through which students articulated how they recognized uncertainty, acted upon it, and retrospectively interpreted their experiences within collaborative diagnostic practice. Variability in length, depth, and analytical detail was treated cautiously as analytically meaningful when aligned with evidence from artifacts and peer evaluations. Such alignment was used to interpret whether and how diagnostic uncertainty appeared as a salient object of reflection for different students and groups . Taken together, this analytic stance foregrounded engagement with diagnostic uncertainty as a process enacted within collaborative practice and rendered visible through the interplay of material artifacts, social positioning, and reflective sense-making, rather than as an individual trait or an instructional outcome. Data analysis Data analysis proceeded iteratively and longitudinally, tracing how collaborative practices shifted in relation to diagnostic uncertainty across successive diagnostic tasks within teams[ 15 ]. A ‘Focus Team’ was purposefully selected for in-depth longitudinal tracing because its trajectory across four cases was especially clear and information-rich. Rather than coding data solely by task or data type, the analysis attended to shifts in collaborative organization over time. Initial coding identified patterns in how groups coordinated roles, articulated assumptions, and responded to uncertainty. We then conducted iterative comparisons(not grounded theory) across cases, teams, and data sources to examine how collaborative practices were sustained, modified, or disrupted as diagnostic challenges increased. Particular analytic attention was given to episodes in which uncertainty prompted changes in collaborative activity, including the revisiting of hypotheses, renegotiation of roles, and collective questioning of prior interpretations. These moments were treated as key analytic sites for understanding how collaboration reorganized in response to diagnostic uncertainty. Building on this longitudinal analysis, codes were clustered into provisional patterns and refined into analytic indicators used to identify configuration shifts over time. We then developed a set of analytic indicators to identify recurring configurations of collaborative engagement with diagnostic uncertainty. These indicators were iteratively derived from reflections, peer feedback, and collaborative artifacts, and were used to distinguish between procedural containment, intermittent interpretive engagement, and collective interpretive engagement (Table 1 ). These configurations functioned as analytic heuristics rather than rigid classifications. They describe episodes of collaborative work and were not used to categorise groups as stable types or developmental stages. Instead, they enabled interpretation of collaborative episodes in relation to how uncertainty was positioned and negotiated, rather than as indicators of performance level[ 12 , 16 ]. Trustworthiness To enhance interpretive credibility, analytic decisions were documented through iterative memo writing, and emerging interpretations were discussed within the research team to examine alternative readings[ 17 ]. Throughout the analysis, the researchers repeatedly returned to the data to ensure that interpretations were grounded in participants’ accounts and learning artifacts. We also sought disconfirming instances to refine configuration boundaries and avoid overgeneralization[ 18 ]. Interpretations were checked across reflections, peer evaluations, and artifacts to ensure that claims about shifts in collaboration were supported by more than one type of data trace.Given the first author’s instructional role, reflexive memos documented how pedagogical assumptions might shape interpretation and were revisited during team discussions. Ethical considerations The study was approved by the institutional teaching ethics committee. Informed consent was obtained from all participants prior to data collection. All materials were anonymized before analysis, and participation in the study had no impact on students’ course grades or academic evaluation.All group identifiers used in this manuscript are anonymized. Student-generated group names have been replaced with alphanumeric codes (Group A–L) to prevent indirect identification within the small cohort context. The ‘Focus Team’ refers to a purposefully selected case for in-depth longitudinal analysis. This team was selected because its collaborative trajectory across the four cases was particularly clear and well-documented, providing an information-rich example for tracing how engagement with diagnostic uncertainty evolved over time within a single group. The label is assigned by the researchers for analytic clarity and does not correspond to any student-generated identity. Table 1 Analytic indicators used to identify collaborative configurations in engagement with diagnostic uncertainty Analytic dimension Configuration 1 Procedural containment Configuration 2 Intermittent interpretive engagement Configuration 3 Collective interpretive engagement Position of diagnostic uncertainty Treated as a gap to be resolved quickly in order to proceed with tasks Occasionally surfaced as an interpretive problem, but not consistently sustained Treated as a shared object of inquiry and maintained through collaborative reasoning Collaborative organization of revision Revision occurred but remained embedded within task execution and role-bound workflow Revision surfaced in group discussion but was not consistently sustained as a shared process Revision became a shared, sustained collaborative process through which multiple explanations were collectively examined Diagnostic pathways Diagnostic explanations organized into a single dominant pathway Diagnostic explanations occasionally expanded but ultimately reorganized into a primary pathway Multiple explanatory pathways were maintained in parallel within shared interpretive work Role of artifacts (worksheet/mechanism map) Used mainly to document or present finalized conclusions Used for partial clarification and structuring, but not consistently as reasoning space Functioned as a shared workspace where competing interpretations were externalized and negotiated Distribution of interpretive responsibility Role-bound; members execute assigned tasks Responsibility occasionally shifts across roles during discussion Responsibility distributed; roles contribute complementary interpretive perspectives Orientation toward closure Strong drive toward diagnostic closure and task completion Alternation between exploration and closure Tolerance of uncertainty; closure delayed until integrative understanding achieved Nature of collaboration Task coordination Transitional / oscillating collaboration Collective explanation-building Empirical grounding in this study Observed across multiple groups and cases Observed in several groups and cases, but unstable Observed episodically in the Focus Team (Case 4 only); not stabilized across cases Result Theme 1 Longitudinal reconfiguration of collaborative engagement with diagnostic uncertainty in the Focus Team Theme 1 traces how collaborative engagement with diagnostic uncertainty changed across four consecutive diagnostic cases within the Focus Team. Rather than representing a linear progression, the analysis illustrates how different forms of collaboration emerged, receded, and interacted over time as the group encountered evolving diagnostic challenges. Case 1: Procedural containment of diagnostic uncertainty In the first case, diagnostic uncertainty was largely absorbed into procedural task execution. Collaboration centered on organizing workflow, allocating roles, and completing required steps of the diagnostic process. Students focused on identifying appropriate methods and generating results, while uncertainty remained largely peripheral to collective interpretation. Reflective accounts indicated that challenges were framed primarily in terms of task clarity, technical understanding, and role coordination. Students reported difficulties such as “not fully understanding the diagnostic mechanism,” “uncertainty about specific experimental steps,” and “reliance on AI explanations when knowledge was insufficient.” These accounts suggest that uncertainty was acknowledged but treated as a gap to be resolved quickly in order to proceed. Case 2: Emergence of interpretive engagement In the second case, diagnostic uncertainty began to surface more explicitly as an interpretive issue. Students occasionally proposed alternative explanations and revisited earlier assumptions, indicating a partial shift from purely procedural coordination toward exploratory reasoning. However, such engagement remained unstable and often gave way to task-oriented execution. Students described developing a more structured approach to diagnosis, such as “starting from the core clinical question and then identifying molecular targets,” and reported increasing communication within the group. Yet these interpretive moments were episodic and did not consistently reorganize collaborative work. Case 3: Technical resolution and workflow stabilization In the third case, collaboration increasingly relied on technical clarification and confirmation as a way of managing uncertainty. Uncertainty was frequently addressed through selecting or refining diagnostic techniques, with emphasis placed on obtaining definitive results. Group interaction focused on method selection, data interpretation, and achieving diagnostic closure. Students highlighted the importance of “choosing appropriate testing technologies” and “following a clear analytical sequence,” suggesting that uncertainty was managed through technical decision-making rather than sustained collective interpretation. Collaboration remained active, but reasoning was structured primarily around procedural and technical progression. Case 4: Episodic collective interpretive engagement In the fourth case, diagnostic uncertainty became a shared object of collaborative reasoning. Multiple explanatory pathways were considered and negotiated, and artifacts—particularly the mechanism diagram—functioned as a shared workspace for testing and revising hypotheses. Collaboration temporarily shifted from sequential task execution to recursive interpretation across clinical, cytogenetic, and molecular evidence. Students described beginning with preliminary diagnostic assumptions, then refining them through discussion and evidence comparison: “We first analyzed possible conditions, identified candidate genes, and then decided on testing methods through group discussion.” Peer feedback also emphasized the generation of alternative explanations, such as proposing chromosomal deletions or gene fusion events, which prompted further collective evaluation . Despite this shift, collective interpretive engagement remained situational and did not stabilize as a consistent collaborative pattern. The group continued to oscillate between interpretive exploration and procedural closure, indicating that shared reasoning was achieved episodically rather than sustained across cases. While Theme 1 presents a longitudinal analytic account of how collaborative engagement with diagnostic uncertainty unfolded within a single team, it does not imply a universal developmental trajectory. The reconfigurations observed in the Focus Team served as an analytic exemplar for examining whether similar patterns occurred across other groups. To address this, the analysis was extended across all student teams to explore how diagnostic uncertainty was taken up, interpreted, and organized in collaborative work beyond a single case trajectory. This cross-group examination aimed to identify recurring configurations of engagement and to assess the extent to which collective interpretive engagement emerged as a shared or stable pattern across teams . Theme 2 Configurations of collaborative engagement with diagnostic uncertainty across groups Building on the process-oriented exemplar presented in Theme 1, this cross-group analysis examined whether and how configurations of engaging with diagnostic uncertainty were similarly enacted across the twelve student groups under a shared instructional design. Although all groups completed the same sequence of case-based diagnostic tasks and produced comparable required learning artifacts, they differed markedly in how diagnostic uncertainty was recognized, acted upon, and made sense of over time.While the instructional design created opportunities for engaging with diagnostic uncertainty, collective interpretive engagement emerged only rarely and did not stabilize as a common group-level pattern. 