Centre for Evidence Based Medicine, Department of Primary Care, Old Road Campus, Headington Oxford OX3 7LF, UK.
J Eval Clin Pract. 2009 Dec;15(6):964-9. doi: 10.1111/j.1365-2753.2009.01243.x.
Rationale and aim The rapidly changing knowledge base of clinical practice highlights the need to keep abreast of knowledge changes that are most relevant for the practitioner. We aimed to develop a model for reflection on clinical practice that identified the key elements of medical knowledge needed for good medical practice. Method The dual theory of cognition, an integration of intuitive and analytic processes, provided the framework for the study. The design looked at the congruence between the clinical thinking process and the dual theory. A one-year study was conducted in general practice clinics in Oxfordshire, UK. Thirty-five general practitioners participated in 20-minute interviews to discuss how they worked through recently seen clinical cases. Over a one-year period 72 cases were recorded from 35 interviews. These were categorized according to emerging themes, which were manually coded and substantiated with verbatim quotations. Results There was a close fit between the dual theory and participants' clinical thinking processes. This included instant problem framing, consistent with automatic intuitive thinking, focusing on the risk and urgency of the case. Salient features accounting for these choices were recognizable. There was a second reflective phase, leading to the review of initial judgements. Conclusions The proposed model highlights the critical steps in decision making. This allows regular recalibration of knowledge that is most critical at each of these steps. In line with good practice, the model also links the crucial knowledge used in decision making, to value judgments made in relation to the patient.
背景与目的 临床实践的知识库变化迅速，这突出表明需要了解与从业者最相关的知识变化。我们旨在开发一种用于反思临床实践的模型，以确定良好医疗实践所需的医学知识的关键要素。
方法 双认知理论（将直觉和分析过程相结合的理论）为这项研究提供了框架。该设计研究了临床思维过程与双认知理论之间的一致性。在英国牛津郡的普通科诊所进行了为期一年的研究。35 名普通科医生参加了 20 分钟的访谈，讨论他们如何处理最近看到的临床病例。在一年的时间里，从 35 次访谈中记录了 72 个案例。这些案例根据出现的主题进行了分类，然后手动对主题进行编码，并提供了逐字引用加以证实。
结果 双认知理论与参与者的临床思维过程非常吻合。这包括即时问题框架，与自动直觉思维一致，重点关注病例的风险和紧迫性。可以识别出导致这些选择的明显特征。然后进入第二个反思阶段，对初始判断进行审查。
结论 所提出的模型突出了决策制定的关键步骤。这允许定期重新校准在这些步骤中每个步骤最关键的知识。与良好实践一致的是，该模型还将决策中使用的关键知识与针对患者做出的价值判断联系起来。
