The differential count of diagnostic expertise: A phenomenological study into complexity and its implications for medical education

The differential count of diagnostic expertise: A phenomenological study into complexity and its implications for medical education | 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 The differential count of diagnostic expertise: A phenomenological study into complexity and its implications for medical education Camillo Coccia, Karen Garvey, Jessica Andras, Megan EL Brown This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7886684/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Diagnostic practice across clinical specialties has become increasingly complex as clinicians integrate descriptive observations, imaging, and molecular data within technologically advanced and collaborative environments. These changes demand an increasing variety of skills that extend beyond traditional models of technical competence. Yet postgraduate medical education has been slow to adapt, continuing to prioritise standardised assessments and procedural knowledge. Haematology provides a salient case: diagnostic reasoning here requires the synthesis of morphological, immunophenotypic, cytogenetic, and molecular information into a coherent clinical interpretation within the context of a diagnostic field that is growing rapidly. This study explores how experienced haematologists make sense of diagnostic complexity and how their insights might inform postgraduate education. Methods An interpretivist–constructivist qualitative design was employed using Interpretative Phenomenological Analysis (IPA). Five consultant haematologists from centres in Ireland, the United Kingdom, France, and the Netherlands participated in semi-structured online interviews (60–90 minutes). Participants were purposively and snowball-sampled through professional networks. Sample size was guided by Malterud’s concept of informational power, recognising that a focused research question and high participant expertise permit rich analysis from a small cohort. Interviews were transcribed verbatim and analysed iteratively to identify experiential themes, with ongoing reflexive dialogue between a clinician-researcher and a medical-education researcher. Ethical approval was granted by the St Vincent’s University Hospital Ethics Board (RS25-007). Results Three interrelated themes were identified: Diagnosis as a lived, integrative act : diagnostic reasoning was experienced as embodied, iterative, and relational, involving perceptual synthesis across modalities and negotiation between structured systems and tacit judgement. Judgement, trust, and the weight of knowing : diagnosis carried ethical and emotional dimensions; clinicians cultivated trust through openness about uncertainty and recognised subjectivity as intrinsic to expertise. Reconfiguring expertise in the age of genomics and AI : participants described adapting to computational and genomic innovations while maintaining a human, interpretive stance toward diagnostic meaning. Conclusions Experienced haematologists conceptualise diagnosis not as a technical algorithm but as an interpretive practice grounded in embodied perception, ethical awareness, and epistemic humility. Postgraduate training should therefore include reflective spaces that legitimise uncertainty, encourage collaborative reasoning, and foster the narrative and integrative capacities required for modern diagnostic work. Introduction Across many clinical specialties, diagnostic practice is becoming increasingly complex (Arber et al., 2024 ). Clinicians must interpret diverse forms of data, ranging from descriptive observations to binary molecular outputs, and make decisions in environments that are technologically advanced, highly collaborative, and often uncertain (Bauer et al., 2020 ). This shift has introduced new cognitive and communicative demands that extend beyond traditional notions of clinical expertise (Xu et al. 2021 ). Yet, despite these developments, postgraduate medical education has not fully kept pace. Contemporary teaching often focuses on technical competence and testable knowledge, prioritising standardised assessments over contextual, interpretative and relational skills. As a result, current diagnostic education tends to emphasise the mastery of discrete procedures and protocols, rather than the nuanced reasoning required in clinical practice ((Heiberg Engel, 2008 ; Gilkes et al., 2022 ). This risks producing clinicians who are technically proficient but underprepared for the uncertainty, integration, and interpersonal dynamics of modern diagnostic work. Teaching within this complex environment is, therefore, challenging. As diagnostic modalities multiply and data sources diversify, educators must support learners to develop both multimodal fluency and the capacity to synthesise, contextualise, and communicate evolving evidence (Arber et al., 2024 ; Xu et al., 2021 ). The complexity of diagnostic education is not solely due to information overload but also stems from the epistemic and ethical challenges of integrating partial, probabilistic, and sometimes conflicting forms of knowledge (Tsai & Harasym, 2010 ; Eastwood et al., 2017 ). Several scholars have argued that diagnostic learning must be reframed to reflect the interpretive nature of diagnostic reasoning and to legitimise the affective and subjective dimensions of knowing in medicine (Pallagrosi et al., 2016 ; Bauer et al., 2020 ). Despite accelerating academic discussion on the importance of reorientating diagnostic education, there seems to have been little practical progress in achieving this goal. We believe this is a result of multiple, interrelated factors, including: the enduring dominance of biomedical models that privilege objectivity and certainty; the structural constraints of curricula that reward speed and accuracy over reflection and dialogue; and a lack of empirical insight into how experienced diagnosticians actually make sense of complexity in real-world practice. In this work, we focus on advancing empirical insight, as, without a grounded understanding of how senior clinicians navigate uncertainty, ambiguity, and interpretive judgement in their diagnostic work, educational reform risks remaining abstract and disconnected from the realities it seeks to address. This study therefore explores the lived experiences of experienced haematologists as they engage in diagnostic reasoning, aiming to further understanding into how expertise is constructed, felt, and enacted within a high-stakes, multimodal diagnostic environment. We treat diagnostic haematology as a case study within this research. Haematology is a branch of medicine that manages a broad range of benign and malignant conditions (Beck, 2008 ). The growing complexity of diagnostic haematology arises from the need to combine descriptive diagnostic methods (like morphology – the practice of reporting the appearance of cells and how they behave with chemical stains under the microscope; and flow cytometry – which uses cell surface proteins to identify groups of cells and classifies them according to abundance and distinct combinations of proteins) with newer, more categorical techniques, such as molecular genetics (which produces more binary outputs, i.e., indicates the presence or absence of a mutation relevant to a specific disease), into a single, coherent diagnostic epithet (Brereton et al., 2015 ; Cree, 2022 ; Arber et al., 2024 ). While in practice the difference in the data produced by these techniques is not absolutely distinct, it has been divided this way by the authors according to the dominant form of reporting. While this study focuses on haematology, the challenges described here – navigating uncertainty, reasoning across diverse data types, and working collaboratively within diagnostic teams – are relevant to postgraduate training across a range of specialties. As diagnostic technologies continue to advance, the ability to make sense of integrated information in real-world clinical contexts will be an increasingly important part of medical education more broadly. Hence, through qualitative interviews with experienced haematologists, this study investigates how clinicians engage with the complexity of integrated diagnostics and considers how these insights might inform postgraduate education in similarly complex fields. Methods Study paradigm Although our analysis followed the idiographic principles of Interpretative Phenomenological Analysis (IPA), it was informed by the broader interpretivist ethos articulated by Braun and Clarke (Braun & Clarke, 2006 ), which focusses on researcher reflexivity and the active co-construction of meaning withiin the process of qualitative analysis. Study approach We adopted an interpretative, phenomenological orientation to this qualitative research (Biggerstaff D et al.; 2008), attending closely to the lived experiences of experienced haematologists as they engage in diagnostic practice. We understand knowledge as arising through situated, embodied, and socially mediated experience (Neubauer et al., 2019 ). Our concern was not only with what clinicians do, but with how they make sense of what they do. In other words, how meaning is generated through the act of diagnosis, especially under conditions of uncertainty and complexity. We sought to surface the often tacit, intuitive, and affective dimensions of diagnostic work, as well as the ways in which practitioners articulate their understandings in retrospect. This orientation enabled us to explore the interpretative and interpersonal dynamics that shape how diagnostic expertise is enacted, and how this may be made visible for educational purposes. Study design We used a qualitative, interpretative phenomenological design, conducting semi-structured interviews to explore the lived experience of diagnostic reasoning among experienced haematologists. Participants were invited to reflect on how they navigate and integrate diverse forms of diagnostic data (including morphology, karyotyping, immunophenotyping, and