2.1 Overview: Variation in configurations of engaging with diagnostic uncertainty across groups and over time Across the 12 groups, three configurations were identified in how diagnostic uncertainty was taken up within collaborative work. These configurations differed in the extent to which uncertainty functioned as a shared object of inquiry and in how explanatory reasoning was distributed across members and artifacts. Configuration 1 and Configuration 2 appeared across multiple groups and cases, representing common ways in which uncertainty was procedurally managed or intermittently explored. By contrast, Configuration 3 was observed only once—within the Focus Team in Case 4—and was not observed as a recurring pattern elsewhere in the dataset. Rather than indicating a stable endpoint, this instance represents a locally achieved configuration in which uncertainty temporarily became a shared focus of collective epistemic work. While moments of technical closure were frequently observed across groups, they were not treated as a distinct configuration. Instead, they functioned as a closure mechanism within procedural containment or as a pathway through which groups shifted from intermittent interpretive engagement back to procedural task execution. This distinction helped clarify the analytic boundary of the typology and ensured that configurations were defined by how uncertainty organized collaborative reasoning rather than by isolated technical problem-solving moves. 2.2 Configuration 1: Procedural containment of diagnostic uncertainty In this configuration, diagnostic uncertainty did not become a sustained object of collective interpretation but was largely contained within procedural task execution. Across cases, students remained actively engaged in completing required diagnostic steps, allocating roles, and producing mandated learning artifacts. However, uncertainty was rarely foregrounded as an epistemic problem requiring collective reconsideration of diagnostic assumptions. Reflective accounts consistently framed challenges in terms of task organization, role positioning, or procedural clarity rather than competing interpretations or evidential ambiguity. Students described their work as oriented toward identifying key problems and advancing diagnostic steps, for example:“Starting from the core problem and then proceeding step by step toward a result.”“First identify the key issue, reach a preliminary molecular diagnosis, then select appropriate techniques and analyze the results.”Such accounts indicate that uncertainty was acknowledged but quickly folded into task progression, rather than treated as an object for sustained interpretive engagement. When difficulties arose, they were typically addressed through linear, task-oriented strategies aimed at restoring workflow continuity. Students emphasized coordination and completion of assigned steps, with limited reference to revisiting diagnostic assumptions or comparing alternative explanations. Even when discussion occurred, it was oriented toward advancing procedures rather than maintaining uncertainty as a shared problem. Material learning artifacts further supported this pattern. Worksheets and mechanism diagrams primarily documented established diagnostic pathways rather than preserving multiple explanatory structures. As one student noted:” I completed parts of the mechanism diagram”Here, the artifact functioned primarily as a product of task completion rather than a shared space for negotiating competing interpretations. Across successive cases, mechanism diagrams and worksheets tended to converge toward a single dominant mechanistic pathway. Additional molecular, technical, or clinical elements were sometimes incorporated, but these elements typically reinforced an existing explanatory structure rather than reorganizing diagnostic reasoning. As a result, uncertainty was subsumed into procedural completion rather than retained as an open explanatory problem. Taken together, this configuration represents a mode of engaging with diagnostic uncertainty in which collaboration supported task execution and coordination, but uncertainty did not become a shared epistemic object for collective explanation-building. 2.3 Configuration 2 : Intermittent interpretive engagement with diagnostic uncertainty In this configuration, diagnostic uncertainty intermittently surfaced as an object of interpretive attention but did not become a sustained or organizing feature of collaborative practice. Groups displaying this pattern occasionally articulated uncertainty, proposed alternative explanations, or engaged in exploratory discussion when encountering complex diagnostic decisions or unexpected data. Reflective accounts sometimes highlighted moments in which multiple possibilities were raised during collaborative work, for example when students “proposed more possibilities during group discussions and attempted alternative technical approaches.” However, such interpretive engagement remained episodic and fragile. Moments of shared exploration were typically followed by a return to role-bound task execution or procedural problem-solving aimed at restoring workflow continuity. Students often described approaching diagnostic tasks by “first identifying the core problem, then searching for relevant experimental principles, and finally selecting an appropriate technique,” indicating a re-alignment with structured task progression rather than sustained interpretive negotiation. Required learning artifacts reflected this instability. Although additional molecular, technical, or clinical elements were occasionally incorporated into worksheets or mechanism-based diagrams, these representations ultimately converged toward a single dominant mechanistic pathway. Alternative explanations were rarely retained over time; instead, groups described narrowing their focus, noting that “after searching for information, we continued working around a single diagnostic direction.” Peer evaluation records further indicated that collaboration in this configuration was primarily oriented toward task support, information sharing, and role fulfillment, with comparatively limited emphasis on collectively interrogating diagnostic assumptions or sustaining multiple diagnostic explanations over time. Taken together, Configuration 2 represents a mode of engaging with diagnostic uncertainty situated between procedural containment and sustained collective engagement. While uncertainty entered collaborative discourse, it remained episodic and did not reorganize the epistemic structure of collaborative work toward sustained collective explanation-building. 2.4 Configuration 3: Collective interpretive engagement with diagnostic uncertainty In this configuration, diagnostic uncertainty functioned as an organizing epistemic object structuring collaborative reasoning and was actively sustained within group interaction. Rather than being treated as a gap to be closed, uncertainty functioned as a productive focus for explanation-building, prompting members to revisit assumptions, compare alternative interpretations, and negotiate diagnostic meaning collectively. Reasoning in this configuration was recursive and integrative, moving across clinical information, cytogenetic findings, and molecular evidence. Multiple explanatory pathways were considered in parallel, and artifacts—particularly the mechanism diagram—functioned as shared epistemic workspaces where hypotheses were externalized, examined, and revised. Responsibility for interpretation was distributed across members, with roles contributing complementary epistemic perspectives rather than operating as fixed task assignments. This configuration was observed empirically in the Focus Team during Case 4, where students described beginning with tentative diagnostic assumptions and refining them through iterative discussion and evidence comparison:“We first analyzed possible conditions, identified candidate genes, and then decided on testing methods through group discussion.” Importantly, this form of engagement did not stabilize as a recurring collaborative pattern. Although collective reasoning was temporarily sustained, the group continued to shift between interpretive exploration and procedural closure across phases of the task. Collective interpretive engagement therefore appeared as a situationally achieved configuration rather than a durable mode of collaboration across cases or groups. 