van Gessel Elisabeth, Nendaz Mathieu R, Vermeulen Bernard, Junod Alain, Vu Nu V
Department of Anaesthesiology, Pharmacology and Surgery Intensive Care, Faculty of Medicine, University of Geneva, Switzerland.
Med Educ. 2003 Nov;37(11):966-74. doi: 10.1046/j.1365-2923.2003.01672.x.
To facilitate students' transition from basic, science-oriented, problem-based learning (PBL) to clinical reasoning-oriented PBL, the University of Geneva School of Medicine introduced a 12-week unit of Introduction to Clinical Reasoning (ICR) at the beginning of its fourth or clerkship year.
The aims of the present study were to determine, after 12 weeks in the ICR unit, to what extent students had: (1) identified the learning content set by the faculty while adapting to the hypothetico-deductive reasoning approach; (2) familiarised themselves with the clinical reasoning-oriented learning process, and (3) transferred and further developed this process during the clinical years.
Students' derived objectives from the problems were compared to the objectives preset by the faculty to determine acquisition of intended learning content. To assess their adaptation to the clinical reasoning-oriented PBL approach, students (n = 124) were asked to list and freely comment on aspects of the unit they felt most at ease with or had difficulty with, and to complete a questionnaire on the clinical reasoning process (CRP). The same questionnaire was administered 6 and 12 months later to assess the evolution of the students' self-perception during clerkships.
On average, student objectives matched 62% of faculty objectives. Half of the missed (38%) objectives were in basic sciences. Students generated 16% additional objectives, also predominantly in the basic sciences category (41%). Free comments indicated that the difficulties perceived by students were very similar to those previously reported in studies on reasoning and errors, such as difficulty in gathering, interpreting and weighting relevant data, synthesising information, and organising it hierarchically. These results were confirmed with the CRP questionnaire administered at the end of the unit. For most of the competencies assessed on the CRP questionnaire, a gradual improvement was seen to have occurred by 6 and 12 months after the unit.
To ease students' transition from the preclinical to clinical years, a learning unit should give them the opportunity to train their clinical reasoning processes on standardised and prototypical problems, before encountering real patients with more ill-structured problems during clerkships. Such a transitional structure should particularly emphasise a developed repertoire of problem representations, recognition of key findings and a hierarchical classification of working hypotheses. It should foster the creation of links between the acquired basic clinical knowledge and the diagnostic, management and therapy steps of problem solving.
为促进学生从以基础科学为导向的基于问题的学习（PBL）过渡到以临床推理为导向的PBL，日内瓦大学医学院在其第四年或实习年开始时引入了一个为期12周的临床推理导论（ICR）单元。
本研究的目的是在ICR单元学习12周后，确定学生在多大程度上：（1）在适应假设-演绎推理方法的同时，识别了教师设定的学习内容；（2）熟悉了以临床推理为导向的学习过程，以及（3）在临床实习期间转移并进一步发展了这一过程。
将学生从问题中得出的目标与教师预先设定的目标进行比较，以确定预期学习内容的掌握情况。为了评估他们对以临床推理为导向的PBL方法的适应情况，要求学生（n = 124）列出并自由评论他们在该单元中感觉最轻松或最困难的方面，并完成一份关于临床推理过程（CRP）的问卷。在6个月和12个月后发放相同的问卷，以评估学生在实习期间自我认知的演变。
学生的目标平均与教师目标的62%相匹配。未达到的目标（38%）中有一半是基础科学方面的。学生还提出了16%的额外目标，也主要集中在基础科学类别（41%）。自由评论表明，学生们意识到的困难与先前关于推理和错误的研究中所报告的困难非常相似，例如在收集、解释和权衡相关数据、综合信息以及进行层次化组织方面的困难。这些结果在单元结束时发放的CRP问卷中得到了证实。对于CRP问卷中评估的大多数能力，在单元结束后的6个月和12个月时出现了逐步改善。
为了缓解学生从临床前阶段到临床阶段的过渡，一个学习单元应该让他们有机会在标准化和典型问题上训练临床推理过程，然后在实习期间遇到结构更不清晰的真实患者之前。这样的过渡结构应该特别强调丰富的问题表征库、关键发现的识别以及工作假设的层次分类。它应该促进在获得的基础临床知识与问题解决的诊断、管理和治疗步骤之间建立联系。
