Simulation en santé et médecine interne : quel avenir ?

Simulation-based learning (SBL) is developing rapidly in France and the question of its use in the teaching of internal medicine (IM) is essential. While HAS encourages its integration into medical education, French Young Internists (AJI) set up a working group to reflect on the added-value of this tool in our specialty. Different sorts of SBL exist: human, synthetic and electronic. It enables student to acquire and evaluate technical skills (strengths, invasive procedures, etc.) and non-technical skills (relational, reasoning…). The debriefing that follows the simulation session is an essential time in pedagogical terms. It enables the acquisition of knowledge by encouraging the students’ reflection to reshape their reasoning patterns by self-correcting. IM interns are supportive of its use. The simulation would allow young internists to acquire skills specific to our specialty such as certain gestures, complex consulting management, the synthesis of difficult clinical cases. SBL remains confronted with human and financial cost issues. The budgets allocated to the development and maintenance of simulation centres are uneven, making the supply of training unequal on the territory. Simulation sessions are time-consuming and require teacher training. Are faculties ready to train and invest their time in simulation, even though the studies do not allow us to conclude on its pedagogical validity?     

Comprehensive ambulatory medicine training for categorical internal medicine residents

It is challenging to create an educational and satisfying experience in the outpatient setting. We developed a 3-year ambulatory curriculum that addresses the special needs of our categorical medicine residents with distinct learning objectives for each year of training and clinical experiences and didactic sessions to meet these goals. All PGY1 residents spend 1 month on a general medicine ambulatory care rotation. PGY2 residents spend 3 months on an ambulatory block focusing on 8 core medicine subspecialties. Third-year residents spend 2 months on an advanced ambulatory rotation. The curriculum was started in July 2000 and has been highly regarded by the house staff, with statistically significant improvements in the PGY2 and PGY3 evaluation scores. By enhancing outpatient clinical teaching and didactics with an emphasis on the specific needs of our residents, we have been able to reframe the thinking and attitudes of a group of inpatient-oriented residents.     

Improving oral presentation skills with a clinical reasoning curriculum: a prospective controlled study

PURPOSE: The oral case presentation is an essential part of clinical medicine, but teaching medical students to present clinical data remains difficult. Presentation skills depend on the ability to obtain, process, and organize patient data. Clinical reasoning is fundamental to the development of these skills. We compared a clinical reasoning curriculum with standard ward instruction for improving presentation skills and clinical performance. SUBJECTS AND METHODS: Between October 1998 and May 1999, 62 third-year medical students at three hospitals were assigned to a 4-week clinical reasoning curriculum (n = 27) or a control group (n = 35) that underwent routine instruction. The curriculum consisted of four 1-hour group sessions and 1 hour of individual videotaped instruction, and taught students to use the principles of clinical reasoning, such as generation and refinement of diagnostic hypothesis, interpretation of diagnostic tests, and causal reasoning, to determine data for inclusion in the oral presentation. We videotaped students presenting two standardized case histories; one at baseline and a second 4 weeks later. Two independent evaluators who were blinded to the group assignments reviewed the videotapes and scored them for presentation quality and efficiency, and general speaking ability. RESULTS: Mean (+/- SD) presentation times at baseline were similar in the two groups (intervention group: 8 +/- 2 minutes; control group: 8 +/- 2 minutes; P = 0.74). Presentation time in students who were taught clinical reasoning decreased by 3 +/- 2 minutes, but increased by 2 +/- 2 minutes in control students. The difference in the changes between the groups was statistically significant (mean difference = 4 minutes; 95% confidence interval [CI]: 3 to 5 minutes; P <0.001). Presentation quality scores at baseline were similar in both groups (intervention group: 17 +/- 8 points; control group: 20 +/- 7 points; P = 0.11). Students who were taught the clinical reasoning curriculum had an improvement of 9 +/- 6 points in the quality of their presentations, while control students had an improvement of 2 +/- 7 points (on a scale of 4-36). The difference in the changes between the groups was statistically significant (mean difference = 4 points; 95% CI: 1 to 7 points; P = 0.04). CONCLUSION: A clinical reasoning curriculum, in combination with video-based individual instruction, improves the efficiency and quality of oral presentations, and may augment clinical performance.     

