Context and clinical reasoning: understanding the perspective of the expert's voice
Context and clinical reasoning: understanding the perspective of the expert's voice
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DOI：
10.1111/j.1365-2923.2011.04053.x
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发表时间：
2011-09-01
影响因子：
6
通讯作者：
Schuwirth, Lambert
中科院分区：
文献类型：
--
作者：
Durning, Steven;Artino, Anthony R., Jr.;Schuwirth, Lambert
目的先前的工作已经发现，医生的临床推理能力在个案(情况)的基础上是不同的；这通常被称为背景特异性。为了探索语境对诊断和治疗临床推理的影响，我们构建了一系列要求医生做出反应的录像带，修改了不同的语境因素(患者、医生、环境)。我们探索了这些背景因素，如录像带的接触所显示的，可能已经影响了委员会认证的内科医生(专家)的临床推理。我们的目的是阐明背景对推理的影响，建立在教育理论的基础上，并产生对教育实践的启示。方法专家的定性数据来自两个来源：反映委员会认证的内科医生观看视频会面时发生的并发思维过程的有声思考协议，以及对明确要求这些专家就选定的背景因素对其临床推理过程的影响发表评论的问题的自由文本回复。这些数据来源提供了关于语境对推理的影响的实际表现数据(大声思考的回答)和对反思的意见(自由文本回答)。结果从我们的数据中产生了几个主题，并将其大致分类为影响背景因素影响的组件、应对背景因素的机制以及背景因素对患者护理的影响。来自两个数据来源的主题有很好的重叠性，表明专家们对语境对他们推理过程的潜在影响有一定的认知；值得注意的例外是在有声思考而不是自由文本分析中出现的遗漏关键发现、目标平衡和相遇环境影响的主题。结论我们的统一模型符合认知负荷、情境认知和生态心理学理论的原则。确定了一些对临床推理的潜在的可修改的影响。讨论了对医生培训和实践的影响。
OBJECTIVES Prior work has found that a doctor's clinical reasoning performance varies on a case-by-case (situation) basis; this is often referred to as 'context specificity'. To explore the influence of context on diagnostic and therapeutic clinical reasoning, we constructed a series of videotapes to which doctors were asked to respond, modifying different contextual factors (patient, doctor, setting). We explored how these contextual factors, as displayed by videotape encounters, may have influenced the clinical reasoning of board-certified internists (experts). Our purpose was to clarify the influence of context on reasoning, to build upon education theory and to generate implications for education practice.METHODS Qualitative data about experts were gathered from two sources: think-aloud protocols reflecting concurrent thought processes that occurred while board-certified internists viewed videotape encounters, and free-text responses to queries that explicitly asked these experts to comment on the influence of selected contextual factors on their clinical reasoning processes. These data sources provided both actual performance data (think-aloud responses) and opinions on reflection (free-text answers) regarding the influence of context on reasoning. Results for each data source were analysed for emergent themes and then combined into a unified theoretical model.RESULTS Several themes emerged from our data and were broadly classified as components influencing the impact of contextual factors, mechanisms for addressing contextual factors, and consequences of contextual factors for patient care. Themes from both data sources had good overlap, indicating that experts are somewhat cognisant of the potential influences of context on their reasoning processes; notable exceptions concerned the themes of missed key findings, balancing of goals and the influence of encounter setting, which emerged in the think-aloud but not the free-text analysis.CONCLUSIONS Our unified model is consistent with the tenets of cognitive load, situated cognition and ecological psychology theories. A number of potentially modifiable influences on clinical reasoning were identified. Implications for doctor training and practice are discussed.