genomic information) in the context of real clinical cases. The interviews were designed to elicit rich, situated accounts of how diagnostic sense-making unfolds over time and within particular clinical contexts. Our analysis was guided by interpretative phenomenological analysis (IPA) (Smith, Larkin, Flowers 2021; Pietkiewicz and Smith, 2014), allowing us to attend both to the experiential textures of participants' accounts and to the broader implications for how diagnostic reasoning might be taught and supported in haematology education. Participants Five Consultants in Diagnostic Haematology across various European sites (France, the United Kingdom, Ireland, the Netherlands) were purposively sampled. (Tindall, 2009) Sampling was based on their exposure to diagnostic haematology through its recent developments. Participants were identified via professional networks of Haematologists by references from interviewees and were recruited via email. Recruitment was difficult, as participation in the study required 60–90 minutes busy clinicians’ time, although we recruited an adequate sample size for phenomenological study. The small sample was also driven by Malteraud et al’s (Malterud et al., 2016 ) concept of informational power, where asking a tightly focused research question, of expert participants, means fewer participants are required to achieve a rich analytic dataset. This study drew on a small number of in-depth, semi-structured interviews, consistent with an interpretative phenomenological approach. Our intention was to cultivate richly textured, idiographic accounts that illuminate how experienced haematologists make sense of their diagnostic practice. In line with phenomenological principles, we focused on the particular rather than the generalisable, attending closely to how meaning is constructed through participants’ reflections on their lived experience. The sample size reflects both the depth of interpretative engagement required by IPA and the rarity of the participant role: senior consultants with sustained, multimodal diagnostic responsibility across large European haematology centres. By working intensively with a small, purposively selected group, we were able to explore the nuanced and often tacit dimensions of diagnostic reasoning and consider their implications for educational practice. Data collection Participants took part in one-to-one semi-structured interviews with an average duration of 70 minutes online via Zoom or Teams (as per interviewee preference), between March and April 2025. Written, informed consent was gathered from all participants. The team drafted the interview questions based on their familiarity with haematology as a speciality, and with surrounding educational literature related to complexity, and diagnostic reasoning. Interview question stems are available (see Supplemental information). Data analysis Data were analysed using interpretative phenomenological analysis (IPA), a qualitative approach that seeks to explore in depth how individuals make sense of their lived experiences (Smith, Larkin, Flowers 2021). Interviews were transcribed verbatim by the lead author (CC), who also led the analysis, working with MB, JA and KG. Following IPA’s idiographic commitment, each transcript was analysed individually before moving to a more integrative cross-case analysis. The analytic process involved several iterative stages. First, the lead author engaged in immersive reading of each transcript, noting initial observations, emotional tone, and language which stood out as prominent or important. This was followed by detailed, line-by-line coding to identify experiential claims, metaphors, and meaning-making processes. Emergent themes were then developed for each case, capturing both the content and the interpretative layers of participants’ accounts. These themes were subsequently clustered into higher-order concepts that reflected shared patterns across cases while retaining sensitivity to individual variation. Throughout the process, we attended closely to the double hermeneutic that characterises IPA (Neubauer, 2019): participants are making sense of their experience, and the researcher, in turn, is making sense of that sense-making. Regular analytic discussions and memo-making between CC and a second researcher (MB) supported reflexivity and rigour, helping to surface taken-for-granted assumptions and alternative interpretations. We were particularly attentive to the language participants used to describe diagnostic reasoning, integration of modalities, and the emotional contours of uncertainty and team-based decision-making. Manual coding and theme development were conducted using Microsoft Word, and Microsoft Excel. Full ethical approval was granted by the St Vincent's Hospital board of ethics (RS25-007). Reflexivity This study was led by a resident haematologist (CC), whose clinical experience and familiarity with diagnostic practice informed both the development of the interview schedule and the interpretation of participant accounts. His position within the specialty provided access to the tacit dimensions of diagnostic reasoning and enabled a grounded understanding of the practical realities participants described. At the same time, the analysis was conducted in dialogue with a medical education researcher (MB) outside the field of haematology, whose external perspective supported a critical and pedagogical reading of the data. This combination of insider insight and educational distance allowed the team to interrogate both the technical and epistemic dimensions of integrated diagnostics, while maintaining a strong focus on their implications for postgraduate learning and teaching. Results Through in-depth, idiographic analysis of participant accounts, we developed three interrelated themes capturing how experienced haematologists make sense of their diagnostic practice. These themes reflect not only what clinicians do, but how they understand, navigate, and articulate their diagnostic roles, often in conditions of uncertainty, interpretive complexity, and within an evolving professional terrain. Quotes are labelled throughout the results with participant numbers. Diagnosis as a lived, integrative act For participants, diagnostic reasoning was experienced not as a linear algorithm, but as an embodied, integrative act: one that unfolds through memory, comparison, pattern recognition, and dialogue. Diagnosis was described as a way of seeing and making meaning across multiple modalities (e.g., cytology, molecular genetics, flow cytometry) each offering a partial view that has to be held in tension with the others. “I might say: ‘I see a hypocellular marrow. I miss red cells. I only see white cells and megakaryocytes, and they are a bit dysplastic.’ Then, I make a conclusion. I still do it, perhaps in an old-fashioned way.” (P4) The process of integration was shaped by professional history. Some participants referred to their former clinical training as shaping how they now interpret laboratory results. Clinicians experience a lasting clinical gaze that not only orients their laboratory work and judgment but also garners a sense of diagnostic urgency. Others noted how visual memory, developed over decades, enabled rapid diagnostic impressions that were often difficult to articulate but deeply known by the diagnostician when seen. “So that's how the story starts because there is a lot of psychology. When you analyse a sample, you see a cell, then you say, “Oh, okay. It reminds me of a such disease”.” (P1) Participants highlighted the interpretive, context-sensitive nature of diagnosis, especially in cytology, where visual artefacts, slide quality, and limited experience could easily lead to misinterpretation. They described how novice diagnosticians had to develop diagnostic “seeing” over time, likening their early attempts to the clinical missteps of junior medical students identifying splenomegaly. “It's almost like... it's a clinical appearance in the same way that, you know, a student comes in and says, oh, there's no splenomegaly... There is a splenomegaly... someone poorly trained in cytology like myself... would say, oh, these look like blasts... because of the way the slide has been laid out or... just streaks of cells.” (P3) Teaching this form of expertise was experienced as challenging. Participants reflected on how structured reporting systems support standardisation, clarity, and auditability – offering clear scaffolding for both experienced and novice diagnosticians. For some, templates served as cognitive prompts, helping mitigate fatigue-related oversight and reinforcing consistency across subjective domains such as cytology. As one participant (P2) noted, structured formats “ help with training and consistency,” ensuring that key features are not missed and that trainees learn to distinguish what is and is not diagnostically significant. At the same time, several participants also described moments where the structure imposed by templates risked flattening nuance or occluding the reasoning behind decisions. In these accounts, the experiential and embodied knowledge that informs integrative diagnosis – what several participants referred to as the “why” behind decisions – could be difficult to capture in rigid categories or single-label outputs. This tension between structured clarity and tacit complexity was not framed as oppositional, but as something to be negotiated in practice. For many, structured systems were not barriers, per se, to meaning-making, but tools that needed actively supplementing through reflective dialogue and narrative elaboration. 