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. 2026 Jul 15;21(7):e0347129. doi: 10.1371/journal.pone.0347129

Assessment of diagnostic reasoning in acute vertigo using vignette-based tools: A cross-sectional comparison between general practitioners and final-year medical students

Charles Maquet 1,*,#, Maxime Wojtecki 2,#, Alexandre Tendron 3,‡, Sophie Deneuve 3,‡, Honorine Claudot 3,‡, Frederic Crampon 3,‡, Julien Burel 4,#
Editor: Renato S Melo5
PMCID: PMC13372113  PMID: 42455821

Abstract

Background

Acute vertigo is a frequent reason for consultation in primary care and poses diagnostic challenges for general practitioners. Although vestibular disorders are addressed during undergraduate medical training, knowledge retention over time is uncertain, while clinical experience accumulates with practice and may contribute to refining diagnostic reasoning. However, how diagnostic reasoning in acute vertigo evolves between the end of initial medical training and routine general practice remains poorly understood. Validated vignette-based tools, such as Script Concordance Tests and Key Feature Problems, enable standardized assessment of diagnostic reasoning. This study compares diagnostic reasoning in acute vertigo between final-year medical students and practicing general practitioners.

Methods and findings

This cross-sectional observational study was conducted between January and March 2024 in a French region. Participants included general practitioners (GPs) in active practice and final-year medical students. All participants completed a self-administered questionnaire based on standardized clinical vignettes representing common presentations of acute vertigo. Diagnostic reasoning was assessed using two validated educational tools: Script Concordance Tests and Key Feature Problems. Scoring keys were established through consensus among 20 expert otolaryngologists. Diagnostic reasoning was expressed as the percentage of correct responses. Associations between diagnostic reasoning and participant characteristics, including clinical experience, consultation volume, vertigo-specific continuing medical education, and self-reported confidence in vertigo management, were analyzed using univariate and multivariate models. A total of 265 participants were included, comprising 173 general practitioners and 92 final-year medical students. Medical students achieved significantly higher diagnostic reasoning scores than GPs (61.0% vs. 54.0%, p < 0.001). Among GPs, higher scores were associated with lower daily consultation volumes (<30 patients/day), prior vertigo-specific continuing medical education, and greater self-reported confidence in the management of acute vertigo. In multivariate analysis, vertigo-specific continuing medical education (β = 0.77; 95% CI, 0.03–1.51; p = 0.041) and self-reported confidence (β = 1.45; 95% CI, 0.54–2.36; p = 0.002) remained independently associated with better diagnostic reasoning.

Conclusion

In this study, final-year medical students outperformed practicing general practitioners on vignette-based assessments of diagnostic reasoning in acute vertigo. The observed difference may be related to differences in recent theoretical exposure and training background. Targeted continuing medical education could be further evaluated as a strategy to support diagnostic reasoning and confidence among general practitioners in primary care.

Introduction

Vertigo is a frequent complaint in primary care, affecting 15% to 35% of individuals over their lifetime [1]. It encompasses a broad spectrum of sensations—spinning, imbalance, floating, or a sense of bodily disconnection—that are often difficult for patients to describe. Approximately 45% of patients with vertigo are seen by general practitioners (GPs) [2]. Vertigo also accounts for 4% of emergency department visits and is the most common presenting symptom of posterior circulation strokes, which represent around 20% of all ischemic strokes [3]. In this context, clinical examination is crucial to differentiate peripheral from central causes.

Acute vertigo management requires specific knowledge and clinical skills in otoneurology, which are not systematically included in GP training. In France, for instance, vestibular disorders are addressed during undergraduate medical education, with learning objectives set by the French College of Otorhinolaryngology [4]. Medical students in their final year are introduced to the theoretical foundations of vestibular syndrome assessment, with an emphasis on identifying red flags suggestive of central causes. However, the limited hands-on experience and clinical exposure at this stage may be insufficient for confidently managing patients with vertigo in real-world practice. This raises the question of how diagnostic reasoning in acute vertigo evolves between the end of undergraduate training and routine general practice, balancing recent theoretical knowledge and accumulated clinical experience.

Several validated tools have been developed to assess diagnostic reasoning in clinical settings using vignette-based assessments. Script Concordance Tests (SCTs) evaluate clinical decision-making under uncertainty and can differentiate levels of expertise  [5]. Key Feature Problems (KFPs) focus on essential decision points in clinical cases and have shown strong validity and reliability in assessing diagnostic reasoning [6].

Existing research on vertigo diagnosis has focused on emergency care settings, with limited data available from general practice [7]. To address this gap, we conducted a study comparing the diagnostic reasoning of practicing general practitioners and final-year medical students in France, using a standardized questionnaire based on complex cases of acute vertigo.

We hypothesized that diagnostic reasoning in the evaluation of acute vertigo would differ between general practitioners and final-year medical students, reflecting the balance between recent academic preparation and accumulated clinical experience.