2.5 Theme-level synthesis: Bounded variation and rare stabilization of collective interpretive engagement Taken together, the cross-case and cross-group analyses indicate that collaborative engagement with diagnostic uncertainty did not follow a linear developmental progression. Instead, groups moved among distinct configurations characterized by different orientations toward uncertainty, reasoning practices, and uses of artifacts and roles. While procedural containment and intermittent interpretive engagement were commonly observed across groups and cases, collective interpretive engagement appeared only episodically and did not stabilize as a persistent collaborative pattern. These patterns suggest variability in how collaborative participation and interpretation were organized over time. Discussion 1 Reconfiguring collaboration under diagnostic uncertainty This study examined how student groups engaged with diagnostic uncertainty across a sequence of case-based molecular diagnostic tasks and identified three recurring configurations of collaborative practice: procedural containment, intermittent interpretive engagement, and collective interpretive engagement. Rather than following a linear progression from novice to expert collaboration, groups moved unevenly across these configurations over time, with uncertainty sometimes being absorbed into task completion and at other times becoming a shared focus of explanation-building. Sustained collective interpretive engagement appeared only episodically and did not stabilize as a common pattern across groups or cases. Rather than functioning primarily as a problem to be resolved, diagnostic uncertainty acted as a practical organizing condition that shaped how collaboration and interpretation unfolded within group diagnostic work [ 19 – 20 ]. Across groups, shifts in collaborative configurations were closely associated with how responsibility for interpretation was organized within the group[ 21 – 22 ]. When diagnostic reasoning remained tightly bound to predefined roles, collaboration tended to prioritize task progression and procedural completion, and uncertainty was rapidly contained. In contrast, when responsibility for interpretation became shared and negotiable, groups were more likely to revisit assumptions, compare alternative explanations, and sustain collective reasoning. Artifact use further mediated how these collaborative configurations unfolded[ 23 – 24 ]. When worksheets and mechanism diagrams were treated primarily as reporting tools, they supported linear task execution and reinforced a single dominant diagnostic explanatory pathway. However, when artifacts functioned as shared reasoning spaces—where hypotheses were externalized, compared, and revised—they enabled members to sustain multiple explanatory possibilities for longer periods. Within this process, diagnostic uncertainty was interpreted in our analysis as becoming salient through how collaboration was organized and mediated. Uncertainty was more likely to be retained and explored collectively when interpretive responsibility was distributed and supported by shared artifacts, and more likely to be closed when collaboration remained role-bound and artifacts were used primarily for documentation rather than for reasoning [ 24 ]. Building on these findings, we present an analytic framework derived from the observed patterns to illustrate how diagnostic uncertainty shaped collaborative reconfiguration (Fig. 1 ). The framework highlights how different configurations of engagement emerged and shifted depending on how uncertainty was recognized, externalized, and negotiated within group activity. Diagnostic uncertainty is presented as a practical condition shaping how collaboration was organized in case-based molecular diagnostic tasks. Three recurring configurations were identified—procedural containment, intermittent interpretive engagement, and collective interpretive engagement—each representing different ways of organizing reasoning, roles, and artifact use in response to uncertainty. Arrows indicate possible movement among configurations rather than a linear developmental progression. Outer elements represent interactional conditions observed in the analysis that appeared to enable or constrain collaborative engagement, including hypothesis visibility, role fluidity, negotiation persistence, and artifact externalization 2 Understanding collaborative diagnostic learning in practice The findings of this study highlight that collaborative diagnostic learning does not unfold in a uniform or predictable manner, even within the same instructional design. Groups working on similar cases demonstrated markedly different patterns of engagement, suggesting that collaboration is not an automatic outcome of task structure but develops differently depending on how groups respond to uncertainty over time[ 22 , 25 ]. Rather than functioning solely as a barrier, diagnostic uncertainty appeared to act as a condition that shaped how groups organized their work, prompting some groups to close discussion quickly while enabling others to sustain interpretive engagement. This variability indicates that collaborative learning is not simply determined by curriculum design but is closely tied to how groups respond to uncertainty in practice[ 13 , 26 ]. These observations point to the importance of examining collaborative processes longitudinally. Understanding how engagement shifts over time may help explain why similar instructional environments produce different learning experiences and outcomes across groups[ 9 ]. 3 Designing for collaborative diagnostic learning The findings of this study suggest that simply organizing students into groups or assigning roles does not necessarily lead to sustained collaborative reasoning. Instead, how learning activities are structured and how students are supported in working with uncertainty appear to influence whether groups engage in shared interpretation[ 22 , 25 ]. From a design perspective, learning artifacts such as worksheets and mechanism diagrams may function more effectively when used as spaces for reasoning rather than solely as tools for reporting answers. Creating opportunities for students to externalize hypotheses, compare interpretations, and revisit assumptions may help sustain discussion rather than lead to premature closure[ 24 ]. Role organization also appears to shape collaborative engagement. While differentiated roles can support task efficiency, allowing flexibility in how students move across roles and share responsibility for interpretation may encourage more active participation in diagnostic reasoning[ 22 ]. In addition, how uncertainty is positioned within the learning task may influence collaborative engagement. When uncertainty is quickly resolved through instructor clarification or predefined solution pathways, opportunities for discussion may be reduced. Designing tasks that allow students to work with incomplete information and explore alternative explanations may help sustain interpretive engagement[ 19 – 20 , 24 ]. Taken together, these observations suggest that supporting collaborative diagnostic learning may depend less on adding new instructional components and more on how existing tasks, roles, artifacts, and uncertainty are used to support discussion and interpretation in practice. 4 Limitations and directions for future research Several limitations should be considered when interpreting the findings of this study. First, the transferability of the identified collaborative configurations may be constrained by the task-specific demands of molecular diagnostic learning. Clinical reasoning unfolds differently across medical specialties and learning environments[ 3 , 27 ], and future research is needed to examine whether similar patterns emerge in other domains of medical education where uncertainty plays a central role[ 28 ]. Second, this study is based on qualitative interpretation of collaborative processes and artifacts, which necessarily involves analytic inference[ 10 , 14 , 17 – 18 ]. Although multiple data sources were used to support credibility, the configurations identified here represent interpretive constructions rather than fixed categories. Future research may benefit from combining qualitative analysis with process-based learning analytics to more precisely trace how collaborative engagement develops over time[ 29 – 30 ]. Such approaches may help make interactional patterns more visible and support further investigation into how instructors and learners respond to uncertainty in collaborative diagnostic tasks. Finally, the findings are situated within a particular instructional context and cohort. While the aim was not statistical generalization, additional studies across diverse curricula, institutional settings, and learner populations would strengthen understanding of how collaborative diagnostic learning unfolds across contexts[ 9 ]. Taken together, these limitations highlight the need for further research that examines collaborative learning processes longitudinally and across varied educational settings, with attention to how uncertainty is experienced and managed within group diagnostic work. Conclusion This study examined how undergraduate biotechnology students collaboratively engaged with diagnostic uncertainty across a sequence of case-based molecular diagnostic tasks. The findings show that, rather than progressing linearly over time, groups shifted among three configurations—procedural containment, intermittent interpretive engagement, and collective interpretive engagement—depending on how uncertainty was recognized and addressed within collaborative work. The results indicate that, in this course setting, diagnostic uncertainty was not merely a challenge to be resolved, but an integral part of collaborative diagnostic learning that influences how students interpret evidence, negotiate explanations, and organize their work together. From a practical perspective, the study suggests that medical education can benefit from designing learning experiences that actively engage students with uncertainty. Structuring case sequences, instructional strategies, and assessments to sustain discussion and make reasoning visible may enhance opportunities for integrative diagnostic thinking, even if sustained collective engagement remains difficult to stabilize. Overall, these findings highlight the importance of treating uncertainty as a productive element of collaborative diagnostic learning rather than as a barrier to task completion. Declarations Ethics approval and consent to participate Ethical approval was obtained from the Teaching Ethics Committee of Guilin Medical University. The study was conducted in accordance with the Declaration of Helsinki. All participants provided informed consent for the use of their learning materials for research purposes. Participation in the study had no impact on students’ course grades or academic evaluation, and all data were anonymized prior to analysis. Consent for publication Not applicable Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This work was supported by the Guangxi Undergraduate Teaching Reform Project (A Category) (Grant number: 2025JGA308). Authors' contributions L.C. and Y.T. contributed equally to this work. 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Mapping educational uncertainty stimuli to support health professions learners’ uncertainty tolerance development: a qualitative study. Adv Health Sci Educ Theory Pract. 2025. 10.1007/s10459-024-10345-z . Ilgen JS, Dhaliwal G. Educational strategies to prepare trainees for clinical uncertainty. N Engl J Med. 2025;393(16):1624–32. 10.1056/NEJMra2408797 . Roschelle J, Teasley SD. The construction of shared knowledge in collaborative problem solving. In: O’Malley C, editor. Computer supported collaborative learning. Berlin: Springer; 1995. pp. 69–97. 10.1007/978-3-642-85098-1_5 . Puntambekar S, Stylianou A, Suthers D, Hundhausen C, Hübscher-Younger T. External representations for collaborative learning and assessment. In: Stahl G, editor. Computer support for collaborative learning: foundations for a CSCL community. Boulder (CO): Lawrence Erlbaum Associates; 2002. pp. 714–5. 10.3115/1658616.1658803 . Scardamalia M, Bereiter C. Knowledge building: theory, pedagogy, and technology. In: Sawyer RK, editor. The Cambridge handbook of the learning sciences. Cambridge: Cambridge University Press; 2006. pp. 97–118. 10.1017/CBO9781139519526.025 . Tracy SJ. Qualitative quality: eight big-tent criteria for excellent qualitative research. Qual Inq. 2010;16(10):837–51. 10.1177/1077800410383121 . Dillenbourg P. What do you mean by collaborative learning? In: Dillenbourg P, editor. Collaborative-learning: cognitive and computational approaches. Oxford: Elsevier; 1999. pp. 1–19. Stephens GC, Sarkar M, Lazarus MD. I was uncertain, but I was acting on it’: a longitudinal qualitative study of medical students’ responses to uncertainty. Med Educ. 2024;58(7):869–79. 