What does research on clinical reasoning have to say to clinical teachers?

Silvia Mamede

doi:10.15448/1980-6108.2020.1.37350

Autores

Silvia Mamede Erasmus University Rotterdam, Rotterdam (RTM) http://orcid.org/0000-0003-1187-2392

DOI:

https://doi.org/10.15448/1980-6108.2020.1.37350

Palavras-chave:

raciocínio clínico, competência médica, raciocínio diagnóstico, ensino clínico

Resumo

O raciocínio clínico é um fator determinante da performance do médico, crucial para chegar a um diagnóstico correto e possibilitar decisões terapêuticas adequadas. Ajudar seus estudantes a desenvolver o raciocínio clínico é um desafio diário de muitos professores e, para selecionar estratégias de ensino adequadas, pode ser útil conhecer um pouco dos resultados da pesquisa sobre raciocínio clínico que vem se desenvolvendo já há algumas décadas. Este artigo traz uma síntese de achados desta pesquisa que ajudam a compreender os processos cognitivos envolvidos no raciocínio clínico, a trajetória que leva o estudante de uma condição de “iniciante” `a de “expert” e abordagens instrucionais que têm se mostrado úteis para facilitar esta trajetória. O foco do artigo é o processo diagnóstico, porque é ele que tem sido o objeto central de pesquisa. Esta pesquisa indica que não há estratégias de raciocínio específicas, próprias do médico expert, que possam ser ensinadas ao estudante. É a existência de uma larga base de conhecimentos
organizados na memória em scripts de doenças de diversos formatos que explica o melhor desempenho do expert. Quanto mais numerosos, mais ricos e melhor organizados são os scripts que um médico tem na memória, mais apto ele está para fazer diagnósticos acurados. Estes scripts são formados gradualmente ao longo dos anos de formação e para desenvolvê-los o estudante deve ser exposto a uma grande diversidade de problemas clínicos, com os quais ele deve interagir de forma ativa. Abordagens instrucionais que requerem que o estudante reflita de forma sistemática sobre os problemas, analisando diferenças e similaridades entre eles, explicando mecanismos subjacentes, comparando e contrastando diagnósticos alternativos têm se mostrado úteis para ajudar a refinar scripts de doenças e são ferramentas valiosas para os professores interessados no desenvolvimento do raciocínio clínico de seus estudantes.

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Biografia do Autor

Silvia Mamede, Erasmus University Rotterdam, Rotterdam (RTM)

PhD in Medical Education from the Erasmus University Rotterdam; associate professor, Institute of Medical Education Research Rotterdam, Erasmus Medical Center, and Erasmus School of Social and Behavioral Sciences, Erasmus University Rotterdam, The Netherlands.

Referências

Norman G. Research in clinical reasoning: past history and current trends. Med Educ. 2005;39(4):418-27. https://doi.org/10.1111/j.1365-2929.2005.02127.x.

Elstein AS. Medical Problem Solving: An Analysis of Clinical Reasoning. Cambridge, MA/London, U.K.: Harvard University Press; 1978.

Neufeld VR, Norman GR, Feightner JW, et al. Clinical problem-solving by medical students: a cross-sectional and longitudinal analysis. Med Educ. 1981;15(5):315-22. https://doi.org/10.1111/j.1365-2923.1981.tb02495.x.

Barrows HS, Norman GR, Neufeld VR, et al. The clinical reasoning of randomly selected physicians in general medical practice. Clin Invest Med. 1982;5(1):49-55.

Eva KW. On the generality of specificity. Med Educ. 2003;37(7):587-8. https://doi.org/10.1046/j.1365-2923.2003.01563.x.

Eva KW, Neville AJ, Norman GR. Exploring the etiology of content specificity: factors influencing analogic transfer and problem solving. Acad Med. 1998;73(10 Suppl):S1-5. https://doi.org/10.1097/00001888-199810000-00028.

Custers EJ, Regehr G, Norman GR. Mental representations of medical diagnostic knowledge: a review. Acad Med. 1996;71(10 Suppl):S55-61. https://doi.org/10.1097/00001888-199610000-00044.

Evans JSBT. Dual-processing accounts of reasoning, judgment, and social cognition. Annu Rev Psychol. 2008;59:255-78. https://doi.org/10.1146/annurev.psych.59.103006.093629.