2. Judgement, trust, and the weight of knowing Participants reflected on diagnostic judgement not simply as an abstract technical skill, but as something relational, ethical, and emotionally charged. Subjectivity was not treated as a flaw within this process, but as an intrinsic dimension of diagnostic practice. Participants saw it as important for this subjectivity to be actively communicated and managed. Skilful navigation of subjectivity was conceptualised as key to the development of trust in one’s diagnostic capability with colleagues. “Even with 20 years of experience, sometimes I look at a bone marrow and have no idea. Then, I tell them: "This is a very strange marrow. I don’t know what it is, but we will do additional tests and get back to you." That way, they trust me when I am sure of a diagnosis.” (P4) Subjectivity was seen not only as a personal experience but as something negotiated interpersonally. Several participants emphasised the value of fostering diagnostic dialogue, creating shared interpretive space with colleagues and referring clinicians. Trust, in this context, was not simply about accuracy, but about co-presence, or the sense of doing diagnosis together and making interpretive work visible and participatory. “Clinicians want to feel like they’re looking at the bone marrow alongside you. That’s how it should feel – they’re involved in the diagnostics and interpreting results with you.” (P4) There was also a sense of personal responsibility associated with the interpretive labour of diagnosis. Participants spoke of the “weight” of a diagnosis, particularly when morphological assessments conflicted with other data, or when decisions needed to be made out of hours, in isolation. One participant described a moment of diagnostic uncertainty that led to the cancellation of an organ transplant – interestingly, a moment which seemed to be experienced as a reckoning with the limits of knowing, rather than as an outright failure. This suggests that the emotional and ethical dimensions of diagnostic responsibility are not only tied to accuracy, but also to epistemic integrity, or the ability to recognise and communicate uncertainty when certainty cannot be claimed. For this participant, restraint was a sign of professional maturity as it represented an awareness that doing less may sometimes mean doing better. “I was called for a patient who was a possible organ giver. He was dead, but he had a hyper lymphocytosis. And I looked at the lymphocytes and I was not sure that these lymphocytes were not, were not tumoral, were not a lymphoma. So I advised not to transplant the organ. And I made a mistake… I still think that I did the good choice because I was not sure… it's better not to harm when you are not sure.” (P1) Reconfiguring expertise in the age of genomics and AI The third theme explored how participants make sense of the shifting landscape of diagnostic haematology. This landscape is increasingly shaped by next-generation sequencing, structured reporting, and AI-driven tools. These changes were not experienced as simply technological, but as epistemological and professional: transformations in what counts as knowledge, and who counts as an expert. “Eventually you will code the disease in a way that the computer understands, and you will extract a therapy for it.” (P3) While many welcomed the speed, precision, and reproducibility of newer methods, they also expressed ambivalence. Participants described a sense of erosion, not of skill, but of narrative. The capacity to trace a diagnostic decision through a process of visual interpretation, embodied judgement, and shared reasoning was seen as threatened by automated outputs and reductive reporting structures. “That’s what the AI would pick up... but that doesn’t help with the clinical context.” (P2) At the same time, participants saw themselves as actively negotiating this terrain. This involved adapting, integrating, and teaching new forms of literacy while resisting the reduction of diagnostic reasoning to code. The future of diagnosis, in their accounts, required not only technological competence but an ongoing reflexivity, which involves a commitment to reinterpreting what it means to know, see, and decide. “Whether that replaces me and human beings…. for the simple stuff… that will be important over the next few years, but I strongly suspect that it will complement and not replace.” (P2) Discussion This study explored how experienced haematologists make sense of diagnostic practice in conditions of uncertainty, interpretive complexity, and technological change. By attending closely to participants’ lived experiences, our analysis shows how diagnosis is not experienced as a sequence of technical decisions by experienced haematologists, but as a process of embodied meaning-making, which is iterative, relational, and integrative. Our first theme demonstrates how diagnostic reasoning unfolds through perceptual synthesis and situated judgement. Participants described how diagnostic impressions are created from attentiveness to visual, narrative, and relational cues that are felt and interpreted in ways that resist linear codification. The metaphor of diagnosis as “seeing” was common, but what was seen could not always be named. This evokes a type of knowing that is tacit, embodied, and drawn from experiential memory, but is also structured as a projection of knowledge onto the objects under consideration, rather than mere passive perception. The implicit theme of seeing also implies the limitations of vision itself. That is to say the observations include the understanding that things that are unseen are potentially present and this ambiguous potential for the unseen is integrated within the final impression of the diagnostician. While structured reporting systems were valued for their standardising function, they were also described as unable to fully capture this diagnostic “seeing.” Rather than opposing standardisation, participants recognised its value while also articulating the need for reflective supplementation – an active negotiation between the visible structure of templates and the invisible work of clinical sense-making. This aligns with phenomenological understandings of expertise as lived familiarity with a domain, shaped by histories of perception and interaction (Dreyfus et al., 1987 ). Our second theme, judgement, trust, and the weight of knowing , extends this view by revealing how diagnostic practice is not only cognitive, but ethical and intersubjective elements are implied. Participants described trust as something cultivated through the consistency of interpretive styles and the ability to communicate uncertainty. Rather than treating subjectivity as a limitation, they articulated it as central to their professional identity. This aligns with sociocultural perspectives that emphasise the context-dependence and relational nature of clinical judgement (Gonzalo et al., 2016 ; Gaufberg et al., 2010 ). It also extends work in medical education that calls for a reframing of uncertainty – from something to be eliminated, to seeing uncertainty as a condition of clinical practice that we must learn to recognise and share (Veen & Brown, 2022 ). Central to this is the concept of epistemic humility. Epistemic humility is about acknowledging the limits of one’s own knowledge, remaining open to other ways of knowing, and embracing uncertainty as an inevitable feature of life (Kidd, 2016 ). It is a relational and moral orientation that underpins responsible diagnostic practice (Kelly & Panush, 2017 ). In our study, it was evident in participants’ willingness to narrate diagnostic uncertainty, invite collaborative sense-making, and prioritise harm reduction over premature certainty. These behaviours reflect a deeper professional maturity grounded in the ethics of “not knowing” well (Kelly & Panush, 2017 ). Postgraduate medical education, which is often tightly focused on the measurement of clinical competence, must therefore broaden its pedagogical scope to include the cultivation of epistemic humility. This means not only teaching doctors-in-training that a diagnosis is merely an exercise of accurate perception, but the limitations of knowledge, inaccuracies and the social domain of communicating these are an implicit part of the process. Such training calls for reflective spaces within curricula where learners can explore the ethical and emotional weight of diagnostic decisions, and develop habits of openness, curiosity, and collaborative reasoning. Finally, our third theme, reconfiguring expertise in the age of genomics and AI , reveals how technological developments are shifting the contours of diagnostic identity. While participants acknowledged the value of computational tools and genomic precision, they also articulated a sense of loss – a loosening of narrative, interpretive, and experiential expertise that previously anchored their diagnostic decisions. The displacement was existential. In other words, it seems to represent a shift in what it means to “know” diagnostically. Interestingly, however, participants did not frame this existential shift as crisis. Instead, they described adapting to their new role, integrating new forms of literacy while retaining a commitment to the human dimensions of diagnosis. Their responses suggest that contemporary diagnostic expertise involves both fluency with emerging technologies and a reflexive stance toward what these tools cannot yet (and maybe ever) replace (for example, embodied perception, relational trust). This finding affirms calls in medical education to foreground interpretive, dialogic, and narrative skills even amidst technological transformation ((Bleakley, 2015 ; Hodges & Lingaard, 2018 ). Although these calls within medical education date back over ten years, it is a critical perspective missing from recent discussions concerning AI since the rise of generative AI in 2022. This has important implications for postgraduate education within haematology and other specialities similarly affected by AI and the deployment of advanced data within diagnostic processes. In terms of education, training must go beyond teaching clinicians how to operate new systems. Rather, training should facilitate postgraduate doctors to question, contextualise, and co-exist with new technologies, whilst retaining their professional outlook, decisiveness and integrity amidst technological development and change. This could be achieved by