Department of Medicine, F. Edward Hébert School Of Medicine, Uniformed Services University, at Naval Medical Centre San Diego, San Diego, CA, USA.
Department of Medicine, University of Texas Health Science Centre at San Antonio, San Antonio, TX, USA.
Perspect Med Educ. 2018 Aug;7(4):256-263. doi: 10.1007/s40037-018-0417-x.
Studies have shown that a physician's clinical reasoning performance can be influenced by contextual factors. We explored how the clinical reasoning performance of medical students was impacted by contextual factors in order to expand upon previous findings in resident and board certified physicians. Using situated cognition as the theoretical framework, our aim was to evaluate the verbalized clinical reasoning processes of medical students in order to describe what impact the presence of contextual factors has on their reasoning performance.
Seventeen medical student participants viewed three video recordings of clinical encounters portraying straightforward diagnostic cases in internal medicine with explicit contextual factors inserted. Participants completed a computerized post-encounter form as well as a think-aloud protocol. Three authors analyzed verbatim transcripts from the think-aloud protocols using a constant comparative approach. After iterative coding, utterances were analyzed and grouped into categories and themes.
Six categories and ten associated themes emerged, which demonstrated overlap with findings from previous studies in resident and attending physicians. Four overlapping categories included emotional disturbances, behavioural inferences about the patient, doctor-patient relationship, and difficulty with closure. Two new categories emerged to include anchoring and misinterpretation of data.
The presence of contextual factors appeared to impact clinical reasoning performance in medical students. The data suggest that a contextual factor can be innate to the clinical scenario, consistent with situated cognition theory. These findings build upon our understanding of clinical reasoning performance from both a theoretical and practical perspective.
研究表明，医生的临床推理表现可能受到情境因素的影响。我们探讨了医学生的临床推理表现如何受到情境因素的影响，以扩展之前在住院医师和认证医师中的发现。本研究以情境认知为理论框架，旨在评估医学生的口头临床推理过程，以描述情境因素对他们推理表现的影响。
17 名医学生参与者观看了三段内科临床接触录像，录像中呈现了带有明确情境因素的简单诊断案例。参与者完成了计算机化的接触后表格以及出声思维协议。三位作者使用恒定比较法分析出声思维协议的逐字记录。经过迭代编码，对表述进行了分析，并将其分为类别和主题。
出现了六个类别和十个相关主题，这些主题与住院医师和主治医生的先前研究结果重叠。四个重叠类别包括情绪障碍、对患者的行为推断、医患关系以及难以结案。两个新类别包括锚定和对数据的误解。
情境因素的存在似乎影响了医学生的临床推理表现。数据表明，情境因素可能是临床情景固有的，与情境认知理论一致。这些发现从理论和实践两个角度加深了我们对临床推理表现的理解。
