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Uncomposed, edited manuscript published online ahead of print.

This published ahead-of-print manuscript is not the final version of this article, but it may
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Authors: Katherine Gavinski, MD; Yvonne N. Covin, MD; Palma J. Longo, PhD

Title: Learning How to Build Illness Scripts

DOI: 10.1097/ACM.0000000000002493
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Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
 ACADEMIC MEDICINE | AM Last Page Learning How to Build Illness Scripts Katherine Gavinski, MD, resident, Internal Medicine, University of Texas Southwestern
Medical Center, Yvonne N. Covin, MD, assistant professor, Internal Medicine, University of
Texas Health Science Center at San Antonio, and Palma J. Longo, PhD, assistant professor,
Health Care Sciences, University of Texas Southwestern Medical Center

Clinical reasoning is a necessary capability for all clinicians and a difficult concept to teach students. We designed this
AM Last Page for medical students to help explain how they can enhance clinical reasoning by using illness scripts.

HOW DO PHYSICIANS BECOME EXPERTS?

NOVICE
How do they do that?
Have you ever observed a physician ask a focused set of questions
and seemingly pull the correct diagnosis out of thin air?
You may assume that accuracy is directly related to increased
medical knowledge: physicians have been practicing longer, know
more, and are thus better problem-solvers. It’s not so simple.
One underlying factor in diagnostic accuracy is the way expert
THEY BUILD ILLNESS SCRIPTS1
At the novice level, they rely on biomedical knowledge
to explain disease.
At the intermediate level, they organize biomedical
knowledge using signs and symptoms to explain disease.
At the expert level, they create a narrative framework of
clinical features to rule in or rule out differential diagnoses.

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clinicians organize their medical knowledge.
What is an illness script? KNO W LED
Illness scripts are mental cue cards used to represent I CAL GE
individual diseases.2 ED BA
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Why are scripts important?

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They… Epidemiological
1. Enable pattern recognition of epidemiological features.3 factors
2. Inform history taking based on the contextual
patterns identified.3
3. Enhance the integration of new clinical knowledge
with prior knowledge.3
4. Improve diagnostic efficiency and accuracy.3 Signs and
Pathophysiology symptoms
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of disease

INTERMEDIATE
How do physicians at the intermediate level build illness scripts?
1. Gain clinical exposure to classic presentations of
common illnesses.4
2. Organize clinical features within an illness script.
3. Compare and contrast distinguishing features between
similar diseases.4
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4. Ask more experienced physicians (e.g., a resident or attending) ILLNESS SCRIPT FEATURES FOR
to discuss the distinguishing features they used to rank their ACUTE APPENDICITIS
differential diagnosis.1,4
1. Epidemiological factors
Gender: men = women; Age: peak incidence 10 - 30
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years old; Risk factors: lymphoid hyperplasia

EXPERT
How are scripts used in practice? 2. Signs and symptoms of disease
When expert physicians encounter a case, they quickly retrieve Vague, unprovoked periumbilical pain that gradually
appropriate illness scripts from their long-term memory to create
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a differential diagnosis.1 In contrast to a novice’s illness script,
which is overflowing with detailed biomedical knowledge, the
expert’s illness script consists of highly organized cues derived
from clinical features. In difficult cases, experts weigh biomedical
knowledge, laboratory findings, and imaging data to further
refine the differential and to determine management. Experts
elaborate upon illness scripts by adding atypical disease
presentations over time. Each patient presentation is an
opportunity to learn and to build more integrated illness scripts.
becomes intense; severe, right lower quadrant pain.
Pain is associated with loss of appetite, fever, and
vomiting. Pain improves with narcotics.
3. Pathophysiology
Appendix obstruction from appendicolith, carcinoid
tumor, or lymphoid hyperplasia. Inflamed appendix
may cause peritoneal signs (e.g., Rovsing’s sign).

References:
1. Schmidt HG, Rikers RM. How expertise develops in medicine: Knowledge encapsulation and illness script formation. Med Educ. 2007;41:1133-1139.
2. Feltovich PJ, Barrows HS. Issues of generality in medical problem solving. In: Schmidt HG, De Volder ML. Tutorials in Problem-Based Learning:
New Directions in Training for the Health Professions. Assen, Holland: Van Gorcum; 1984; pp 128-142.
3. Charlin B, Boshuizen HP, Custers EJ, Feltovich PJ. Scripts and clinical reasoning. Med Educ. 2007;41:1178-1184.
4. Bowen JL. Educational strategies to promote clinical diagnostic reasoning. NEJM. 2006;355:2217-2225.
Author Contact: CovinY@uthscsa.edu, Twitter: @DrYCovin

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.