facilitating protected, reflective teaching practices within training programmes. Simulation, peer-dialogue, and formal case-based reflection could be employed to cultivate this learning. The future of diagnostic expertise, as portrayed by our participants, is not simply about keeping up with innovation; it is about sustaining a diagnostic gaze that is adaptive, reflexive, situated, and human. Limitations This study has several limitations. The small sample size, while appropriate for IPA, limits the range of perspectives and may not capture variation across institutions or subspecialties. All participants were highly experienced consultants, which may introduce bias toward reflective or pedagogically engaged views. Although the analysis was strengthened by collaboration between a clinician-researcher and a medical education specialist, initial data collection and coding were led by an insider to the field, which may have shaped interpretive priorities. The findings are contextually grounded in diagnostic haematology and may not be directly transferable to other specialties, though the themes identified –particularly around integration, subjectivity, and interpretive judgement – are likely relevant to diagnostic work in other complex clinical domains. Conclusion Together, these findings contribute to an emerging body of literature whose aim is to re-centre diagnosis as a situated and interpretive practice, as well as a technical one. While much attention in medical education has focused on clinical reasoning at the point of bedside decision-making, our study highlights the underexplored complexity of reasoning in laboratory and diagnostic contexts. As diagnostic work becomes increasingly multimodal and technologically mediated, postgraduate education must evolve to reflect this complexity. This not only involves expanding technical educational content, but also involves developing clinicians’ interpretive capacities, epistemic reflexivity, and narrative sensibility. Algorithms cannot fully capture diagnostic reasoning, as it requires careful attention and sensitivity to uncertainty and the ability to integrate fragmented data into meaningful wholes and to integrate reflective practice as part of the diagnostic process. Our participants demonstrated that this integration is not solely cognitive, but embodied, relational, and often affectively charged. Postgraduate education must, therefore, create space for trainees to engage with the tacit dimensions of diagnostic expertise. By this we mean learning not just what to conclude, but how to see, interpret, and justify. This includes opportunities to rehearse cross-modal synthesis, to articulate the "why" behind conclusions. This is a philosophical task and means a deeper undertaking is required to make explicit how these forms of knowledge are constituted within a diagnostician. This would allow us to witness how experienced diagnosticians navigating the tensions between structure and their own felt understanding of a diagnosis and translate this into substantive teachable practice. Future research regarding how these dynamics play out across other specialties, the development of diagnostic judgement over time, and the effectiveness of educational interventions designed to foster interpretive and collaborative reasoning would be of particular use. Studies involving more novice diagnosticians and multidisciplinary teams could help clarify how conceptual, linguistic, and relational dimensions of diagnosis are learned and enacted in practice. The formation of a broader range of philosophically informed analytic frameworks is of great interest within medical education and could provide us the tools to better understand how precisely the diagnostic process functions. If medical education is to prepare clinicians for the realities of contemporary diagnostic care, we must attend not only to what is known, but to how knowledge is made, trusted, and formulated into communication. This requires a shift in how we teach, assess, and value diagnostic expertise –one that embraces uncertainty, supports collaboration, and equips doctors to work within, rather than around, complexity. Declarations Ethical approval for this study was granted by the St. Vincent’s University Hospital Research and Ethics Committee, Dublin, Ireland (Reference: RS25-007). Consent to Participate All participants provided written informed consent to participate in this study after receiving a full explanation of the research purpose, procedures, and their right to withdraw at any time without consequence. Consent for Publication All participants consented to the use of anonymised quotations in publications arising from this research. Clinical Trial Registration Clinical trial number: not applicable. Human Ethics and Consent to Participate Declarations All relevant ethical and consent procedures were followed. Human Ethics and Consent to Participate declarations: applicable as above. Funding Declaration This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution C.C. Performed the interviews, transcribed the interviews, did the analysis, wrote the bulk of the paper.M.B. 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Available from: https://doi.org/10.1007/978-981-19-1512-3_4 Kidd IJ. Inevitability, contingency, and epistemic humility. Stud History Philos Sci Part A. 2016;55:12–9. Kelly A, Panush RS. Diagnostic uncertainty and epistemologic humility. Clin Rheumatol. 2017;36(6):1211–4. Montgomery K. How Doctors Think [Internet]. Oxford University PressNew York, NY; 2005 [cited 2025 Oct 15]. Available from: https://doi.org/10.1093/oso/9780195187120.001.0001 Bleakley A. Medical Humanities and Medical Education [Internet]. Routledge; 2015 [cited 2025 Oct 15]. Available from: https://doi.org/10.4324/9781315771724 Hodges BD, Lingaard L. The Question of Competence [Internet]. Cornell University Press; 2018 [cited 2025 Oct 15]. Available from: https://doi.org/10.7591/9780801465802 Tirrell L. Seeing Metaphor as Seeing-As: Remarks on Davidson’s Positive View of Metaphor. Philosophical Investigations. 1991;14(2):143–54. A practical guide to using Interpretative Phenomenological Analysis in qualitative research psychology. Czasopismo Psychologiczne Psychological Journal. 2014;20(1). Additional Declarations No competing interests reported. Supplementary Files Questionairre.odt Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 15 Dec, 2025 Reviewers agreed at journal 06 Dec, 2025 Reviewers invited by journal 28 Nov, 2025 Editor invited by journal 05 Nov, 2025 Editor assigned by journal 27 Oct, 2025 Submission checks completed at journal 27 Oct, 2025 First submitted to journal 17 Oct, 2025 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. 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Coccia","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYJCCAw8KoAyGCgYGAzCDkJYEA5iWM0RqYYBpYWBsg2jBC/jbTycCbbGR52c//PDAz3l1idv5FzAe+IBHi8SZ3A1ALWmGM3vSDA72bjucuHPGA4aDM/BoMWAAazmcYHCDh+EA77YDxgY3DjAc5sGnhf8tQsvBv3PqIFr+4NMigWTLYd4GZjmD8w0Mh/F5X+LGW4RfDsscOyxncIOx4WAPHi38/bmbP3yoAIfY449vaup4DM4fPvzhBz5rsFic2ECaBqDFB0jVMQpGwSgYBcMcAADC1Fpa3upTjAAAAABJRU5ErkJggg==","orcid":"","institution":"St Vincent’s University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Camillo","middleName":"","lastName":"Coccia","suffix":""},{"id":552465756,"identity":"5f8081a0-6a53-428e-842f-26b57d0b7495","order_by":1,"name":"Karen Garvey","email":"","orcid":"","institution":"University Hospital 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clinical specialties, diagnostic practice is becoming increasingly complex (Arber et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Clinicians must interpret diverse forms of data, ranging from descriptive observations to binary molecular outputs, and make decisions in environments that are technologically advanced, highly collaborative, and often uncertain (Bauer et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This shift has introduced new cognitive and communicative demands that extend beyond traditional notions of clinical expertise (Xu et al. \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Yet, despite these developments, postgraduate medical education has not fully kept pace. Contemporary teaching often focuses on technical competence and testable knowledge, prioritising standardised assessments over contextual, interpretative and relational skills. As a result, current diagnostic education tends to emphasise the mastery of discrete procedures and protocols, rather than the nuanced reasoning required in clinical practice ((Heiberg Engel, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Gilkes et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This risks producing clinicians who are technically proficient but underprepared for the uncertainty, integration, and interpersonal dynamics of modern diagnostic work.\u003c/p\u003e\u003cp\u003eTeaching within this complex environment is, therefore, challenging. As diagnostic modalities multiply and data sources diversify, educators must support learners to develop both multimodal fluency and the capacity to synthesise, contextualise, and communicate evolving evidence (Arber et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Xu et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The complexity of diagnostic education is not solely due to information overload but also stems from the epistemic and ethical challenges of integrating partial, probabilistic, and sometimes conflicting forms of knowledge (Tsai \u0026amp; Harasym, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Eastwood et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Several scholars have argued that diagnostic learning must be reframed to reflect the interpretive nature of diagnostic reasoning and to legitimise the affective and subjective dimensions of knowing in medicine (Pallagrosi et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Bauer et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Despite accelerating academic discussion on the importance of reorientating diagnostic education, there seems to have been little practical progress in achieving this goal. We believe this is a result of multiple, interrelated factors, including: the enduring dominance of biomedical models that privilege objectivity and certainty; the structural constraints of curricula that reward speed and accuracy over reflection and dialogue; and a lack of empirical insight into how experienced diagnosticians actually make sense of complexity in real-world practice. In this work, we focus on advancing empirical insight, as, without a grounded understanding of how senior clinicians navigate uncertainty, ambiguity, and interpretive judgement in their diagnostic work, educational reform risks remaining abstract and disconnected from the realities it seeks to address. This study therefore explores the lived experiences of experienced haematologists as they engage in diagnostic reasoning, aiming to further understanding into how expertise is constructed, felt, and enacted within a high-stakes, multimodal diagnostic environment.