Materials and methods

Ethics approval

This study consisted of a voluntary, anonymous survey of medical students and GPs. Prior to participation, all participants received an information notice describing the study objectives, procedures, and use of the collected data for research and publication purposes. All participants provided implied informed consent through voluntary, uncompensated participation. No patient data or clinical interventions were involved. The study protocol received approval from the Research Ethics Committee of the University Hospital of Rouen (approval No. E2025-58). We confirm that the entire questionnaire used in this study was fully developed by the authors and is made openly available under a CC BY 4.0 license.

Study design and population

A multicenter, cross-sectional observational study was conducted via a self-administered online questionnaire, available from January to March 2024. The questionnaire focused on diagnostic reasoning assessed through vignette-based cases of acute vertigo. Participation was open to GPs practicing in Eastern Normandy and to final-year undergraduate medical students from the region’s medical school. The survey was distributed through the LimeSurvey© platform (LimeSurvey GmbH, Hamburg, Germany; URL: http://www.limesurvey.org).

According to data from the regional Medical Council, approximately 1,616 general practitioners were practicing in Eastern Normandy, including fully licensed physicians, locum doctors, collaborators, and residents. The questionnaire was distributed via email with the support of the Council and, simultaneously, it was sent to all final-year medical students enrolled at the University of Rouen. Incomplete questionnaires were excluded from the analysis. All participants provided implied informed consent through voluntary, uncompensated participation. Given the voluntary nature of participation, the risk of selection bias cannot be excluded.

Questionnaire design

The questionnaire was developed and validated by three senior otorhinolaryngologists (S.D., F.C., C.M.) experienced in managing vestibular disorders and actively involved in teaching at the regional university hospital. It consisted of three parts: (i) practice-related information, (ii) a case-based diagnostic test, and (iii) self-perceived confidence in diagnosing acute vertigo. The full version of the questionnaire was intended for GPs, while medical students received only the case-based diagnostic test component.

GPs were asked to report their gender and years in clinical practice. Additional variables included practice setting (solo, multidisciplinary, or locum), average number of daily consultations, and weekly frequency of vertigo-related visits. They also indicated whether they had completed an ENT clinical rotation and whether they had participated in any vertigo-specific continuing medical education, such as theoretical courses, practical workshops or clinical simulations.

The case-based diagnostic test included five SCTs, each based on a distinct clinical vignette related to acute vertigo and composed of three diagnostic reasoning items. For each item, a diagnostic hypothesis was followed by a new clinical finding, and participants were asked to indicate whether the finding supported, weakened, or had no effect on the hypothesis, using a Likert scale. To establish the SCTs scoring key, responses were collected from a reference panel of 20 otorhinolaryngologists with varying levels of expertise, including residents, hospital-based physicians, and professors. Maximum points were awarded when a participant’s answer matched the majority response of the expert panel. In addition, three independent clinical scenarios were presented as KFPs. The same expert panel completed the KFPs and achieved a mean score of 84% (± 16%), with a normal distribution, supporting the overall quality and discriminatory capacity of the KFP items. Item-level scores from the SCTs and KFPs were summed to generate a total diagnostic reasoning score, with equal weighting of both components. All test items were developed in accordance with established guidelines, and their content was aligned with the learning objectives of the French medical curriculum program  [5,8].

A final item assessed participants’ confidence in managing acute vertigo using a binary response (yes/no). The full questionnaire and the information notice are available in Supporting Information (S1 and S2 File).

Statistical analysis

Continuous variables were expressed as means (± standard deviation) or medians (interquartile range), and categorical variables as counts (percentages). Group comparisons used Student’s t-test or Mann–Whitney U test for continuous variables, and chi-square or Fisher’s exact test for categorical variables. To identify factors associated with higher diagnostic scores, univariate analyses were first conducted for the following characteristics: gender, training in the practice region, practice setting (solo vs. group), years in practice (≤10 vs. > 10), number of daily consultations (≤30 vs. > 30), prior ENT rotation, participation in vertigo-related training, frequency of vertigo consultations (≤5 vs. > 5/week), and self-reported confidence in vertigo management. A multivariable linear regression model was used to assess diagnostic reasoning as a continuous outcome, given the robustness of this approach to mild departures from normality. All tests were two-tailed, with p < 0.05 considered statistically significant. Analyses were performed using SPSS software (version 29.0.2.0; IBM Corp).

Results

Participant characteristics

A total of 265 participants fully completed the questionnaire between January and March 2024, including 173 general practitioners (GPs; 65.3%) and 92 final-year medical students (34.7%). Initially, 232 responses were received from GPs, of which 59 incomplete questionnaires were excluded from the analysis. The sample had a slight female majority (56.1%), with most participants practicing in group settings (89.6%) and approximately half having ≤10 years of clinical experience (50.9%). Approximately 60% had completed their undergraduate medical training in the region of practice, while 25% had undertaken vertigo-specific continuing medical education. The demographic and professional characteristics of the GPs are summarized in Table 1.

