1、Medical Heuristics and Teaching Clinical Decision-Making启发式教学法及临床决策教导,Timothy Stephens, M.D.Faculty PhysicianInternational Clinic, Haikou Municipal Hospital General Practice Residency,Conflicts of Interest / Financial Disclosures利益冲突/财务批露,None无,Learning Objectives教学目标,Participants will be able to参加者
2、需要能1) describe a learning theory model to explain the steps to achieve competence描述一种学习理论模型来解释获得能力的步骤。2) describe common clinical decision making strategies that can be used in teaching residents描述可用于住院医师教学的一般临床决定策略。3) describe the concept of heuristics and how it applies to medical education描述启发式的概
3、念以及在医学教育中的应用。,Clinical Decision Making: Example做临床决定：例子,How do we teach competency?如何教授能力？,Know what outcomes we are looking for知道我们所要的结果(easier said than done)（说起来容易，做起来难）Build assessment tools 建立评估工具Formative and Summative feedback形成性反馈和终结性反馈Identify gaps in knowledge, understanding, and applicati
4、on找出知识、理解和应用上的差距Requires direct observation要直接观察Give timely, specific, constructive feedback给予及时、具体和有建造性的回馈Requires culture change要文化变革,Four Stages for Learning Any New Skill学习新技能的四个步骤,Gordon Training International employee, Noel Burch,不知道,知道,没有意识到技能欠缺,意识到欠缺某项技能,技能熟练，可以不用再刻意去想,尽管需要很多努力，但主动去学习掌握这种技能。
5、,无技能,掌握技能,Conscious Incompetence自觉能力欠缺,今天工作上完成了一件事。,我学会了如何使用传真机。,哇那明天你可能就学会使用手机了。,那当然好啦!不过，我想今天是把某个人运到到洗手间去了。,汗.,Conscious Competence自觉有能力,Unconscious Competence不自觉有能力,How do we get our residents如何帮助住院医师成长？,From Here从这儿,To There?到那儿？,Strategies in Clinical Decision Making做临床决定的策略,Pattern Recognition
6、模式识别Rule Out Worst-case Scenario (ROWS)排除最坏的情形Exhaustive Method穷举法Hypothetico-deductive method假设-演绎法Heuristics启发式,Heuristics in Medicine医学启发式,Failed Heuristics = Cognitive Biases失败的启发=认知偏差,Anchoring Bias定锚偏差“jumping to conclusions”“过早下结论”Ascertainment Bias 确定偏倚“seeing what you expect to find”看到你希望发现
7、的Confirmation Bias证实偏差look for confirming evidence for the hypothesis, subsequent or disconforming evidence may be ignored为假设寻找确支持认证据，却可能忽略后续的证据，或与假设不一致的证据。Availability & Non-availability可获得性&非可获得性“common things are common”“常见的常发生”“out of sight, out of mind”“眼不见心不烦”,Failed Heuristics = Cognitive Bia
8、ses失败的启发=认知偏差,Commission Bias 任务偏倚“urge to do something”急切地去做些什么Diagnosis Momentum诊断驱从Patient is “prediagnosed,” lay opinion passed from person to person病人之前已被诊断了，此后从这人到那人都会依从这个诊断。Premature closure过早下结论“counting chickens before they are hatched”蛋未孵出,勿先数鸡（不要高兴得太早）。,Putting it all together两者相结合,Dual p
9、rocessing (Ewa)双过程Analytical and non-analytical mental processes分析性和非分析性心理过程,Heuristics applied: decision tools启发式应用：决策工具,Correct assignment of patients with chest pain to a coronary care unit正确安排胸痛病人到冠心病监护病房。,Heuristics applied: decision tools启发式教学法应用：决策工具,Appropriate use of macrolide antibiotics i
10、n children with suspected community-acquired pneumonia正确使用大环内酯类抗生素治疗疑似社区获得性肺炎的儿童。,System 2 Thinking applied: Patient decision tools系统2 思维应用：病人决策工具,NNT tables NNT表(number needed to treat)需治人数A Cates plot of the effects of statin therapy on risk of cardiovascular events in people at 20% 10-year risk.使
11、用他汀类药物治疗10年心血管事件风险为20%的人群效果“表情图”。NNT = 20http:/ 2 Thinking applied: “Foraging” and “Hunting” tools系统2 思维应用：“觅食”与“狩猎”工具,信息管理金字塔,例子,图书馆、临床证据,循证医学期刊,“常青藤”联盟期刊教科书,医学，谷歌学术搜索,效用度,Summary总结,Learners must follow a series of steps from “unconsciously incompetent” to “unconsciously competent” in order to achi
12、eve expert status学员要达到专家水平必须遵照“不自觉无能力”到“不自觉有能力”的一系列步骤。Identifying effective strategies to manage uncertainty in clinical decision making is an important part of the process of feedback and assessment to achieve competence确定有效策略来管理做临床决定中的不确定性，是回馈评估技能达标的重要组成部分。We must role model and teach how to use a
13、 balanced approach that incorporates both heuristics-based tools and analytical problem-solving methods我们必须做好将基于启发式的工具和分析式问题-解决方法相融合，平衡使用的榜样，并教导学员如何这样做。,Special thanks to特别鸣谢:,Haikou Medical Society海南省医学会Dr. Cassie Zhou 周仲华Dr. Ann Huang黄文娟Stephen, translation 郭敬柱翻译,Questions? Comments?问题？评论？,Referen
14、ces参考文献,Croskerry P. “Achieving quality in clinical decision making: cognitive strategies and detection of bias.” Acad Emerg Med. 2002 Nov;9(11):1184-204.Gladwell, Malcom. Blink. Little, Brown and Company: 2005.McDonald CJ. “Medical heuristics: the silent adjudicators of clinical practice.” Ann Inte
15、rn Med. 1996 Jan 1;124(1 Pt 1):56-62.Wegwarth O, et al. “Smart strategies 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 参考文献,Hutchinson et al. Web Chapter: Information Mastery: Decision-making and dealing with information overload. The Essential Handbook for GP Training & Education (Editor: Ramesh Mehay),