\u003c/p\u003e\u003cp\u003eWe treat diagnostic haematology as a case study within this research. Haematology is a branch of medicine that manages a broad range of benign and malignant conditions (Beck, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). The growing complexity of diagnostic haematology arises from the need to combine descriptive diagnostic methods (like morphology – the practice of reporting the appearance of cells and how they behave with chemical stains under the microscope; and flow cytometry – which uses cell surface proteins to identify groups of cells and classifies them according to abundance and distinct combinations of proteins) with newer, more categorical techniques, such as molecular genetics (which produces more binary outputs, i.e., indicates the presence or absence of a mutation relevant to a specific disease), into a single, coherent diagnostic epithet (Brereton et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Cree, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Arber et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). While in practice the difference in the data produced by these techniques is not absolutely distinct, it has been divided this way by the authors according to the dominant form of reporting.\u003c/p\u003e\u003cp\u003eWhile this study focuses on haematology, the challenges described here – navigating uncertainty, reasoning across diverse data types, and working collaboratively within diagnostic teams – are relevant to postgraduate training across a range of specialties. As diagnostic technologies continue to advance, the ability to make sense of integrated information in real-world clinical contexts will be an increasingly important part of medical education more broadly. Hence, through qualitative interviews with experienced haematologists, this study investigates how clinicians engage with the complexity of integrated diagnostics and considers how these insights might inform postgraduate education in similarly complex fields.\u003c/p\u003e\n\n"},{"header":"Methods","content":"\u003ch3\u003eStudy paradigm\u003c/h3\u003e\u003cp\u003eAlthough our analysis followed the idiographic principles of Interpretative Phenomenological Analysis (IPA), it was informed by the broader interpretivist ethos articulated by Braun and Clarke (Braun \u0026amp; Clarke, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2006\u003c/span\u003e), which focusses on researcher reflexivity and the active co-construction of meaning withiin the process of qualitative analysis.\u003c/p\u003e\u003ch2\u003eStudy approach\u003c/h2\u003e\u003cp\u003eWe adopted an interpretative, phenomenological orientation to this qualitative research (Biggerstaff D et al.; 2008), attending closely to the lived experiences of experienced haematologists as they engage in diagnostic practice. We understand knowledge as arising through situated, embodied, and socially mediated experience (Neubauer et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Our concern was not only with what clinicians do, but with how they make sense of what they do. In other words, how meaning is generated through the act of diagnosis, especially under conditions of uncertainty and complexity. We sought to surface the often tacit, intuitive, and affective dimensions of diagnostic work, as well as the ways in which practitioners articulate their understandings in retrospect. This orientation enabled us to explore the interpretative and interpersonal dynamics that shape how diagnostic expertise is enacted, and how this may be made visible for educational purposes.\u003c/p\u003e\n\u003ch3\u003eStudy design\u003c/h3\u003e\n\u003cp\u003eWe used a qualitative, interpretative phenomenological design, conducting semi-structured interviews to explore the lived experience of diagnostic reasoning among experienced haematologists. Participants were invited to reflect on how they navigate and integrate diverse forms of diagnostic data (including morphology, karyotyping, immunophenotyping, and genomic information) in the context of real clinical cases. The interviews were designed to elicit rich, situated accounts of how diagnostic sense-making unfolds over time and within particular clinical contexts. Our analysis was guided by interpretative phenomenological analysis (IPA) (Smith, Larkin, Flowers 2021; Pietkiewicz and Smith, 2014), allowing us to attend both to the experiential textures of participants' accounts and to the broader implications for how diagnostic reasoning might be taught and supported in haematology education.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eFive Consultants in Diagnostic Haematology across various European sites (France, the United Kingdom, Ireland, the Netherlands) were purposively sampled. (Tindall, 2009) Sampling was based on their exposure to diagnostic haematology through its recent developments. Participants were identified via professional networks of Haematologists by references from interviewees and were recruited via email. Recruitment was difficult, as participation in the study required 60\u0026ndash;90 minutes busy clinicians\u0026rsquo; time, although we recruited an adequate sample size for phenomenological study. The small sample was also driven by \u003cem\u003eMalteraud\u003c/em\u003e et al\u0026rsquo;s (Malterud et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) concept of informational power, where asking a tightly focused research question, of expert participants, means fewer participants are required to achieve a rich analytic dataset.\u003c/p\u003e\u003cp\u003eThis study drew on a small number of in-depth, semi-structured interviews, consistent with an interpretative phenomenological approach. Our intention was to cultivate richly textured, idiographic accounts that illuminate how experienced haematologists make sense of their diagnostic practice. In line with phenomenological principles, we focused on the particular rather than the generalisable, attending closely to how meaning is constructed through participants\u0026rsquo; reflections on their lived experience. The sample size reflects both the depth of interpretative engagement required by IPA and the rarity of the participant role: senior consultants with sustained, multimodal diagnostic responsibility across large European haematology centres. By working intensively with a small, purposively selected group, we were able to explore the nuanced and often tacit dimensions of diagnostic reasoning and consider their implications for educational practice.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eParticipants took part in one-to-one semi-structured interviews with an average duration of 70 minutes online via Zoom or Teams (as per interviewee preference), between March and April 2025. Written, informed consent was gathered from all participants. The team drafted the interview questions based on their familiarity with haematology as a speciality, and with surrounding educational literature related to complexity, and diagnostic reasoning. Interview question stems are available (see Supplemental information).\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eData were analysed using interpretative phenomenological analysis (IPA), a qualitative approach that seeks to explore in depth how individuals make sense of their lived experiences (Smith, Larkin, Flowers 2021). Interviews were transcribed verbatim by the lead author (CC), who also led the analysis, working with MB, JA and KG. Following IPA\u0026rsquo;s idiographic commitment, each transcript was analysed individually before moving to a more integrative cross-case analysis.\u003c/p\u003e\u003cp\u003eThe analytic process involved several iterative stages. First, the lead author engaged in immersive reading of each transcript, noting initial observations, emotional tone, and language which stood out as prominent or important. This was followed by detailed, line-by-line coding to identify experiential claims, metaphors, and meaning-making processes. Emergent themes were then developed for each case, capturing both the content and the interpretative layers of participants\u0026rsquo; accounts. These themes were subsequently clustered into higher-order concepts that reflected shared patterns across cases while retaining sensitivity to individual variation.\u003c/p\u003e\u003cp\u003eThroughout the process, we attended closely to the double hermeneutic that characterises IPA (Neubauer, 2019): participants are making sense of their experience, and the researcher, in turn, is making sense of that sense-making. Regular analytic discussions and memo-making between CC and a second researcher (MB) supported reflexivity and rigour, helping to surface taken-for-granted assumptions and alternative interpretations. We were particularly attentive to the language participants used to describe diagnostic reasoning, integration of modalities, and the emotional contours of uncertainty and team-based decision-making.