Table 1. Characteristics of respondent General Practitioners (n = 173).

Characteristic n (%)
Demographic Characteristics
Gender Male 76 (43.9%)
Female 97 (56.1%)
Type of practice setting Solo practice 18 (10.4%)
Group practice 155 (89.6%)
Education and Training
Years of clinical experience ≤10 years 88 (50.9%)
>10 years 85 (49.1%)
Current Clinical Activity
Undergraduate training in the region of practice Yes 103 (59.5%)
No 70 (40.5%)
Completed ENT clinical rotation Yes 29 (16.8%)
No 144 (83.2%)
Completed vertigo-specific continuing medical education Yes 44 (25.4%)
No 129 (74.6%)
Average number of daily consultations ≤30 138 (79.8%)
>30 35 (20.2%)
Average weekly vertigo-related consultations ≤5 141 (81.5%)
>5 32 (18.5%)
Self-reported confidence in managing acute vertigo Yes 25 (14.4%)
No 148 (85.6%)
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Diagnostic reasoning and associated factors

Final-year medical students achieved higher scores than general practitioners on the vignette-based assessment of diagnostic reasoning in acute vertigo. The mean total score was significantly higher among students than among GPs (61.0% ± 12.9 vs. 54.0% ± 10.9; p < 0.001). This difference was observed across both assessment components, including the SCTs (58.7% vs. 53.1%; p = 0.003) and the KFPs (65.0% vs. 55.8%; p < 0.001) (Table 2). Although statistically significant, the absolute difference in mean scores was modest. The anonymized dataset supporting the findings of this study is available in Supporting Information (S3 Table).

Table 2. Results of the case-based diagnostic test for acute vertigo management.

Test component GPs (n = 173) mean (%) Final-year medical students (n = 92) mean (%) p-value
Total score 54.0% 61.0% <0.001*
Script Concordance Tests (SCT) 53.1% 58.7% 0.003*
Key Feature Problems (KFP) 55.8% 65.0% <0.001*
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* p-values indicate statistically significant differences. GP, general practitioner

Among GPs, univariate subgroup analyses identified several factors associated with higher diagnostic scores (Table 3). Statistically significant differences were found for daily consultation volume (≤30 patients: 55.0% vs. > 30 patients: 50.5%, p = 0.031), participation in vertigo-specific continuing medical education (57.0% vs. 53.0%, p = 0.047), and self-reported confidence in managing acute vertigo (60.0% vs. 53.0%, p = 0.003). Completion of an ENT rotation and frequency of vertigo consultations were not significantly associated with scores.

Table 3. Mean Diagnostic Test Scores (%) according to General Practitioner Characteristics (Univariate Analysis).

Characteristic Category n (%) Mean score (%) p-value
Gender Male 76 (43.9%) 54.0% 0.953
Female 97 (56.1%) 54.0%
Undergraduate training in region of practice Yes 103 (59.5%) 54.5% 0.474
No 70 (40.5%) 53.5%
Practice setting Solo practice 18 (10.4%) 49.9% 0.079
Group practice 155 (89.6%) 54.5%
Years in clinical practice ≤ 10 years 88 (50.9%) 55.5% 0.084
> 10 years 85 (49.1%) 52.5%
Average daily consultations ≤ 30 138 (79.8%) 55.0% 0.031*
> 30 35 (20.2%) 50.5%
Completed ENT rotation Yes 29 (16.8%) 53.0% 0.526
No 144 (83.2%) 54.5%
Completed vertigo-specific continuing medical education Yes 44 (25.4%) 57.0% 0.047*
No 129 (74.6%) 53.0%
Weekly vertigo consultations ≤ 5 141 (81.5%) 54.5% 0.192
> 5 32 (18.5%) 52.0%
Self-reported diagnostic confidence Yes 25 (14.4%) 60.0% 0.003*
No 148 (85.6%) 53.0%
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* Statistically significant (p < 0.05).

In multivariable linear regression analysis, participation in vertigo-specific continuing medical education (β = 0.769, 95% CI [0.032; 1.506], p = 0.041) and self-reported diagnostic confidence (β = 1.449, 95% CI [0.542; 2.355], p = 0.002) remained independent predictors of higher scores, while other factors did not retain statistical significance (Table 4).

Table 4. Multivariable linear regression analysis of factors associated with higher diagnostic test scores among general practitioners.

Characteristic Reference group Regression coefficient (β) 95% Confidence Interval p-value
Gender Male 0.046 [-0.615; 0.707] 0.892
Undergraduate training in region of practice Yes 0.249 [-0.404; 0.902] 0.453
Practice setting Group practice 0.716 [-0.338; 1.769] 0.182
Years in clinical practice > 10 years −0.561 [-1.214; 0.092] 0.092
Average daily consultations > 30 −0.795 [-1.661; 0.072] 0.072
Completed ENT rotation Yes −0.324 [-1.181; 0.534] 0.457
Completed vertigo-specific continuing medical education Yes 0.769 [0.032; 1.506] 0.041*
Weekly vertigo consultations > 5 −0.219 [-1.065; 0.627] 0.610
Self-reported diagnostic confidence Yes 1.449 [0.542; 2.355] 0.002*
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* Statistically significant (p < 0.05).