Early clinical exposure to geriatric medicine in second-year medical school students--the McGill experience

This study examined the effect of a curriculum change on early clinical exposure to geriatrics for second-year medical students at McGill University and its effects on learning and students' appreciation of geriatrics as a subspecialty. Second-year medical students (N = 200) were exposed to a change in the curriculum involving the integration of 10 weekly sessions into one integrated week in geriatric medicine. Students participating in 10 weekly sessions were Group 1 and students participating in one integrated week were Group 2. Students rated their rotation using two different scales. The students completed 12-item questionnaires during their feedback sessions at the end of the 10-week session experience or the integrated week. The first six items assessed the students' appreciation of their improvement of knowledge in the subject of geriatrics and aging. The second and third part of the survey (questions 7 and 8) included the students' opinions about the quality of the instruction (teaching feedback) and evaluation. Students in Group 2 found their rotation more effective as a learning experience and expressed greater satisfaction with interaction with the tutors, community settings, and multidisciplinary team sessions. Grades obtained on final examinations showed a better and more-effective acquisition of knowledge by Group 2. The integrated week is a more-effective learning tool in the early clinical experience for medical students in geriatric medicine than 10 weekly sessions as the first introductory experience to the field of geriatric medicine.     

基于SPOC的流行病学线上线下混合式教学的探索与实践

流行病学是预防医学的基础学科,具有很强的理论性和实践性。新冠肺炎疫情防控阶段,如何提高学生的实践能力,更好地为疾病防控服务是流行病学课程教学改革面临的重要问题。基于小规模限制性在线课程（small private online course,SPOC）概念的线上线下混合式教学是一种新兴的教学模式,目前已在多所高校推广应用。本文结合流行病学课程特点和教学现状,从开展混合式教学的必要性、流行病学SPOC混合式教学实践过程以及教学反思等方面进行了探讨,为流行病学教学改革工作提供参考。     

The geriatrics excellence in teaching series: an integrated educational skills curriculum for faculty and fellows development

Geriatricians need to acquire skills in teaching and curriculum development to educate physicians caring for the growing population of adults aged 65 and older. To meet this challenge, educators in the Duke University Center for the Study of Aging and Human Development introduced a monthly seminar series to promote the development of geriatrics faculty and fellows as clinician educators. Ten educational skills development seminars were incorporated into geriatrics grand rounds in the first year of the program. These sessions were implemented using a variety of active learning strategies to expose participants to innovative adult learning-centered approaches for enhancing learning and instruction in medical education. Participants assessed all sessions using a feedback form and were surveyed at the end of the series to measure their overall satisfaction with the program and ascertain its effect on their roles as educators. Participants rated individual sessions highly, and respondents to the survey at the end of the course agreed that the Geriatrics Excellence in Teaching Series provided them with resources for use in their teaching practices and attested to having already applied knowledge and skills learned in the series in their teaching practices. Key elements for the program's success included an upfront needs assessment to prioritize topics, interactive sessions promoting skill development through actual practice of various strategies, open discussions to identify challenges and solutions, and a convenient and customary time slot. This format can be replicated with other geriatrics programs, providing a needed opportunity for faculty and fellows to learn about education principles.     

Diagnostic reasoning

Research in cognitive science, decision sciences, and artificial intelligence has yielded substantial insights into the nature of diagnostic reasoning. Many elements of the diagnostic process have been identified, and many principles of effective clinical reasoning have been formulated. Three reasoning strategies are considered here: probabilistic, causal, and deterministic. Probabilistic reasoning relies on the statistical relations between clinical variables and is frequently used in formal calculations of disease likelihoods. Probabilistic reasoning is especially useful in evoking diagnostic hypotheses and in assessing the significance of clinical findings and test results. Causal reasoning builds a physiologic model and assesses a patient's findings for coherency and completeness against the model; it functions especially effectively in verification of diagnostic hypotheses. Deterministic reasoning consists of sets of compiled rules generated from routine, well-defined practices. Much human problem solving may derive from activation and implementation of such rules. A deeper understanding of clinical cognition should enhance clinical teaching and patient care.     

Clinical reasoning. What is its nature? Can it be taught?

Clinical reasoning constitutes the core of medical practice, being the structural basis that defines the clinician as an expert. The common conviction--mostly among health care managers and politicians--that medicine is above all a scientific endeavor, and therefore all clinical decisions must be based exclusively on scientific evidence, is limited and does not take into account the inescapable need for clinical judgement in all its practical facets. The old saying "medicine is an art as well as a science" emphasizes the need to integrate the methodology of evidence-based medicine (EBM) with the methodology of the arts and humanities, seeking a medical praxis that satisfies patients as well as doctors. Clinical reasoning, as a crucial tool for medical practice, should be the subject of ongoing learning during medical school, post-graduation and continuing medical education. The teaching of clinical reasoning--in diagnosis, therapeutics and prognosis--requires from teachers an understanding of its two main aspects: its intrinsic nature and its development from novice to expert. This article discusses the nature of clinical reasoning, its evolution from student to medical specialist and its practical teaching.     

