Clinical reasoning
http://www.100md.com
《英国医生杂志》
1 Division of Medical Education, Warwick Medical School, University of Warwick, Coventry CV4 7AL ed.peile@warwick.ac.uk
Many BMJ readers have participated in the web discussion of this evolving case presentation and have been intrigued by the complexities of diagnosis. Initially, there was consensus around the broad diagnosis of heart failure, but responding to the twists and turns of the evolving clinical story, many medical readers showed traits of the amateur detective and the crossword puzzle enthusiast. It was this that led me to comment favourably on the learning to be had from doctors interacting with one another's clinical reasoning processes. I hope that the trend away from just submitting answers in a right or wrong format towards exposing the workings of our medical minds will continue.
What is clinical reasoning? The process by which doctors funnel their thinking towards probable diagnosis is classically thought of as a mixture of pattern recognition and "hypothetico-deductive" reasoning.1 2 The reasoning process depends on medical knowledge in areas such as disease prevalence and pathophysiological mechanisms. Teaching on the process of reasoning, as diagnostic tests provide new information, has included modifications of Bayes's theorem in an attempt to get clinicians to think constructively about pre-test and post-test possibilities.1
Looking at the web discussions, we can see more everyday clinical reasoning processes at work. The maxim that "common things occur commonly" is obviously tried and trusted by many. We also see a good example of biases affecting the cognitive process, when wily clinicians are aware that cases published in the BMJ are likely to have uncommon aspects. An aspect of clinical reasoning that is perhaps under-represented in these discussions is intuition.3
Learning from experts is a traditional foundation of medical learning. But, experts4 are not always the best people to teach—because they have become unconscious of the processes that novices and those with intermediate levels of proficiency need to learn.5 This is the value of learning from each other.
A word of caution. Just as in bedside teaching doctors and students need to be aware of the sensitivities of the patient from whom we are learning, so in these interactive case discussions we need to avoid getting so absorbed in the trail of diagnostic clues that we forget the patient. All patients have consented, and they are well cared for throughout the publication process by the case contributors, but it behoves us to check that this novel form of learning (where potentially serious diagnoses are bandied around) does not cause harm. I am pleased to see doctors still debating energetically the patient communication issues.
Competing interests: None declared.
References
Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical epidemiology. A basic science for clinical medicine. Boston: Little, Brown, 1991.
Dowie J, Elstein A. Professional judgement. A reader in clinical decision making. Cambridge: Cambridge University Press, 1988.
Grant J. Clinical decision making: rational principles, clinical intuition or clinical thinking? In: Balla JI, Gibson M, Chang AM, eds. Learning in medical school: a model for the clinical professions. Hong Kong: Hong Kong University Press, 1989: 81-100.
Dreyfus HL, Dreyfus SE. Mind over machine: the power of human intuition and expertise in the era of the computer. Oxford: Basil Blackwell, 1986.
Benner P. From novice to expert: excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley, 1984.(Ed Peile, professor of me)
Many BMJ readers have participated in the web discussion of this evolving case presentation and have been intrigued by the complexities of diagnosis. Initially, there was consensus around the broad diagnosis of heart failure, but responding to the twists and turns of the evolving clinical story, many medical readers showed traits of the amateur detective and the crossword puzzle enthusiast. It was this that led me to comment favourably on the learning to be had from doctors interacting with one another's clinical reasoning processes. I hope that the trend away from just submitting answers in a right or wrong format towards exposing the workings of our medical minds will continue.
What is clinical reasoning? The process by which doctors funnel their thinking towards probable diagnosis is classically thought of as a mixture of pattern recognition and "hypothetico-deductive" reasoning.1 2 The reasoning process depends on medical knowledge in areas such as disease prevalence and pathophysiological mechanisms. Teaching on the process of reasoning, as diagnostic tests provide new information, has included modifications of Bayes's theorem in an attempt to get clinicians to think constructively about pre-test and post-test possibilities.1
Looking at the web discussions, we can see more everyday clinical reasoning processes at work. The maxim that "common things occur commonly" is obviously tried and trusted by many. We also see a good example of biases affecting the cognitive process, when wily clinicians are aware that cases published in the BMJ are likely to have uncommon aspects. An aspect of clinical reasoning that is perhaps under-represented in these discussions is intuition.3
Learning from experts is a traditional foundation of medical learning. But, experts4 are not always the best people to teach—because they have become unconscious of the processes that novices and those with intermediate levels of proficiency need to learn.5 This is the value of learning from each other.
A word of caution. Just as in bedside teaching doctors and students need to be aware of the sensitivities of the patient from whom we are learning, so in these interactive case discussions we need to avoid getting so absorbed in the trail of diagnostic clues that we forget the patient. All patients have consented, and they are well cared for throughout the publication process by the case contributors, but it behoves us to check that this novel form of learning (where potentially serious diagnoses are bandied around) does not cause harm. I am pleased to see doctors still debating energetically the patient communication issues.
Competing interests: None declared.
References
Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical epidemiology. A basic science for clinical medicine. Boston: Little, Brown, 1991.
Dowie J, Elstein A. Professional judgement. A reader in clinical decision making. Cambridge: Cambridge University Press, 1988.
Grant J. Clinical decision making: rational principles, clinical intuition or clinical thinking? In: Balla JI, Gibson M, Chang AM, eds. Learning in medical school: a model for the clinical professions. Hong Kong: Hong Kong University Press, 1989: 81-100.
Dreyfus HL, Dreyfus SE. Mind over machine: the power of human intuition and expertise in the era of the computer. Oxford: Basil Blackwell, 1986.
Benner P. From novice to expert: excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley, 1984.(Ed Peile, professor of me)