Durning Steven J, Ratcliffe Temple, Artino Anthony R, van der Vleuten Cees, Beckman Thomas J, Holmboe Eric, Lipner Rebecca S, Schuwirth Lambert
Professor of Medicine and Pathology, Uniformed Services University.
J Contin Educ Health Prof. 2013 Fall;33(4):215-23. doi: 10.1002/chp.21188.
There is limited understanding of how clinical reasoning is developed, maintained, and objectively assessed. Using the theoretical lens of deliberate practice, we explored physicians' views on clinical reasoning. We compared responses from internists (faculty) and internal medicine interns, to identify potential qualitative and/or quantitative differences in how clinical reasoning is developed and maintained.
Participants' free-text comments regarding how clinical reasoning is developed, maintained, and objectively assessed were analyzed. Three investigators coded responses using a constant-comparative, grounded theory approach. We also compared the frequencies of each theme between the 2 groups.
Twenty-two faculty and 17 interns participated in this study. Faculty and intern themes for how clinical reasoning is developed, maintained, and objectively assessed were similar, but quantitative and qualitative differences emerged. Interrater reliability of themes was high (overall kappa: 0.92; range: 0.88-0.98). Only experts (faculty) mentioned the value of teaching for development and maintenance of clinical reasoning. Interns focused on knowledge acquisition activities and use of online resources. Experts and intern participants both struggled with how to best measure clinical reasoning; direct observation was rarely mentioned as a strategy.
Consistent with our theoretical expectations, we found quantitative and qualitative differences in participants' responses, which have implications for teaching and assessment of clinical reasoning. By capturing the types of activities and their relative frequencies within and between these groups, this work adds to the deliberate practice literature.
目前对于临床推理如何发展、维持以及客观评估的理解有限。我们运用刻意练习的理论视角，探讨了医生对临床推理的看法。我们比较了内科医生（教员）和内科实习医生的回答，以确定在临床推理的发展和维持方式上潜在的定性和/或定量差异。
分析了参与者关于临床推理如何发展、维持以及客观评估的自由文本评论。三名研究人员采用持续比较的扎根理论方法对回答进行编码。我们还比较了两组之间每个主题的出现频率。
22名教员和17名实习医生参与了本研究。教员和实习医生关于临床推理如何发展、维持以及客观评估的主题相似，但出现了定量和定性差异。主题的评分者间信度较高（总体kappa值：0.92；范围：0.88 - 0.98）。只有专家（教员）提到了教学对临床推理发展和维持的价值。实习医生关注知识获取活动和在线资源的使用。专家和实习参与者都在如何最好地衡量临床推理方面存在困难；直接观察很少被提及为一种策略。
与我们的理论预期一致，我们在参与者的回答中发现了定量和定性差异，这对临床推理的教学和评估具有启示意义。通过捕捉这些组内和组间活动的类型及其相对频率，这项工作为刻意练习文献增添了内容。
