Wimmers Paul F, Fung Cha-Chi
Dean's Office, Department of Educational Development and Research, School of Medicine, University of California Los Angeles, Los Angeles, California, USA.
Med Educ. 2008 Jun;42(6):580-8. doi: 10.1111/j.1365-2923.2008.03089.x.
The finding of case or content specificity in medical problem solving moved the focus of research away from generalisable skills towards the importance of content knowledge. However, controversy about the content dependency of clinical performance and the generalisability of skills remains.
This study aimed to explore the relative impact of both perspectives (case specificity and generalisable skills) on different components (history taking, physical examination, communication) of clinical performance within and across cases.
Data from a clinical performance examination (CPX) taken by 350 Year 3 students were used in a correlated traits-correlated methods (CTCM) approach using confirmatory factor analysis, whereby 'traits' refers to generalisable skills and 'methods' to individual cases. The baseline CTCM model was analysed and compared with four nested models using structural equation modelling techniques. The CPX consisted of three skills components and five cases.
Comparison of the four different models with the least-restricted baseline CTCM model revealed that a model with uncorrelated generalisable skills factors and correlated case-specific knowledge factors represented the data best. The generalisable processes found in history taking, physical examination and communication were responsible for half the explained variance, in comparison with the variance related to case specificity. Conclusions Pure knowledge-based and pure skill-based perspectives on clinical performance both seem too one-dimensional and new evidence supports the idea that a substantial amount of variance contributes to both aspects of performance. It could be concluded that generalisable skills and specialised knowledge go hand in hand: both are essential aspects of clinical performance.
在医学问题解决中发现病例或内容特异性，使得研究重点从可推广技能转向内容知识的重要性。然而，关于临床能力的内容依赖性和技能可推广性的争议仍然存在。
本研究旨在探讨这两种观点（病例特异性和可推广技能）对病例内和病例间临床能力不同组成部分（病史采集、体格检查、沟通）的相对影响。
采用验证性因子分析的相关特质-相关方法（CTCM），使用了350名三年级学生的临床能力考试（CPX）数据，其中“特质”指可推广技能，“方法”指个体病例。使用结构方程建模技术分析基线CTCM模型，并与四个嵌套模型进行比较。CPX由三个技能组成部分和五个病例组成。
将四个不同模型与限制最少的基线CTCM模型进行比较，结果显示，一个具有不相关可推广技能因子和相关病例特异性知识因子的模型最能代表数据。与病例特异性相关的方差相比，在病史采集、体格检查和沟通中发现的可推广过程解释了一半的方差。结论关于临床能力的纯粹基于知识和纯粹基于技能的观点似乎都过于片面，新证据支持这样一种观点，即大量方差对能力的两个方面都有贡献。可以得出结论，可推广技能和专业知识相辅相成：两者都是临床能力的重要方面。
