Virginia Commonwealth University School of Medicine/VCU Health, Department of Internal Medicine, Richmond, Virginia.
University of Michigan, Department of Internal Medicine, Ann Arbor, Michigan.
West J Emerg Med. 2020 Nov 2;21(6):125-131. doi: 10.5811/westjem.2020.7.47832.
Emergency physicians (EP) make clinical decisions multiple times daily. In some instances, medical errors occur due to flaws in the complex process of clinical reasoning and decision-making. Cognitive error can be difficult to identify and is equally difficult to prevent. To reduce the risk of patient harm resulting from errors in critical thinking, it has been proposed that we train physicians to understand and maintain awareness of their thought process, to identify error-prone clinical situations, to recognize predictable vulnerabilities in thinking, and to employ strategies to avert cognitive errors. The first step to this approach is to gain an understanding of how physicians make decisions and what conditions may predispose to faulty decision-making. We review the dual-process theory, which offers a framework to understand both intuitive and analytical reasoning, and to identify the necessary conditions to support optimal cognitive processing. We also discuss systematic deviations from normative reasoning known as cognitive biases, which were first described in cognitive psychology and have been identified as a contributing factor to errors in medicine. Training physicians in common biases and strategies to mitigate their effect is known as debiasing. A variety of debiasing techniques have been proposed for use by clinicians. We sought to review the current evidence supporting the effectiveness of these strategies in the clinical setting. This discussion of improving clinical reasoning is relevant to medical educators as well as practicing EPs engaged in continuing medical education.
急诊医师（EP）每天要做出多次临床决策。在某些情况下，由于临床推理和决策过程复杂而存在缺陷，会导致医疗错误。认知错误很难识别，也很难预防。为了降低因批判性思维失误而导致患者受到伤害的风险，有人提议我们培训医师，使其了解并保持对思维过程的认识，识别易出错的临床情况，认识思维中可预测的弱点，并采用策略来避免认知错误。这种方法的第一步是了解医师如何做出决策以及哪些情况可能导致决策失误。我们回顾了双加工理论，该理论提供了一个理解直觉和分析推理的框架，并确定了支持最佳认知加工的必要条件。我们还讨论了认知心理学中首次描述的、被认为是导致医学错误的一个因素的认知偏差，即系统偏离规范推理。通过培训医师了解常见偏差和减轻其影响的策略，被称为去偏。已经为临床医生提出了各种去偏技术。我们试图回顾现有证据，以支持这些策略在临床环境中的有效性。这种关于改善临床推理的讨论不仅与医学教育者有关，也与从事继续医学教育的执业 EP 有关。