Discussion

This study found that final-year medical students achieved higher scores on vignette-based assessments of diagnostic reasoning in acute vertigo than participating GPs from the same region. While it is unclear whether clinical experience or recent academic training would have a greater influence on diagnostic reasoning, the results suggest an association between proximity to medical training and higher diagnostic reasoning scores. Although the “school-like” format of the assessment may have favored students, these findings highlight the potential relevance of ongoing postgraduate training, particularly given that theoretical knowledge has been shown to decline after graduation [9,10]. SCTs have been used since 1998 to assess clinical reasoning in complex and uncertain cases across multiple disciplines, and have demonstrated their value in evaluating diagnostic reasoning skills [11–13]. The integration of SCTs and practical vestibular examination training into postgraduate education may represent a relevant educational approach for GPs.

GPs who reported participation in post-graduate training focused on vertigo achieved higher scores than their peers, suggesting an association between engagement in such programs and performance on vignette-based assessments. In France, GPs have been required to update their knowledge through post-graduate training since 2016; however, the content and availability of these programs vary across regions. To date, few studies have evaluated the effectiveness of these training programs. A 2022 Irish study reported that 74% of general practitioners perceived an improvement in patient care following participation in post-graduate training [14].

Self-reported confidence in diagnosing acute vertigo was independently associated with higher diagnostic reasoning scores among GPs. Although the exact role of this self-confidence is not fully understood, it may be related to prior training experiences. Confidence may influence how clinicians engage with diagnostic tasks and apply clinical reasoning strategies. However, confidence does not necessarily equate to competence; previous studies have reported that overconfidence may increase the risk of diagnostic errors, whereas low confidence may lead to unnecessary referrals or investigations [15]. From an educational perspective, postgraduate training should therefore aim not only to reinforce knowledge, but also to support the development of appropriately calibrated confidence.

Univariate analysis also indicated that GPs reporting fewer daily patients performed better at the tests. This association may reflect greater time availability per consultation or increased cognitive resources for reflective clinical reasoning. The clinical evaluation of patients presenting with acute vertigo can be time-consuming, particularly in the presence of nausea, vomiting, or anxiety. Longer consultation times may be associated with higher diagnostic reasoning and may also enhance GPs’ self-confidence and facilitate self-directed learning in vertigo diagnosis. However, consultation durations in primary care are often constrained and may not adequately reflect the healthcare needs of the population, with significant regional variability [16].

This study had several limitations. Final-year medical students may have been more familiar with structured assessment formats such as SCTs and KFPs, potentially conferring an advantage in this setting, although clear instructions were provided and the expert panel included otorhinolaryngologists unfamiliar with SCT methodology. The response rate among GPs was low (approximately 10%), which may have introduced selection bias, although participating GPs did not necessarily achieve higher diagnostic reasoning scores. In addition, it was not possible to verify whether participants consulted external resources while completing the questionnaire, although the information note encouraged spontaneous responses and the vignettes were designed to be complex and original. Medical students completed only the diagnostic reasoning component of the questionnaire, whereas general practitioners completed the full questionnaire, which may have influenced engagement or fatigue and should be considered when interpreting between-group comparisons. Participants’ self-reported confidence was assessed using a binary response (yes/no), which may oversimplify individual perceptions of confidence and does not capture its gradations; this limitation should be considered when interpreting associations between confidence and diagnostic reasoning.

Importantly, the findings of this study relate to diagnostic reasoning assessed through vignette-based tools and should not be interpreted as reflecting real-life clinical performance or actual patient management.

Conclusion

In conclusion, Fig 1 summarizes factors associated with higher diagnostic reasoning among general practitioners in vignette-based assessments of acute vertigo. These findings suggest that targeted continuing medical education may be associated with higher diagnostic reasoning in this context. Future educational approaches may benefit from integrating clinical cases inspired by real-life situations, combining theoretical input with practical application, particularly through patient simulations. These findings should be interpreted within the context of vignette-based assessments and do not directly reflect real-life clinical care.

Fig 1. Factors associated with diagnostic reasoning in vignette-based assessments of acute vertigo among general practitioners.

Fig 1

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Solid arrows indicate factors independently associated with higher diagnostic reasoning scores in multivariable analysis, while dashed arrows indicate associations observed in univariate analyses only.

Supporting information

S1 File. Questionnaire used for the assessment of diagnostic reasoning in acute vertigo.

Full questionnaire used in the study, including participant demographics, prior training and clinical exposure to vertigo, Script Concordance Test (SCT) and Key Features Problems (KFP)–based clinical vignettes assessing diagnostic reasoning in acute vertigo.

