Clinical Problem-Solving

Jerome P Kassirer先生達がHospital Practice誌で始めたClinical Problem-Solvingは、CPCが法学のケースメソッドを医学教育に応用したものであるのに対し、より臨床の現場に即し、認知科学の成果を診断過程に応用したものである。認知科学の裾の広さは、ダニエル・カーネマンらがノーベル経済学賞を受賞したことからも窺い知ることができる。HP誌での連載の成果は、"Learning Clinical Reasoning"にまとめられ、Kassirer先生が1991年NEJM誌の編集長に就任した翌年の今日、NEJMでのClinical Problem-Solvingの連載が始まった。最近出版された"Learning Clinical Reasoning"第二版では、NEJM誌での連載の症例が付け加えられた。翻訳は、岩田健太郎教授が手掛けている。第二版の症例集の部分の目次とNEJM誌のオリジナル記事へのリンクを下に掲げておく。

Diagnostic Hypothesis Generation

• Case 1 Generation of Diagnostic Hypotheses 

• Case 2 Hypothesis Triggering by an Expert 

• Case 3 A Diagnostic Coup 

• Case 4 A Quick and Accurate Solution 

• Case 5 Better Late Than Never

• Case 6 A Hit After a Miss 

• Case 7 The Critical Role of Context in the Diagnostic Process 

• Case 8 A Masked Marauder

• Case 9 A Serious Lack of Focus 

Refinement of Diagnostic Hypotheses

• Case10 What is a Differential Diagnosis? 

• Case11 An Orderly, Sequential Approach 

• Case12 Weak Reasoning: Diagnosis by Drug Reaction

• Case13 Narrowing Down the Diagnostic Options 

• Case14 A Picture is Worth a Thousand Words 

• Case15 Strategies of Information Gathering 

• Case16 A Fatal Flaw in Sutton's Law 

• Case17 How to Disregard Red Herrings 

• Case18 Discrimination: The Problem of Look-Alikes 

• Case19 Location, Location, Location 

Use and Interpretation of Diagnostic Tests

• Case20 Interpreting a Negative Test Result 

• Case21 Diagnosis and the Risks of the Primrose 

• Case22 Path Searching for a Pony 

• Case23 Interpreting Hoofbeats: Can Bayes Help Clear the Haze?

• Case24 Short-Circuiting the Diagnostic Process 

• Case25 The Bypass on the Way to the Bypass 

• Case26 It is What You Believe That Counts 

• Case27 Renal Rescue by Reverend Bayes 

• Case28 A Diagnostic Fluke 

• Case29 Surprise! 

• Case30 Tripping Over Technology 

• Case31 The Probability of a Probability 

Causal Reasoning

• Case32 Judging Causality 

• Case33 Post Hoc, Ergo Propter Hoc 

• Case34 The Case for Causal Reasoning 

• Case35 The Tricky Task of Attributing Causation 

• Case36 The Right Answer for the Wrong Reason 

Diagnostic Verification

• Case37 A Point-By-Point Dissection of Clinical Reasoning 

• Case38 Leaving No Stone Unturned 

• Case39 Verification 

• Case40 A Meticulous Approach 

• Case41 A Diagnostic Quandary 

• Case42 Diagnosis by Fiat 

• Case43 Iron Pyrite and Diagnostic Confirmation 

Therapeutic Decision Making

• Case44 The Surgeon Opts to Operate: Why? 

• Case45 Treat or Keep Testing? 

• Case46 Watch and Wait, or Operate? 

• Case47 An Apple or an Orange? 

Examining Evidence

• Case48 A Difficult Tradeoff  

• Case49 Making Judgments When the Evidence is Not 

• Case50 Definitive Using and Citing Published Evidence 

• Case51 A Little Math Makes the Medicine Go Down

• Case52 A Rewarding Pursuit of Certainty

• Case53 Treating Before Knowing

Cognitive Errors

• Case54 A Defective Detective 

• Case55 Remedies for Faulty Hypothesis Generation

• Case56 A Disaster Averted 

• Case57 Derailed by the Availability Heuristic 

• Case58 Wrong Diagnosis, Wrong Tests, Wrong 

• Case59 Treatment Reconsidering Failures of Therapy 

• Case60 The Cheetah and the Snail 

• Case61 A Collection of Cognitive Diagnostic 

Errors Some Cognitive Concepts

• Case62 A Message about Methods 

• Case63 Memory: How We Overcome its Limitations 

• Case64 Diagnosis and the Structure of Memory;  Disease Polymorphism and Mental Models

• Case65 Intuitive and Inspirational, or Inductive and Incremental? 

• Case66 Knowledge and Clinical Expertise

Learning Clinical Problem Solving

• Case67 Learning Clinical Reasoning from Examples 

• Case68 Making a Silk Purse out of a Sow's Ear 

• Case69 Optimizing Case Discussions