Mamede Silvia, Schmidt Henk G, Rikers Remy M J P, Penaforte Júlio César, Coelho-Filho João Macedo
Faculty of Social Sciences, Erasmus University, Rotterdam, the Netherlands.
Acad Med. 2008 Dec;83(12):1210-6. doi: 10.1097/ACM.0b013e31818c71d7.
While diagnosing problems, physicians frequently switch from nonanalytical to reflective reasoning. The conditions inducing doctors to reflect are largely unknown. The authors investigated whether a shift to reflection occurs when physicians perceive a case as problematic, and its effects on diagnostic accuracy.
The authors conducted two within-subjects experiments in Brazilian teaching hospitals in 2007. In Experiment 1, 20 medical residents diagnosed the same 10 clinical cases under two experimental conditions: a nonproblematic versus a problematic context. (The latter was created by informing participants that other physicians failed to diagnose the case previously.) In addition, participants judged whether a set of medical concepts were related to the case, and response time was measured. In Experiment 2, 18 residents diagnosed two cases while thinking aloud. The authors hypothesized that a case perceived as problematic would trigger reflection, leading to higher diagnostic accuracy, lower response times for recognizing concepts (Experiment 1), more time for diagnosing, and more elaborate think-aloud protocols (Experiment 2).
Experiment 1: Accuracy of diagnosis was significantly higher within the problematic context, and participants were faster in deciding whether concepts were related to the case. The same cases were evaluated as more complex and less frequently seen. Experiment 2: Time spent on diagnosis, memory for case findings, and inferences derived from the cases were significantly higher within the problematic context.
A context perceived as problematic induced reflection in the participating clinicians, as indicated by lower response times, more time spent on diagnosis, and more elaborate protocols. Reflective reasoning comprised more careful analysis of findings and alternative diagnoses, and increased diagnostic accuracy.
在诊断问题时，医生常常从非分析性推理转向反思性推理。促使医生进行反思的条件在很大程度上尚不明确。作者调查了医生在认为某个病例存在问题时是否会转向反思，以及这种转变对诊断准确性的影响。
作者于2007年在巴西教学医院进行了两项受试者内实验。在实验1中，20名住院医生在两种实验条件下诊断相同的10个临床病例：无问题情境与有问题情境。（后者是通过告知参与者其他医生之前未能诊断出该病例而创设的。）此外，参与者判断一组医学概念是否与该病例相关，并测量反应时间。在实验2中，18名住院医生在边思考边大声说出想法的同时诊断两个病例。作者假设，被认为有问题的病例会引发反思，从而提高诊断准确性、缩短识别概念的反应时间（实验1）、增加诊断时间，并产生更详尽的出声思考记录（实验2）。
实验1：在有问题情境下诊断准确性显著更高且参与者判断概念是否与病例相关时速度更快。相同病例被评估为更复杂且较少见。实验2：在有问题情境下，用于诊断的时间、对病例发现的记忆以及从病例中得出的推论显著更多。
如反应时间缩短、诊断时间增加以及记录更详尽所表明的，被认为有问题的情境会促使参与的临床医生进行反思。反思性推理包括对发现和替代诊断进行更仔细的分析，并提高了诊断准确性。
