Sengupta Malavika Pia, Crawford Timothy N, Leeds Frederic Stuart
Wright State University Boonshoft School of Medicine, Dayton, OH, USA.
J Med Educ Curric Dev. 2021 Oct 29;8:23821205211035235. doi: 10.1177/23821205211035235. eCollection 2021 Jan-Dec.
Differential diagnosis (DDx) is a core clinical reasoning skill that all medical students and physicians must acquire and develop. Metamemory techniques (MMTs), including mnemonic devices and other heuristics, are frequently taught to students as a means of enhancing DDx generation. (HIAH) an MMT that works by prompting students to think about cardiac disease in terms of four structural subsystems, can be used to facilitate the generation of cardiac differentials, but its efficacy has not been studied.
In a 3-hour DDx workshop, second-year medical students were given a brief case vignette of a patient with chest pain and dyspnea and asked to generate initial differential diagnoses before and after learning HIAH. Descriptive statistics and paired T-tests were used to compare the sizes of cardiac-only and total differentials pre-/post-HIAH. Cardiac diagnoses were classified according to the structural categories described by HIAH, and Simpson's Diversity Index (SDI) was used to evaluate the effect of HIAH on the variety of cardiac diagnoses produced.
All students in the course ( = 111) submitted pre-post differential lists. The mean number of diagnoses included in their differentials did not change significantly after exposure to HIAH (7.98 vs. 8.71, = .09). However, the number of potentially correct cardiac diagnoses increased from 1.79 to 4.75 ( < .0001), and the variety of structure/function cardiac categories considered by students increased more than twofold (from an SDI of 0.16 to 0.4, < .0001). These increases were accompanied by a small increase in incorrect diagnoses ( + 2.47%, = .0003) and a larger decrease in potentially correct noncardiac diagnoses (-41.88%, < .0001).
The use of HIAH was associated with an increase in the size and variety of cardiac differentials. This increase may have come at the cost of a reduced noncardiac differential. Educators may find HIAH useful for guiding students as they reason through cases involving potential cardiac etiologies. As with all heuristics, care must be exercised to avoid introducing unwanted bias.
鉴别诊断（DDx）是所有医学生和医生都必须掌握和培养的一项核心临床推理技能。元记忆技巧（MMTs），包括记忆术和其他启发法，经常被传授给学生，作为增强鉴别诊断生成的一种手段。心脏启发式鉴别法（HIAH）是一种通过促使学生从四个结构子系统的角度思考心脏病来发挥作用的MMT，可用于促进心脏鉴别诊断的生成，但其效果尚未得到研究。
在一个为期3小时的鉴别诊断研讨会上，给二年级医学生提供了一个胸痛和呼吸困难患者的简短病例 vignette，并要求他们在学习HIAH之前和之后生成初步鉴别诊断。使用描述性统计和配对t检验来比较学习HIAH前后仅心脏相关和总体鉴别诊断的数量。根据HIAH描述的结构类别对心脏诊断进行分类，并使用辛普森多样性指数（SDI）来评估HIAH对所产生的心脏诊断多样性的影响。
该课程中的所有学生（n = 111）都提交了学习前后的鉴别诊断清单。接触HIAH后，他们鉴别诊断中包含的诊断平均数量没有显著变化（7.98对8.71，p = 0.09）。然而，潜在正确的心脏诊断数量从1.79增加到4.75（p < 0.0001），学生考虑的心脏结构/功能类别的多样性增加了两倍多（从SDI为0.16增加到0.4，p < 0.0001）。这些增加伴随着错误诊断的小幅增加（+2.47%，p = 0.0003）和潜在正确的非心脏诊断的大幅减少（-41.88%，p < 0.0001）。
使用HIAH与心脏鉴别诊断的数量和多样性增加有关。这种增加可能是以减少非心脏鉴别诊断为代价的。教育工作者可能会发现HIAH有助于指导学生对涉及潜在心脏病因的病例进行推理。与所有启发法一样，必须谨慎行事，以避免引入不必要的偏差。
