Ng Isaac K S, Goh Wilson G W, Teo Desmond B, Chong Kar Mun, Tan Li Feng, Teoh Chia Meng
Department of Medicine, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore.
Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore 117597, Singapore.
Postgrad Med J. 2024 Dec 23;101(1191):68-75. doi: 10.1093/postmj/qgae079.
Clinical reasoning is a crucial skill and defining characteristic of the medical profession, which relates to intricate cognitive and decision-making processes that are needed to solve real-world clinical problems. However, much of our current competency-based medical education systems have focused on imparting swathes of content knowledge and skills to our medical trainees, without an adequate emphasis on strengthening the cognitive schema and psychological processes that govern actual decision-making in clinical environments. Nonetheless, flawed clinical reasoning has serious repercussions on patient care, as it is associated with diagnostic errors, inappropriate investigations, and incongruent or suboptimal management plans that can result in significant morbidity and even mortality. In this article, we discuss the psychological constructs of clinical reasoning in the form of cognitive 'thought processing' models and real-world contextual or emotional influences on clinical decision-making. In addition, we propose practical strategies, including pedagogical development of a personal cognitive schema, mitigating strategies to combat cognitive bias and flawed reasoning, and emotional regulation and self-care techniques, which can be adopted in medical training to optimize physicians' clinical reasoning in real-world practice that effectively translates learnt knowledge and skill sets into good decisions and outcomes.
临床推理是医学专业的一项关键技能和决定性特征，它涉及解决现实世界临床问题所需的复杂认知和决策过程。然而，我们当前基于能力的医学教育体系大多侧重于向医学实习生传授大量的知识内容和技能，而没有充分强调强化在临床环境中实际决策的认知模式和心理过程。尽管如此，有缺陷的临床推理会对患者护理产生严重影响，因为它与诊断错误、不适当的检查以及不一致或不理想的管理计划相关，这些可能导致严重的发病率甚至死亡率。在本文中，我们以认知“思维处理”模型的形式讨论临床推理的心理结构以及对临床决策的现实情境或情感影响。此外，我们提出了一些实用策略，包括个人认知模式的教学发展、对抗认知偏差和有缺陷推理的缓解策略，以及情绪调节和自我护理技巧，这些策略可在医学培训中采用，以优化医生在现实世界实践中的临床推理，从而有效地将所学知识和技能转化为良好的决策和结果。