Physical health,subjective health,and psychological distress in older adults: Reciprocal relationships concurrently and over time

This study addresses the reciprocal associations between physical health (objectively assessed and self-rated) and psychological distress among older adults. Psychological distress (both depressive symptoms and anxiety level) made a significant independent contribution to the prediction of concurrent and future negative perception of one’s health, over and above objective health. As anxious and depressive components of psychological distress intensify, a negative outlook on life includes an increased negative view of one’s health among older adults. Conversely, negative subjective health independently predicted both depressive symptoms and anxiety level, concurrently and over time, over and above objective health. It thus appears that negative health appraisal heralds psychological distress, manifested as depressive symptoms and also anxiety among older adults. Taken together these findings draw the picture of a vicious circle of negative health appraisal leading to depression and anxiety, these in turn leading to further negative perception of health. His research and teaching activities are in the domain of psychogerontology, especially clinical geropsychology. His research interests include the treatment of depression, and reminiscence and autobiographical memory. Sabine Sèvre-Rousseau, Psy.D., defended her thesis in developmental psychology at the University of Paris V, Sorbonne. She was the coordinator of the mental health division of the Quebec Research Network on Aging during this study. She is also teaching psychology and statistical sciences at the Universities of Montreal and Sherbrooke. His research and teaching activities are in the domain of clinical geropsychology. In terms of research, he has a special interest for the etiology, assessment, and treatment of agitation and depression. Michel Préville, Ph.D., is associate professor at the Université de Sherbrooke, and Researcher at the Research Center on Aging, Scherbrooke Geriatric University Institute. He is director of the Mental Health Division of the Quebec Research Network on Aging.     

多形式混合教学法在人体寄生虫学教学的实践探索

为适应当前社会寄生虫病的流行趋势及临床需求,提高人体寄生虫学的教学质量,本教研室针对教学内容和教学模式,对寄生虫学理论课教学进行了优化和改革。以西安医学院2016级本科临床医学专业2个大班为研究对象,分为教改组(176人)和对照组(非教改组,172人)。基于新兴教学模式,探索了适用于大班教学的多形式混合教学法,包括应用微课翻转课堂、引入互联网资源讨论、分析热点时事及文献报道应用于教改组;非教改组按常规方式上课。通过课堂效果、成绩评估、学生评价和问卷调查4个方面评估教学改革实施效果。结果显示,教改组学生课堂效果测验的满分率(49.4%)高于对照组(27.9%)。期末考试成绩评估中,教改组学生平均分(81.1±8.4)明显高于对照组(73.1±9.0);教改组学生及格率(97.7%)与对照组及格率(95.9%)差异无统计学意义,但优秀率明显高于对照组(分别为10.8%和2.9%,P<0.01)。教改组学生对教师的综合评价分为97.5,高于对照组的94.4(P<0.01)。问卷调查回收率为92%(162/176),其中,90.2%(146/162)的学生喜欢多形式混合教学法;57.4%(93/162)的学生认为多形式混合教学法对寄生虫学的学习有很大帮助,36.4%(59/162)的学生认为有一定的帮助;多形式混合教学法还对提高学习兴趣(43.2%,70/162)、培养临床思维(35.8%,58/162)、促进师生关系(19.1%,31/162)等方面有较大改善。研究结果提示,相比于传统教学,多形式混合教学法可提升学生对寄生虫学的学习兴趣和自主学习性,提高学习成绩,有利于拓宽知识面,增强学生分析问题、解决问题的能力。     

Caloric restriction for longevity: II—The systematic neglect of behavioural and psychological outcomes in animal research

Research on caloric restriction for longevity (CRL) has generated hundreds of articles on the physiology of food deprivation, yet almost no data on consequences in other domains. The first paper in this series outlined the generally positive physical effects of CRL; the second analyses the meagre and sometimes disturbing record of research on behaviour, cognition and affect. The available evidence suggests that nutrient‐dense CRL in animals—just like nutrient‐poor semi‐starvation in people—is associated with a number of adverse effects. Changes include abnormal food‐related behaviour, heightened aggression and diminished sexual activity. Studies of learning and memory in underfed rodents yield inconsistent findings; no information is available on cognitive effects in primates. To date, the CRL field has ignored other variables that are crucial to the human case and known to be disrupted by chronic hunger, including sociability, curiosity and emotionality. Promotion of CRL for people is irresponsible in the absence of more reassuring data on the full range of expected outcomes. Eating disorder specialists should be contributing to scientific and public discussions of this increasingly prominent paradigm. Copyright © 2004 John Wiley & Sons, Ltd and Eating Disorders Association.     

