目的 检索基于科学引文数据库(Web of Science,WOS)的临床思维研究文献,描绘其外部特征并揭示其研究主题,为我国临床思维教学与评价改革提供参考。方法 采用HistCite文献计量分析软件,以WOS核心合集中从数据库建立到2022年12月31日相关文献为研究对象,以“clinical thinking”或“clinical reasoning”为检索主题词,对数据库中相关文章数量、机构分布、研究方向与前沿主题等进行分析,梳理临床思维研究总体态势。结果 共检索到3 094篇文献,临床思维研究的发文量可以大致划分为3个发展阶段:起步期(1966至1990年,年发文量维持在个位数)、上升期(1991至2011年,年发文量在50至100篇)、陡升期(2012年至今,2022年发文量达341篇)。发文量排在第一的机构是加拿大蒙特利尔大学,共发表80篇。高频关键词有教学(teaching)、一致性(concordance)和脚本(script)等。研究前沿主题集中于临床思维的本质,对临床思维的评估和如何开展临床思维教学这3个方面,出现对普适性指南制定的呼吁。结论 临床思维研究发文量不断增长,中国发文量较低;发文机构多集中于英美两国,研究内容多集中在对临床思维综合性分析和思考,实证研究不足;逐步出现对脚本、教学和评价等专题的研究。未来我国应该重视对临床思维的理论研究,重点关注构建临床思维的教学和评价体系、新兴技术在临床思维的应用以及制定普适性的指南与规范,并提高研究的国际展示度及影响力。
Objective To explore the current status and development trend of clinical thinking research based on Web of Science (WOS). Methods Using the HistCite software, the literature from the WOS database established up to December 31, 2022 is taken as the research object. ″Clinical thinking″ or ″clinical reasoning″ are used as search keywords to analyze the number of related articles in the database, institutional distribution, research directions, and frontier topics, in order to outline the overall trend of research on clinical thinking. Results A total of 3,094 articles were retrieved. The research on clinical thinking can be roughly divided into three development stages: an initial stage (1966 to 1990, with an annual publication volume in single digits), a rising stage (1991 to 2011, with an annual publication volume between 50 and 100), and a steep rise stage (2012 to the present, with 341 articles published in 2022). The institution with the highest number of publications is McGill University in Canada, with the number of 80. High-frequency keywords include teaching, concordance, and script. The forefront topics of research are focused on the nature of clinical thinking, assessment of clinical thinking, and how to conduct clinical thinking teaching, with calls for the formulation of universal guidelines. Conclusions The volume of publications on clinical thinking research continues to grow. China has a low publication volume, with most publications coming from institutions in the United Kingdom and the United States. Research content mainly focuses on comprehensive analysis and reflection on clinical thinking, with insufficient empirical research. Specialized studies on scripts, teaching, and evaluation are gradually emerging. In the future, China should focus on theoretical research on clinical thinking, with emphasis on building teaching and evaluation systems for clinical thinking, as well as the application of emerging technologies in clinical thinking and the formulation of universal guidelines and standards. Additionally, efforts should be made to increase the international visibility and impact of research.
[1] Charlin B, Boshuizen HP, Custers EJ, et al. Scripts and clinical reasoning[J]. Med Educ, 2007,41(12):1178-1184. DOI: 10.1111/j.1365-2923.2007.02924.x.
[2] Barrows HS, Feltovich PJ. The clinical reasoning process[J]. Med Educ, 1987,21(2):86-91. DOI: 10.1111/j.1365-2923.1987.tb00671.x.
[3] Mattingly C. What is clinical reasoning?[J]. Am J Occup Ther, 1991,45(11):979-986. DOI: 10.5014/ajot.45.11.979.
[4] Brailovsky C, Charlin B, Beausoleil S, et al. Measurement of clinical reflective capacity early in training as a predictor of clinical reasoning performance at the end of residency: an experimental study on the script concordance test[J]. Med Educ, 2001,35(5):430-436. DOI: 10.1046/j.1365-2923.2001.00911.x.
[5] (英)尼古拉·库珀,(英)约翰·弗莱恩; 兰学立, 向阳(译).临床推理——从入门到实践[M].北京大学医学出版社,2022:1-5.