(DOCX)

pone.0347129.s001.docx (21.4KB, docx)
S2 File. Participant information and consent statement.

Information notice provided to participants prior to questionnaire completion, describing the study objectives, voluntary participation, anonymization of data, and consent for use of responses for research and publication purposes.

(DOCX)

pone.0347129.s002.docx (13.5KB, docx)
S3 Table. Anonymized study dataset.

Fully anonymized dataset used for all analyses presented in the manuscript. The dataset contains no directly or indirectly identifying information.

(XLSX)

pone.0347129.s003.xlsx (44.3KB, xlsx)

Acknowledgments

The authors acknowledge the assistance of ChatGPT 5.2 in translation refinement.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

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Reviewers' comments:

Reviewer's Responses to Questions-->

-->Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Partly

Reviewer #2: Yes

**********

-->2. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #1: No

Reviewer #2: Yes

**********

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The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

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-->5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1:  This manuscript reports a cross-sectional comparison of vignette-based diagnostic performance in acute vertigo between general practitioners (GPs) and final-year medical students, using Script Concordance Tests (SCTs) and Key Feature Problems (KFPs). The topic is relevant to primary care education, and the use of validated assessment tools is a strength. However, important methodological and interpretative limitations substantially weaken the clinical implications of the findings. In its current form, the manuscript overextends its conclusions beyond what the data can robustly support.1. Misclassification of the study as “diagnostic accuracy”

The manuscript repeatedly refers to “diagnostic accuracy,” yet no real patients, reference clinical diagnoses, or patient outcomes are included.The study assesses performance on educational assessment tools, not diagnostic accuracy in the clinical sense.SCTs and KFPs evaluate clinical reasoning under uncertainty, not bedside diagnostic competence.

Recommendation:

Reframe the study consistently as an educational assessment of diagnostic reasoning, not a diagnostic accuracy study. The title, abstract, and conclusions should be modified accordingly.

Reviewer #2:  This manuscript addresses an important and under-studied issue in primary care and medical education: diagnostic reasoning in acute vertigo, comparing general practitioners and final-year medical students using validated assessment tools. The study is methodologically sound, ethically conducted, and clearly reported, and the conclusions are, to a great extent, supported by the data.

The work is appropriate for publication by PLOS ONE as an observational study that has been rigorously conducted and has clearly reported its methodology. However, I believe that the use of some of the conceptual clarification, methodological refinement, and presentation issues will strengthen the interpretability, reproducibility, and balance of the conclusions drawn.

I have provided comments and actionable recommendations on a section-by-section basis.

1. Abstract

Strengths

• Clear structure with standard PLOS ONE headings.

• Objectives, methods, and main findings are accurately reported.

• Effects, estimates, and p-values are appropriately reported.

Issues & Recommendations

1. Interpretive language should be slightly tempered

o The conclusion attributes the superior performance of students mainly to ‘’ recent targeted training. ‘’While plausible, this inference is not directly tested.

o Recommend softening to:

o ‘’…possibly reflecting more recent theoretical exposure.’’

2. Clarify clinical vs. Test-based performance

o Readers may interpret ‘’ diagnostic accuracy’’ as real-clinical accuracy

o Suggest adding ‘’ in vignette-based assessments’’ to the conclusion sentence.

2. Introductory

Strengths

- The introduction contains an appropriate epidemiological context.

- The introduction states the importance of vertigo for primary care practitioners.

- The paper correctly identifies and names structured clinical tests (SCTs) and knowledge and feedback protocols (KFPs) using citation support.

Issues & Recommendations

1. Provide clarification of the educational paradox earlier in the introduction.

- The statement on the unexpected hypothesis (students have superior diagnostic skills to GPs) appears relatively late in the introduction.

2. As a way of clarifying what the authors mean by "educational paradox," the authors may want to include the following statement in the final paragraph of the introduction: "This study looks at the balance between a student's academic preparation and the clinical experience of a GP when conducting structured clinical tests (SCTs)."

3. Materials and Methods

3.1 Study Design and Population

Strengths

- The study had clearly defined eligibility criteria.

- The recruitment approach was transparent.

- There were appropriate ethical considerations in the project.

Issues and Recommendations

- Response rate bias was an issue.

- The physician response rate (approximately 10%) is discussed later in the paper; it should have been addressed earlier in the paper.

- Include a brief statement addressing the potential for selection bias.

- There is an imbalance between how many times students and doctors were exposed to this study's content.

- Students only participated in completing the diagnostic section of this study.

- Clarify if this difference in exposure may lead to differences in levels of fatigue or engagement when participating.

3.2 Design of the Questionnaire

Strengths

The questionnaire's use of validated tools (the SCT and KFP) is a significant strength. In addition, there is a good description of how the expert panel was developed, as well as the way in which the expert panel's scoring was carried out. There are also good supporting materials.

Issues & Recommendations

Explain how the scores were aggregated to obtain the total score.

Clarify if the SCT and KFP scores are equally weighted in the total score.