Teaching medical students the important connection between communication and clinical reasoning

BACKGROUND: Medical students are rarely taught how to integrate communication and clinical reasoning. Not understanding the relation between these skills may lead students to undervalue the connection between psychosocial and biomedical aspects of patient care. OBJECTIVE: To improve medical students' communication and clinical reasoning and their appreciation of how these skills interrelate in medical practice. DESIGN: In 2003, we conducted a randomized trial of a curricular intervention at Johns Hopkins University School of Medicine. In a 6-week course, participants learned communication and clinical reasoning skills in an integrative fashion using small group exercises with role-play, reflection and feedback through a structured iterative reflective process. PARTICIPANTS: Second-year medical students. MEASUREMENTS: All students interviewed standardized patients who evaluated their communication skills in establishing rapport, data gathering and patient education/counseling on a 5-point scale (1=poor; 5=excellent). We assessed clinical reasoning through the number of correct problems listed and differential diagnoses generated and the Diagnostic Thinking Inventory. Students rated the importance of learning these skills in an integrated fashion. RESULTS: Standardized patients rated curricular students more favorably in establishing rapport (4.1 vs 3.9; P=.05). Curricular participants listed more psychosocial history items on their problem lists (65% of curricular students listing > or =1 item vs 44% of controls; P=.008). Groups did not differ significantly in other communication or clinical reasoning measures. Ninety-five percent of participants rated the integration of these skills as important. CONCLUSIONS: Intervention students performed better in certain communication and clinical reasoning skills. These students recognized the importance of biomedical and psychosocial issues in patient care. Educators may wish to teach the integration of these skills early in medical training.     

Is problem-based learning an ideal format for developing ethical decision skills?

Ethical decision making is a complex process, which involves the interaction of knowledge, skills, and attitude. To enhance the teaching and learning on ethics reasoning, multiple teaching strategies have to be applied. A medical ethical reasoning (MER) model served as a framework of the development of ethics reasoning and their suggested instructional strategies. Problem-based learning (PBL), being used to facilitate students' critical thinking, self-directed learning, collaboration, and communication skills, has been considered effective on ethics education, especially when incorporated with experiential experience. Unlike lecturing that mainly disseminates knowledge and activates the left brain, PBL encourages “whole-brain” learning. However, PBL has several disadvantages, such as its inefficiency, lack of adequately trained preceptors, and the in-depth, silo learning within a relatively small number of cases. Because each school tends to utilize PBL in different ways, either the curriculum designer or the learning strategy, it is important to maximize the advantages of a PBL session, PBL then becomes an ideal format for refining students' ethical decisions and behaviors.     

A clinician’s approach to clinical ethical reasoning

We offer a systematic strategy that situates clinical ethical reasoning within the paradigm of clinical reasoning. The trajectory of this strategy parallels clinical reasoning: a plain statement of the initial problem, careful gathering of data, a differential diagnostic assessment, and articulation and confirmation of a justified plan. This approach pays special attention to the goals of medical care, because so much depends on whether or not physician and patient share the same goals. This approach also addresses the heterogeneity of clinical problems that at first appear ethical and acknowledges the ethical pluralism that pervades clinical ethics.     

