Office of Applied Scholarship and Education Science, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA.
Perspect Med Educ. 2022 Aug;11(4):196-206. doi: 10.1007/s40037-022-00714-y. Epub 2022 Jun 2.
Management reasoning is distinct from diagnostic reasoning and remains incompletely understood. The authors sought to empirically investigate the concept of management scripts.
In November 2020, 4 investigators each reviewed 10 video clips of simulated outpatient physician-patient encounters, and used a coding form to document observations about management reasoning. The team used constant comparative analysis to integrate empirically-grounded insights with theories related to cognitive scripts and Type 1/Type 2 thinking.
Management scripts are precompiled conceptual knowledge structures that represent and connect management options and clinician tasks in a temporal or logical sequence. Management scripts appear to differ substantially from illness scripts. Management scripts varied in quality (in content, sequence, flexibility, and fluency) and generality. The authors empirically identified six key features (components) of management scripts: the problem (diagnosis); management options; preferences, values, and constraints; education needs; interactions; and encounter flow. The authors propose a heuristic framework describing script activation, selection, instantiation with case-specific details, and application to guide development of the management plan. They further propose that management reasoning reflects iterative, back-and-forth involvement of both Type 1 (non-analytic, effortless) and Type 2 (analytic, effortful) thinking. Type 1 thinking likely influences initial script activation, selection, and initial instantiation. Type 2 increasingly influences subsequent script revisions, as activation, selection, and instantiation become more deliberate (effortful) and more hypothetical (involving mental simulation).
Management scripts constitute a key feature of management reasoning, and could represent a new target for training in clinical reasoning (distinct from illness scripts).
管理推理有别于诊断推理，且尚未被充分理解。作者试图通过实证研究来考察管理脚本的概念。
2020 年 11 月，4 位调查员每人审查了 10 个模拟门诊医患医患接触的视频片段，并使用编码表记录有关管理推理的观察结果。该团队使用恒定性比较分析，将基于经验的见解与认知脚本和 1 型/2 型思维相关理论相结合。
管理脚本是预先编译的概念知识结构，它以时间或逻辑顺序表示和连接管理选项和临床医生的任务。管理脚本似乎与疾病脚本有很大不同。管理脚本在质量（内容、顺序、灵活性和流畅性）和通用性方面存在差异。作者从实证角度确定了管理脚本的六个关键特征（组成部分）：问题（诊断）；管理选项；偏好、价值观和限制；教育需求；交互；和会诊流程。作者提出了一个启发式框架，描述了脚本的激活、选择、与具体案例细节的实例化以及应用，以指导管理计划的制定。他们进一步提出，管理推理反映了 1 型（非分析、不费力）和 2 型（分析、费力）思维的迭代、来回参与。1 型思维可能会影响初始脚本的激活、选择和初始实例化。随着脚本的激活、选择和实例化变得更加刻意（费力）和更加假设（涉及心理模拟），2 型思维越来越多地影响后续脚本的修订。
管理脚本构成了管理推理的一个关键特征，并且可能代表临床推理培训的一个新目标（与疾病脚本不同）。
