T.M. Chan is associate professor, Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada, assistant dean, Program for Faculty Development, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada, and adjunct scientist, McMaster Education Research, Innovation and Theory (MERIT), McMaster University, Hamilton, Ontario, Canada.
M. Mercuri is assistant professor, Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada, and senior research associate, African Centre for Epistemology and Philosophy of Science, Department of Philosophy, University of Johannesburg, Johannesburg, South Africa.
Acad Med. 2020 Aug;95(8):1230-1237. doi: 10.1097/ACM.0000000000003098.
Physicians are often asked to integrate clinical decision rules (CDRs) with their own cognitive processes to reach a diagnosis. Clinicians, researchers, and educators must understand these cognitive processes to evaluate and improve the diagnostic process. The authors sought to explore emergency physicians' diagnostic processes and to examine how they integrated CDRs into their reasoning using simulated cases (with chest pain or leg pain).
From August 2015 to July 2016, 16 practicing emergency physicians from 3 teaching hospitals associated with McMaster University, Ontario, Canada, were interviewed via a novel "teach aloud" protocol. Six videos of simulated patients with chest pain, breathlessness, or leg discomfort were used as prompts for the physicians to demonstrate their diagnostic thinking. Using a constructivist grounded theory analysis, 3 investigators independently reviewed the interview transcripts, meeting regularly to discuss identified themes and subthemes until sufficiency was reached.
A model to describe how clinicians integrate their own decision making with CDRs was developed, showing that physicians engage in an iterative diagnostic process that repeatedly refines the differential diagnosis list. The steps in the diagnostic process were: refinement of the differential diagnosis, ordering a hierarchy of risk, the decision to test, choosing the tests, and interpreting test results. Physicians applied CDRs when they had already decided to test.
To date, CDRs assume a static, linear model of clinical decision making. Findings demonstrate that participants engaged in iterative and dynamic decision-making processes that changed throughout their patient encounter, contingent on multiple contextual features. Understanding these processes could inform future development of CDRs and educational strategies around these decision aids.
医生经常被要求将临床决策规则 (CDR) 与自己的认知过程相结合以做出诊断。临床医生、研究人员和教育工作者必须了解这些认知过程，以评估和改进诊断过程。作者试图探讨急诊医师的诊断过程，并研究他们如何使用模拟病例（胸痛或腿痛）将 CDR 纳入其推理。
2015 年 8 月至 2016 年 7 月，来自加拿大安大略省麦克马斯特大学附属的 3 家教学医院的 16 名执业急诊医师通过一种新颖的“大声说出来”协议接受了访谈。使用 6 个模拟胸痛、呼吸困难或腿部不适的患者视频作为提示，让医生展示他们的诊断思维。使用建构主义扎根理论分析，3 名研究人员独立审查访谈记录，定期开会讨论确定的主题和子主题，直到达到充分性。
开发了一个描述临床医生如何将自己的决策与 CDR 相结合的模型，表明医生进行反复诊断的过程，不断完善鉴别诊断清单。诊断过程的步骤包括：细化鉴别诊断、对风险进行排序、决定进行测试、选择测试和解释测试结果。医生在决定进行测试后应用 CDR。
到目前为止，CDR 假设临床决策的静态、线性模型。研究结果表明，参与者进行了迭代和动态的决策过程，在整个患者就诊过程中不断变化，取决于多个上下文特征。了解这些过程可以为未来的 CDR 开发和这些决策辅助工具的教育策略提供信息。
