Koufidis Charilaos, Manninen Katri, Nieminen Juha, Wohlin Martin, Silén Charlotte
Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden.
Med Educ. 2022 Jan;56(1):98-109. doi: 10.1111/medu.14545. Epub 2021 May 26.
All thinking occurs in some sort of context, rendering the relation between context and clinical reasoning a matter of significant interest. Context, however, has a notoriously vague and contested meaning. A profound disagreement exists between different research traditions studying clinical reasoning in how context is understood. However, empirical evidence examining the impact (or not) of context on clinical reasoning cannot be interpreted without reference to the meaning ascribed to context. Such meaning is invariably determined by assumptions concerning the nature of knowledge and knowing. The epistemology of clinical reasoning determines in essence how context is conceptualised.
Our intention is to provide a sound epistemological framework of clinical reasoning that puts context into perspective and demonstrates how context is understood and researched in relation to clinical reasoning.
We identify three main epistemological dimensions of clinical reasoning research, each of them corresponding to fundamental patterns of knowing: the representational dimension views clinical reasoning as an act of categorisation, the interactional dimension as a cognitive state emergent from the interactions in a system, while the interpretative dimension as an act of intersubjectivity and socialisation. We discuss the main theories of clinical reasoning under each dimension and consider how the implicit epistemological assumptions of these theories determine the way context is conceptualised. These different conceptualisations of context carry important implications for the phenomenon of context specificity and for learning of clinical reasoning.
The study of context may be viewed as the study of the epistemology of clinical reasoning. Making sense of 'what is going on with this patient' necessitates reading the context in which the encounter is unfolding and deliberating a path of response justified in that specific context. Mastery of the context in this respect becomes a core activity of medical practice.
所有的思考都发生在某种情境之中，这使得情境与临床推理之间的关系成为一个备受关注的重要问题。然而，情境的含义 notoriously 模糊且存在争议。在研究临床推理的不同研究传统之间，对于情境的理解存在着深刻的分歧。然而，如果不参考赋予情境的含义，就无法解释检验情境对临床推理影响（或无影响）的实证证据。这种含义总是由关于知识和认知本质的假设所决定。临床推理的认识论本质上决定了情境是如何被概念化的。
我们的目的是提供一个合理的临床推理论认识论框架，该框架能正确看待情境，并展示情境与临床推理相关时是如何被理解和研究的。
我们确定了临床推理研究的三个主要认识论维度，每个维度都对应着基本的认知模式：表征维度将临床推理视为一种分类行为，互动维度将其视为系统中互动产生的一种认知状态，而解释维度将其视为一种主体间性和社会化行为。我们讨论了每个维度下的主要临床推理理论，并考虑这些理论隐含的认识论假设如何决定情境的概念化方式。这些对情境的不同概念化对于情境特异性现象和临床推理学习具有重要意义。
对情境的研究可被视为对临床推理论认识论的研究。理解“这个患者正在发生什么”需要解读相遇发生的情境，并在该特定情境中思考一条合理的应对路径。在这方面掌握情境成为医疗实践的核心活动。