[6] 李新龙, 朱爽, 刘岩, 等. 中医临床思维研究热点和趋势可视化分析[J].中国中医药信息杂志,2023,30(1):47-52. DOI: 10.19879/j.cnki.1005-5304.202201389.
[7] 于宏, 张进, 李艳君, 等. 线上模拟教学在医学生临床思维训练中的应用效果评价[J].中华医学教育杂志,2020,40(11):909-912. DOI: 10.3760/cma.j.cn115259-20200324-00417.
[8] 陆媛, 于德华, 张斌, 等. PBL教学模式在全科医师规范化培训中的实践应用[J].中国全科医学,2014,(16):1880-1883. DOI: 10.3969/j.issn.1007-9572.2014.16.019.
[9] 蒋莹. 临床思维能力的评价方法与应用效果[J].中国毕业后医学教育,2020,4(3):204-209. DOI: 10.3969/j.issn.2096-4293.2020.03.003.
[10] Pedowitz RA, Marsh JL. Motor skills training in orthopaedic surgery: a paradigm shift toward a simulation-based educational curriculum[J]. J Am Acad Orthop Surg, 2012,20(7):407-409. DOI: 10.5435/JAAOS-20-07-407.
[11] 高玲央, 牛学胜, 沈宁. 从临床思维能力考核结果看临床医学研究生教育的改革[J].学位与研究生教育,2005,(2):41-43. DOI: 10.3969/j.issn.1001-960X.2005.02.012.
[12] 姜宇, 姚泰康, 陈心航, 等. 基于科学引文数据库的骨科教育研究文献计量学分析[J].中华医学教育杂志,2022,42(11):1014-1019. DOI: 10.3760/cma.j.cn115259-20220513-00623.
[13] Eva KW. What every teacher needs to know about clinical reasoning[J]. Med Educ, 2005,39(1):98-106. DOI: 10.1111/j.1365-2929.2004.01972.x.
[14] Norman G. Research in clinical reasoning: past history and current trends[J]. Med Educ, 2005,39(4):418-427. DOI: 10.1111/j.1365-2929.2005.02127.x.
[15] Croskerry P. Cognitive forcing strategies in clinical decisionmaking[J]. Ann Emerg Med, 2003,41(1):110-120. DOI: 10.1067/mem.2003.22.
[16] Elstein AS. Thinking about diagnostic thinking: a 30-year perspective[J]. Adv Health Sci Educ Theory Pract, 2009,14 Suppl 1:7-18. DOI: 10.1007/s10459-009-9184-0.
[17] Durning SJ, Artino AR Jr, Schuwirth L, et al. Clarifying assumptions to enhance our understanding and assessment of clinical reasoning[J]. Acad Med, 2013,88(4):442-448. DOI: 10.1097/ACM.0b013e3182851b5b.
[18] Gagnon R, Charlin B, Coletti M, et al. Assessment in the context of uncertainty: how many members are needed on the panel of reference of a script concordance test?[J]. Med Educ, 2005,39(3):284-291. DOI: 10.1111/j.1365-2929.2005.02092.x.
[19] Barrows HS, Feltovich PJ. The clinical reasoning process[J]. Med Educ, 1987,21(2):86-91. DOI: 10.1111/j.1365-2923.1987.tb00671.x.
[20] Jensen GM, Gwyer J, Shepard KF. Expert practice in physical therapy[J]. Phys Ther, 2000,80(1):28-43; discussion 44-52.
[21] Norman G. Dual processing and diagnostic errors[J]. Adv Health Sci Educ Theory Pract, 2009,14 Suppl 1:37-49. DOI: 10.1007/s10459-009-9179-x.
[22] Zornic N, Radojevic DJ, Jankovic S, et al. Monitoring of drug-associated electrolyte disturbances in a hospital[J]. Pharmacoepidemiol Drug Saf, 2009,18(11):1026-1033. DOI: 10.1002/pds.1816.
[23] Durning S, Artino AR Jr, Pangaro L, et al. Context and clinical reasoning: understanding the perspective of the expert′s voice[J]. Med Educ, 2011,45(9):927-938. DOI: 10.1111/j.1365-2923.2011.04053.x.
