Benbassat Jochanan, Baumal Reuben, Heyman Samuel N, Brezis Mayer
Myers-JDC-Brookdale Institute, Smokler Center for Health Policy Research, PO Box 3886, Jerusalem 91037, Israel.
Acad Med. 2005 Dec;80(12):1121-6. doi: 10.1097/00001888-200512000-00012.
How medical students are taught physical examination (PE) skills appears to have changed little since the 1950s. Textbooks are organized according to organ systems and describe methods of eliciting and recording history and PE data using a routine format. In many medical schools, the preclinical teaching programs for clinical examination skills similarly emphasize an orderly collection of data. Teaching students to use diagnostic reasoning is postponed until students have learned history-taking and PE skills. The authors propose three modifications to this educational approach. First, rather than performing the clinical examination using a routine format, students should be encouraged to form diagnostic hypotheses early on while listening to the patient's narrative, and conduct the subsequent search for history and PE data in a reflective way in order to confirm or refute these hypotheses. Second, the authors propose that interviewing patients and conducting the PE be taught by one-on-one tutoring until students achieve mastery. Last, they suggest that the PE be guided not only by students' diagnostic hypotheses, but also by patients' expectations. These modifications are consistent with current trends in medical education that encourage a reflective practice and problem-based learning (PBL), and they also introduce medical students to the precepts of clinical reasoning. The authors suggest that challenging students to seek specific physical findings may increase the likelihood of detecting findings when they are present, and may transform patient interviewing and conducting the PE from routine activities into intellectually exciting experiences.
自20世纪50年代以来，医学生体格检查（PE）技能的教学方式似乎变化不大。教科书是按照器官系统编排的，并描述了使用常规格式引出和记录病史及体格检查数据的方法。在许多医学院校，临床检查技能的临床前教学项目同样强调有序收集数据。在学生学会病史采集和体格检查技能之前，教导他们运用诊断推理的过程会被推迟。作者对这种教育方法提出了三点改进建议。首先，学生不应按照常规格式进行临床检查，而应在倾听患者叙述时尽早形成诊断假设，并以反思的方式随后搜索病史和体格检查数据，以证实或反驳这些假设。其次，作者建议在学生掌握之前，通过一对一辅导来教授询问患者和进行体格检查。最后，他们建议体格检查不仅要以学生的诊断假设为指导，还要以患者的期望为指导。这些改进与当前医学教育中鼓励反思性实践和基于问题的学习（PBL）的趋势相一致，并且它们还向医学生介绍了临床推理的原则。作者认为，要求学生寻找特定的体格检查发现可能会增加发现这些发现的可能性，并可能将询问患者和进行体格检查从常规活动转变为令人兴奋的智力体验。
