Crebbin Wendy, Beasley Spencer W, Watters David A K
Education Development and Research Department, Royal Australasian College of Surgeons, Melbourne, Victoria, Australia.
ANZ J Surg. 2013 Jun;83(6):422-8. doi: 10.1111/ans.12180. Epub 2013 May 3.
Clinical decision making is a core competency of surgical practice. It involves two distinct types of mental process best considered as the ends of a continuum, ranging from intuitive and subconscious to analytical and conscious. In practice, individual decisions are usually reached by a combination of each, according to the complexity of the situation and the experience/expertise of the surgeon. An expert moves effortlessly along this continuum, according to need, able to apply learned rules or algorithms to specific presentations, choosing these as a result of either pattern recognition or analytical thinking. The expert recognizes and responds quickly to any mismatch between what is observed and what was expected, coping with gaps in information and making decisions even where critical data may be uncertain or unknown. Even for experts, the cognitive processes involved are difficult to articulate as they tend to be very complex. However, if surgeons are to assist trainees in developing their decision-making skills, the processes need to be identified and defined, and the competency needs to be measurable. This paper examines the processes of clinical decision making in three contexts: making a decision about how to manage a patient; preparing for an operative procedure; and reviewing progress during an operative procedure. The models represented here are an exploration of the complexity of the processes, designed to assist surgeons understand how expert clinical decision making occurs and to highlight the challenge of teaching these skills to surgical trainees.
临床决策是外科实践的一项核心能力。它涉及两种截然不同的思维过程，最好将其视为一个连续体的两端，范围从直觉和潜意识的一端到分析和有意识的另一端。在实际操作中，根据情况的复杂性以及外科医生的经验/专业知识，个体决策通常是通过这两种思维过程的结合来达成的。专家能够根据需要在这个连续体上轻松移动，能够将所学的规则或算法应用于特定的临床表现，通过模式识别或分析性思维来做出选择。专家能够迅速识别并应对观察到的情况与预期情况之间的任何不匹配，即使在关键数据可能不确定或未知的情况下，也能处理信息缺口并做出决策。即使对于专家来说，所涉及的认知过程也很难清晰表述，因为它们往往非常复杂。然而，如果外科医生要帮助实习生培养他们的决策技能，就需要识别和定义这些过程，并且这种能力需要是可衡量的。本文在三种情境下审视临床决策过程：决定如何管理患者；为手术操作做准备；以及在手术过程中评估进展情况。这里所呈现的模型是对这些过程复杂性的一种探索，旨在帮助外科医生理解专家临床决策是如何发生的，并突出向外科实习生传授这些技能所面临的挑战。