This would provide more transparency and reproducibility.

Confidence Assessment

The confidence question is binary (yes/no), which may oversimplify the perception of the participant. This limitation should be explicitly mentioned.

3.3 Statistical Analysis

Strengths

- Univariate and multivariable analysis methods were appropriate to the study's objectives.

- The regression model was reported, including reporting of coefficients and confidence intervals.

- The software used and the threshold for significance were reported.

Minor Recommendations

- Briefly describe why linear regression was used as the analysis method. (normality of residuals or robustness of the regression analysis).

4. Results

Strengths

Logical connection of client attributes to results from performance.

The tables provided are organized with clarity and are all labelled appropriately, informing the reader about their content.

The rates of effect size associated with the tables are consistently presented throughout the text.

Issues & Recommendations

Clinical vs. Statistical Significance.

The absolute difference in percentages between groups (~7%).

Add a single sentence explaining whether this statistic can be considered educationally meaningful.

Do not over-analyze or conclude.

The written results section is primarily objective; thus, it should not include any type of causal terminology.

5. Discussion

Strengths

Both systemic and educational Elements are equally accounted for.

Knowledge Decay and Continuing Education Resources were cited and included in the literature review.

Limitations were noted.

Issue & Recommendations

Assessment Format Bias

In the discussion, students may be advantaged by school-type assessments.

Suggest further expansion on the limits of Construct Validity.

Confidence vs. Competence

Discussion of the confidence-calibration concept is well thought out.

Suggest reiterating that confidence is an educational target and not the endpoint of education.

Figure 1 Interpretation

The legend for Figure 1 describes the figure's findings using interpretative terminology (ie, "appears to promote better management").

Suggest using terminology consistent with PLOS ONE to label this finding, for example, "Higher Diagnostic Scores are associated with these Factors."

6. Conclusion

Strengths

The findings of this report are concise and establish a solid connection to the findings.

A clear request was made for continued medical education.

Recommendation

In regard to recommendations, there will be recommendations to replace residual phrases regarding causation with phrases of association and to clarify that these findings relate to performance on diagnostic reasoning, not performance on clinical care.

7. Ethics, Data Availability, and Transparency

Minor Note: The ethics approval numbers appear to be somewhat inconsistent between these sections; please align them to maintain continuity.

8. Language and Presentation: English was written in a clear and professional tone without errors in grammar or style. A few minor typographical and stylistic corrections and adjustments, such as spacing, hyphenation, etc., have been suggested. I suggest that light editorial revisions prior to acceptance be made.

**********

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Do you want your identity to be public for this peer review?  For information about this choice, including consent withdrawal, please see our Privacy Policy.-->

Reviewer #1: Yes:  Sergio Carmona

Reviewer #2: No

**********

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PLoS One. 2026 Jul 15;21(7):e0347129. doi: 10.1371/journal.pone.0347129.r002

Author response to Decision Letter 1

15 Jan 2026

General Evaluation Questions

1. Technical soundness and support of conclusions

Reviewer #1: Partly

Response:

We acknowledge Reviewer #1’s concern regarding the initial overextension of conclusions. In response, we have carefully revised the manuscript to ensure that all conclusions are strictly supported by the data. The study has been consistently reframed as an educational assessment of diagnostic reasoning using vignette-based tools, rather than an evaluation of clinical diagnostic accuracy. Interpretive and causal language has been systematically removed or replaced with associative terminology throughout the manuscript, including the abstract, results, discussion, and conclusion.

2. Statistical analysis

Reviewer #1: No

Response:

The statistical analyses were not modified, but their rationale and presentation have been clarified. In particular:

- We clarified the aggregation of SCT and KFP scores into a single diagnostic reasoning score.

- We explicitly stated that SCT and KFP components were equally weighted.

- We added a brief justification for the use of linear regression to model diagnostic reasoning scores as a continuous outcome, noting the robustness of this approach.

- These clarifications were added to the Statistical Analysis section to improve transparency and reproducibility.

Reviewer #1 – Specific Comments

Misclassification as “diagnostic accuracy”

Recommendation:

Reframe the study consistently as an educational assessment of diagnostic reasoning, not a diagnostic accuracy study. The title, abstract, and conclusions should be modified accordingly.

Response:

- We fully agree with this comment. The manuscript has been comprehensively revised to:

- Replace all instances of diagnostic accuracy with diagnostic reasoning.

- Explicitly state that SCTs and KFPs assess diagnostic reasoning under uncertainty using vignette-based tools.

- Reframe the title, abstract, results, discussion, figure legends, and conclusion accordingly.

- Additionally, we now explicitly state in the Discussion that the findings do not reflect real-life clinical performance or patient management.

Reviewer #2 – Section-by-Section Responses

Abstract

Issues & Recommendations:

Interpretive language should be slightly tempered

The conclusion attributes the superior performance of students mainly to ‘’ recent targeted training. ‘’While plausible, this inference is not directly tested.

