實用的臨床推理教學方法

Practical Methods and Techniques for Teaching Clinical Reasoning

本文描述臨床醫學教師如何教導醫學生或受訓醫師作臨床診斷推理，討論關於有效臨床推理教學的各種考量，並建議有效和實用的教學方法。近代文獻指出，醫師以類似資訊處理模式，將專業知識有組織地建構並且儲存，來有效地分析判讀所蒐集到的臨床資訊，進行臨床推理，建立診斷，施予治療。醫學教育界廣泛地運用資訊處理模式於臨床推理的教學上，引伸了認知負荷模式，其中特別是疾病稿本，協助醫師們獲取有用的臨床資訊，同時運用短期工作記憶處理及分析資訊，儲存資訊在長期記憶的庫藏中，來提取使用。同時，醫師以雙重運轉的推理思考模式，來進行診斷的推理。文獻也指出，專注的練習以及自我調整的學習，能有效促進臨床推理的學習。本文將探討這些現代推理模式的理論基礎與一般性教學方法的相關性，以及在教學上的應用，來達到有效的臨床推理教學。接著討論如何運用特殊的教學方式包括「本能性臨床教學步驟」、「一分鐘教學模式（亦稱五個步驟微技巧）」與「SNAPPS 教學模式」，以及如何善用有效的課堂教學技巧，以促進臨床推理教學與學習。

This article presents an overview of how to best guide medical students and residents learning clinical reasoning, discusses the considerations for effective teaching approaches, and provides suggestions for several effective and practical general teaching methods and special teaching techniques. Recent research on information-processing model suggests that clinicians organize knowledge in memory similar to the orderly modeling of a computer program. The more effective a clinician processes medical information, the more likely it would lead to efficient clinical reasoning and derive in correct diagnosis. Information-processing model allows medical education researchers to build on knowledge representation in memory, known as “illness script”, i.e., mental representations of the clinical manifestations and findings that can be observed with a given disease, which results in the enhancement of acquiring, storing and recalling knowledge in memory. It leads to the development and application of “illness script” model as a general teaching approach in clinical reasoning. Current literature indicates that clinical reasoning is based on the dual process theory, integrating non-analytical and analytical models of thinking and decision making process. Learners are expected to develop reasoning abilities for recognizing disease pattern, generating initial hypotheses, and making differential diagnosis. Teachers should help students build their own “illness script” library to improve clinical reasoning. The importance of “deliberate practice” and “self-regulated learning” toward the optimal development of reasoning skills and ability is emphasized and discussed. Specific teaching tools such as instinctive clinical teaching approach, the “one-minute preceptor” model, and SNAPPS are introduced to promote “think out loud” during teaching and discussion sessions. It makes reasoning process visible to learners to enhance reflective learning. The tactics for effective delivery of lectures are also discussed. The goal of this article is to provide clinical faculties teaching tools to guide students learning clinical reasoning effectively.