現代臨床推理教學的學理及觀念

The Concepts and Theoretical View on Teaching Clinical Reasoning

「臨床推理」在本質上屬於一種「回溯性的推論」（abductive reasoning），乃是醫師在一給定的醫療情境中，面對病患，根據疾病外在表徵、病史詢問、理學診查，甚而結合實驗室檢驗及影像學報告，進行回溯性的推斷，建立最佳假設，其後再經由合乎邏輯的推理與驗證，達成正確診斷的心智活動。無可否 認地，成功的臨床推理是一位醫師的專業展現。然而，醫學教育上對於醫師臨床推理能力的養成方式， 至今仍需要多方的整合、努力與研究。本文回顧醫學史上臨床推理觀念的三個演進時期，介紹當代建立於認知科學與心理學上重要的臨床推理理論，並於其中嘗試指出醫師本身具備的系統化醫學知識，「雙重 認知論」（dual-process cognition theory）的靈活運用，以及在「情境理論」（situativity theory）框架下醫學與 非醫學脈絡的掌握，以上三者的整合是臨床推理活動與學習的重要關鍵。希望經由本論文的探討，能幫助臨床教師更完整地了解臨床推理活動的內涵，並且協助臨床推理教學的規劃以及實際教學上的運用。

“Reasoning” originates from philosophy. According to its Greek origin, “reasoning” is the art of thinking, which is an analysis of thoughts for educated persons engaged in theoretical or practical activities. A 'thesis' (or conclusion) is derived from a set of 'premise' through a process of logical reasoning deduction (logos). Similarly, clinical reasoning is a process in which physicians utilize logical hypotheses, reasoning and testing based on patient’s clinical information to establish diagnoses in everyday practice. A physician’s proficiency is best demonstrated by the exercise of effective and efficient clinical reasoning. An integrated educational program for teaching clinical reasoning is still under development. In this article, we describe the current concepts of clinical reasoning, review the history of understanding clinical reasoning including 3 periods of prevailing hypothesis. Important theories of clinical reasoning based on modern cognitive and psychological sciences are summarized and presented. It is suggested that understanding today’s key theories of clinical reasoning including “cognitive load, dual process cognition and situated cognition” will enhance clinical reasoning abilities for learners of all levels and clinicians. This article will also provide guidance to apply theory to teach clinical reasoning effectively.