Recommend softening to:

‘’…possibly reflecting more recent theoretical exposure.’’

Clarify clinical vs. Test-based performance

Readers may interpret ‘’ diagnostic accuracy’’ as real-clinical accuracy

Suggest adding ‘’ in vignette-based assessments’’ to the conclusion sentence.

Response :

- Interpretive language was tempered.

- References to “recent targeted training” were softened to possibly reflecting more recent theoretical exposure.

- The conclusion now explicitly refers to vignette-based assessments of diagnostic reasoning.

Introduction

1. Provide clarification of the educational paradox earlier in the introduction.

- The statement on the unexpected hypothesis (students have superior diagnostic skills to GPs) appears relatively late in the introduction.

2. As a way of clarifying what the authors mean by "educational paradox," the authors may want to include the following statement in the final paragraph of the introduction: "This study looks at the balance between a student's academic preparation and the clinical experience of a GP when conducting structured clinical tests (SCTs)."

Responses :

1. The “educational paradox” is introduced earlier in the Introduction.

2. The final paragraph now explicitly frames the study as examining the balance between recent academic preparation and accumulated clinical experience when completing structured clinical tests (SCTs and KFPs).

3. Materials and Methods

3.1 Study Design and Population

- Response rate bias was an issue.

- The physician response rate (approximately 10%) is discussed later in the paper; it should have been addressed earlier in the paper.

- Include a brief statement addressing the potential for selection bias.

- There is an imbalance between how many times students and doctors were exposed to this study's content.

- Students only participated in completing the diagnostic section of this study.

- Clarify if this difference in exposure may lead to differences in levels of fatigue or engagement when participating.

Response :

The low response rate among general practitioners (~10%) is now reported in the Methods.

A statement acknowledging potential selection bias has been added.

Differences in questionnaire exposure between students and GPs are clearly described.

3.2 Questionnaire Design

Explain how the scores were aggregated to obtain the total score.

Clarify if the SCT and KFP scores are equally weighted in the total score.

This would provide more transparency and reproducibility.

Confidence Assessment

The confidence question is binary (yes/no), which may oversimplify the perception of the participant. This limitation should be explicitly mentioned.

Response:

The method used to aggregate SCT and KFP scores into a total diagnostic reasoning score is explicitly described.

Equal weighting of SCT and KFP components is stated.

The binary nature of the confidence question (yes/no) is specified.

3.3 Statistical Analysis

Briefly describe why linear regression was used as the analysis method. (normality of residuals or robustness of the regression analysis).

Response:

A justification for the use of linear regression has been added, highlighting its appropriateness and robustness.

4. Results

Clinical vs. Statistical Significance.

The absolute difference in percentages between groups (~7%).

Add a single sentence explaining whether this statistic can be considered educationally meaningful.

Do not over-analyze or conclude.

The written results section is primarily objective; thus, it should not include any type of causal terminology.

Response:

The Results section now strictly uses descriptive, non-causal language.

A single sentence clarifies that, although statistically significant, the absolute difference in mean scores (~7%) was modest, without interpreting its educational relevance.

5. Discussion

Comments addressed: Assessment Format Bias

In the discussion, students may be advantaged by school-type assessments.

Suggest further expansion on the limits of Construct Validity.

Confidence vs. Competence

Discussion of the confidence-calibration concept is well thought out.

Suggest reiterating that confidence is an educational target and not the endpoint of education.

Figure 1 Interpretation

The legend for Figure 1 describes the figure's findings using interpretative terminology (ie, "appears to promote better management").

Suggest using terminology consistent with PLOS ONE to label this finding, for example, "Higher Diagnostic Scores are associated with these Factors."

Response:

Potential bias related to the vignette-based assessment format is explicitly discussed.

The limits of construct validity are expanded.

The distinction between confidence and competence is reinforced, emphasizing confidence as an educational target rather than an endpoint.

Figure 1 legend has been revised to use strictly associative terminology (associated with).

A clear statement now specifies that findings relate to diagnostic reasoning assessed through vignette-based tools and should not be interpreted as reflecting real-life clinical care.

6. Conclusion

Comments addressed: In regard to recommendations, there will be recommendations to replace residual phrases regarding causation with phrases of association and to clarify that these findings relate to performance on diagnostic reasoning, not performance on clinical care.

Response: Residual causal language was removed.

The conclusion now explicitly states that findings pertain to vignette-based diagnostic reasoning and not to clinical care outcomes.

7. Ethics, Data Availability, and Transparency

Response: Modifications done in editor section

8. Language and Presentation

Response:

Minor typographical and stylistic issues were corrected. The manuscript was carefully edited to ensure clarity and consistency.

