Olgu Temelli Klinik Akıl Yürütme ve Karar Verme

Yıl 2020, , 97 - 107, 30.12.2020

Ali İhsan Taşçı , Esra Akdeniz

https://doi.org/10.25282/ted.751588

Öz

Amaç: Klinik akıl yürütmeyi, klinik süreçlerde, indirgemeci olmayan, çok boyutlu, ön yargılardan uzak düşünme ve karar verme becerisi olarak tanımlayabiliriz. Klinik akıl yürütme hekimin sahip olması gereken temel bir yeterliktir. Bu makalede klinik akıl yürütme ve karar verme ile ilgili teorileri, aşamaları, eğitim, ölçme ve değerlendirme yöntemlerini ve klinik akıl yürütmenin tıbbi hata ilişkisini tartışılmış ve ilgili kanıtlar sunulmuştur.

Yöntem: Makale geleneksel derleme yöntemi ile hazırlanmıştır.

Bulgular: Klinik akıl yürütmenin nasıl gerçekleştiği ile ilgili teoriler arasında analitik olmayan (sistem 1), analitik (sistem 2) düşünme ve dual process teorileri kabul görmektedir. Analitik olmayan düşünme, hızlı gerçekleşen, fazla bir zihinsel efor gerektirmeyen sezgisel bir düşünmedir. Analitik düşünmede (sistem 2 düşünme) ise neden sonuç ilişkisi kurularak sonuca varılır. Klinik akıl yürütmede, bilgi toplama, hipotez oluşturma ve hipotezi test etme aşamaları genel bir çerçeve oluşturmaktadır. Klinik akıl yürütme eğitimi için, ilk yıllardan itibaren eğitim aktivitelerinde, ölçme ve değerlendirmelerde bu yeterliğe yönelik çerçeveler/modeller belirlenmeli, kullanımı teşvik edilmelidir. Tıbbi hatalar ile klinik akıl yürütme süreçlerindeki yetersizlikler ilişkilidir. Bu nedenle, eğitim yaklaşımlarında klinik akıl yürütme yetersizlik alanlarını dikkate alınması önemlidir. Klinik akıl yürütme değerlendirmeleri, akıl yürütmenin tüm aşamalarını kapsamalıdır. Klinik akıl yürütmenin değerlendirilmesinde çok sayıda yöntem, soru/sorgulama çerçeveleri belirlenmiştir. Bunlarda temel prensipler, klinik akıl yürütme aşamalarına uygun olarak yapılandırılmış klavuzlar ile akıl yürütmeyi gerektiren soruların sorulmasıdır.

Sonuçlar: Klinik akıl yürütme becerisi, tıbbi hataları azaltarak hasta güvenliğini sağlamak, sağlıkta gereksiz iş ve işlemleri azaltmak, hasta hekim uyuşmazlıkları ve bu nedenle ortaya çıkan şiddet olaylarını önlemek için hekimin sahip olması gereken temel yeterliktir. Öğrenme ve değerlendirme aktiviteleri, klinik akıl yürütme teorilerine ve aşamalarına uygun modeller kullanılarak planlanmalıdır.  

Anahtar Kelimeler

Klinik akıl yürütme, Olgu temelli çalışma, Tıp eğitimi

Case-Based Clinical Reasoning And Decision Making

Öz

Aim: We can define clinical reasoning as the ability to think and decide in clinical processes, which is non-reductive, multidimensional and free from prejudices. Clinical reasoning is a basic competence that a physician should have. In this article, theories about clinical reasoning, stages of clinical reasoning, training and evaluation methods, and the relationship between clinical reasoning and medical malpractice are discussed and related evidence is presented.