10.1111/medu.15269 . Sarkis S, Raphael C. Understanding uncertainty and ambiguity in medicine and medical education: a narrative review with implications for training. Postgrad Med J. 2025;qgaf170. 10.1093/postmj/qgaf170 . Belhomme N, Robin F, Lescoat A, et al. Evolution of medical students’ tolerance for uncertainty throughout their curriculum: a systematic mixed studies review protocol. BMJ Open. 2025;15:e096117. 10.1136/bmjopen-2024-096117 . Dang B, Nguyen A, Järvelä S. Deliberative interactions for socially shared regulation in collaborative learning: an AI-driven learning analytics study. J Learn Anal. 2024;11(3):192–209. 10.18608/jla.2024.8393 . Villa-Torrano C, Suraworachet W, Gómez-Sánchez E, Asensio-Pérez JI, Bote-Lorenzo ML, Martínez-Monés A, Zhou Q, Cukurova M, Dimitriadis Y. Using learning design and learning analytics to promote, detect and support socially shared regulation of learning: a systematic literature review. Comput Educ. 2025;224:105261. 10.1016/j.compedu.2025.105261 . ·. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 07 May, 2026 Reviews received at journal 04 May, 2026 Reviewers agreed at journal 26 Apr, 2026 Reviews received at journal 23 Apr, 2026 Reviewers agreed at journal 07 Apr, 2026 Reviewers invited by journal 02 Apr, 2026 Editor assigned by journal 03 Mar, 2026 Submission checks completed at journal 02 Mar, 2026 First submitted to journal 02 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8966520\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":619058774,\"identity\":\"e710f40e-c457-40a1-b8db-8ed1275b0d7d\",\"order_by\":0,\"name\":\"Li Chen\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Guilin Medical University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Li\",\"middleName\":\"\",\"lastName\":\"Chen\",\"suffix\":\"\"},{\"id\":619058775,\"identity\":\"ced35446-38f0-440d-adc0-030b2da2bd50\",\"order_by\":1,\"name\":\"Yiming Tao\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Guilin Medical University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Yiming\",\"middleName\":\"\",\"lastName\":\"Tao\",\"suffix\":\"\"},{\"id\":619058776,\"identity\":\"f408ffd5-b09d-4117-b373-d38e1985926a\",\"order_by\":2,\"name\":\"Hua Zhu\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYBACNvbmAwcSKiTk5NkbGA+AhQ4Q0MLHcyzxwYczNsaGPQcYiNMiJ5FjbDizJS2R4UYCkVrYGBLMpHkbDicwznx+4dDNNgY5vhsJjJ8L8Go5kCbNu+NwHrt0TsHh3DYGY8kbCczSM/BpYWw4Js175nAx4+ycBJCWxA03EtiYefBpYWZsk+ZtO5zYcPMMWEs9YS1szMyGM9vSEhtusB8AaUkwIKiFh40RGsg5DIdzzkkYzjzzsFkanxb5+e8/QKPy+MPHOWU28nzHkw9+xqcFCfAYAAkJIGZsIE4DAwP7A2JVjoJRMApGwQgDAHxCVHQbKg/jAAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"Guilin Medical University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Hua\",\"middleName\":\"\",\"lastName\":\"Zhu\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-02-25 10:24:29\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-8966520/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-8966520/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":106534320,\"identity\":\"68c9d6eb-0ddf-42c9-aa61-44b984f06eef\",\"added_by\":\"auto\",\"created_at\":\"2026-04-09 15:03:12\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":261350,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eAn analytic framework of collaborative reconfiguration under diagnostic uncertainty.\\u003cbr\\u003e\\nDiagnostic uncertainty is presented as a practical condition shaping how collaboration was organized in case-based molecular diagnostic tasks. Three recurring configurations were identified—procedural containment, intermittent interpretive engagement, and collective interpretive engagement—each representing different ways of organizing reasoning, roles, and artifact use in response to uncertainty. Arrows indicate possible movement among configurations rather than a linear developmental progression. Outer elements represent interactional conditions observed in the analysis that appeared to enable or constrain collaborative engagement, including hypothesis visibility, role fluidity, negotiation persistence, and artifact externalization\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8966520/v1/e8dc94144b08438bd7187766.png\"},{\"id\":106726395,\"identity\":\"65b087a8-8ec2-4047-b22c-779443ec2ebf\",\"added_by\":\"auto\",\"created_at\":\"2026-04-12 18:36:01\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1335557,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8966520/v1/4d873c1a-f623-4c8d-9536-4457700d5367.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Collaborative engagement with diagnostic uncertainty across sequential molecular diagnostic cases: an interpretive thematic analysis\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eContemporary medical and biomedical education increasingly emphasizes preparing learners to engage with complex problems and collaborate effectively in uncertain and evolving professional contexts [\\u003cspan additionalcitationids=\\\"CR2\\\" citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. However, traditional content-centered instructional approaches often provide limited opportunities for students to experience how such processes unfold in practice, particularly in authentic problem-solving situations where knowledge and interpretations remain provisional [\\u003cspan additionalcitationids=\\\"CR5\\\" citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eIn response to these challenges, instructional approaches such as problem-based learning, inquiry-based learning, and gamified designs have been introduced to enhance student engagement and learning outcomes [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. Empirical studies have shown that such approaches can positively influence students\\u0026rsquo; motivation, participation, and perceived competence development [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. However, much of this literature remains outcome-oriented, focusing primarily on performance indicators, satisfaction measures, or self-reported gains [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. As a result, we still have limited insight into how collaborative learning processes unfold over time within these instructional environments [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eDespite growing interest in collaborative and inquiry-based learning in medical education, we know relatively little about how collaborative practices are reorganized when students encounter diagnostic uncertainty, particularly over successive learning tasks in authentic settings where evidence and interpretations remain provisional [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. The aim of this study is to examine how collaborative engagement with diagnostic uncertainty takes different forms and evolves over time in a case-based molecular diagnostics course.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStudy design and methodological approach\\u003c/h2\\u003e \\u003cp\\u003eThis study adopted an interpretive, process-oriented qualitative approach to examine how collaborative practices unfolded over time in an authentic educational setting[\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. Rather than seeking to evaluate instructional effectiveness or learning outcomes, the analysis focused on how learning-related practices were enacted, reorganized, and inferred from students\\u0026rsquo; documented collaborative artifacts and reflections as students engaged with increasing diagnostic uncertainty[\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. Data analysis followed an interpretive thematic approach to identify and compare patterns of collaborative work under diagnostic uncertainty across cases, without aiming to generate a formal theory[\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e].\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eEducational context and participants\\u003c/h3\\u003e\\n\\u003cp\\u003eThe study was conducted at a medical university in China within a Molecular Diagnostics elective course for undergraduate biotechnology students in their fourth semester. A total of 42 students participated and were organized into 12 small groups of three to four members. The course lasted five weeks. The same cohort of students and fixed group compositions were maintained throughout the course.\\u003c/p\\u003e \\u003cp\\u003eThe course was organized around a sequence of four case-based diagnostic tasks of increasing complexity[\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. In each task, students were required to propose diagnostic hypotheses, select molecular targets, design appropriate diagnostic strategies, and interpret results to reach a diagnostic conclusion. Each case lasted one week and engaged the same student groups in longitudinal collaborative work.\\u003c/p\\u003e \\u003cp\\u003eUncertainty was an inherent feature of the course design. As tasks progressed, students encountered increasingly incomplete information, alternative explanations, and multiple plausible diagnostic pathways\\u0026mdash;conditions aligned with established taxonomies and frameworks of medical uncertainty[\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. These conditions prompted students to revisit earlier assumptions, coordinate disciplinary knowledge, and discuss and revise their interpretations collaboratively over time.\\u003c/p\\u003e\\n\\u003ch3\\u003eData sources and analytic stance\\u003c/h3\\u003e\\n\\u003cp\\u003eThis study drew on multiple qualitative data sources collected across four sequential case-based diagnostic tasks to examine how collaborative engagement with diagnostic uncertainty unfolded over time[\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]. These sources included:\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003e(1)Group diagnostic worksheets completed through role-differentiated sections.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e(2)Mechanism-based diagrams linking molecular, protein, clinical, and diagnostic reasoning.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cp\\u003e(3)Within-group peer evaluation records following each case.\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003e(4)Individual reflective writings submitted after each case and at the end of the course.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cp\\u003eImportantly, these data sources served distinct analytic functions rather than being treated as parallel outcome measures. Diagnostic worksheets and mechanism maps were mandatory course artifacts generated under shared task constraints. In this study, they were not analyzed as indicators of performance quality or learning outcomes. Instead, they were used as material traces of diagnostic reasoning-in-practice, anchoring the analysis of when and how uncertainty emerged, was operationalized, and revised during collaborative work, particularly as evidential ambiguity increased in later cases.\\u003c/p\\u003e \\u003cp\\u003ePeer evaluation records provided complementary insight into the social positioning of interpretive contributions within groups, capturing how students recognized and attributed roles, influence, and responsibility as diagnostic challenges unfolded. These records were used to contextualize shifts in collaborative organization rather than to evaluate individual competence.