Diagnosis is one of the most important tasks performed by internal medicine physicians, and diagnostic reasoning is perhaps the most critical of an internist's skills. The foundation of the diagnostic process is the patient's medical history and the physical examination, which lead to an initial differential diagnosis that is adjudicated through an ever-increasing array of diagnostic tests and data points as well as the patient's course over time. Historically, diagnostic reasoning and expertise have been highly valued in residency training, figuring prominently in curricula, conferences, and teaching rounds. However, despite growing recognition of the importance of diagnostic error with regard to patient safety and the need to “enhance healthcare professional education and training in the diagnostic process” (1), several signs indicate that the focus on diagnostic reasoning in internal medicine training may be threatened (2). Indeed, only 2 of the 22 Internal Medicine Milestones of the Accreditation Council for Graduate Medical Education and American Board of Internal Medicine—milestones 1 and 7—explicitly include diagnostic skills (3). Although this disconnect between the importance of diagnostic reasoning skills and the current approach to medical education has not gone unnoticed, responses largely have focused on adding clinical reasoning courses to medical school curricula and incorporating clinical reasoning into certification assessments (1, 4).

诊断是内科医师执行的最重要的任务之一，而诊断推理可能是内科医生最关键的技能。诊断过程的基础是患者的病史和体格检查，这将导致最初的鉴别诊断，通过不断增加的一系列诊断测试和数据点以及随着时间的推移，可以对患者进行诊断。从历史上看，诊断推理和专业知识在住院医师培训中受到高度重视，在课程，会议和教学轮次中占有重要地位。但是，尽管人们越来越认识到诊断错误对患者安全的重要性，并且需要“加强诊断过程中的医疗保健专业教育和培训”（1），一些迹象表明，内部医学培训中对诊断推理的关注可能会受到威胁（2）。确实，研究生医学教育鉴定委员会和美国内科医学委员会的22种内科医学里程碑中，只有2项（里程碑1和7里程碑）明确地包含了诊断技能（3）。尽管诊断推理技能的重要性与当前医学教育方法之间的这种脱节并没有引起人们的注意，但应对措施主要集中于在医学院课程中增加临床推理课程并将临床推理纳入认证评估中（1、4）。研究生医学教育认证委员会和美国内科医学委员会的22种内科医学里程碑中，只有2项（里程碑1和7）明确包含了诊断技能（3）。尽管诊断推理技能的重要性与当前医学教育方法之间的这种脱节并没有引起人们的注意，但应对措施主要集中于在医学院课程中增加临床推理课程并将临床推理纳入认证评估中（1、4）。研究生医学教育认证委员会和美国内科医学委员会的22种内科医学里程碑中，只有2项（里程碑1和7）明确包含了诊断技能（3）。尽管诊断推理技能的重要性与当前医学教育方法之间的这种脱节并没有引起人们的注意，但应对措施主要集中于在医学院课程中增加临床推理课程并将临床推理纳入认证评估中（1、4）。