Torre Dario, Daniel Michelle, Ratcliffe Temple, Durning Steven J, Holmboe Eric, Schuwirth Lambert
Department of Medical Education, University of Central Florida, Orlando, FL, USA.
Department of Emergency Medicine, University of California, San Diego, CA, USA.
Teach Learn Med. 2024 May 25:1-9. doi: 10.1080/10401334.2024.2333921.
Clinical reasoning is essential to physicians' competence, yet assessment of clinical reasoning remains a significant challenge. Clinical reasoning is a complex, evolving, non-linear, context-driven, and content-specific construct which arguably cannot be assessed at one point in time or with a single method. This has posed challenges for educators for many decades, despite significant development of individual assessment methods. Programmatic assessment is a systematic assessment approach that is gaining momentum across health professions education. Programmatic assessment, and in particular assessment for learning, is well-suited to address the challenges with clinical reasoning assessment. Several key principles of programmatic assessment are particularly well-aligned with developing a system to assess clinical reasoning: longitudinality, triangulation, use of a mix of assessment methods, proportionality, implementation of intermediate evaluations/reviews with faculty coaches, use of assessment for feedback, and increase in learners' agency. Repeated exposure and measurement are critical to develop a clinical reasoning assessment narrative, thus the assessment approach should optimally be longitudinal, providing multiple opportunities for growth and development. Triangulation provides a lens to assess the multidimensionality and contextuality of clinical reasoning and that of its different, yet related components, using a mix of different assessment methods. Proportionality ensures the richness of information on which to draw conclusions is commensurate with the stakes of the decision. Coaching facilitates the development of a feedback culture and allows to assess growth over time, while enhancing learners' agency. A programmatic assessment model of clinical reasoning that is developmentally oriented, optimizes learning though feedback and coaching, uses multiple assessment methods, and provides opportunity for meaningful triangulation of data can help address some of the challenges of clinical reasoning assessment.
临床推理对医生的能力至关重要，但对临床推理的评估仍然是一项重大挑战。临床推理是一个复杂、不断演变、非线性、受情境驱动且特定于内容的结构， arguably无法在某一时刻或用单一方法进行评估。尽管个别评估方法有了显著发展，但这几十年来一直给教育工作者带来挑战。程序性评估是一种系统的评估方法，在卫生专业教育中越来越受到关注。程序性评估，特别是形成性评估，非常适合应对临床推理评估的挑战。程序性评估的几个关键原则与开发临床推理评估系统特别契合：纵向性、三角测量法、使用多种评估方法、相称性、与教师指导者一起进行中期评估/审查、利用评估获取反馈以及增强学习者的自主性。反复接触和测量对于构建临床推理评估记录至关重要，因此评估方法最好是纵向的，提供多次成长和发展的机会。三角测量法提供了一个视角，通过使用多种不同的评估方法来评估临床推理及其不同但相关组成部分的多维性和情境性。相称性确保得出结论所依据的信息丰富程度与决策的利害关系相称。指导有助于培养反馈文化，并能够评估随时间的成长，同时增强学习者的自主性。一个以发展为导向、通过反馈和指导优化学习、使用多种评估方法并提供有意义的数据三角测量机会的临床推理程序性评估模型，有助于应对临床推理评估的一些挑战。