\\u003c/p\\u003e \\u003cp\\u003eIndividual reflective writings constituted the primary analytic lens for examining engagement with diagnostic uncertainty. Rather than being treated as measures of reflective ability or learning gain, reflections were analyzed as sense-making accounts through which students articulated how they recognized uncertainty, acted upon it, and retrospectively interpreted their experiences within collaborative diagnostic practice. Variability in length, depth, and analytical detail was treated cautiously as analytically meaningful when aligned with evidence from artifacts and peer evaluations. Such alignment was used to interpret whether and how diagnostic uncertainty appeared as a salient object of reflection for different students and groups .\\u003c/p\\u003e \\u003cp\\u003eTaken together, this analytic stance foregrounded engagement with diagnostic uncertainty as a process enacted within collaborative practice and rendered visible through the interplay of material artifacts, social positioning, and reflective sense-making, rather than as an individual trait or an instructional outcome.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec6\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eData analysis\\u003c/h2\\u003e \\u003cp\\u003eData analysis proceeded iteratively and longitudinally, tracing how collaborative practices shifted in relation to diagnostic uncertainty across successive diagnostic tasks within teams[\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. A \\u0026lsquo;Focus Team\\u0026rsquo; was purposefully selected for in-depth longitudinal tracing because its trajectory across four cases was especially clear and information-rich. Rather than coding data solely by task or data type, the analysis attended to shifts in collaborative organization over time.\\u003c/p\\u003e \\u003cp\\u003eInitial coding identified patterns in how groups coordinated roles, articulated assumptions, and responded to uncertainty. We then conducted iterative comparisons(not grounded theory) across cases, teams, and data sources to examine how collaborative practices were sustained, modified, or disrupted as diagnostic challenges increased.\\u003c/p\\u003e \\u003cp\\u003eParticular analytic attention was given to episodes in which uncertainty prompted changes in collaborative activity, including the revisiting of hypotheses, renegotiation of roles, and collective questioning of prior interpretations. These moments were treated as key analytic sites for understanding how collaboration reorganized in response to diagnostic uncertainty.\\u003c/p\\u003e \\u003cp\\u003eBuilding on this longitudinal analysis, codes were clustered into provisional patterns and refined into analytic indicators used to identify configuration shifts over time. We then developed a set of analytic indicators to identify recurring configurations of collaborative engagement with diagnostic uncertainty. These indicators were iteratively derived from reflections, peer feedback, and collaborative artifacts, and were used to distinguish between procedural containment, intermittent interpretive engagement, and collective interpretive engagement (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThese configurations functioned as analytic heuristics rather than rigid classifications. They describe episodes of collaborative work and were not used to categorise groups as stable types or developmental stages. Instead, they enabled interpretation of collaborative episodes in relation to how uncertainty was positioned and negotiated, rather than as indicators of performance level[\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e].\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eTrustworthiness\\u003c/h3\\u003e\\n\\u003cp\\u003eTo enhance interpretive credibility, analytic decisions were documented through iterative memo writing, and emerging interpretations were discussed within the research team to examine alternative readings[\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e]. Throughout the analysis, the researchers repeatedly returned to the data to ensure that interpretations were grounded in participants\\u0026rsquo; accounts and learning artifacts. We also sought disconfirming instances to refine configuration boundaries and avoid overgeneralization[\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]. Interpretations were checked across reflections, peer evaluations, and artifacts to ensure that claims about shifts in collaboration were supported by more than one type of data trace.Given the first author\\u0026rsquo;s instructional role, reflexive memos documented how pedagogical assumptions might shape interpretation and were revisited during team discussions.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eEthical considerations\\u003c/h2\\u003e \\u003cp\\u003e The study was approved by the institutional teaching ethics committee. Informed consent was obtained from all participants prior to data collection. All materials were anonymized before analysis, and participation in the study had no impact on students\\u0026rsquo; course grades or academic evaluation.All group identifiers used in this manuscript are anonymized. Student-generated group names have been replaced with alphanumeric codes (Group A\\u0026ndash;L) to prevent indirect identification within the small cohort context. The \\u0026lsquo;Focus Team\\u0026rsquo; refers to a purposefully selected case for in-depth longitudinal analysis. This team was selected because its collaborative trajectory across the four cases was particularly clear and well-documented, providing an information-rich example for tracing how engagement with diagnostic uncertainty evolved over time within a single group. The label is assigned by the researchers for analytic clarity and does not correspond to any student-generated identity.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eAnalytic indicators used to identify collaborative configurations in engagement with diagnostic uncertainty\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAnalytic dimension\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eConfiguration 1 Procedural containment\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eConfiguration 2 Intermittent interpretive engagement\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eConfiguration 3 Collective interpretive engagement\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003ePosition of diagnostic uncertainty\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTreated as a gap to be resolved quickly in order to proceed with tasks\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eOccasionally surfaced as an interpretive problem, but not consistently sustained\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eTreated as a shared object of inquiry and maintained through collaborative reasoning\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eCollaborative organization of revision\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRevision occurred but remained embedded within task execution and role-bound workflow\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eRevision surfaced in group discussion but was not consistently sustained as a shared process\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eRevision became a shared, sustained collaborative process through which multiple explanations were collectively examined\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eDiagnostic pathways\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eDiagnostic explanations organized into a single dominant pathway\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eDiagnostic explanations occasionally expanded but ultimately reorganized into a primary pathway\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eMultiple explanatory pathways were maintained in parallel within shared interpretive work\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eRole of artifacts (worksheet/mechanism map)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUsed mainly to document or present finalized conclusions\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUsed for partial clarification and structuring, but not consistently as reasoning space\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFunctioned as a shared workspace where competing interpretations were externalized and negotiated\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eDistribution of interpretive responsibility\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRole-bound; members execute assigned tasks\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eResponsibility occasionally shifts across roles during discussion\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eResponsibility distributed; roles contribute complementary interpretive perspectives\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eOrientation toward closure\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eStrong drive toward diagnostic closure and task completion\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eAlternation between exploration and closure\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eTolerance of uncertainty; closure delayed until integrative understanding achieved\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eNature of collaboration\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTask coordination\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eTransitional / oscillating collaboration\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eCollective explanation-building\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eEmpirical grounding in this study\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eObserved across multiple groups and cases\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eObserved in several groups and cases, but unstable\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eObserved episodically in the Focus Team (Case 4 only); not stabilized across cases\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Result\",\"content\":\"\\u003cdiv id=\\\"Sec10\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eTheme 1 Longitudinal reconfiguration of collaborative engagement with diagnostic uncertainty in the Focus Team\\u003c/h2\\u003e \\u003cp\\u003eTheme 1 traces how collaborative engagement with diagnostic uncertainty changed across four consecutive diagnostic cases within the Focus Team. Rather than representing a linear progression, the analysis illustrates how different forms of collaboration emerged, receded, and interacted over time as the group encountered evolving diagnostic challenges.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eCase 1: Procedural containment of diagnostic uncertainty\\u003c/h2\\u003e \\u003cp\\u003eIn the first case, diagnostic uncertainty was largely absorbed into procedural task execution. Collaboration centered on organizing workflow, allocating roles, and completing required steps of the diagnostic process. Students focused on identifying appropriate methods and generating results, while uncertainty remained largely peripheral to collective interpretation.\\u003c/p\\u003e \\u003cp\\u003eReflective accounts indicated that challenges were framed primarily in terms of task clarity, technical understanding, and role coordination. Students reported difficulties such as \\u0026ldquo;not fully understanding the diagnostic mechanism,\\u0026rdquo; \\u0026ldquo;uncertainty about specific experimental steps,\\u0026rdquo; and \\u0026ldquo;reliance on AI explanations when knowledge was insufficient.