Attachment

Submitted filename: Response to Reviewers.docx

pone.0347129.s005.docx (21.8KB, docx)

Decision Letter 1

Renato Melo, Renato Melo

29 Mar 2026

Assessment of diagnostic reasoning in acute vertigo using vignette-based tools: a cross-sectional comparison between general practitioners and final-year medical students

PONE-D-25-58696R1

Dear Dr. Maquet,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Renato S. Melo, PhD

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.-->

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

-->2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Yes

Reviewer #2: Yes

**********

-->3. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #1: Yes

Reviewer #2: Yes

**********

-->4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #2: (No Response)

**********

-->5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: Yes

Reviewer #2: Yes

**********

-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: The issue is not only that vignette-based tools do not reflect real-life performance, but that in acute vestibular syndrome, diagnostic reasoning is inseparable from bedside examination (e.g., oculomotor findings). Therefore, vignette-based assessments may lack construct validity for this specific clinical domain, limiting the interpretability of comparisons between learners and practitioners

Reviewer #2: I’d like to take a moment to thank you for the opportunity to comment on this revised version of the manuscript. I see that the authors have very effectively addressed many of the comments from the previous review cycle, especially those comments related to issues of interpretive overreach, construct validity, and clarifying the definition of what is and is not being measured.

Abstract and Title:

The authors have revised the abstract and title to more accurately reflect the vignette-based nature of the assessment of diagnostic reasoning and less on how accurately it can diagnose clinically. The author's interpretive language has been toned down, and the conclusions drawn in the study now reflect the design of the study.

Introduction:

The authors nicely frame the educational context by explaining that an “educational paradox” exists when there is more emphasis placed on theoretical content versus what has been gained through experience. The hypothesis of the study is presented in a more appropriate position and provides a more cohesive rationale for the decision to use SCTs and KFPs.

Methods:

I can now see that the authors have provided detailed descriptions of the study population, how the questionnaires were constructed, and how the Expert Panel was created. By including detailed explanations of how the scores were aggregated and equally weighed between the SCT and KFP scores, the authors have increased the amount of transparency and reproducibility of the methods. The authors appropriately acknowledge that selection bias may have occurred as a result of response rates or different levels of exposure to the subjects.

Statistical Analysis:

The statistical methods employed by the authors appear to be appropriate and are clearly articulated. Including an additional explanation of the rational of using linear regression modeling provides more clarity in respect to the design and methodology of the study. The reporting of information is consistent with the expectations outlined in PLOS ONE.

Results:

In my opinion, the results presented by the authors were objectively presented. The authors utilized non-causal, descriptive language when discussing the results of the study. The authors acknowledged that although statistically significant differences were found to exist in between groups, the magnitude of these differences may not be significant enough to have an impact from an educational standpoint or from a clinical standpoint.

Discussion:

The Discussion section of the manuscript is very well balanced and thought out by the authors. The authors provide clear discussions on potential sources of assessment-format bias, limitations to construct validity, and the differences between confidence and competence. In addition to the previous comment, the manuscript continues to reinforce that the findings of the study should not be generalized to the real-world clinical outcomes but rather to performance on vignette-based tasks for diagnostic reasoning.

Conclusion:

The conclusion of the manuscript is concise, accurate, and presented in a moderately reserved fashion. The authors have removed any residual causal language that may still be present.

Ethics, Data Availability, and Transparency:

The authors have appropriately completed, communicated, and were compliant with all PLOS ONE guidelines regarding these sections.

Overall Assessment:

This revised manuscript has been written in accordance with the methodological, ethical, and reporting requirements of PLOS ONE, and the authors have effectively responded to the review comments and have greatly enhanced the clarity, rigor, and interpretability of their study. I would recommend that the manuscript be accepted for publication.

**********

-->7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review?  For information about this choice, including consent withdrawal, please see our Privacy Policy.-->

Reviewer #1: Yes:  Sergio Carmona

Reviewer #2: No

**********

Acceptance letter

Renato Melo, Renato Melo

PONE-D-25-58696R1

PLOS One

Dear Dr. Maquet,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

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on behalf of

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Academic Editor

PLOS One

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 File. Questionnaire used for the assessment of diagnostic reasoning in acute vertigo.

    Full questionnaire used in the study, including participant demographics, prior training and clinical exposure to vertigo, Script Concordance Test (SCT) and Key Features Problems (KFP)–based clinical vignettes assessing diagnostic reasoning in acute vertigo.

    (DOCX)

    pone.0347129.s001.docx (21.4KB, docx)
    S2 File. Participant information and consent statement.

    Information notice provided to participants prior to questionnaire completion, describing the study objectives, voluntary participation, anonymization of data, and consent for use of responses for research and publication purposes.

    (DOCX)

    pone.0347129.s002.docx (13.5KB, docx)
    S3 Table. Anonymized study dataset.

    Fully anonymized dataset used for all analyses presented in the manuscript. The dataset contains no directly or indirectly identifying information.

    (XLSX)

    pone.0347129.s003.xlsx (44.3KB, xlsx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    pone.0347129.s005.docx (21.8KB, docx)

    Data Availability Statement

    All relevant data are within the paper and its Supporting Information files.

    Articles from PLOS One are provided here courtesy of PLOS

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