Braun Leah T, Borrmann Katharina F, Lottspeich Christian, Heinrich Daniel A, Kiesewetter Jan, Fischer Martin R, Schmidmaier Ralf
Ludwig-Maximilians-University (LMU) Munich, Klinikum der Universität München, Medizinische Klinik und Poliklinik IV, München, Germany.
Ludwig-Maximilians-University (LMU) Munich, Klinikum der Universität München, Institut für Didaktik und Ausbildungsforschung in der Medizin, München, Germany.
GMS J Med Educ. 2019 Nov 15;36(6):Doc85. doi: 10.3205/zma001293. eCollection 2019.
Clinical reasoning is one of the central competencies in everyday clinical practice. Diagnostic competence is often measured based on diagnostic accuracy. It is implicitly assumed that a correct diagnosis is based on a proper diagnostic process, although this has never been empirically tested. The frequency and nature of errors in students' diagnostic processes in correctly solved cases was analyzed in this study. 148 medical students processed 15 virtual patient cases in internal medicine. After each case, they were asked to state their final diagnosis and justify it. These explanations were qualitatively analyzed and assigned to one of the following three categories: correct explanation, incorrect explanation and diagnosis guessed right. The correct diagnosis was made 1,135 times out of 2,080 diagnostic processes. The analysis of the associated diagnostic explanations showed that 92% (1,042) reasoning processes were correct, 7% (80) were incorrect, and 1% (13) of the diagnoses were guessed right. Causes of incorrect diagnostic processes were primarily a lack of pathophysiological knowledge (50%) and a lack of diagnostic skills (30%). Generally, if the diagnosis is correct, the diagnostic process is also correct. The rate of guessed diagnoses is quite low at 1%. Nevertheless, about every 14th correct diagnosis is based on a false diagnostic explanation and thus, a wrong diagnostic process. To assess the diagnostic competence, both the diagnosis result and the diagnostic process should be recorded.
临床推理是日常临床实践中的核心能力之一。诊断能力通常基于诊断准确性来衡量。人们隐含地认为正确的诊断基于恰当的诊断过程，尽管这从未经过实证检验。本研究分析了学生在正确解决的病例中诊断过程错误的频率和性质。148名医学生处理了15例内科虚拟患者病例。在每个病例之后，要求他们陈述最终诊断并说明理由。对这些解释进行了定性分析，并归类为以下三类之一：正确解释、错误解释和猜对诊断。在2080次诊断过程中，做出正确诊断1135次。对相关诊断解释的分析表明，92%（1042次）的推理过程是正确的，7%（80次）是错误的，1%（13次）的诊断是猜对的。错误诊断过程的原因主要是缺乏病理生理学知识（50%）和缺乏诊断技能（30%）。一般来说，如果诊断正确，诊断过程也是正确的。猜对诊断的比例相当低，为1%。然而，大约每14次正确诊断中就有一次基于错误的诊断解释，因此诊断过程也是错误的。为了评估诊断能力，应该记录诊断结果和诊断过程。
