书写首次病程记录在临床推理能力评估中的应用探讨

Discussion on the Application of Writing the First Course Record in the Assessment of Clinical Reasoning

临床推理是临床实践中思考和决策的过程,其过程包括综合临床数据,确定优先级鉴别诊断和最优诊断,并提出安全和有针对性的患者管理计划,书写首次病程记录可充分反应临床医生对病例诊断和决策推理全过程。文章按临床推理步骤依次分析了临床数据完整性、病例总结、诊断和鉴别诊断、临床决策的常见的临床推理评估方法,但单一方法无法评价临床推理的全部过程,因此需要使用多种方法在临床推理的多个层面进行评估,即需要开发结构性临床推理评价方法。改善医学诊断协会开发的推理评估工具以及解释性总结、鉴别诊断、最可能诊断和备选诊断推理解释(the interpretive summary,differential diagnosis,explanation of reasoning,and alternatives,IDEA)评估工具均可有效的用于临床推理评估。机器学习结合自然语言处理已用于评估临床推理文档,是目前研究的新方向。医学教育者可以采用当代国外临床推理评估方法结合我国医学教育实际,开发适合我国医(学)生的临床推理评估方法。

Clinical reasoning is the thinking and decisionmaking processes associated with clinical practice that involves synthesizing clinical data,prioritizing differential diagnosis and optimal diagnosis,and proposing safe and targeted management plans.Writing the first course record can fully reflect the whole process of diagnosis and decisionmaking of the clinician.In this paper,common clinical reasoning assessment methods for clinical data integrity,case summary,diagnosis and differential diagnosis,and clinical decision-making are analyzed successively according to the steps of clinical reasoning.However,a single method could not evaluate the whole process of clinical reasoning,so a variety of methods should be used to evaluate the clinical reasoning at multiple levels,that is,a structural clinical reasoning assessment method should be developed.A fivecomponent assessment process described by society to improve diagnosis in medicine and the interpretive summary,differential diagnosis,explanation of reasoning,and alternatives(IDEA)assessment tool is effective for clinical reasoning assessment.Machine learning combined with natural language processing which has been used to evaluate clinical reasoning documents is a new research direction.Medical educator can adopt the contemporary foreign clinical reasoning assessment methods combined with the practice of Chinese medical education to develop a suitable clinical reasoning assessment method for Chinese resident or medical students.