\\u0026rdquo; These accounts suggest that uncertainty was acknowledged but treated as a gap to be resolved quickly in order to proceed.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eCase 2: Emergence of interpretive engagement\\u003c/h2\\u003e \\u003cp\\u003eIn the second case, diagnostic uncertainty began to surface more explicitly as an interpretive issue. Students occasionally proposed alternative explanations and revisited earlier assumptions, indicating a partial shift from purely procedural coordination toward exploratory reasoning. However, such engagement remained unstable and often gave way to task-oriented execution.\\u003c/p\\u003e \\u003cp\\u003eStudents described developing a more structured approach to diagnosis, such as \\u0026ldquo;starting from the core clinical question and then identifying molecular targets,\\u0026rdquo; and reported increasing communication within the group. Yet these interpretive moments were episodic and did not consistently reorganize collaborative work.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eCase 3: Technical resolution and workflow stabilization\\u003c/h2\\u003e \\u003cp\\u003eIn the third case, collaboration increasingly relied on technical clarification and confirmation as a way of managing uncertainty. Uncertainty was frequently addressed through selecting or refining diagnostic techniques, with emphasis placed on obtaining definitive results. Group interaction focused on method selection, data interpretation, and achieving diagnostic closure.\\u003c/p\\u003e \\u003cp\\u003eStudents highlighted the importance of \\u0026ldquo;choosing appropriate testing technologies\\u0026rdquo; and \\u0026ldquo;following a clear analytical sequence,\\u0026rdquo; suggesting that uncertainty was managed through technical decision-making rather than sustained collective interpretation. Collaboration remained active, but reasoning was structured primarily around procedural and technical progression.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eCase 4: Episodic collective interpretive engagement\\u003c/h2\\u003e \\u003cp\\u003eIn the fourth case, diagnostic uncertainty became a shared object of collaborative reasoning. Multiple explanatory pathways were considered and negotiated, and artifacts\\u0026mdash;particularly the mechanism diagram\\u0026mdash;functioned as a shared workspace for testing and revising hypotheses. Collaboration temporarily shifted from sequential task execution to recursive interpretation across clinical, cytogenetic, and molecular evidence.\\u003c/p\\u003e \\u003cp\\u003eStudents described beginning with preliminary diagnostic assumptions, then refining them through discussion and evidence comparison: \\u0026ldquo;We first analyzed possible conditions, identified candidate genes, and then decided on testing methods through group discussion.\\u0026rdquo; Peer feedback also emphasized the generation of alternative explanations, such as proposing chromosomal deletions or gene fusion events, which prompted further collective evaluation .\\u003c/p\\u003e \\u003cp\\u003eDespite this shift, collective interpretive engagement remained situational and did not stabilize as a consistent collaborative pattern. The group continued to oscillate between interpretive exploration and procedural closure, indicating that shared reasoning was achieved episodically rather than sustained across cases.\\u003c/p\\u003e \\u003cp\\u003eWhile Theme 1 presents a longitudinal analytic account of how collaborative engagement with diagnostic uncertainty unfolded within a single team, it does not imply a universal developmental trajectory. The reconfigurations observed in the Focus Team served as an analytic exemplar for examining whether similar patterns occurred across other groups.\\u003c/p\\u003e \\u003cp\\u003eTo address this, the analysis was extended across all student teams to explore how diagnostic uncertainty was taken up, interpreted, and organized in collaborative work beyond a single case trajectory. This cross-group examination aimed to identify recurring configurations of engagement and to assess the extent to which collective interpretive engagement emerged as a shared or stable pattern across teams .\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec15\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eTheme 2 Configurations of collaborative engagement with diagnostic uncertainty across groups\\u003c/h2\\u003e \\u003cp\\u003eBuilding on the process-oriented exemplar presented in Theme 1, this cross-group analysis examined whether and how configurations of engaging with diagnostic uncertainty were similarly enacted across the twelve student groups under a shared instructional design. Although all groups completed the same sequence of case-based diagnostic tasks and produced comparable required learning artifacts, they differed markedly in how diagnostic uncertainty was recognized, acted upon, and made sense of over time.While the instructional design created opportunities for engaging with diagnostic uncertainty, collective interpretive engagement emerged only rarely and did not stabilize as a common group-level pattern.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003e2.1 Overview: Variation in configurations of engaging with diagnostic uncertainty across groups and over time\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eAcross the 12 groups, three configurations were identified in how diagnostic uncertainty was taken up within collaborative work. These configurations differed in the extent to which uncertainty functioned as a shared object of inquiry and in how explanatory reasoning was distributed across members and artifacts.\\u003c/p\\u003e \\u003cp\\u003eConfiguration 1 and Configuration 2 appeared across multiple groups and cases, representing common ways in which uncertainty was procedurally managed or intermittently explored. By contrast, Configuration 3 was observed only once\\u0026mdash;within the Focus Team in Case 4\\u0026mdash;and was not observed as a recurring pattern elsewhere in the dataset. Rather than indicating a stable endpoint, this instance represents a locally achieved configuration in which uncertainty temporarily became a shared focus of collective epistemic work.\\u003c/p\\u003e \\u003cp\\u003eWhile moments of technical closure were frequently observed across groups, they were not treated as a distinct configuration. Instead, they functioned as a closure mechanism within procedural containment or as a pathway through which groups shifted from intermittent interpretive engagement back to procedural task execution. This distinction helped clarify the analytic boundary of the typology and ensured that configurations were defined by how uncertainty organized collaborative reasoning rather than by isolated technical problem-solving moves.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003e2.2 Configuration 1: Procedural containment of diagnostic uncertainty\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eIn this configuration, diagnostic uncertainty did not become a sustained object of collective interpretation but was largely contained within procedural task execution. Across cases, students remained actively engaged in completing required diagnostic steps, allocating roles, and producing mandated learning artifacts. However, uncertainty was rarely foregrounded as an epistemic problem requiring collective reconsideration of diagnostic assumptions.\\u003c/p\\u003e \\u003cp\\u003eReflective accounts consistently framed challenges in terms of task organization, role positioning, or procedural clarity rather than competing interpretations or evidential ambiguity. Students described their work as oriented toward identifying key problems and advancing diagnostic steps, for example:\\u0026ldquo;Starting from the core problem and then proceeding step by step toward a result.\\u0026rdquo;\\u0026ldquo;First identify the key issue, reach a preliminary molecular diagnosis, then select appropriate techniques and analyze the results.\\u0026rdquo;Such accounts indicate that uncertainty was acknowledged but quickly folded into task progression, rather than treated as an object for sustained interpretive engagement.\\u003c/p\\u003e \\u003cp\\u003eWhen difficulties arose, they were typically addressed through linear, task-oriented strategies aimed at restoring workflow continuity. Students emphasized coordination and completion of assigned steps, with limited reference to revisiting diagnostic assumptions or comparing alternative explanations. Even when discussion occurred, it was oriented toward advancing procedures rather than maintaining uncertainty as a shared problem.\\u003c/p\\u003e \\u003cp\\u003eMaterial learning artifacts further supported this pattern. Worksheets and mechanism diagrams primarily documented established diagnostic pathways rather than preserving multiple explanatory structures. As one student noted:\\u0026rdquo; I completed parts of the mechanism diagram\\u0026rdquo;Here, the artifact functioned primarily as a product of task completion rather than a shared space for negotiating competing interpretations.\\u003c/p\\u003e \\u003cp\\u003eAcross successive cases, mechanism diagrams and worksheets tended to converge toward a single dominant mechanistic pathway. Additional molecular, technical, or clinical elements were sometimes incorporated, but these elements typically reinforced an existing explanatory structure rather than reorganizing diagnostic reasoning. As a result, uncertainty was subsumed into procedural completion rather than retained as an open explanatory problem.\\u003c/p\\u003e \\u003cp\\u003eTaken together, this configuration represents a mode of engaging with diagnostic uncertainty in which collaboration supported task execution and coordination, but uncertainty did not become a shared epistemic object for collective explanation-building.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003e2.3 Configuration 2 : Intermittent interpretive engagement with diagnostic uncertainty\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eIn this configuration, diagnostic uncertainty intermittently surfaced as an object of interpretive attention but did not become a sustained or organizing feature of collaborative practice. Groups displaying this pattern occasionally articulated uncertainty, proposed alternative explanations, or engaged in exploratory discussion when encountering complex diagnostic decisions or unexpected data. Reflective accounts sometimes highlighted moments in which multiple possibilities were raised during collaborative work, for example when students \\u0026ldquo;proposed more possibilities during group discussions and attempted alternative technical approaches.\\u0026rdquo;\\u003c/p\\u003e \\u003cp\\u003eHowever, such interpretive engagement remained episodic and fragile. Moments of shared exploration were typically followed by a return to role-bound task execution or procedural problem-solving aimed at restoring workflow continuity. Students often described approaching diagnostic tasks by \\u0026ldquo;first identifying the core problem, then searching for relevant experimental principles, and finally selecting an appropriate technique,\\u0026rdquo; indicating a re-alignment with structured task progression rather than sustained interpretive negotiation.