Quantitative evaluation of the diagnostic thinking process in medical students
Quantitative evaluation of the diagnostic thinking process in medical students
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DOI：
10.1046/j.1525-1497.2002.20139.x
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发表时间：
2002-11-01
影响因子：
5.7
通讯作者：
Fukui, T
中科院分区：
文献类型：
--
作者：
Noguchi, Y;Matsui, K;Fukui, T
目的：探讨医学生的诊断思维过程。 对象与方法：向224名医学生提出3种临床情景，分别对应冠状动脉疾病的高、低、中预测概率。对运动压力测试的测试特征以及每种场景的测试前和测试后概率的估计是从学生（直观估计）和文献（参考估计）中得出的。基于直观估计（测试后概率的贝叶斯估计）和参考估计（测试后概率的参考估计），使用贝叶斯定理计算测试后概率。参考估计与直观估计之间以及贝叶斯估计与直观估计之间的差异用于评估对测试特征的了解以及估计测试前和测试后疾病概率的能力。 结果：医学生无法在低或中等测试前概率设置中排除疾病，这主要是因为测试前对疾病概率的估计较差。他们也很容易对与预期结果不同的测试结果感到困惑，这可能是因为他们不擅长将贝叶斯定理应用于实际的临床情况。这些诊断思维模式导致医学生或新手医生重复不必要的检查。结论：医学生的诊断能力可以通过以下教育策略来提高：1）强调在临床实践中排除疾病的重要性，2）根据病史和体格检查进行测试前疾病概率估计的培训，3）结合贝叶斯概率思维及其在实际临床情况中的应用。
OBJECTIVE: To explore the diagnostic thinking process of medical students.SUBJECTS AND METHODS: Two hundred twenty-four medical students were presented with 3 clinical scenarios corresponding to high, low, and intermediate pre-test probability of coronary artery disease. Estimates of test characteristics of the exercise stress test, and pre-test and post-test probability for each scenario were elicited from the students (intuitive estimates) and from the literature (reference estimates). Post-test probabilities were calculated using Bayes' theorem based upon the intuitive estimates (Bayesian estimates of post-test probability) and upon the reference estimates (reference estimates of post-test probability). The differences between the reference estimates and the intuitive estimates, and between Bayesian estimates and the intuitive estimates were used for assessing knowledge of test characteristics, and ability of estimating pre-test and post-test probability of disease.RESULTS: Medical students could not rule out disease in low or intermediate pre-test probability settings, mainly because of poor pre-test estimates of disease probability. They were also easily confused by test results that differed from their anticipated results, probably because of their inaptitude in applying Bayes' theorem to real clinical situations. These diagnostic thinking patterns account for medical students or novice physicians repeating unnecessary examinations.CONCLUSIONS: Medical students' diagnostic ability may be enhanced by the following educational strategies: 1) emphasizing the importance of ruling out disease in clinical practice, 2) training in the estimation of pre-test disease probability based upon history and physical examination, and 3) incorporation of the Bayesian probabilistic thinking and its application to real clinical situations.