Pauker S G, Gorry G A, Kassirer J P, Schwartz W B
Am J Med. 1976 Jun;60(7):981-96. doi: 10.1016/0002-9343(76)90570-2.
Remarkably little is known about the cognitive processes which are employed in the solution of clinical problems. This paucity of information is probably accounted for in large part by the lack of suitable analytic tools for the study of the physician's thought processes. Here we report on the use of the computer as a laboratory for the study of clinical cognition. Our experimental approach has consisted of several elements. First, cognitive insights gained from the study of clinicians' behavior were used to develop a computer program designed to take the present illness of a patient with edema. The program was then tested with a series of prototypical cases, and the present illnesses generated by the computer were compared to those taken by the clinicians in our group. Discrepant behavior on the part of the program was taken as a stimulus for further refinement of the evolving cognitive theory of the present illness. Corresponding refinements were made in the program, and the process of testing and revision was continued until the program's behavior closely resembled that of the clinicians. The advances in computer science that made this effort possible include "goal-directed" programming, pattern-matching and a large associative memory, all of which are products of research in the field known as "artificial intelligence". The information used by the program is organized in a highly connected set of associations which is used to guide such activities as checking the validity of facts, generating and testing hypotheses, and constructing a coherent picture of the patient. As the program pursues its interrelated goals of information gathering and diagnosis, it uses knowledge of diseases and pathophysiology, as well as "common sense", to dynamically assemble many small problem-solving strategies into an integrated history-taking process. We suggest that the present experimental approach will facilitate accomplishment of the long-term goal of disseminating clinical expertise via the computer.
令人惊讶的是，对于解决临床问题时所采用的认知过程，我们知之甚少。这种信息匮乏的情况很大程度上可能是由于缺乏适用于研究医生思维过程的分析工具。在此，我们报告将计算机用作研究临床认知的实验室的情况。我们的实验方法包含几个要素。首先，从对临床医生行为的研究中获得的认知见解被用于开发一个计算机程序，该程序旨在处理水肿患者的现病史。然后，该程序用一系列典型病例进行测试，并将计算机生成的现病史与我们小组中临床医生所采用的现病史进行比较。程序出现的差异行为被用作进一步完善现病史不断发展的认知理论的刺激因素。对程序进行了相应的改进，并且持续进行测试和修订的过程，直到程序的行为与临床医生的行为非常相似。使这项工作成为可能的计算机科学进展包括“目标导向”编程、模式匹配和大容量关联记忆，所有这些都是被称为“人工智能”领域研究的产物。程序所使用的信息以一组高度关联的关联形式组织起来，用于指导诸如检查事实的有效性、生成和检验假设以及构建患者的连贯情况等活动。当程序追求其信息收集和诊断的相关目标时，它利用疾病和病理生理学知识以及“常识”，将许多小的问题解决策略动态地整合到一个综合的病史采集过程中。我们认为，目前的实验方法将有助于实现通过计算机传播临床专业知识这一长期目标。
