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To identify those radiological diagnostic thinking approaches associated with success or failure in film interpretation.A questionnaire was designed, piloted and tested for validity and reliability prior to use. This questionnaire was adapted and modified from the 'diagnostic thinking inventory' by Bordage et al.21 One hundred and eighty students anonymously answered the questionnaire prior to their 15-case comprehensive film interpretation examination. Oral film-reading sessions were performed on a stratified random sample (n = 48) of students with complete transcripts of each session recorded. Spearman's correlation coefficient and multiple regression analysis statistics were applied to the questionnaire data. The unpaired t-test, ANOVA and correlation statistics were used to analyse the oral film-reading sessions.The most successful students were those who could easily see the integration of radiology with other subjects (P = 0.0042), students who could easily link the clinical information to the radiographic signs (P = 0.0354), and students who could easily identify the 'key' abnormal radiographic findings (P = 0.047). Students who used a flexible but complete search pattern performed significantly better (P = 0.0235) than students using any other search pattern approach.Radiology is a classic example of clinical problem solving and thus should be taught in that format. Those same factors which differentiate expert from novice diagnosticians are also evident in more successful vs. less successful students in radiology.