全科住院醫(yī)生思維訓練

1、Medical Heuristics and Teaching Clinical Decision-Making啟發(fā)式教學法及臨床決策教導,Timothy Stephens, M.D.Faculty PhysicianInternational Clinic, Haikou Municipal Hospital General Practice Residency,Conflicts of Interest / Financial

2、 Disclosures利益沖突/財務批露,None無,Learning Objectives教學目標,Participants will be able to…參加者需要能…1) describe a learning theory model to explain the steps to achieve competence描述一種學習理論模型來解釋獲得能力的步驟。2) describe common clinical d

3、ecision making strategies that can be used in teaching residents描述可用于住院醫(yī)師教學的一般臨床決定策略。3) describe the concept of heuristics and how it applies to medical education描述啟發(fā)式的概念以及在醫(yī)學教育中的應用。,Clinical Decision Making: Example做臨

4、床決定：例子,How do we teach competency?如何教授能力？,Know what outcomes we are looking for知道我們所要的結果(easier said than done…)（說起來容易，做起來難）Build assessment tools 建立評估工具Formative and Summative feedback形成性反饋和終結性反饋Identify gaps in kn

5、owledge, understanding, and application找出知識、理解和應用上的差距Requires direct observation要直接觀察Give timely, specific, constructive feedback給予及時、具體和有建造性的回饋Requires culture change要文化變革,Four Stages for Learning Any New Skill學習新技能

6、的四個步驟,Gordon Training International employee, Noel Burch,,,,不知道,知道,沒有意識到技能欠缺,意識到欠缺某項技能,技能熟練，可以不用再刻意去想,盡管需要很多努力，但主動去學習掌握這種技能。,無技能,掌握技能,Conscious Incompetence自覺能力欠缺,今天工作上完成了一件事。,我學會了如何使用傳真機。,哇~那明天你可能就學會使用手機了。,那當然好啦!不過，我想

7、今天是把某個人運到到洗手間去了。,汗…..,Conscious Competence自覺有能力,Unconscious Competence不自覺有能力,How do we get our residents如何幫助住院醫(yī)師成長？,From Here…從這兒,To There?到那兒？,Strategies in Clinical Decision Making做臨床決定的策略,Pattern Recognition模式識別R

8、ule Out Worst-case Scenario (ROWS)排除最壞的情形Exhaustive Method窮舉法Hypothetico-deductive method假設-演繹法Heuristics啟發(fā)式,Heuristics in Medicine醫(yī)學啟發(fā)式,Failed Heuristics = Cognitive Biases失敗的啟發(fā)=認知偏差,Anchoring Bias定錨偏差“jumping to

9、conclusions”“過早下結論”Ascertainment Bias 確定偏倚“seeing what you expect to find”看到你希望發(fā)現(xiàn)的Confirmation Bias證實偏差look for confirming evidence for the hypothesis, subsequent or disconforming evidence may be ignored為假設尋找確支持認證據(jù)，卻

10、可能忽略后續(xù)的證據(jù)，或與假設不一致的證據(jù)。Availability & Non-availability可獲得性&非可獲得性“common things are common”“常見的常發(fā)生”“out of sight, out of mind”“眼不見心不煩”,Failed Heuristics = Cognitive Biases失敗的啟發(fā)=認知偏差,Commission Bias 任務偏倚“urge to

11、 do something”急切地去做些什么Diagnosis Momentum診斷驅從Patient is “prediagnosed,” lay opinion passed from person to person病人之前已被診斷了，此后從這人到那人都會依從這個診斷。Premature closure過早下結論“counting chickens before they are hatched”蛋未孵出,勿先數(shù)雞（不

12、要高興得太早）。,Putting it all together…兩者相結合,Dual processing (Ewa)雙過程Analytical and non-analytical mental processes分析性和非分析性心理過程,,,,,,Heuristics applied: decision tools啟發(fā)式應用：決策工具,Correct assignment of patients with chest pa

13、in to a coronary care unit正確安排胸痛病人到冠心病監(jiān)護病房。,Heuristics applied: decision tools啟發(fā)式教學法應用：決策工具,Appropriate use of macrolide antibiotics in children with suspected community-acquired pneumonia正確使用大環(huán)內酯類抗生素治療疑似社區(qū)獲得性肺炎的兒童。,S

14、ystem 2 Thinking applied: Patient decision tools系統(tǒng)2 思維應用：病人決策工具,NNT tables NNT表(number needed to treat)需治人數(shù)A Cates plot of the effects of statin therapy on risk of cardiovascular events in people at 20% 10-year ri

15、sk.使用他汀類藥物治療10年心血管事件風險為20%的人群效果“表情圖”。NNT = 20http://www.nntonline.net/,System 2 Thinking applied: “Foraging” and “Hunting” tools系統(tǒng)2 思維應用：“覓食”與“狩獵”工具,信息管理金字塔,例子,圖書館、臨床證據(jù),循證醫(yī)學期刊,“常青藤”聯(lián)盟期刊教科書,醫(yī)學，谷歌學術搜索,效用度,Summary總結,Le

16、arners must follow a series of steps from “unconsciously incompetent” to “unconsciously competent” in order to achieve expert status學員要達到專家水平必須遵照“不自覺無能力”到“不自覺有能力”的一系列步驟。Identifying effective strategies to manage uncert

17、ainty in clinical decision making is an important part of the process of feedback and assessment to achieve competence確定有效策略來管理做臨床決定中的不確定性，是回饋評估技能達標的重要組成部分。We must role model and teach how to use a balanced approach th

18、at incorporates both heuristics-based tools and analytical problem-solving methods我們必須做好將基于啟發(fā)式的工具和分析式問題-解決方法相融合，平衡使用的榜樣，并教導學員如何這樣做。,Special thanks to特別鳴謝:,Haikou Medical Society海南省醫(yī)學會Dr. Cassie Zhou 周仲華Dr. Ann Huang黃文

19、娟Stephen, translation 郭敬柱翻譯,Questions? Comments?問題？評論？,References參考文獻,Croskerry P. “Achieving quality in clinical decision making: cognitive strategies and detection of bias.” Acad Emerg Med. 2002 Nov;9(11):1184-204.G

20、ladwell, Malcom. Blink. Little, Brown and Company: 2005.McDonald CJ. “Medical heuristics: the silent adjudicators of clinical practice.” Ann Intern Med. 1996 Jan 1;124(1 Pt 1):56-62.Wegwarth O, et al. “Smart strategies

21、 for doctors and doctors-in-training: heuristics in medicine.” Med Educ. 2009 Aug;43(8):721-8Norman GR, Eva KW, “Diagnostic error and clinical reasoning.” Medical Education, 2010 Jan; 44 (1): 94-100.,References 參考文獻,Hut