Sleep Medicine Program, Louisiana State University Health Sciences Center, Shreveport, LA 71130, USA.
J Clin Sleep Med. 2010 Jun 15;6(3):292-6.
The rule of diagnostic parsimony--otherwise known as "Ockham's Razor"--teaches students of medicine to find a single unifying diagnosis to explain a given patient's symptoms. While this approach has merits in some settings, a more comprehensive approach is often needed for patients with chronic, nonspecific presentations for which there is a broad differential diagnosis. The cardinal manifestations of sleep disorders--daytime neurocognitive impairment and subjective sleep disturbances-are examples of such presentations. Successful sleep medicine clinicians therefore approach every patient with the knowledge that multiple diagnoses-rather than simply one-are likely to be found. Teaching an integrated and comprehensive approach to other clinicians in an organized and reproducible fashion is challenging, and the evaluation of effectiveness of such teaching is even more so. As a practical aid for teaching the approach to--and evaluation of--a comprehensive sleep medicine encounter, five functional domains of sleep medicine clinical problem-solving are presented as potential sources for sleep/wake disruption: (1) circadian misalignment, (2) pharmacologic factors, (3) medical factors, (4) psychiatric/psychosocial factors, and (5) primary sleep medicine diagnoses. These domains are presented and explained in an easy-to-remember "five finger" format. The five finger format can be used in real time to evaluate the completeness of a clinical encounter, or can be used in the design of standardized patients to identify areas of strength and potential weakness. A score sheet based upon this approach is offered as an alternative to commonly used Likert scales as a potentially more objective and practical measure of clinical problem-solving competence, making it useful for training programs striving to achieve or maintain fellowship accreditation.
诊断简约法则——也称为“奥卡姆剃刀”——教导医学学生寻找一个单一的统一诊断来解释给定患者的症状。虽然这种方法在某些情况下有其优点，但对于慢性、非特异性表现且存在广泛鉴别诊断的患者，通常需要更全面的方法。睡眠障碍的主要表现——白天神经认知障碍和主观睡眠障碍——就是这种表现的例子。因此，成功的睡眠医学临床医生在为每位患者提供治疗时，都知道可能会发现多种诊断，而不仅仅是一种诊断。以有组织且可重复的方式向其他临床医生传授这种综合全面的方法具有挑战性，而对这种教学的有效性进行评估则更加困难。作为教授综合睡眠医学就诊和评估综合睡眠医学就诊的实用辅助工具，提出了睡眠/唤醒障碍的五个潜在功能领域，即睡眠医学临床问题解决的五个功能域：（1）昼夜节律失调；（2）药物因素；（3）医学因素；（4）精神科/心理社会因素；（5）原发性睡眠医学诊断。这些领域以易于记忆的“五指”格式呈现和解释。五指格式可用于实时评估临床就诊的完整性，也可用于设计标准化患者以识别优势和潜在弱点领域。提供基于这种方法的评分表作为常用李克特量表的替代方案，作为临床问题解决能力的潜在更客观和实用的衡量标准，使其成为努力实现或保持研究员认证的培训计划的有用工具。
