Department of Internal Medicine, Nantes University Hospital Centre, Nantes, FranceTeam for Biostatistics (EA 4572), Department of Clinical Research and Subjective Measures in Health Science, University of Nantes, Nantes, FranceWilson Centre for Research in Education, University of Toronto, Toronto, Ontario, CanadaDepartment of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
Med Educ. 2010 Sep;44(9):926-935. doi: 10.1111/j.1365-2923.2010.03748.x.
A key element of medical competence is problem solving. Previous work has shown that doctors use inductive reasoning to progress from facts to hypotheses and deductive reasoning to move from hypotheses to the gathering of confirmatory information. No individual assessment method has been designed to quantify the use of inductive and deductive procedures within clinical reasoning. The aim of this study was to explore the feasibility and reliability of a new method which allows for the rapid identification of the style (inductive or deductive) of clinical reasoning in medical students and experts.
The study included four groups of four participants. These comprised groups of medical students in Years 3, 4 and 5 and a group of specialists in internal medicine, all at a medical school with a 6-year curriculum in France. Participants were asked to solve four clinical problems by thinking aloud. The thinking expressed aloud was immediately transcribed into concept maps by one or two 'writers' trained to distinguish inductive and deductive links. Reliability was assessed by estimating the inter-writer correlation. The calculated rate of inductive reasoning, the richness score and the rate of exhaustiveness of reasoning were compared according to the level of expertise of the individual and the type of clinical problem.
The total number of maps drawn amounted to 32 for students in Year 4, 32 for students in Year 5, 16 for students in Year 3 and 16 for experts. A positive correlation was found between writers (R = 0.66-0.93). Richness scores and rates of exhaustiveness of reasoning did not differ according to expertise level. The rate of inductive reasoning varied as expected according to the nature of the clinical problem and was lower in experts (41% versus 67%).
This new method showed good reliability and may be a promising tool for the assessment of medical problem-solving skills, giving teachers a means of diagnosing how their students think when they are confronted with clinical problems.
医学能力的一个关键要素是解决问题。先前的研究表明，医生使用归纳推理从事实进展到假设，使用演绎推理从假设进展到收集确认信息。目前还没有设计出任何单一的评估方法来量化临床推理中归纳和演绎程序的使用。本研究旨在探讨一种新方法的可行性和可靠性，该方法可以快速识别医学生和专家临床推理的风格（归纳或演绎）。
该研究包括四组各四名参与者。这些组包括法国六年制医学院三年级、四年级和五年级的医学生组以及内科专家组。要求参与者通过大声思考来解决四个临床问题。立即由一两名经过训练可区分归纳和演绎联系的“作家”将大声表达的思维转录成语义图。通过估计作家之间的相关性来评估可靠性。根据个人的专业水平和临床问题的类型，比较归纳推理率、丰富度得分和推理的完备率。
学生四年级共绘制了 32 张图，五年级绘制了 32 张图，三年级学生绘制了 16 张图，专家绘制了 16 张图。作家之间存在正相关（R = 0.66-0.93）。推理的丰富度得分和完备率与专业水平无关。归纳推理率与预期相符，根据临床问题的性质而变化，专家的比率较低（41%比 67%）。
这种新方法具有良好的可靠性，可能是评估医学解决问题能力的一种有前途的工具，为教师提供了一种诊断学生在面对临床问题时如何思考的方法。