Evans JST. The heuristic-analytic theory of reasoning: Extension and evaluation. Psychon B Rev. 2006;13(3):378-95. https://doi.org/10.3758/BF03193858.

Kahneman D. A Perspective on Judgment and Choice: Mapping Bounded Rationality. Am Psychol. 2003;58(9):697-720. https://doi.org/10.1037/0003-066X.58.9.697.

Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-80. https://doi.org/10.1097/00001888-200308000-00003.

Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med. 2003;41(1):110-20. https://doi.org/10.1067/mem.2003.22.

Norman G. Dual processing and diagnostic errors. Adv Health Sci Educ Theory Pract. 2009;14 Suppl 1:37-49. https://doi.org/10.1007/s10459-009-9179-x.

Lambe KA, O’Reilly G, Kelly BD, et al. Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. BMJ Qual Saf. 2016. https://doi.org/10.1136/bmjqs-2015-004417.

Norman GR, Monteiro SD, Sherbino J, et al. The Causes of Errors in Clinical Reasoning: Cognitive Biases, Knowledge Deficits, and Dual Process Thinking. Acad Med. 2017;92(1):23-30. https://doi.org/10.1097/ACM.0000000000001421.

Eva KW. What every teacher needs to know about clinical reasoning. Med Educ. 2005;39(1):98-106. https://doi.org/10.1111/j.1365-2929.2004.01972.x.

Schmidt HG, Rikers RM. How expertise develops in medicine: knowledge encapsulation and illness script formation. Med Educ. 2007;41(12):1133-9.

Schmidt HG, Norman GR, Boshuizen HPA. A Cognitive Perspective on Medical Expertise - Theory and Implications. Acad Med. 1990;65(10):611-21. https://doi.org/10.1097/00001888-199010000-00001.

Schmidt HG, Boshuizen HPA. On the Origin of Intermediate Effects in Clinical Case Recall. Mem Cognit. 1993;21(3):338-51. https://doi.org/10.3758/BF03208266.

Rikers RMJP, Schmidt HG, Boshuizen HPA. Knowledge encapsulation and the intermediate effect. Contemp Educ Psychol. 2000;25(2):150-66. https://doi.org/10.1006/ceps.1998.1000.

Charlin B, Boshuizen HPA, Custers EJ, et al. Scripts and clinical reasoning. Med Educ. 2007;41(12):1178-84. https://doi.org/10.1111/j.1365-2923.2007.02924.x.

Schmidt HG, Boshuizen HPA. On Acquiring Expertise in Medicine. Educ Psychol Rev. 1993;5(3):205-21. https://doi.org/10.1007/BF01323044.

Hobus PPM, Schmidt HG, Boshuizen HPA, et al. Contextual Factors in the Activation of 1st Diagnostic Hypotheses - Expert Novice Differences. Med Educ. 1987;21(6):471-6. https://doi.org/10.1111/j.1365-2923.1987.tb01405.x.

Schmidt HG, Mamede S. How to improve the teaching of clinical reasoning: a narrative review and a proposal. Med Educ. 2015;49(10):961-73. https://doi.org/10.1111/medu.12775.

Sherbino J, Dore KL, Wood TJ, et al. The relationship between response time and diagnostic accuracy. Acad Med. 2012;87(6):785-91. https://doi.org/10.1097/ACM.0b013e318253acbd.

Sherbino J, Kulasegaram K, Howey E, et al. Ineffectiveness of cognitive forcing strategies to reduce biases in diagnostic reasoning: a controlled trial. CJEM. 2014;16(1):34-40. https://doi.org/10.2310/8000.2013.130860.

Mamede S, de Carvalho-Filho MA, de Faria RMD, et al. ‘Immunising’ physicians against availability bias in diagnostic reasoning: a randomised controlled experiment. BMJ Qual Saf. 2020. https://doi.org/10.1136/bmjqs-2019-010079.

Loewenstein J, Thompson L, Gentner D. Analogical Learning in Negotiation Teams: Comparing Cases Promotes Learning and Transfer. Acad Manag Learn Edu. 2003;2(2):119-27. https://doi.org/10.5465/amle.2003.9901663.