\u003c/p\u003e\u003cp\u003eManual coding and theme development were conducted using Microsoft Word, and Microsoft Excel. Full ethical approval was granted by the St Vincent's Hospital board of ethics (RS25-007).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eReflexivity\u003c/h2\u003e\u003cp\u003eThis study was led by a resident haematologist (CC), whose clinical experience and familiarity with diagnostic practice informed both the development of the interview schedule and the interpretation of participant accounts. His position within the specialty provided access to the tacit dimensions of diagnostic reasoning and enabled a grounded understanding of the practical realities participants described. At the same time, the analysis was conducted in dialogue with a medical education researcher (MB) outside the field of haematology, whose external perspective supported a critical and pedagogical reading of the data. This combination of insider insight and educational distance allowed the team to interrogate both the technical and epistemic dimensions of integrated diagnostics, while maintaining a strong focus on their implications for postgraduate learning and teaching.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThrough in-depth, idiographic analysis of participant accounts, we developed three interrelated themes capturing how experienced haematologists make sense of their diagnostic practice. These themes reflect not only what clinicians do, but how they understand, navigate, and articulate their diagnostic roles, often in conditions of uncertainty, interpretive complexity, and within an evolving professional terrain.\u003c/p\u003e\u003cp\u003eQuotes are labelled throughout the results with participant numbers.\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eDiagnosis as a lived, integrative act\u003c/b\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eFor participants, diagnostic reasoning was experienced not as a linear algorithm, but as an embodied, integrative act: one that unfolds through memory, comparison, pattern recognition, and dialogue. Diagnosis was described as a way of seeing and making meaning across multiple modalities (e.g., cytology, molecular genetics, flow cytometry) each offering a partial view that has to be held in tension with the others.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I might say: \u0026lsquo;I see a hypocellular marrow. I miss red cells. I only see white cells and megakaryocytes, and they are a bit dysplastic.\u0026rsquo; Then, I make a conclusion. I still do it, perhaps in an old-fashioned way.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe process of integration was shaped by professional history. Some participants referred to their former clinical training as shaping how they now interpret laboratory results. Clinicians experience a lasting clinical gaze that not only orients their laboratory work and judgment but also garners a sense of diagnostic urgency. Others noted how visual memory, developed over decades, enabled rapid diagnostic impressions that were often difficult to articulate but deeply known by the diagnostician when seen.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So that's how the story starts because there is a lot of psychology. When you analyse a sample, you see a cell, then you say, \u0026ldquo;Oh, okay. It reminds me of a such disease\u0026rdquo;.\u0026rdquo; (P1)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eParticipants highlighted the interpretive, context-sensitive nature of diagnosis, especially in cytology, where visual artefacts, slide quality, and limited experience could easily lead to misinterpretation. They described how novice diagnosticians had to develop diagnostic \u0026ldquo;seeing\u0026rdquo; over time, likening their early attempts to the clinical missteps of junior medical students identifying splenomegaly.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It's almost like... it's a clinical appearance in the same way that, you know, a student comes in and says, oh, there's no splenomegaly... There is a splenomegaly... someone poorly trained in cytology like myself... would say, oh, these look like blasts... because of the way the slide has been laid out or... just streaks of cells.\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTeaching this form of expertise was experienced as challenging. Participants reflected on how structured reporting systems support standardisation, clarity, and auditability \u0026ndash; offering clear scaffolding for both experienced and novice diagnosticians. For some, templates served as cognitive prompts, helping mitigate fatigue-related oversight and reinforcing consistency across subjective domains such as cytology. As one participant (P2) noted, structured formats \u0026ldquo;\u003cem\u003ehelp with training and consistency,\u0026rdquo;\u003c/em\u003e ensuring that key features are not missed and that trainees learn to distinguish what is and is not diagnostically significant.\u003c/p\u003e\u003cp\u003eAt the same time, several participants also described moments where the structure imposed by templates risked flattening nuance or occluding the reasoning behind decisions. In these accounts, the experiential and embodied knowledge that informs integrative diagnosis \u0026ndash; what several participants referred to as the \u0026ldquo;why\u0026rdquo; behind decisions \u0026ndash; could be difficult to capture in rigid categories or single-label outputs. This tension between structured clarity and tacit complexity was not framed as oppositional, but as something to be negotiated in practice. For many, structured systems were not barriers, per se, to meaning-making, but tools that needed actively supplementing through reflective dialogue and narrative elaboration.\u003c/p\u003e\u003cp\u003e\u003cb\u003e2. Judgement, trust, and the weight of knowing\u003c/b\u003e\u003c/p\u003e\u003cp\u003eParticipants reflected on diagnostic judgement not simply as an abstract technical skill, but as something relational, ethical, and emotionally charged. Subjectivity was not treated as a flaw within this process, but as an intrinsic dimension of diagnostic practice. Participants saw it as important for this subjectivity to be actively communicated and managed. Skilful navigation of subjectivity was conceptualised as key to the development of trust in one\u0026rsquo;s diagnostic capability with colleagues.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Even with 20 years of experience, sometimes I look at a bone marrow and have no idea. Then, I tell them: \"This is a very strange marrow. I don\u0026rsquo;t know what it is, but we will do additional tests and get back to you.\" That way, they trust me when I am sure of a diagnosis.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSubjectivity was seen not only as a personal experience but as something negotiated interpersonally. Several participants emphasised the value of fostering diagnostic dialogue, creating shared interpretive space with colleagues and referring clinicians. Trust, in this context, was not simply about accuracy, but about co-presence, or the sense of doing diagnosis together and making interpretive work visible and participatory.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Clinicians want to feel like they\u0026rsquo;re looking at the bone marrow alongside you. That\u0026rsquo;s how it should feel \u0026ndash; they\u0026rsquo;re involved in the diagnostics and interpreting results with you.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThere was also a sense of personal responsibility associated with the interpretive labour of diagnosis. Participants spoke of the \u0026ldquo;weight\u0026rdquo; of a diagnosis, particularly when morphological assessments conflicted with other data, or when decisions needed to be made out of hours, in isolation. One participant described a moment of diagnostic uncertainty that led to the cancellation of an organ transplant \u0026ndash; interestingly, a moment which seemed to be experienced as a reckoning with the limits of knowing, rather than as an outright failure. This suggests that the emotional and ethical dimensions of diagnostic responsibility are not only tied to accuracy, but also to epistemic integrity, or the ability to recognise and communicate uncertainty when certainty cannot be claimed. For this participant, restraint was a sign of professional maturity as it represented an awareness that doing less may sometimes mean doing better.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I was called for a patient who was a possible organ giver. He was dead, but he had a hyper lymphocytosis. And I looked at the lymphocytes and I was not sure that these lymphocytes were not, were not tumoral, were not a lymphoma. So I advised not to transplant the organ. And I made a mistake\u0026hellip; I still think that I did the good choice because I was not sure\u0026hellip; it's better not to harm when you are not sure.\u0026rdquo; (P1)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003col start=3\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eReconfiguring expertise in the age of genomics and AI\u003c/b\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThe third theme explored how participants make sense of the shifting landscape of diagnostic haematology. This landscape is increasingly shaped by next-generation sequencing, structured reporting, and AI-driven tools. These changes were not experienced as simply technological, but as epistemological and professional: transformations in what counts as knowledge, and who counts as an expert.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Eventually you will code the disease in a way that the computer understands, and you will extract a therapy for it.\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWhile many welcomed the speed, precision, and reproducibility of newer methods, they also expressed ambivalence. Participants described a sense of erosion, not of skill, but of narrative. The capacity to trace a diagnostic decision through a process of visual interpretation, embodied judgement, and shared reasoning was seen as threatened by automated outputs and reductive reporting structures.