临床思维的基本原理  

General Principles of Clinical Reasoning

作　　者：王筝扬[1] 向阳[2] WANG Zhengyang;XIANG Yang(Internal Medicine Department,Sir Run Run Shaw Hospital,School of Medicine,Zhejiang University,Hangzhou,Zhejiang 310016,China;General Surgery,Huashan Hospital,School of Medicine,Fudan University,Shanghai 200040 China)

机构地区：[1]浙江大学医学院附属邵逸夫医院内科,浙江杭州310016 [2]复旦大学医学院附属华山医院普外科,上海200040

出　　处：《中国毕业后医学教育》2020年第2期97-107,共11页Chinese Journal of Graduate Medical Education

基　　金：浙江省医药卫生科技一般基金资助项目(2019KY430);浙江省教育厅“十三五”第二批教学改革基金资助项目(jg20190005);浙江大学高水平教学成果培育基金资助项目(cgyb20192008)。

摘　　要：临床思维是医生行医所须具备最重要的能力之一,其本质是人类的认知能力在特殊的医学诊断决策场景下的一种应用。本文回顾了近年来对临床思维研究的发展过程,尤其是认知心理学研究对临床思维的认识,着重介绍了认知信息加工模型中知识组织与疾病脚本理论如何影响工作记忆、如何减少认知偏差导致的诊断错误以及双相推理过程原理作为主流理论在临床思维教学中的意义。从认知原理出发,要特别重视对学生系统2分析性思维的培养,鼓励他们运用假设-演绎等诊断推理模型开展诊断与决策。本文进一步讨论了采用数学中贝叶斯定理在量化评估临床思维过程中的价值,以及如何同循证医学相结合,来认识临床思维的科学本质,理解为何临床思维能力对于医生准确解决医学中的不确定性问题有着不可替代的作用。Clinical reasoning,whose essence is to apply human cognition in specific medical diagnosis and decision making,is one of the key capabilities of doctors in their medical profession.By reviewing studies on clinical reasoning in recent years,especially those on cognitive psychology on clinical reasoning,we introduce here how a cognitive information processing model,including its knowledge organization and illness script hypothesis,impacts working memory,how diagnostic errors caused by cognitive bias are to be reduced and why a dual-process model becomes a prevailing theory in the curricular design of clinical reasoning.According to cognitive psychological perspectives,special attention should be paid to nurturing students’system 2,the analytical thinking,and encouraging students to adopt a hypothetical-deductive reasoning model in clinical diagnosis and decision-making.In addition,We discuss the value of applying the Bayes theorem of mathematics in making quantitative evaluation of clinical reasoning and how it can be integrated with evidencebased medicine to understand the scientific nature of clinical reasoning and why it plays an irreplaceable role in empowering doctors to accurately address uncertainty in medicine.

关 键 词：临床思维 认知心理学 疾病脚本 模式识别 假设-演绎推理 贝叶斯定理 

分 类 号：G40[文化科学—教育学原理]