Gentner D, Loewenstein J, Thompson L. Learning and transfer: A general role for analogical encoding. J Educ Psychol. 2003;95(2):393-408. https://doi.org/10.1037/0022-0663.95.2.393.

Ericsson KA. Acquisition and Maintenance of Medical Expertise: A Perspective From the Expert-Performance Approach With Deliberate Practice. Acad Med. 2015;90(11):1471-86. https://doi.org/10.1097/ACM.0000000000000939.

Ericsson KA, Krampe RT, Teschromer C. The Role of Deliberate Practice in the Acquisition of Expert Performance. Psychol Rev. 1993;100(3):363-406. https://doi.org/10.1037/0033-295X.100.3.363.

Woods NN, Brooks LR, Norman GR. It all make sense: biomedical knowledge, causal connections and memory in the novice diagnostician. Adv Health Sci Educ Theory Pract. 2007;12(4):405-15. https://doi.org/10.1007/s10459-006-9055-x.

Ark TK, Brooks LR, Eva KW. The benefits of flexibility: the pedagogical value of instructions to adopt multifaceted diagnostic reasoning strategies. Med Educ. 2007;41(3):281-7. https://doi.org/10.1111/j.1365-2929.2007.02688.x.

Hatala RM, Brooks LR, Norman GR. Practice makes perfect: the critical role of mixed practice in the acquisition of ECG interpretation skills. Adv Health Sci Educ Theory Pract. 2003;8(1):17-26. https://doi.org/10.1023/A:1022687404380.

Chamberland M, Mamede S. Self-Explanation, An Instructional Strategy to Foster Clinical Reasoning in Medical Students. Health Professions Education. 2015;1(1):24-33. https://doi.org/10.1016/j.hpe.2015.11.005.

Chamberland M, Mamede S, St-Onge C, et al. Self-explanation in learning clinical reasoning: the added value of examples and prompts. Med Educ. 2015;49(2):193-202. https://doi.org/10.1111/medu.12623.

Chamberland M, Setrakian J, St-Onge C, et al. Does providing the correct diagnosis as feedback after self-explanation improve medical students diagnostic performance? BMC Med Educ. 2019;19(1):194. https://doi.org/10.1186/s12909-019-1638-3.

Chamberland M, St-Onge C, Setrakian J, et al. The influence of medical students’ self-explanations on diagnostic performance. Med Educ. 2011;45(7):688-95. https://doi.org/10.1111/j.1365-2923.2011.03933.x.

Mamede S, Figueiredo-Soares T, Eloi Santos SM, et al. Fostering novice students’ diagnostic ability: the value of guiding deliberate reflection. Med Educ. 2019;53(6):628-37. https://doi.org/10.1111/medu.13829.

Mamede S, van Gog T, Moura AS, et al. Reflection as a strategy to foster medical students’ acquisition of diagnostic competence. Med Educ. 2012;46(5):464-72. https://doi.org/10.1111/j.1365-2923.2012.04217.x.

Mamede S, van Gog T, Sampaio AM, et al. How can students’ diagnostic competence benefit most from practice with clinical cases? The effects of structured reflection on future diagnosis of the same and novel diseases. Acad Med. 2014;89(1):121-7. https://doi.org/10.1097/ACM.0000000000000076.

Rattner SL, Louis DZ, Rabinowitz C, et al. Documenting and comparing medical students’ clinical experiences. JAMA. 2001;286(9):1035-40. https://doi.org/10.1001/jama.286.9.1035.

Wimmers PF, Schmidt HG, Splinter TA. Influence of clerkship experiences on clinical competence. Med Educ. 2006;40(5):450-8. https://doi.org/10.1111/j.1365-2929.2006.02447.x.

de Giovanni D, Roberts T, Norman G. Relative effectiveness of high- versus low-fidelity simulation in learning heart sounds. Med Educ. 2009;43(7):661-8. https://doi.org/10.1111/j.1365-2923.2009.03398.x.

Massoth C, Roder H, Ohlenburg H, et al. High-fidelity is not superior to low-fidelity simulation but leads to overconfidence in medical students. BMC Med Educ. 2019;19(1):29. https://doi.org/10.1186/s12909-019-1464-7.