\\u003c/p\\u003e \\u003cp\\u003eRequired learning artifacts reflected this instability. Although additional molecular, technical, or clinical elements were occasionally incorporated into worksheets or mechanism-based diagrams, these representations ultimately converged toward a single dominant mechanistic pathway. Alternative explanations were rarely retained over time; instead, groups described narrowing their focus, noting that \\u0026ldquo;after searching for information, we continued working around a single diagnostic direction.\\u0026rdquo;\\u003c/p\\u003e \\u003cp\\u003ePeer evaluation records further indicated that collaboration in this configuration was primarily oriented toward task support, information sharing, and role fulfillment, with comparatively limited emphasis on collectively interrogating diagnostic assumptions or sustaining multiple diagnostic explanations over time.\\u003c/p\\u003e \\u003cp\\u003eTaken together, Configuration 2 represents a mode of engaging with diagnostic uncertainty situated between procedural containment and sustained collective engagement. While uncertainty entered collaborative discourse, it remained episodic and did not reorganize the epistemic structure of collaborative work toward sustained collective explanation-building.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003e2.4 Configuration 3: Collective interpretive engagement with diagnostic uncertainty\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eIn this configuration, diagnostic uncertainty functioned as an organizing epistemic object structuring collaborative reasoning and was actively sustained within group interaction. Rather than being treated as a gap to be closed, uncertainty functioned as a productive focus for explanation-building, prompting members to revisit assumptions, compare alternative interpretations, and negotiate diagnostic meaning collectively.\\u003c/p\\u003e \\u003cp\\u003eReasoning in this configuration was recursive and integrative, moving across clinical information, cytogenetic findings, and molecular evidence. Multiple explanatory pathways were considered in parallel, and artifacts\\u0026mdash;particularly the mechanism diagram\\u0026mdash;functioned as shared epistemic workspaces where hypotheses were externalized, examined, and revised. Responsibility for interpretation was distributed across members, with roles contributing complementary epistemic perspectives rather than operating as fixed task assignments.\\u003c/p\\u003e \\u003cp\\u003eThis configuration was observed empirically in the Focus Team during Case 4, where students described beginning with tentative diagnostic assumptions and refining them through iterative discussion and evidence comparison:\\u0026ldquo;We first analyzed possible conditions, identified candidate genes, and then decided on testing methods through group discussion.\\u0026rdquo;\\u003c/p\\u003e \\u003cp\\u003eImportantly, this form of engagement did not stabilize as a recurring collaborative pattern. Although collective reasoning was temporarily sustained, the group continued to shift between interpretive exploration and procedural closure across phases of the task. Collective interpretive engagement therefore appeared as a situationally achieved configuration rather than a durable mode of collaboration across cases or groups.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003e2.5 Theme-level synthesis: Bounded variation and rare stabilization of collective interpretive engagement\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eTaken together, the cross-case and cross-group analyses indicate that collaborative engagement with diagnostic uncertainty did not follow a linear developmental progression. Instead, groups moved among distinct configurations characterized by different orientations toward uncertainty, reasoning practices, and uses of artifacts and roles. While procedural containment and intermittent interpretive engagement were commonly observed across groups and cases, collective interpretive engagement appeared only episodically and did not stabilize as a persistent collaborative pattern.\\u003c/p\\u003e \\u003cp\\u003eThese patterns suggest variability in how collaborative participation and interpretation were organized over time.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003e \\u003cb\\u003e1 Reconfiguring collaboration under diagnostic uncertainty\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eThis study examined how student groups engaged with diagnostic uncertainty across a sequence of case-based molecular diagnostic tasks and identified three recurring configurations of collaborative practice: procedural containment, intermittent interpretive engagement, and collective interpretive engagement. Rather than following a linear progression from novice to expert collaboration, groups moved unevenly across these configurations over time, with uncertainty sometimes being absorbed into task completion and at other times becoming a shared focus of explanation-building. Sustained collective interpretive engagement appeared only episodically and did not stabilize as a common pattern across groups or cases. Rather than functioning primarily as a problem to be resolved, diagnostic uncertainty acted as a practical organizing condition that shaped how collaboration and interpretation unfolded within group diagnostic work [\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eAcross groups, shifts in collaborative configurations were closely associated with how responsibility for interpretation was organized within the group[\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e]. When diagnostic reasoning remained tightly bound to predefined roles, collaboration tended to prioritize task progression and procedural completion, and uncertainty was rapidly contained. In contrast, when responsibility for interpretation became shared and negotiable, groups were more likely to revisit assumptions, compare alternative explanations, and sustain collective reasoning.\\u003c/p\\u003e \\u003cp\\u003eArtifact use further mediated how these collaborative configurations unfolded[\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e]. When worksheets and mechanism diagrams were treated primarily as reporting tools, they supported linear task execution and reinforced a single dominant diagnostic explanatory pathway. However, when artifacts functioned as shared reasoning spaces\\u0026mdash;where hypotheses were externalized, compared, and revised\\u0026mdash;they enabled members to sustain multiple explanatory possibilities for longer periods.\\u003c/p\\u003e \\u003cp\\u003eWithin this process, diagnostic uncertainty was interpreted in our analysis as becoming salient through how collaboration was organized and mediated. Uncertainty was more likely to be retained and explored collectively when interpretive responsibility was distributed and supported by shared artifacts, and more likely to be closed when collaboration remained role-bound and artifacts were used primarily for documentation rather than for reasoning [\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eBuilding on these findings, we present an analytic framework derived from the observed patterns to illustrate how diagnostic uncertainty shaped collaborative reconfiguration (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). The framework highlights how different configurations of engagement emerged and shifted depending on how uncertainty was recognized, externalized, and negotiated within group activity.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eDiagnostic uncertainty is presented as a practical condition shaping how collaboration was organized in case-based molecular diagnostic tasks. Three recurring configurations were identified\\u0026mdash;procedural containment, intermittent interpretive engagement, and collective interpretive engagement\\u0026mdash;each representing different ways of organizing reasoning, roles, and artifact use in response to uncertainty. Arrows indicate possible movement among configurations rather than a linear developmental progression. Outer elements represent interactional conditions observed in the analysis that appeared to enable or constrain collaborative engagement, including hypothesis visibility, role fluidity, negotiation persistence, and artifact externalization\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003e2 Understanding collaborative diagnostic learning in practice\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe findings of this study highlight that collaborative diagnostic learning does not unfold in a uniform or predictable manner, even within the same instructional design. Groups working on similar cases demonstrated markedly different patterns of engagement, suggesting that collaboration is not an automatic outcome of task structure but develops differently depending on how groups respond to uncertainty over time[\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eRather than functioning solely as a barrier, diagnostic uncertainty appeared to act as a condition that shaped how groups organized their work, prompting some groups to close discussion quickly while enabling others to sustain interpretive engagement. This variability indicates that collaborative learning is not simply determined by curriculum design but is closely tied to how groups respond to uncertainty in practice[\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThese observations point to the importance of examining collaborative processes longitudinally. Understanding how engagement shifts over time may help explain why similar instructional environments produce different learning experiences and outcomes across groups[\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003e3 Designing for collaborative diagnostic learning\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe findings of this study suggest that simply organizing students into groups or assigning roles does not necessarily lead to sustained collaborative reasoning. Instead, how learning activities are structured and how students are supported in working with uncertainty appear to influence whether groups engage in shared interpretation[\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eFrom a design perspective, learning artifacts such as worksheets and mechanism diagrams may function more effectively when used as spaces for reasoning rather than solely as tools for reporting answers. Creating opportunities for students to externalize hypotheses, compare interpretations, and revisit assumptions may help sustain discussion rather than lead to premature closure[\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eRole organization also appears to shape collaborative engagement. While differentiated roles can support task efficiency, allowing flexibility in how students move across roles and share responsibility for interpretation may encourage more active participation in diagnostic reasoning[\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eIn addition, how uncertainty is positioned within the learning task may influence collaborative engagement. When uncertainty is quickly resolved through instructor clarification or predefined solution pathways, opportunities for discussion may be reduced. Designing tasks that allow students to work with incomplete information and explore alternative explanations may help sustain interpretive engagement[\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eTaken together, these observations suggest that supporting collaborative diagnostic learning may depend less on adding new instructional components and more on how existing tasks, roles, artifacts, and uncertainty are used to support discussion and interpretation in practice.