Dr. Ilgen is assistant professor, Division of Emergency Medicine, University of Washington, School of Medicine, Seattle, Washington. Dr. Bowen is professor, Department of Medicine, Oregon Health & Science University, School of Medicine, Portland, Oregon. Mr. McIntyre is a student, University of Washington, School of Medicine, Seattle, Washington. Dr. Banh is assistant clinical professor, Department of Emergency Medicine, University of California, San Francisco, School of Medicine, Fresno, California. Dr. Barnes is assistant professor, Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, California. Dr. Coates is professor of clinical medicine, Department of Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine, and Los Angeles Biomedical Research Institute, Los Angeles, California. Dr. Druck is associate professor, Department of Emergency Medicine, University of Colorado, School of Medicine, Denver, Colorado. Dr. Fix is assistant professor, Division of Emergency Medicine, University of Utah, School of Medicine, Salt Lake City, Utah. Dr. Rimple is associate professor, Department of Emergency Medicine, University of New Mexico, School of Medicine, Albuquerque, New Mexico. Dr. Yarris is associate professor, Department of Emergency Medicine, Oregon Health & Science University, School of Medicine, Portland, Oregon. Dr. Eva is professor and director of education research and scholarship, Department of Medicine, and senior scientist, Centre for Health Education Scholarship, University of British Columbia, Vancouver, British Columbia, Canada.
Acad Med. 2013 Oct;88(10):1545-51. doi: 10.1097/ACM.0b013e3182a31c1e.
Although decades of research have yielded considerable insight into physicians' clinical reasoning processes, assessing these processes remains challenging; thus, the authors sought to compare diagnostic performance and the utility of clinical vignette-based assessment under testing conditions designed to encourage either automatic or analytic thought.
This 2011-2012 multicenter randomized study of 393 clinicians (medical students, postgraduate trainees, and faculty) measured diagnostic accuracy on clinical vignettes under two conditions: one encouraged participants to give their first impression (FI), and the other led participants through a directed search (DS) for the correct diagnosis. The authors compared accuracy, feasibility, reliability, and relation to United States Medical Licensing Exam (USMLE) scores under each condition.
A 2 (instructional condition) × 2 (vignette complexity) × 3 (experience level) analysis of variance revealed no difference in accuracy as a function of instructional condition (F[1,379] = 2.44, P = .12), but demonstrated the expected main effects of vignette complexity (F[1,379] = 965.2, P < .001) and experience (F[2,379] = 39.6, P < .001). Pearson correlations revealed greater associations between assessment scores and USMLE performance in the FI condition than in the DS condition (P < .001). Spearman-Brown calculations consistently indicated that alpha ≥ 0.75 could be achieved more efficiently under the FI condition relative to the DS condition.
Instructions to trust one's first impres-sions result in similar performance when compared with instructions to consider clinical information in a systematic fashion, but have greater utility when used for the purposes of assessment.
尽管几十年来的研究已经深入了解了医生的临床推理过程，但评估这些过程仍然具有挑战性；因此，作者试图比较在旨在鼓励自动或分析性思维的测试条件下，诊断表现和基于临床情况的评估的效用。
这项 2011 年至 2012 年对 393 名临床医生（医学生、研究生和教师）进行的多中心随机研究，在两种情况下通过临床情况评估诊断准确性：一种情况鼓励参与者给出第一印象（FI），另一种情况引导参与者进行正确诊断的定向搜索（DS）。作者比较了在每种情况下的准确性、可行性、可靠性和与美国医师执照考试（USMLE）分数的关系。
2（教学条件）×2（情况复杂性）×3（经验水平）方差分析显示，教学条件对准确性没有影响（F[1,379]=2.44，P=0.12），但显示了情况复杂性（F[1,379]=965.2，P<.001）和经验（F[2,379]=39.6，P<.001）的预期主效应。皮尔逊相关显示，FI 条件下评估分数与 USMLE 表现之间的相关性大于 DS 条件（P<.001）。斯皮尔曼-布朗计算一致表明，FI 条件下比 DS 条件下更有效地达到 α≥0.75。
与系统考虑临床信息的指令相比，信任第一印象的指令导致相似的表现，但在评估目的下具有更大的效用。