Methods: The article was prepared by the traditional review method

Results: Non-analytical (system 1), analytical (system 2) thinking and dual process theories are accepted among the theories of how clinical reasoning is realized. Non-analytical thinking is an intuitive thinking that takes place fast and does not require much mental effort. Analytical thinking (system 2 thinking) is established by establishing a cause-effect relationship. In clinical reasoning, the stages of gathering information, forming hypothesis and testing hypothesis constitute a general framework. For clinical reasoning education, frameworks / models for this competence should be determined in educational activities, assessment and evaluation from the first years, and their use should be encouraged. Medical errors and inadequate clinical reasoning processes are related. For this reason, it is important to consider the clinical reasoning insufficiency areas in educational approaches. Clinical reasoning assessments should cover all stages of reasoning. Numerous methods and question / inquiry frameworks have been identified in the evaluation of clinical reasoning. In these, the basic principles are to ask questions that require reasoning with guides structured in accordance with the clinical reasoning stages.

Conclusions: Clinical reasoning ability is the basic competence that a physician should have in order to ensure patient safety by reducing medical errors, to reduce unnecessary work and procedures in health, to prevent patient physician disputes and therefore violent events. Learning and assessment activities should be planned using models suitable for clinical reasoning terms and stages.

Anahtar Kelimeler

Clinical reasoning, Case based study, Medical education

Kaynakça

• 1. Gruppen LD. Clinical reasoning: Defining it, teaching it, assessing it, studying it. West J Emerg Med. 2017;18(1):4–7.
• 2. Eva KW, Hatala RM, LeBlanc VR, Brooks LR. Teaching from the clinical reasoning literature: Combined reasoning strategies help novice diagnosticians overcome misleading information. Med Educ. 2007;41(12):1152–8.
• 3. Lisa A, Kenneth D, Andrev T. Teaching clinical reasoning to medical students. Br J Hosp Med. 2017;78(7):399–401.
• 4. Kahneman D, Klein G. Conditions for Intuitive Expertise: A Failure to Disagree. Am Psychol. 2009;64(6):515–26.
• 5. Norman GR, Brooks LR. The non-analytical basis of clinical reasoning. Adv Heal Sci Educ. 1997;2(2):173–84.
• 6. Charlin B, Tardif J, Boshuizen HPA. Scripts and medical diagnostic knowledge: Theory and applications for clinical reasoning instruction and research. Acad Med. 2000;75(2):182–90.
• 7. Thampy H, Willert E, Ramani S. Assessing Clinical Reasoning: Targeting the Higher Levels of the Pyramid. J Gen Intern Med. 2019;34(8):1631–6.
• 8. Kassirer JP. Teaching clinical reasoning: Case-based and coached. Acad Med. 2010;85(7):1118–24.
• 9. Yazdani S, Hosseinzadeh M, Hosseini Fakrolsadat. Models of clinical reasoning with a focus on general practice: a critical review. J Adv Med Educ Prof. 2017;5(4):177–84.
• 10. Norman G, Monteiro S, Sherbino J. Is clinical cognition binary or continuous. Acad Med. 2013;88(8):1058–60.
• 11. Norman G, Sherbino J, Dore K, Wood T, Young M, Gaissmaier W, et al. The etiology of diagnostic errors: A controlled trial of system 1 versus system 2 reasoning. Acad Med. 2014;89(2):277–84.
• 12. Hruska P, Hecker KG, Coderre S, McLaughlin K, Cortese F, Doig C, et al. Hemispheric activation differences in novice and expert clinicians during clinical decision making. Adv Heal Sci Educ. 2016;21(5):921–33.
• 13. Nendaz MR, Gut AM, Perrier A, Louis-Simonet M, Reuille O, Junod AF, et al. Common strategies in clinical data collection displayed by experienced clinician-teachers in internal madicine. Med Teach. 2005;27(5):415–21.
• 14. Williamson JML, Osborne AJ. Critical analysis of case based discussions. Br J Med Pract. 2012;5(2):5–8.
