D.A. Cook is professor of medicine and medical education, director of education science, Office of Applied Scholarship and Education Science, and consultant, Division of General Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota; ORCID: http://orcid.org/0000-0003-2383-4633. S.J. Durning is professor of medicine and director, Division of Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland. J. Sherbino is assistant dean, Health Professions Education Research, Faculty of Health Sciences, and professor, Department of Medicine, McMaster University, Hamilton, Ontario, Canada. L.D. Gruppen is professor, Department of Learning Health Sciences, and director, Master of Health Professions Education Program, University of Michigan Medical School, Ann Arbor, Michigan.
Acad Med. 2019 Sep;94(9):1310-1316. doi: 10.1097/ACM.0000000000002768.
Substantial research has illuminated the clinical reasoning processes involved in diagnosis (diagnostic reasoning). Far less is known about the processes entailed in patient management (management reasoning), including decisions about treatment, further testing, follow-up visits, and allocation of limited resources. The authors' purpose is to articulate key differences between diagnostic and management reasoning, implications for health professions education, and areas of needed research.Diagnostic reasoning focuses primarily on classification (i.e., assigning meaningful labels to a pattern of symptoms, signs, and test results). Management reasoning involves negotiation of a plan and ongoing monitoring/adjustment of that plan. A diagnosis can usually be established as correct or incorrect, whereas there are typically multiple reasonable management approaches. Patient preferences, clinician attitudes, clinical contexts, and logistical constraints should not influence diagnosis, whereas management nearly always involves prioritization among such factors. Diagnostic classifications do not necessarily require direct patient interaction, whereas management prioritizations require communication and negotiation. Diagnoses can be defined at a single time point (given enough information), whereas management decisions are expected to evolve over time. Finally, management is typically more complex than diagnosis.Management reasoning may require educational approaches distinct from those used for diagnostic reasoning, including teaching distinct skills (e.g., negotiating with patients, tolerating uncertainty, and monitoring treatment) and developing assessments that account for underlying reasoning processes and multiple acceptable solutions.Areas of needed research include if and how cognitive processes differ for management and diagnostic reasoning, how and when management reasoning abilities develop, and how to support management reasoning in clinical practice.
大量研究阐明了诊断（诊断推理）所涉及的临床推理过程。对于患者管理（管理推理）所涉及的过程，包括治疗、进一步测试、随访和有限资源的分配，人们了解得就少得多。作者的目的是阐明诊断推理和管理推理之间的关键区别、对卫生专业教育的影响以及需要研究的领域。诊断推理主要侧重于分类（即将有意义的标签分配给症状、体征和测试结果模式）。管理推理涉及计划的谈判以及该计划的持续监测/调整。诊断通常可以确定为正确或错误，而管理方法通常有多种合理的方法。患者偏好、临床医生态度、临床环境和后勤限制不应影响诊断，而管理几乎总是涉及此类因素的优先级排序。诊断分类不一定需要直接与患者互动，而管理优先级排序需要沟通和协商。诊断可以在一个时间点（有足够的信息）定义，而管理决策预计会随着时间的推移而演变。最后，管理通常比诊断更复杂。管理推理可能需要与诊断推理不同的教育方法，包括教授不同的技能（例如与患者协商、容忍不确定性和监测治疗）以及开发考虑潜在推理过程和多个可接受解决方案的评估。需要研究的领域包括管理和诊断推理的认知过程是否不同以及如何不同，管理推理能力何时以及如何发展，以及如何在临床实践中支持管理推理。
