What's in a Label? Is Diagnosis the Start or the End of Clinical Reasoning?
What's in a Label? Is Diagnosis the Start or the End of Clinical Reasoning?
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DOI：
10.1007/s11606-016-3592-7
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发表时间：
2016-04-01
影响因子：
5.7
通讯作者：
Regehr, Glenn
中科院分区：
文献类型：
--
作者：
Ilgen, Jonathan S.;Eva, Kevin W.;Regehr, Glenn
诊断推理在文献中受到了广泛关注，但我们所说的“诊断”的含义可能有所不同。诊断可以与“标签”的分配保持一致，其中一系列体征、症状和测试结果在单个时间点统一为解决方案。这种“诊断标签”概念体现在我们基于案例的学习课程、已发表的案例报告和研究中，所有这些都将诊断准确性作为主要结果。然而，这种概念化可能过于简单化了许多环境下临床推理的丰富迭代和进化本质。诊断还可以代表一个通过从本质上动态的、特殊经验的、团队成员之间协商的、并且充满探索机会的数据“创造意义”来指导一个人的思想的过程。因此，诊断有两种互补的结构：1）诊断推理过程产生的正确解决方案，2）对正在进行的临床推理过程的动态帮助。本文讨论了认识“诊断”这两种概念的重要性，概述了强调诊断标签作为临床推理的主要目标所带来的意想不到的后果，并提出了如何将诊断视为一个持续的意义构建过程，从而改变我们对临床推理教学和评估的看法。
Diagnostic reasoning has received substantial attention in the literature, yet what we mean by "diagnosis" may vary. Diagnosis can align with assignment of a "label," where a constellation of signs, symptoms, and test results is unified into a solution at a single point in time. This "diagnostic labeling" conceptualization is embodied in our case-based learning curricula, published case reports, and research studies, all of which treat diagnostic accuracy as the primary outcome. However, this conceptualization may oversimplify the richly iterative and evolutionary nature of clinical reasoning in many settings. Diagnosis can also represent a process of guiding one's thoughts by "making meaning" from data that are intrinsically dynamic, experienced idiosyncratically, negotiated among team members, and rich with opportunities for exploration. Thus, there are two complementary constructions of diagnosis: 1) the correct solution resulting from a diagnostic reasoning process, and 2) a dynamic aid to an ongoing clinical reasoning process. This article discusses the importance of recognizing these two conceptualizations of "diagnosis," outlines the unintended consequences of emphasizing diagnostic labeling as the primary goal of clinical reasoning, and suggests how framing diagnosis as an ongoing process of meaning-making might change how we think about teaching and assessing clinical reasoning.