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;That\u0026rsquo;s what the AI would pick up... but that doesn\u0026rsquo;t help with the clinical context.\u0026rdquo; (P2)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAt the same time, participants saw themselves as actively negotiating this terrain. This involved adapting, integrating, and teaching new forms of literacy while resisting the reduction of diagnostic reasoning to code. The future of diagnosis, in their accounts, required not only technological competence but an ongoing reflexivity, which involves a commitment to reinterpreting what it means to know, see, and decide.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Whether that replaces me and human beings\u0026hellip;. for the simple stuff\u0026hellip; that will be important over the next few years, but I strongly suspect that it will complement and not replace.\u0026rdquo; (P2)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored how experienced haematologists make sense of diagnostic practice in conditions of uncertainty, interpretive complexity, and technological change. By attending closely to participants\u0026rsquo; lived experiences, our analysis shows how diagnosis is not experienced as a sequence of technical decisions by experienced haematologists, but as a process of embodied meaning-making, which is iterative, relational, and integrative.\u003c/p\u003e\u003cp\u003eOur first theme demonstrates how diagnostic reasoning unfolds through perceptual synthesis and situated judgement. Participants described how diagnostic impressions are created from attentiveness to visual, narrative, and relational cues that are felt and interpreted in ways that resist linear codification. The metaphor of diagnosis as \u0026ldquo;seeing\u0026rdquo; was common, but what was seen could not always be named. This evokes a type of knowing that is tacit, embodied, and drawn from experiential memory, but is also structured as a projection of knowledge onto the objects under consideration, rather than mere passive perception. The implicit theme of seeing also implies the limitations of vision itself. That is to say the observations include the understanding that things that are unseen are potentially present and this ambiguous potential for the unseen is integrated within the final impression of the diagnostician. While structured reporting systems were valued for their standardising function, they were also described as unable to fully capture this diagnostic \u0026ldquo;seeing.\u0026rdquo; Rather than opposing standardisation, participants recognised its value while also articulating the need for reflective supplementation \u0026ndash; an active negotiation between the visible structure of templates and the invisible work of clinical sense-making. This aligns with phenomenological understandings of expertise as lived familiarity with a domain, shaped by histories of perception and interaction (Dreyfus et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e1987\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur second theme, \u003cem\u003ejudgement, trust, and the weight of knowing\u003c/em\u003e, extends this view by revealing how diagnostic practice is not only cognitive, but ethical and intersubjective elements are implied. Participants described trust as something cultivated through the consistency of interpretive styles and the ability to communicate uncertainty. Rather than treating subjectivity as a limitation, they articulated it as central to their professional identity. This aligns with sociocultural perspectives that emphasise the context-dependence and relational nature of clinical judgement (Gonzalo et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Gaufberg et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). It also extends work in medical education that calls for a reframing of uncertainty \u0026ndash; from something to be eliminated, to seeing uncertainty as a condition of clinical practice that we must learn to recognise and share (Veen \u0026amp; Brown, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCentral to this is the concept of epistemic humility. Epistemic humility is about acknowledging the limits of one\u0026rsquo;s own knowledge, remaining open to other ways of knowing, and embracing uncertainty as an inevitable feature of life (Kidd, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). It is a relational and moral orientation that underpins responsible diagnostic practice (Kelly \u0026amp; Panush, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). In our study, it was evident in participants\u0026rsquo; willingness to narrate diagnostic uncertainty, invite collaborative sense-making, and prioritise harm reduction over premature certainty. These behaviours reflect a deeper professional maturity grounded in the ethics of \u0026ldquo;not knowing\u0026rdquo; well (Kelly \u0026amp; Panush, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Postgraduate medical education, which is often tightly focused on the measurement of clinical competence, must therefore broaden its pedagogical scope to include the cultivation of epistemic humility. This means not only teaching doctors-in-training that a diagnosis is merely an exercise of accurate perception, but the limitations of knowledge, inaccuracies and the social domain of communicating these are an implicit part of the process. Such training calls for reflective spaces within curricula where learners can explore the ethical and emotional weight of diagnostic decisions, and develop habits of openness, curiosity, and collaborative reasoning.\u003c/p\u003e\u003cp\u003eFinally, our third theme, \u003cem\u003ereconfiguring expertise in the age of genomics and AI\u003c/em\u003e, reveals how technological developments are shifting the contours of diagnostic identity. While participants acknowledged the value of computational tools and genomic precision, they also articulated a sense of loss \u0026ndash; a loosening of narrative, interpretive, and experiential expertise that previously anchored their diagnostic decisions. The displacement was existential. In other words, it seems to represent a shift in what it means to \u0026ldquo;know\u0026rdquo; diagnostically. Interestingly, however, participants did not frame this existential shift as crisis. Instead, they described adapting to their new role, integrating new forms of literacy while retaining a commitment to the human dimensions of diagnosis. Their responses suggest that contemporary diagnostic expertise involves both fluency with emerging technologies and a reflexive stance toward what these tools cannot yet (and maybe ever) replace (for example, embodied perception, relational trust). This finding affirms calls in medical education to foreground interpretive, dialogic, and narrative skills even amidst technological transformation ((Bleakley, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Hodges \u0026amp; Lingaard, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Although these calls within medical education date back over ten years, it is a critical perspective missing from recent discussions concerning AI since the rise of generative AI in 2022.\u003c/p\u003e\u003cp\u003eThis has important implications for postgraduate education within haematology and other specialities similarly affected by AI and the deployment of advanced data within diagnostic processes. In terms of education, training must go beyond teaching clinicians how to operate new systems. Rather, training should facilitate postgraduate doctors to question, contextualise, and co-exist with new technologies, whilst retaining their professional outlook, decisiveness and integrity amidst technological development and change. This could be achieved by facilitating protected, reflective teaching practices within training programmes. Simulation, peer-dialogue, and formal case-based reflection could be employed to cultivate this learning. The future of diagnostic expertise, as portrayed by our participants, is not simply about keeping up with innovation; it is about sustaining a diagnostic gaze that is adaptive, reflexive, situated, and human.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis study has several limitations. The small sample size, while appropriate for IPA, limits the range of perspectives and may not capture variation across institutions or subspecialties. All participants were highly experienced consultants, which may introduce bias toward reflective or pedagogically engaged views. Although the analysis was strengthened by collaboration between a clinician-researcher and a medical education specialist, initial data collection and coding were led by an insider to the field, which may have shaped interpretive priorities. The findings are contextually grounded in diagnostic haematology and may not be directly transferable to other specialties, though the themes identified \u0026ndash;particularly around integration, subjectivity, and interpretive judgement \u0026ndash; are likely relevant to diagnostic work in other complex clinical domains.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTogether, these findings contribute to an emerging body of literature whose aim is to re-centre diagnosis as a situated and interpretive practice, as well as a technical one. While much attention in medical education has focused on clinical reasoning at the point of bedside decision-making, our study highlights the underexplored complexity of reasoning in laboratory and diagnostic contexts. As diagnostic work becomes increasingly multimodal and technologically mediated, postgraduate education must evolve to reflect this complexity. This not only involves expanding technical educational content, but also involves developing clinicians\u0026rsquo; interpretive capacities, epistemic reflexivity, and narrative sensibility. Algorithms cannot fully capture diagnostic reasoning, as it requires careful attention and sensitivity to uncertainty and the ability to integrate fragmented data into meaningful wholes and to integrate reflective practice as part of the diagnostic process. Our participants demonstrated that this integration is not solely cognitive, but embodied, relational, and often affectively charged.