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003e4 Limitations and directions for future research\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eSeveral limitations should be considered when interpreting the findings of this study. First, the transferability of the identified collaborative configurations may be constrained by the task-specific demands of molecular diagnostic learning. Clinical reasoning unfolds differently across medical specialties and learning environments[\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e], and future research is needed to examine whether similar patterns emerge in other domains of medical education where uncertainty plays a central role[\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eSecond, this study is based on qualitative interpretation of collaborative processes and artifacts, which necessarily involves analytic inference[\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]. Although multiple data sources were used to support credibility, the configurations identified here represent interpretive constructions rather than fixed categories. Future research may benefit from combining qualitative analysis with process-based learning analytics to more precisely trace how collaborative engagement develops over time[\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e]. Such approaches may help make interactional patterns more visible and support further investigation into how instructors and learners respond to uncertainty in collaborative diagnostic tasks.\\u003c/p\\u003e \\u003cp\\u003eFinally, the findings are situated within a particular instructional context and cohort. While the aim was not statistical generalization, additional studies across diverse curricula, institutional settings, and learner populations would strengthen understanding of how collaborative diagnostic learning unfolds across contexts[\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eTaken together, these limitations highlight the need for further research that examines collaborative learning processes longitudinally and across varied educational settings, with attention to how uncertainty is experienced and managed within group diagnostic work.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eThis study examined how undergraduate biotechnology students collaboratively engaged with diagnostic uncertainty across a sequence of case-based molecular diagnostic tasks. The findings show that, rather than progressing linearly over time, groups shifted among three configurations\\u0026mdash;procedural containment, intermittent interpretive engagement, and collective interpretive engagement\\u0026mdash;depending on how uncertainty was recognized and addressed within collaborative work.\\u003c/p\\u003e \\u003cp\\u003eThe results indicate that, in this course setting, diagnostic uncertainty was not merely a challenge to be resolved, but an integral part of collaborative diagnostic learning that influences how students interpret evidence, negotiate explanations, and organize their work together.\\u003c/p\\u003e \\u003cp\\u003eFrom a practical perspective, the study suggests that medical education can benefit from designing learning experiences that actively engage students with uncertainty. Structuring case sequences, instructional strategies, and assessments to sustain discussion and make reasoning visible may enhance opportunities for integrative diagnostic thinking, even if sustained collective engagement remains difficult to stabilize.\\u003c/p\\u003e \\u003cp\\u003eOverall, these findings highlight the importance of treating uncertainty as a productive element of collaborative diagnostic learning rather than as a barrier to task completion.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003eEthics approval and consent to participate\\u003c/p\\u003e\\n\\u003cp\\u003eEthical approval was obtained from the Teaching Ethics Committee of Guilin Medical University. The study was conducted in accordance with the Declaration of Helsinki. All participants provided informed consent for the use of their learning materials for research purposes. Participation in the study had no impact on students\\u0026rsquo; course grades or academic evaluation, and all data were anonymized prior to analysis.\\u003c/p\\u003e\\n\\u003cp\\u003eConsent for publication\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable\\u003c/p\\u003e\\n\\u003cp\\u003eAvailability of data and materials\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003eCompeting interests\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they have no competing interests.\\u003c/p\\u003e\\n\\u003cp\\u003eFunding\\u003c/p\\u003e\\n\\u003cp\\u003eThis work was supported by the Guangxi Undergraduate Teaching Reform Project (A Category) (Grant number: 2025JGA308).\\u003c/p\\u003e\\n\\u003cp\\u003eAuthors\\u0026apos; contributions\\u003c/p\\u003e\\n\\u003cp\\u003eL.C. and Y.T. contributed equally to this work. L.C. and Y.T. participated in the research and performed data analysis. H.Z. conceived the study, conducted the experiments, and wrote the initial draft of the manuscript. All authors reviewed and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003eAcknowledgements\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors thank the teaching team and participating students for their engagement in the case-based molecular diagnostics course.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eFrenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. 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Comput Educ. 2025;224:105261. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1016/j.compedu.2025.105261\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.compedu.2025.105261\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e\\u0026amp;#183.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-medical-education\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"meed\",\"sideBox\":\"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/meed/default.aspx\",\"title\":\"BMC Medical Education\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Diagnostic uncertainty, Collaborative learning, Qualitative research, Thematic analysis, Medical education, Collaborative reasoning\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8966520/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8966520/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eIntroduction\\u003c/h2\\u003e \\u003cp\\u003ePreparing health professions students to work collaboratively under conditions of diagnostic uncertainty is an important goal in contemporary medical education. While problem-based and inquiry-based approaches are widely used, less is known about how collaborative practices unfold over time when students encounter uncertainty in authentic diagnostic tasks. This study examined how collaborative engagement with diagnostic uncertainty developed across a sequence of case-based molecular diagnostic activities.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eAn interpretive qualitative study was conducted within a five-week molecular diagnostics elective for undergraduate biotechnology students (n\\u0026thinsp;=\\u0026thinsp;42) at a medical university in China. Students worked in fixed small groups across four progressively complex diagnostic cases. Data included group diagnostic worksheets, mechanism-based diagrams, peer evaluation records, and individual reflective writings collected longitudinally. Data were analyzed using an interpretive thematic approach to identify patterns in how collaboration was organized in response to diagnostic uncertainty over time.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eThree recurring configurations of collaborative engagement with diagnostic uncertainty were identified: procedural containment, intermittent interpretive engagement, and collective interpretive engagement. Groups shifted among these configurations rather than progressing linearly. Procedural containment and intermittent interpretive engagement were commonly observed across groups and cases, whereas collective interpretive engagement appeared only episodically and did not stabilize as a sustained collaborative pattern. Changes in how interpretive responsibility was distributed and how artifacts were used as shared reasoning spaces appeared to shape these shifts.\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e \\u003cp\\u003eCollaborative diagnostic learning under uncertainty does not develop uniformly, even within the same instructional design. Rather, engagement fluctuates depending on how uncertainty is recognized, negotiated, and supported within group activity. Designing learning environments that position uncertainty as a shared object of inquiry and support the use of artifacts for collective reasoning may help sustain collaborative interpretation in diagnostic learning.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Collaborative engagement with diagnostic uncertainty across sequential molecular diagnostic cases: an interpretive thematic analysis\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-04-09 15:03:08\",\"doi\":\"10.21203/rs.3.rs-8966520/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-05-07T10:09:28+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-05-04T20:42:02+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"2565642082415184146866846262839426057\",\"date\":\"2026-04-26T16:20:04+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-04-23T18:24:43+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"302638707374890509255225133868649242548\",\"date\":\"2026-04-07T15:01:17+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-04-02T13:23:38+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-03-03T08:29:35+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-03-02T21:35:17+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Medical Education\",\"date\":\"2026-03-02T13:36:06+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-medical-education\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"meed\",\"sideBox\":\"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/meed/default.aspx\",\"title\":\"BMC Medical Education\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"0585ff70-9397-466f-b519-aa292e0e3c92\",\"owner\":[],\"postedDate\":\"April 9th, 2026\",\"published\":true,\"recentEditorialEvents\":[{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-05-07T10:09:28+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-05-04T20:42:02+00:00\",\"index\":60,\"fulltext\":\"\"}],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"in-revision\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-05-07T10:26:58+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-04-09 15:03:08\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8966520\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8966520\",\"identity\":\"rs-8966520\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}