Monteiro Sandra D, Sherbino Jonathan, Schmidt Henk, Mamede Silvia, Ilgen Jonathan, Norman Geoff
Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.
McMaster Faculty of Health Sciences Program in Education Research, Innovation and Theory (MERIT), McMaster University, Hamilton, ON, Canada.
Adv Health Sci Educ Theory Pract. 2020 Mar;25(1):19-29. doi: 10.1007/s10459-019-09903-7. Epub 2019 Jul 22.
While multiple theories exist to explain the diagnostic process, there are few available assessments that reliably determine diagnostic competence in trainees. Most methods focus on aspects of the process of diagnostic reasoning, such as the relation between case features and diagnostic hypotheses. Inevitably, detailed elucidation of aspects of the process requires substantial time per case and limits the number of cases that can be examined given a limited testing time. Shifting assessment to the outcome of diagnostic reasoning, accuracy of the diagnosis, may serve as a reliable measure of diagnostic competence and would allow increased sampling across cases. The present study is a retrospective analysis of 7 large studies, conducted by 3 research teams, that all used a series of brief written cases to examine the outcome of diagnostic reasoning-the diagnosis. The studies involved over 600 clinicians ranging from final year medical students to practicing emergency physicians. For 4 studies with usable reliability data, reliability for a 2 h test ranged from .63 to .94. On average speeded tests were more reliable (.85 vs. .73).To achieve a reliability of .75 required an average test time of 1.11 h for speeded tests and 1.99 for unspeeded tests. The measure was shown to be positively correlated with both written knowledge tests and measures of problem solving derived from OSCE performance tests. This retrospective analysis provides evidence to support the implementation of outcome-based assessments of clinical reasoning.
虽然存在多种理论来解释诊断过程，但几乎没有可用的评估方法能够可靠地确定实习生的诊断能力。大多数方法侧重于诊断推理过程的各个方面，例如病例特征与诊断假设之间的关系。不可避免的是，对过程各方面的详细阐释每个病例都需要大量时间，并且在测试时间有限的情况下会限制可检查的病例数量。将评估转向诊断推理的结果，即诊断的准确性，可能是诊断能力的可靠衡量标准，并且可以增加跨病例的抽样。本研究是对3个研究团队进行的7项大型研究的回顾性分析，这些研究均使用一系列简短的书面病例来检查诊断推理的结果——诊断。这些研究涉及600多名临床医生，从医学专业最后一年的学生到执业急诊医生。对于4项有可用可靠性数据的研究，2小时测试的可靠性范围为0.63至0.94。平均而言，限时测试更可靠（0.85对0.73）。要达到0.75的可靠性，限时测试平均需要1.11小时的测试时间，非限时测试需要1.99小时。该测量结果与书面知识测试以及从客观结构化临床考试（OSCE）表现测试得出的解决问题的测量结果均呈正相关。这项回顾性分析为支持实施基于结果的临床推理评估提供了证据。
