Grant J, Marsden P
Med Educ. 1987 Mar;21(2):92-8. doi: 10.1111/j.1365-2923.1987.tb00672.x.
This paper provides for the first time evidence of a consistent difference in the memory structures of novice and expert clinicians. The diagnostic performance of first- and third-year clinical medical students, senior house officers, registrars and consultants on four clinical problems in general medicine was studied. Comparisons were made of all diagnostic interpretations offered and the forceful features (personally important pieces of information which act as a key to particular memory structures which in turn give rise to the clinical interpretation) from which these were derived. Results demonstrate that the numbers of interpretations made and the numbers of forceful features identified did not differ significantly between groups (P greater than 0.05). However, the actual interpretations made in three out of four cases, and the actual forceful features identified in all cases, did differ significantly between groups (P less than 0.05). The numbers of interpretations made by all groups were large and demonstrated enormous variability. Highly individualized multiple responses to clinical information are associated with easy diagnoses. We conclude that there is no difference between groups of differing clinical experience in the breadth of thought but that there are marked differences in the precise content and structure of thought. This allows coherent explanation of variation in diagnostic expertise with clinical experience. The significance of the findings is discussed.
本文首次提供了新手临床医生和专家临床医生记忆结构存在持续差异的证据。研究了一年级和三年级临床医学学生、住院医师、专科住院医师和会诊医生对四个普通医学临床问题的诊断表现。对所有提供的诊断解释以及从中得出这些解释的有力特征（个人认为重要的信息片段，这些信息作为特定记忆结构的关键，进而产生临床解释）进行了比较。结果表明，各组之间做出的解释数量和确定的有力特征数量没有显著差异（P大于0.05）。然而，在四分之三的病例中实际做出的解释，以及在所有病例中确定的实际有力特征，在各组之间确实存在显著差异（P小于0.05）。所有组做出的解释数量都很多，并且显示出巨大的变异性。对临床信息的高度个性化的多种反应与容易诊断相关。我们得出结论，不同临床经验组在思维广度上没有差异，但在思维的精确内容和结构上存在显著差异。这使得能够连贯地解释诊断专业知识随临床经验的变化。讨论了这些发现的意义。
