McBee Elexis, Blum Christina, Ratcliffe Temple, Schuwirth Lambert, Polston Elizabeth, Artino Anthony R, Durning Steven J
Department of Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, USA.
Department of Medicine, Naval Hospital Camp Pendleton, Oceanside, CA, USA.
Diagnosis (Berl). 2019 Jun 26;6(2):127-135. doi: 10.1515/dx-2018-0077.
Background A framework of clinical reasoning tasks used by physicians during clinical encounters was previously developed proposing that clinical reasoning is a complex process composed of 26 possible tasks. The aim of this paper was to analyze the verbalized clinical reasoning processes of medical students utilizing commonly encountered internal medicine cases. Methods In this mixed-methods study, participants viewed three video recorded clinical encounters. After each encounter, participants completed a think-aloud protocol. The qualitative data from the transcribed think-aloud transcripts were analyzed by two investigators using a constant comparative approach. The type, frequency, and pattern of codes used were analyzed. Results Seventeen third and fourth year medical students participated. They used 15 reasoning tasks across all cases. The average number of tasks used in cases 1, 2, and 3 was (respectively) 5.6 (range 3-8), 5.9 (range 4-8), and 5.3 (range 3-10). The order in which medical students verbalized reasoning tasks varied and appeared purposeful but non-sequential. Conclusions Consistent with prior research in residents, participants progressed through the encounter in a purposeful but non-sequential fashion. Reasoning tasks related to framing the encounter and diagnosis were not used in succession but interchangeably. This suggests that teaching successful clinical reasoning may involve encouraging or demonstrating multiple pathways through a problem. Further research exploring the association between use of clinical reasoning tasks and clinical reasoning accuracy could enhance the medical community's understanding of variance in clinical reasoning.
背景 先前已开发出一个医生在临床会诊期间使用的临床推理任务框架，提出临床推理是一个由26种可能任务组成的复杂过程。本文的目的是分析医学生利用常见内科病例时的言语化临床推理过程。方法 在这项混合方法研究中，参与者观看了三段临床会诊视频记录。每次会诊后，参与者完成出声思考协议。两位研究者使用持续比较法对转录的出声思考记录中的定性数据进行分析。分析所使用代码的类型、频率和模式。结果 17名三年级和四年级医学生参与。他们在所有病例中使用了15种推理任务。病例1、2和3中使用的任务平均数量分别为5.6（范围3 - 8）、5.9（范围4 - 8）和5.3（范围3 - 10）。医学生言语化推理任务的顺序各不相同，且看似有目的但不具有连贯性。结论 与先前对住院医师的研究一致，参与者以有目的但不连贯的方式完成会诊。与构建会诊和诊断相关的推理任务并非依次使用，而是交替使用。这表明教授成功的临床推理可能涉及鼓励或展示解决问题的多种途径。进一步探索临床推理任务的使用与临床推理准确性之间关联的研究，可能会增进医学界对临床推理差异的理解。
