Erasmus Medical Center, Institute of Medical Education Research Rotterdam, Rotterdam, the Netherlands.
Department of Critical Care, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
BMC Med Educ. 2023 Sep 21;23(1):684. doi: 10.1186/s12909-023-04541-5.
Diagnostic errors are a large burden on patient safety and improving clinical reasoning (CR) education could contribute to reducing these errors. To this end, calls have been made to implement CR training as early as the first year of medical school. However, much is still unknown about pre-clerkship students' reasoning processes. The current study aimed to observe how pre-clerkship students use clinical information during the diagnostic process.
In a prospective observational study, pre-clerkship medical students completed 10-11 self-directed online simulated CR diagnostic cases. CR skills assessed included: creation of the differential diagnosis (Ddx), diagnostic justification (DxJ), ordering investigations, and identifying the most probable diagnosis. Student performances were compared to expert-created scorecards and students received detailed individualized formative feedback for every case.
121 of 133 (91%) first- and second-year medical students consented to the research project. Students scored much lower for DxJ compared to scores obtained for creation of the Ddx, ordering tests, and identifying the correct diagnosis, (30-48% lower, p < 0.001). Specifically, students underutilized physical exam data (p < 0.001) and underutilized data that decreased the probability of incorrect diagnoses (p < 0.001). We observed that DxJ scores increased 40% after 10-11 practice cases (p < 0.001).
We implemented deliberate practice with formative feedback for CR starting in the first year of medical school. Students underperformed in DxJ, particularly with analyzing the physical exam data and pertinent negative data. We observed significant improvement in DxJ performance with increased practice.
诊断错误给患者安全带来了巨大负担，而改善临床推理（CR）教育则有助于减少这些错误。为此，人们呼吁在医学院的第一年就开始进行 CR 培训。然而，关于预科医学生的推理过程，我们还有很多不了解的地方。本研究旨在观察预科医学生在诊断过程中如何使用临床信息。
在一项前瞻性观察性研究中，预科医学生完成了 10-11 个自我指导的在线模拟 CR 诊断病例。评估的 CR 技能包括：建立鉴别诊断（Ddx）、诊断证明（DxJ）、安排检查以及确定最可能的诊断。学生的表现与专家创建的记分卡进行了比较，每位学生都收到了每一个案例的详细个性化形成性反馈。
共有 133 名第一和第二年的医学生中的 121 名同意参与该研究项目。与建立 Ddx、安排检查和确定正确诊断相比，学生在 DxJ 上的得分要低得多（低 30-48%，p<0.001）。具体来说，学生对体格检查数据的利用不足（p<0.001），对降低错误诊断概率的数据的利用不足（p<0.001）。我们观察到，在进行了 10-11 个练习案例后，DxJ 分数提高了 40%（p<0.001）。
我们从医学院第一年开始就采用了有形成性反馈的刻意练习来进行 CR 培训。学生在 DxJ 方面表现不佳，尤其是在分析体格检查数据和相关的阴性数据方面。随着练习的增加，我们观察到 DxJ 表现有显著的提高。