• 15. Audétat M, Laurin S, Sanche G, Béïque C, Fon NC, Blais J, et al. Clinical reasoning difficulties : A taxonomy for clinical teachers Clinical reasoning difficulties : A taxonomy for clinical teachers. Med Teach. 2013;35(3):e984–9.
• 16. Maudsley G, Strivens J. “Science”, “critical thinking” and “competence” for Tomorrow’s Doctors. A review of terms and concepts. Med Educ. 2000;34(1):53–60.
• 17. Schuwirth L. Can clinical reasoning be taught or can it only be learned. Med Educ. 2002;36(8):695–6.
• 18. Bowen JL. Educational Strategies to Promote Clinical Diagnostic Reasoning. N Engl J Med. 2006;355:2217–25.
• 19. Thistlethwaite JE, Davies D, Ekeocha S, Kidd JM, MacDougall C, Matthews P, et al. The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. Med Teach. 2012;34(6):142–59.
• 20. McLean SF. Case-Based Learning and its Application in Medical and Health-Care Fields: A Review of Worldwide Literature. J Med Educ Curric Dev. 2016;3:39-49. 21. WolpawTerry, Daniel W, Papp K. SNAPPS: A Learner-centered Model for Outpatient Education. Acad Med. 2003;(78):893–8.
• 22. Gülpınar Mehmet Ali. İş başında/Klinikte Öğrenme, Klinik Kültür/İklim ve Olumlu Öğrenme İklimi Oluşturma. Turkiye Klin J Med Educ-Special Top. 2016;1(ı):48–58.
• 23. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills” model of clinical teaching. J Am Board Fam Pract. 1992;5(4):419–24.
• 24. Lee A, Joynt GM, Lee AKT, Ho AMH, Groves M, Vlantis AC, et al. Using illness scripts to teach clinical reasoning skills to medical students. Fam Med. 2010;42(4):255–61. 25. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493–9.
• 26. Audétat MC, Laurin S, Dory V, Charlin B, Nendaz MR. Diagnosis and management of clinical reasoning difficulties: Part I. Clinical reasoning supervision and educational diagnosis. Med Teach. 2017;39(8):792–6.
• 27. Audétat MC, Laurin S, Dory V, Charlin B, Nendaz MR. Diagnosis and management of clinical reasoning difficulties: Part II. Clinical reasoning difficulties: Management and remediation strategies. Med Teach. 2017;39(8):797–801.
• 28. Ilgen JS, Humbert AJ, Kuhn G, Hansen ML, Norman GR, Eva KW, et al. Assessing diagnostic reasoning: A consensus statement summarizing theory, practice, and future needs. Acad Emerg Med. 2012;19(12):1454–61.
• 29. Miller GE. The assessment of clinical skills/competence/performance. Academic Medicine. 1990. p. S63–7.
• 30. Newble DI, Hoare J, Baxter A. Patient management problems Issues of validity. Med Educ. 1982;16(3):137–42. 31. Wainwright SF, Shepard KF, Harman LB, Stephens J. Factors That Influence the Clinical Decision Making of Novice and Experienced Physical Therapists. Phys Ther. 2011;91(1):87–101.
• 32. Farmer EA, Page G. A practical guide to assessing clinical decision-making skills using the key features approach. Med Educ. 2005;39(12):1188–94.
• 33. Hrynchak P, Glover Takahashi S, Nayer M. Key-feature questions for assessment of clinical reasoning: A literature review. Med Educ. 2014;48(9):870–83.
• 34. Charlin B, Van Der Vleuten C. Standardized assessment of reasoning in contexts of uncertainty: The script concordance approach. Eval Heal Prof. 2004;27(3):304–19.
• 35. Norcini J, Burch V. Workplace-based assessment as an educational tool: AMEE Guide No. 31. Med Teach. 2007;29(9–10):855–71.
• 36. Norcini JJ, McKinley DW. Assessment methods in medical education. Teach Teach Educ. 2007;23(3):239–50.
• 37. Bianchi L, Gallagher EJ, Korte R, Ham HP. Interexaminer agreement on the American Board of Emergency Medicine oral certification examination. Ann Emerg Med. 2003;41(6):859–64.
• 38. Society to Improve Diagnosis in Medicine. Assessment of Reasoning Tool. Available from: https://www.improvediagnosis.org
• 39. Baker EA, Ledford CH, Fogg L, Way DP, Park YS. The IDEA Assessment Tool: Assessing the Reporting, Diagnostic Reasoning, and Decision-Making Skills Demonstrated in Medical Students’ Hospital Admission Notes. Teach Learn Med. 2015;27(2):163–73.