[24] Mattingly C. The narrative nature of clinical reasoning[J]. Am J Occup Ther, 1991,45(11):998-1005. DOI: 10.5014/ajot.45.11.998.
[25] Norman GR, Brooks LR. The Non-Analytical Basis of Clinical Reasoning[J]. Adv Health Sci Educ Theory Pract, 1997,2(2):173-184. DOI: 10.1023/A:1009784330364.
[26] Edwards I, Jones M, Carr J, et al. Clinical reasoning strategies in physical therapy[J]. Phys Ther, 2004,84(4):312-330; discussion 331-335.
[27] Norman GR, Eva KW. Diagnostic error and clinical reasoning[J]. Med Educ, 2010,44(1):94-100. DOI: 10.1111/j.1365-2923.2009.03507.x.
[28] Simmons B. Clinical reasoning: concept analysis[J]. J Adv Nurs, 2010,66(5):1151-1158. DOI: 10.1111/j.1365-2648.2010.05262.x.
[29] Mamede S, van Gog T, van den Berge K, et al. Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents[J]. JAMA, 2010,304(11):1198-1203. DOI: 10.1001/jama.2010.1276.
[30] Durning SJ, Artino AR, Boulet JR, et al. The impact of selected contextual factors on experts′ clinical reasoning performance (does context impact clinical reasoning performance in experts?)[J]. Adv Health Sci Educ Theory Pract, 2012,17(1):65-79. DOI: 10.1007/s10459-011-9294-3.
[31] Barrows HS, Norman GR, Neufeld VR, et al. The clinical reasoning of randomly selected physicians in general medical practice[J]. Clin Invest Med, 1982,5(1):49-55.
[32] Lubarsky S, Dory V, Duggan P, et al. Script concordance testing: from theory to practice: AMEE guide no. 75[J]. Med Teach, 2013,35(3):184-193. DOI: 10.3109/0142159X.2013.760036.
[33] Charlin B, Tardif J, Boshuizen HP. Scripts and medical diagnostic knowledge: theory and applications for clinical reasoning instruction and research[J]. Acad Med, 2000,75(2):182-190. DOI: 10.1097/00001888-200002000-00020.
[34] Tanner CA. Thinking like a nurse: a research-based model of clinical judgment in nursing[J]. J Nurs Educ, 2006,45(6):204-211. DOI: 10.3928/01484834-20060601-04.
[35] Eva KW, Hatala RM, Leblanc VR, et al. Teaching from the clinical reasoning literature: combined reasoning strategies help novice diagnosticians overcome misleading information[J]. Med Educ, 2007,41(12):1152-1158. DOI: 10.1111/j.1365-2923.2007.02923.x.
[36] Woods NN. Science is fundamental: the role of biomedical knowledge in clinical reasoning[J]. Med Educ, 2007,41(12):1173-1177. DOI: 10.1111/j.1365-2923.2007.02911.x.
[37] Kassirer JP. Teaching clinical reasoning: case-based and coached[J]. Acad Med, 2010,85(7):1118-1124. DOI: 10.1097/acm.0b013e3181d5dd0d.
[38] Durning SJ, Artino AR Jr, Schuwirth L, et al. Clarifying assumptions to enhance our understanding and assessment of clinical reasoning[J]. Acad Med, 2013,88(4):442-448. DOI: 10.1097/ACM.0b013e3182851b5b.
[39] Norman GR, Monteiro SD, Sherbino J, et al. The Causes of Errors in Clinical Reasoning: Cognitive Biases, Knowledge Deficits, and Dual Process Thinking[J]. Acad Med, 2017,92(1):23-30. DOI: 10.1097/ACM.0000000000001421.
[40] Rencic J, Trowbridge RL Jr, Fagan M, et al. Clinical Reasoning Education at US Medical Schools: Results from a National Survey of Internal Medicine Clerkship Directors[J]. J Gen Intern Med, 2017,32(11):1242-1246. DOI: 10.1007/s11606-017-4159-y.
[41] Payton OD. Clinical reasoning process in physical therapy[J]. Phys Ther, 1985,65(6):924-928. DOI: 10.1093/ptj/65.6.924.
