Dunlop Mark, Schwartzstein Richard M
Department of Medicine and.
Division of Pulmonary, Critical Care and Sleep Medicine, Shapiro Institute for Education and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
ATS Sch. 2020 Sep 16;1(4):364-371. doi: 10.34197/ats-scholar.2020-0043PS.
As medicine continues to advance with improvements in technology, factual information has become more easily available at the bedside. Nevertheless, diagnostic error remains a salient concern for the medical community and public. To address this problem, two fundamental characteristics of the physician remain important: curiosity and the ability to apply critical reasoning to solve problems, often in the setting of imperfect knowledge and uncertainty. Historically, the teaching and recall of factual information, illness scripts, and pattern recognition are emphasized early in medical education. Students are often left with the impression that there is a single correct answer for every question; discussions of uncertainty are rare. Consequently, discomfort with uncertainty is common among doctors. As attention to explicit teaching of clinical reasoning increases, one must consider how to incorporate uncertainty into that teaching and to transform the clinical learning environment to embrace uncertainty. The authors propose the use of several simple methods easily employed in the critical care setting to make uncertainty explicit by changing the language used for expressing differential diagnosis, incorporating probabilities into daily sign-outs, and by implementing inductive reasoning when teaching critical thinking to offer learners a strategy for working through unknown problems; these approaches may normalize uncertainty, improve comfort with it, and reduce the impact of cognitive bias in decision-making. Comfort with uncertainty may result not only in improved clinical experiences for learning by transforming a once negative cognitive experience to a positive one but also in reduced susceptibility to thinking errors.
随着医学随着技术进步而不断发展，床边更容易获取事实性信息。然而，诊断错误仍然是医学界和公众关注的一个突出问题。为了解决这个问题，医生的两个基本特征仍然很重要：好奇心以及在知识不完整和存在不确定性的情况下运用批判性推理解决问题的能力。从历史上看，医学教育早期强调事实性信息、疾病脚本和模式识别的传授与记忆。学生们常常留下这样的印象，即每个问题都只有一个正确答案；关于不确定性的讨论很少见。因此，医生们普遍对不确定性感到不适。随着对临床推理明确教学的关注度增加，人们必须考虑如何将不确定性纳入该教学中，并转变临床学习环境以接受不确定性。作者提出使用几种在重症监护环境中易于采用的简单方法，通过改变用于表达鉴别诊断的语言、将概率纳入日常交班以及在教授批判性思维时运用归纳推理，使不确定性变得明确，为学习者提供一种解决未知问题的策略；这些方法可能会使不确定性常态化，提高对它的接受度，并减少决策中认知偏差的影响。对不确定性的接受不仅可能通过将曾经消极的认知体验转变为积极的体验来改善临床学习体验，还可能降低思维错误的易感性。
