Fürstenberg Sophie, Helm Tillmann, Prediger Sarah, Kadmon Martina, Berberat Pascal O, Harendza Sigrid
Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, III Medizinische Klinik, Martinistr. 52, D-20246, Hamburg, Germany.
Faculty of Medicine, University of Augsburg, Deanery, Augsburg, Germany.
BMC Med Educ. 2020 Oct 19;20(1):368. doi: 10.1186/s12909-020-02260-9.
The clinical reasoning process, which requires biomedical knowledge, knowledge about problem-solving strategies, and knowledge about reasons for diagnostic procedures, is a key element of physicians' daily practice but difficult to assess. The aim of this study was to empirically develop a Clinical Reasoning Indicators-History Taking-Scale (CRI-HT-S) and to assess the clinical reasoning ability of advanced medical students during a simulation involving history taking.
The Clinical Reasoning Indictors-History Taking-Scale (CRI-HT-S) including a 5-point Likert scale for assessment was designed from clinical reasoning indicators identified in a qualitative study in 2017. To assess indicators of clinical reasoning ability, 65 advanced medical students (semester 10, n = 25 versus final year, n = 40) from three medical schools participated in a 360-degree competence assessment in the role of beginning residents during a simulated first workday in hospital. This assessment included a consultation hour with five simulated patients which was videotaped. Videos of 325 patient consultations were assessed using the CRI-HT-S. A factor analysis was conducted and the students' results were compared according to their advancement in undergraduate medical training.
The clinical reasoning indicators of the CRI-HT-S loaded on three factors relevant for clinical reasoning: 1) focusing questions, 2) creating context, and 3) securing information. Students reached significantly different scores (p < .001) for the three factors (factor 1: 4.07 ± .47, factor 2: 3.72 ± .43, factor 3: 2.79 ± .83). Students in semester 10 reached significantly lower scores for factor 3 than students in their final year (p < .05).
The newly developed CRI-HT-S worked well for quantitative assessment of clinical reasoning indicators during history taking. Its three-factored structure helped to explore different aspects of clinical reasoning. Whether the CRI-HT-S has the potential to be used as a scale in objective structured clinical examinations (OCSEs) or in workplace-based assessments of clinical reasoning has to be investigated in further studies with larger student cohorts.
临床推理过程需要生物医学知识、问题解决策略知识以及诊断程序依据知识，是医生日常实践的关键要素，但难以评估。本研究的目的是通过实证开发一个临床推理指标——病史采集量表（CRI-HT-S），并在涉及病史采集的模拟过程中评估高年级医学生的临床推理能力。
临床推理指标——病史采集量表（CRI-HT-S）包括一个用于评估的5点李克特量表，它是根据2017年一项定性研究中确定的临床推理指标设计的。为了评估临床推理能力指标，来自三所医学院的65名高年级医学生（第10学期，n = 25；最后一年，n = 40）在模拟的医院首个工作日中扮演住院医师新手的角色，参与了360度能力评估。该评估包括与五名模拟患者的会诊，并进行了录像。使用CRI-HT-S对325次患者会诊的视频进行了评估。进行了因子分析，并根据学生在本科医学培训中的进展情况比较了他们的结果。
CRI-HT-S的临床推理指标加载在与临床推理相关的三个因子上：1）聚焦问题，2）创建背景，3）获取信息。学生在这三个因子上的得分有显著差异（p <.001）（因子1：4.07±.47，因子2：3.72±.43，因子3：2.79±.83）。第10学期的学生在因子3上的得分显著低于最后一年的学生（p <.05）。
新开发的CRI-HT-S在病史采集过程中对临床推理指标的定量评估效果良好。其三个因子结构有助于探索临床推理的不同方面。CRI-HT-S是否有潜力用作客观结构化临床考试（OCSEs）或基于工作场所的临床推理评估量表，必须在更大规模学生群体的进一步研究中进行调查。
