Quantitative evaluation of the diagnostic thinking process of physicians

背景在以往的研究中，我们分析了医学生诊断能力的假设演绎法的三个要素，即，测试特性知识（灵敏度和特异性）、根据临床病史估计测试前疾病概率的能力以及根据测试前概率和测试特征估计测试后概率的能力（1，2）。目的我们计划这项研究以澄清临床经验是否能提高上述能力。（研究生年（PGY）1和2），高级住院医师（PGY 3或以上）在日本的11个教育医院。我们向住院医师提出了胸痛患者的假设情景，并要求他们回答问题。提供了典型心绞痛、非典型心绞痛和非心绞痛胸痛的临床病例。每个居民被要求独立地提供答案，以她最大的能力，根据情景沿着他们的生活。 ...更多信息 结果262名居民回答了问卷。结果表明：1）在高验前概率情景下，居民能够判定疾病; 2）在低验前概率情景下，居民不能排除疾病，主要原因是验前概率估计较差; 3）在中验前概率情景下，居民不能改变验后概率; 4）居民也容易被检验结果与预期相混淆，这可能是由于他们不善于将贝叶斯定理应用于真实的临床情况; 5）在高验前概率情景下，随着PGY的增加，估计值提高。低预检验概率情景下的估计值显示出一定的改善，但不足以提高实际诊断能力。6）将贝叶斯定理应用于临床情景的能力并没有随着PGY的增加而提高。这些诊断思维模式解释了为什么医学生或新手医生最终会重复不必要的检查。诊断性能中的这些缺陷不能通过临床“经验”自发地纠正。少

BackgroundIn previous study, we analyzed diagnostic abilities of medical students in terms of three elements of the hypothetico-deductive method, i.e., knowledge of test characteristics (sensitivity and specificity), ability to estimate pre-test disease probability from clinical history, and ability to estimate post-test probability from pre-test probability and test characteristic (1,2).PurposeWe planned this research to clarify whether or not clinical experience improves above-mentioned abilities.MethodsWe surveyed junior residents (Post Graduate Year (PGY) 1 and 2), senior residents (PGY3 or more) in 11 educational hospitals in Japan. We presented hypothetical scenarios of chest pain patients to the residents and asked them to answer questions. Clinical scenarios of typical anginal pain, atypical anginal pain, and non-anginal chest pain were provided. Each resident was asked to provide answers independently to the best of ****r her ability, based on the scenarios along with their ow … More n knowledge and experience.ResultsTwo hundred and sixty two residents answered the questionnaire. Following findings were obtained:1)Residents could rule in diseases in high pre-test probability scenario.2)Residents could not rule out disease in low pre-test probability scenario, mainly because of poor pre-test estimates of disease probability.3)Residents could not change the post-test probability in intermediate pre-test probability scenario.4)They were also easily confused by the test results against their anticipation, which is likely to be due to their inaptitude in applying Bayes' theorem to real clinical situations.5)The estimates in high pre-test probability scenario improved with increase in PGY. The estimates in low pretest probability scenario showed some improvements but not enough to improve practical diagnostic ability.6)The capacity in applying Bayes' theorem to clinical scenarios did not improve with increase in PGY.ConclusionNovice physicians could not rule out disease in low pre-test probability setting and could not utilize information from history due to inaptitude in applying Bayes' theorem to real clinical situations. These diagnostic thinking patterns account for why medical students or novice physicians end up repeating unnecessary examinations. These faults in diagnostic performance were not corrected by clinical "experience" spontaneously. Less