Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.
Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, USA.
Med Educ. 2024 Aug;58(8):961-969. doi: 10.1111/medu.15377. Epub 2024 Mar 25.
The clinical reasoning literature has increasingly considered context as an important influence on physicians' thinking. Physicians' relationships with patients, and their ongoing efforts to maintain these relationships, are important influences on how clinical reasoning is contextualised. The authors sought to understand how physicians' relationships with patients shaped their clinical reasoning.
Drawing from constructivist grounded theory, the authors conducted semi-structured interviews with primary care physicians. Participants were asked to reflect on recent challenging clinical experiences, and probing questions were used to explore how participants attended to or leveraged relationships in conjunction with their clinical reasoning. Using constant comparison, three investigators coded transcripts, organising the data into codes and conceptual categories. The research team drew from these codes and categories to develop theory about the phenomenon of interest.
The authors interviewed 15 primary care physicians with a range of experience in practice and identified patient agency as a central influence on participants' clinical reasoning. Participants drew from and managed relationships with patients while attending to patients' agency in three ways. First, participants described how contextualised illness constructions enabled them to individualise their approaches to diagnosis and management. Second, participants managed tensions between enacting their typical approaches to clinical problems and adapting their approaches to foster ongoing relationships with patients. Finally, participants attended to relationships with patients' caregivers, seeing these individuals' contributions as important influences on how their clinical reasoning could be enacted within patients' unique social contexts.
Clinical reasoning is influenced in important ways by physicians' efforts to both draw from, and maintain, their relationships with patients and patients' caregivers. Such efforts create tensions between their professional standards of care and their orientations toward patient-centredness. These influences of relationships on physicians' clinical reasoning have important implications for training and clinical practice.
临床推理文献越来越多地认为背景是影响医生思维的重要因素。医生与患者的关系以及他们为维持这些关系所做的持续努力，对临床推理的背景化有重要影响。作者试图了解医生与患者的关系如何塑造他们的临床推理。
本研究采用建构主义扎根理论，对初级保健医生进行了半结构化访谈。要求参与者反思最近具有挑战性的临床经历，并使用探究性问题探讨他们如何关注或利用与临床推理相结合的关系。使用恒定性比较，三位研究人员对转录本进行编码，将数据组织成代码和概念类别。研究团队从这些代码和类别中得出关于感兴趣现象的理论。
作者采访了 15 名初级保健医生，他们在实践中有不同的经验，并确定患者的能动性是参与者临床推理的主要影响因素。参与者通过三种方式从与患者的关系中汲取并管理关系，同时关注患者的能动性。首先，参与者描述了情境化的疾病构建如何使他们能够针对诊断和管理个性化他们的方法。其次，参与者管理着实施他们对临床问题典型方法与适应方法以促进与患者持续关系之间的紧张关系。最后，参与者关注患者照顾者的关系，认为这些人对他们的临床推理如何在患者独特的社会背景中实施具有重要影响。
临床推理受到医生努力从与患者及其患者照顾者的关系中汲取并维持这些关系的重要影响。这些努力在他们的护理标准和以患者为中心的倾向之间造成紧张关系。这些关系对医生临床推理的影响对培训和临床实践具有重要意义。
