Chopra Vineet, Harrod Molly, Winter Suzanna, Forman Jane, Quinn Martha, Krein Sarah, Fowler Karen E, Singh Hardeep, Saint Sanjay
VA Ann Arbor Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.
Department of Internal Medicine, Division of Hospital Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.
J Hosp Med. 2018 Oct 1;13(10):668-672. doi: 10.12788/jhm.2966. Epub 2018 Apr 25.
Approaches of trainees to diagnosis in teaching hospitals are poorly understood. Identifying cognitive and system-based barriers and facilitators to diagnosis may improve diagnosis in these settings.
We conducted a focused ethnography of trainees at 2 academic medical centers to understand the barriers and facilitators to diagnosis. Field notes regarding the diagnostic process (eg, information gathering, integration and interpretation, working diagnosis) and the work system (eg, team members, organization, technology and tools, physical environment, tasks) were recorded. Following observations, focus groups and interviews were conducted to understand the viewpoints, problems, and solutions to improve diagnosis.
Between January 2016 and May 2016, 4 teaching teams (4 attendings, 4 senior residents, 9 interns, and 12 medical students) were observed for 168 h. Observations of diagnosis during care led to identification of the following 4 key themes: (a) diagnosis is a social phenomenon; (b) data necessary to make diagnoses are fragmented; (c) distractions interfere with the diagnostic process; and (d) time pressures impede diagnostic decision-making. These themes suggest that specific interventions tailored to the academic setting such as team-based discussions of diagnostic workups, scheduling diagnostic time-outs during the day, and strategies to "protect" learners from interruptions might prove to be useful in improving the process of diagnosis. Future studies that implement these ideas (either alone or within a multimodal intervention) appear to be necessary.
Diagnosis in teaching hospitals is a unique process that requires improvement. Contextual insights gained from this ethnography may be used to inform future interventions.
实习医生在教学医院的诊断方法尚不清楚。识别认知和基于系统的诊断障碍及促进因素可能会改善这些环境中的诊断情况。
我们对两家学术医疗中心的实习医生进行了重点人种志研究，以了解诊断的障碍和促进因素。记录了有关诊断过程（如信息收集、整合与解读、初步诊断）和工作系统（如团队成员、组织、技术与工具、物理环境、任务）的实地记录。观察之后，进行了焦点小组讨论和访谈，以了解改善诊断的观点、问题和解决方案。
在2016年1月至2016年5月期间，观察了4个教学团队（4名主治医生、4名高年资住院医师、9名实习医生和12名医学生），共168小时。对护理过程中的诊断观察得出了以下4个关键主题：（a）诊断是一种社会现象；（b）做出诊断所需的数据是分散的；（c）干扰因素会妨碍诊断过程；（d）时间压力会阻碍诊断决策。这些主题表明，针对学术环境量身定制的特定干预措施，如基于团队的诊断检查讨论、在白天安排诊断暂停时间以及“保护”学习者免受干扰的策略，可能有助于改善诊断过程。实施这些想法的未来研究（单独或在多模式干预中）似乎是必要的。
教学医院的诊断是一个独特的过程，需要改进。从这人种志研究中获得的背景见解可用于为未来的干预措施提供信息。