\u003c/p\u003e\u003cp\u003ePostgraduate education must, therefore, create space for trainees to engage with the tacit dimensions of diagnostic expertise. By this we mean learning not just what to conclude, but how to see, interpret, and justify. This includes opportunities to rehearse cross-modal synthesis, to articulate the \"why\" behind conclusions. This is a philosophical task and means a deeper undertaking is required to make explicit how these forms of knowledge are constituted within a diagnostician. This would allow us to witness how experienced diagnosticians navigating the tensions between structure and their own felt understanding of a diagnosis and translate this into substantive teachable practice.\u003c/p\u003e\u003cp\u003eFuture research regarding how these dynamics play out across other specialties, the development of diagnostic judgement over time, and the effectiveness of educational interventions designed to foster interpretive and collaborative reasoning would be of particular use. Studies involving more novice diagnosticians and multidisciplinary teams could help clarify how conceptual, linguistic, and relational dimensions of diagnosis are learned and enacted in practice. The formation of a broader range of philosophically informed analytic frameworks is of great interest within medical education and could provide us the tools to better understand how precisely the diagnostic process functions.\u003c/p\u003e\u003cp\u003eIf medical education is to prepare clinicians for the realities of contemporary diagnostic care, we must attend not only to what is known, but to how knowledge is made, trusted, and formulated into communication. This requires a shift in how we teach, assess, and value diagnostic expertise \u0026ndash;one that embraces uncertainty, supports collaboration, and equips doctors to work within, rather than around, complexity.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003cp\u003e for this study was granted by the St. Vincent\u0026rsquo;s University Hospital Research and Ethics Committee, Dublin, Ireland (Reference: RS25-007).\u003c/p\u003e\u003ch2\u003eConsent to Participate\u003c/h2\u003e\u003cp\u003e All participants provided written informed consent to participate in this study after receiving a full explanation of the research purpose, procedures, and their right to withdraw at any time without consequence.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003cp\u003eAll participants consented to the use of anonymised quotations in publications arising from this research.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eClinical Trial Registration\u003c/h2\u003e\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate Declarations\u003c/strong\u003e\u003cp\u003eAll relevant ethical and consent procedures were followed.\u003c/p\u003e\u003cp\u003eHuman Ethics and Consent to Participate declarations: applicable as above.\u003c/p\u003e\u003ch2\u003eFunding Declaration\u003c/h2\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eC.C. Performed the interviews, transcribed the interviews, did the analysis, wrote the bulk of the paper.M.B. Assisted with Analysis, wrote the discussion and conclusion, did referencing.K.G. assisted with background research and aided in data analysisJ.A. assisted with background research and aided in data analysis\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThis data can be accessed through St Vincent's University Hospital Ethics approval process\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eChernikova O, Heitzmann N, Fink MC, Timothy V, Seidel T, Fischer F. Facilitating diagnostic competences in higher education\u0026mdash;a meta-analysis in medical and teacher education. Educational Psychol Rev. 2019;32(1):157\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrereton M, De La Salle B, Ardern J, Hyde K, Burthem J. Do We Know Why We Make Errors in Morphological Diagnosis? 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7591/9780801465802\u003c/span\u003e\u003cspan address=\"10.7591/9780801465802\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTirrell L. Seeing Metaphor as Seeing-As: Remarks on Davidson\u0026rsquo;s Positive View of Metaphor. Philosophical Investigations. 1991;14(2):143\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eA practical guide to using Interpretative Phenomenological Analysis in qualitative research psychology. Czasopismo Psychologiczne Psychological Journal. 2014;20(1).\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":"[email protected]","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":"","lastPublishedDoi":"10.21203/rs.3.rs-7886684/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7886684/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003cbr\u003e\nDiagnostic practice across clinical specialties has become increasingly complex as clinicians integrate descriptive observations, imaging, and molecular data within technologically advanced and collaborative environments. These changes demand an increasing variety of skills that extend beyond traditional models of technical competence. Yet postgraduate medical education has been slow to adapt, continuing to prioritise standardised assessments and procedural knowledge. Haematology provides a salient case: diagnostic reasoning here requires the synthesis of morphological, immunophenotypic, cytogenetic, and molecular information into a coherent clinical interpretation within the context of a diagnostic field that is growing rapidly. This study explores how experienced haematologists make sense of diagnostic complexity and how their insights might inform postgraduate education.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003cbr\u003e\nAn interpretivist–constructivist qualitative design was employed using Interpretative Phenomenological Analysis (IPA). Five consultant haematologists from centres in Ireland, the United Kingdom, France, and the Netherlands participated in semi-structured online interviews (60–90 minutes). Participants were purposively and snowball-sampled through professional networks. Sample size was guided by Malterud’s concept of informational power, recognising that a focused research question and high participant expertise permit rich analysis from a small cohort. Interviews were transcribed verbatim and analysed iteratively to identify experiential themes, with ongoing reflexive dialogue between a clinician-researcher and a medical-education researcher. Ethical approval was granted by the St Vincent’s University Hospital Ethics Board (RS25-007).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\nThree interrelated themes were identified:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eDiagnosis \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;as a lived, integrative act\u003c/strong\u003e: diagnostic reasoning was experienced as embodied, iterative, and \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;relational, involving perceptual synthesis across modalities and \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;negotiation between structured systems and tacit judgement.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eJudgement, \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;trust, and the weight of knowing\u003c/strong\u003e: diagnosis carried ethical and emotional \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;dimensions; clinicians cultivated trust through openness about uncertainty \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;and recognised subjectivity as intrinsic to expertise.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eReconfiguring \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;expertise in the age of genomics and AI\u003c/strong\u003e: participants described adapting to \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;computational and genomic innovations while maintaining a human, \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;interpretive stance toward diagnostic meaning.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003cbr\u003e\nExperienced haematologists conceptualise diagnosis not as a technical algorithm but as an interpretive practice grounded in embodied perception, ethical awareness, and epistemic humility. Postgraduate training should therefore include reflective spaces that legitimise uncertainty, encourage collaborative reasoning, and foster the narrative and integrative capacities required for modern diagnostic work.\u003c/p\u003e","manuscriptTitle":"The differential count of diagnostic expertise: A phenomenological study into complexity and its implications for medical education","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-01 13:19:19","doi":"10.21203/rs.3.rs-7886684/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-15T09:48:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"208406509517483121853913507657203777593","date":"2025-12-06T17:09:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-28T11:19:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-05T06:26:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-27T12:11:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-27T12:08:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-10-17T12:19:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","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":"2826b35a-eca3-4dae-98ce-87f1ea5b2334","owner":[],"postedDate":"December 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T13:19:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-01 13:19:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7886684","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7886684","identity":"rs-7886684","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}