Evaluating the performance of inpatient attending physicians

OBJECTIVE: Instruments available to evaluate attending physicians fail to address their diverse roles and responsibilities in current inpatient practice. We developed a new instrument to evaluate attending physicians on medical inpatient services and tested its reliability and validity. DESIGN: Analysis of 731 evaluations of 99 attending physicians over a 1-year period. SETTING: Internal medicine residency program at a university-affiliated public teaching hospital. PARTICIPANTS: All medical residents (N= 145) and internal medicine attending physicians (N= 99) on inpatient ward rotations for the study period. MEASUREMENTS: A 32-item questionnaire assessed attending physician performance in 9 domains: evidence-based medicine, bedside teaching, clinical reasoning, patient-based teaching, teaching sessions, patient care, rounding, professionalism, and feedback. A summary score was calculated by averaging scores on all items. RESULTS: Eighty-five percent of eligible evaluations were completed and analyzed. Internal consistency among items in the summary score was 0.95 (Cronbach's alpha). Interrater reliability, using an average of 8 evaluations, was 0.87. The instrument discriminated among attending physicians with statistically significant differences on mean summary score and all 9 domain-specific mean scores (all comparisons, P <.001). The summary score predicted winners of faculty teaching awards (odds ratio [OR], 17; 95% confidence interval [CI], 8 to 36) and was strongly correlated with residents' desire to work with the attending again (r =.79; 95% CI, 0.74 to 0.83). The single item that best predicted the summary score was how frequently the physician made explicit his or her clinical reasoning in making medical decisions (r(2)=.90). CONCLUSION: The new instrument provides a reliable and valid method to evaluate the performance of inpatient teaching attending physicians.     

Human resource capacity building on TB laboratory work for TB control program--through the experience of international TB laboratory training course for TB control at the Research Institute of Tuberculosis, JATA, Japan

The international training course on TB laboratory work for national tuberculosis program (NTP) has been conducted at the Research Institute of Tuberculosis since 1975 funded by Japan International Cooperation Agency in collaboration with WHO Western Pacific Regional Office. The aim of the course is to train key personnel in TB laboratory field for NTP in resource-limited countries. The course has trained 265 national key personnel in TB laboratory service from 57 resource-limited countries in the last 33 years. The number of participants trained may sound too small in the fight against the large TB problem in resource-limited countries. However, every participant is playing an important role as a core and catalyst for the TB control program in his/her own country when they were back home. The curriculum is composed of technical aspects on TB examination, mainly sputum microscopy in addition since microscopy service is provided at many centers that are deployed in a widely spread area, the managerial aspect of maintaining quality TB laboratory work at the field laboratory is another component of the curriculum. Effective teaching methods using materials such as artificial sputum, which is useful for panel slide preparation, and technical manuals with illustrations and pictures of training procedure have been developed through the experience of the course. These manuals are highly appreciated and widely used by the front line TB workers. The course has also contributed to the expansion of EQA (External Quality Assessment) system on AFB microscopy for the improvement of the quality of TB laboratory service of NTP. The course is well-known for not only having a long history, but also for its unique learning method emphasizing "Participatory Training", particularly for practicum sessions to master the skills on AFB microscopy. The method in learning AFB microscopy, which was developed by the course, was published as a training manual by IUATLD, RIT and USAID. As it is mentioned, the course has been contributing to human resource capacity building including management of laboratory service to improve NTP in the resource-limited countries. Currently, expansion of technology transfer on culture examination for drug susceptibility test has been attempted to the resource-limited countries due to the occurrence of MDR-TB (Multi drug-resistant tuberculosis) and XDR-TB (Extensively drug-resistant tuberculosis) cases. However, since sputum smear examination is most effective method of detection of infectious TB, the writers believe it is still a core component of TB control, unless a new diagnostic tool that is practicable and effective in the resource-limited countries is developed. Therefore the course will keep focused on the smear examination as the basic curriculum. The course is highly appreciated by international experts and it is our responsibility to answer the expectation from them.     

What’s in a Label? Is Diagnosis the Start or the End of Clinical Reasoning?

Diagnostic reasoning has received substantial attention in the literature, yet what we mean by “diagnosis” may vary. Diagnosis can align with assignment of a “label,” where a constellation of signs, symptoms, and test results is unified into a solution at a single point in time. This “diagnostic labeling” conceptualization is embodied in our case-based learning curricula, published case reports, and research studies, all of which treat diagnostic accuracy as the primary outcome. However, this conceptualization may oversimplify the richly iterative and evolutionary nature of clinical reasoning in many settings. Diagnosis can also represent a process of guiding one’s thoughts by “making meaning” from data that are intrinsically dynamic, experienced idiosyncratically, negotiated among team members, and rich with opportunities for exploration. Thus, there are two complementary constructions of diagnosis: 1) the correct solution resulting from a diagnostic reasoning process, and 2) a dynamic aid to an ongoing clinical reasoning process. This article discusses the importance of recognizing these two conceptualizations of “diagnosis,” outlines the unintended consequences of emphasizing diagnostic labeling as the primary goal of clinical reasoning, and suggests how framing diagnosis as an ongoing process of meaning-making might change how we think about teaching and assessing clinical reasoning.