臨床推理教學的理論與實務

Teaching Clinical Reasoning: Theory and Practice

醫師做診斷與常人在常理上的推理思緒，基本上都是經驗性的觀察與反思性的推理思考過程。最近的研究顯示，醫師通常是以「非分析性」與「分析性」兩種思考操作構成的雙重運轉過程來進行臨床推理。臨床上的診斷程序一般是從假設的建立開始，藉著非分析性思考過程裡的推理，運用疾病模式辦認的架構來產生初步的假設。醫師在遇到較困難的病例或看到初步診斷假設不符合臨床情況或不尋常時，會藉著分析性的思考來協助醫師做診斷上的推理，以及辨識初步假設的可靠性。文獻指出，臨床老師必須瞭解現代臨床推理原理，來有效的推展臨床推理課程。要教導學生以雙重運轉推理思緒貫穿病史收集、身體檢查、檢驗及影像檢查過程，同時結合資料的分析與臨床上病人的評估，來做診斷與治療。

Clinical reasoning is a pivotal component for providing optimal medical care. The reasoning process that a physician uses for making diagnosis is similar to the thought process for making decisions that an ordinary person does in daily life. Both are common sense inferences of thoughts involving empirical observation and reflective reasoning. Recent research indicates that clinical reasoning is a dual process integrating nonanalytical and analytical models of decision making. Clinical diagnostic processing commonly starts with the genesis of hypothesis through nonanalytical reasoning, which relies on unconscious, intuitive, and pattern recognition. Analytical processing is activated when a physician cannot recognize symptoms and signs of illness. This conscious, purposeful and logical thinking process allows a clinician to consider what should or should not happen in unfamiliar situations in order to explore alternative causes of events. It is recognized that clinical reasoning isn't merely a skill or a trait, but more of a state or an ability of clinicians. It is important to indicate that teaching clinical reasoning should involve students in thoughtfully practicing its component parts i.e., history-taking, physical examination, laboratory interpretation as well as incorporate these components into assessing patients in clinical settings. However, modern literature has stressed that clinical faculties need to have a good understanding of underlying mechanism of clinical reasoning to teach it effectively.