Le test de concordance de script (TCS) explore-t-il des processus de raisonnement clinique différents de ceux du QCM à contexte riche (basés sur des cas cliniques) ? : et si oui, quels sont-ils ?

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

L’identification et la remédiation des difficultés de raisonnement clinique en médecine (État des pratiques, recherche d’outils et processus pour soutenir les cliniciens enseignants)

INTRODUCTION : Le raisonnement clinique est au coeur de l’exercice professionnel. Cependant, nous manquons d'instruments pour identifier et objectiver les difficultés de raisonnement clinique, et il existe relativement peu de descriptions de méthodes de remédiation définies. Un important travail reste donc à faire, pour mieux comprendre comment les difficultés se manifestent dans le raisonnement clinique des étudiants en formation, mais également pour rendre ces concepts plus accessibles aux enseignants; ceci permettra alors d’améliorer la qualité de la démarche d’identification des difficultés, et d’envisager des remédiations ciblées et efficaces. OBJECTIFS : Cette recherche s’articule d’une part, autour de l’objectivation et la compréhension des pratiques actuelles des cliniciens enseignants en médecine, d’autre part, autour de la construction et l’implantation d’outils et de processus susceptibles de faciliter la démarche de diagnostic et de remédiation des difficultés de raisonnement clinique. MÉTHODOLOGIE : Une recherche de type qualitative, utilisant les méthodes de la recherche action participative s’est révélée pertinente pour atteindre nos objectifs. La recherche est composée de quatre étapes : 1. Une étude exploratoire. 2. La construction et de l’implantation d’un premier outil dans trois milieux cliniques en médecine familiale. 3. L’élaboration d’une taxonomie des difficultés de raisonnement clinique ainsi que la construction d’un nouvel outil. 4. Le développement d’une approche globale pour soutenir et former les cliniciens enseignants. RÉSULTATS : Les enseignants ont une perception rapide, mais qui demeure globale et intuitive, des potentielles difficultés de raisonnement clinique des résidents. Cette perception ne se traduit pas forcément en termes pédagogiques. Nous avons pu observer l’absence de processus pédagogiques organisés et structurés pour la gestion de ces difficultés. Ceci semble projeter les cliniciens enseignants dans une zone d’inconfort, en les confrontant à un manque de maîtrise et à l’incertitude au sujet de leurs actions pédagogiques. La catégorisation des difficultés de raisonnement clinique que nous avons construite permet d’identifier les difficultés telles qu’elles se manifestent dans le quotidien des supervisions cliniques. Cet outil a cependant besoin d’être intégré dans un processus plus global. CONCLUSION : Une approche globale qui comprenne le développement de processus implantés par le Département, l’implantation d’outils, la vulgarisation de la théorie, et la formation des enseignants est déterminante.CONTEXT: Clinical reasoning is central to medical practice. However, we lack tools to identify and objectify the difficulties of clinical reasoning, and there are relatively few descriptions of remediation methods defined. Much work remains to be done to better understand how the problems manifest themselves in the clinical reasoning of students in training, but also to make these concepts more accessible to teachers.Then this will improve the quality of the identification process difficulties, and allow considering targeted and effective remediations.PURPOSE: This research is based on the one hand, around the objectification and understanding of current practices of clinical teachers, on the other hand, around the construction and implementation of tools and processes to facilitate the process of diagnosis and remediation of difficulties in clinical reasoning. METHODOLOGY: A qualitative research, mainly using the methods of participatory action research has been relevant to achieving our goals. The research consists of four steps: 1. An exploratory study 2. The construction and implementation of a first tool in three clinical settings 3. The development of a taxonomy of difficulties in clinical reasoning and the construction of a new tool. 4. The development of a comprehensive approach to support and train clinical teachers RESULTS: Teachers have a quick perception, but still global and intuitive, of the potential difficulties of clinical reasoning residents. This perception does not necessarily move into pedagogical terms. We observed the absence of organized and structured pedagogical processes to manage these difficulties. This seems to project the clinical teachers in a zone of discomfort, by confronting them with a lack of control and uncertainty about their educational activities. The categorization of clinical reasoning difficulties that we have built allows identifying the problems as they occur in everyday clinical supervision. This tool, however, needs to be integrated into a larger process. CONCLUSION: It is necessary to develop a comprehensive approach that includes faculty development process, implementation tools, vulgarization of the theory, and teacher training

Using script theory to cultivate illness script formation and clinical reasoning in health professions education

Background: Script theory proposes an explanation for how information is stored in and retrieved from the human mind to influence individuals’ interpretation of events in the world. Applied to medicine, script theory focuses on knowledge organization as the foundation of clinical reasoning during patient encounters. According to script theory, medical knowledge is bundled into networks called ‘illness scripts’ that allow physicians to integrate new incoming information with existing knowledge, recognize patterns and irregularities in symptom complexes, identify similarities and differences between disease states, and make predictions about how diseases are likely to unfold. These knowledge networks become updated and refined through experience and learning. The implications of script theory on medical education are profound. Since clinician-teachers cannot simply transfer their customized collections of illness scripts into the minds of learners, they must create opportunities to help learners develop and fine-tune their own sets of scripts. In this essay, we provide a basic sketch of script theory, outline the role that illness scripts play in guiding reasoning during clinical encounters, and propose strategies for aligning teaching practices in the classroom and the clinical setting with the basic principles of script theory

Using script theory to cultivate illness script formation and clinical reasoning in health professions education

Background: Script theory proposes an explanation for how information is stored in and retrieved from the human mind to influence individuals’ interpretation of events in the world. Applied to medicine, script theory focuses on knowledge organization as the foundation of clinical reasoning during patient encounters. According to script theory, medical knowledge is bundled into networks called ‘illness scripts’ that allow physicians to integrate new incoming information with existing knowledge, recognize patterns and irregularities in symptom complexes, identify similarities and differences between disease states, and make predictions about how diseases are likely to unfold. These knowledge networks become updated and refined through experience and learning. The implications of script theory on medical education are profound. Since clinician-teachers cannot simply transfer their customized collections of illness scripts into the minds of learners, they must create opportunities to help learners develop and fine-tune their own sets of scripts. In this essay, we provide a basic sketch of script theory, outline the role that illness scripts play in guiding reasoning during clinical encounters, and propose strategies for aligning teaching practices in the classroom and the clinical setting with the basic principles of script theory

FROM INTUITION TO PROFESSIONALIZATION: A QUALITATIVE STUDY ABOUT THE DEVELOPMENT OF TEACHER IDENTITY IN INTERNAL MEDICINE SENIOR RESIDENTS

Objectives: Professional identity can be defined as a developmental process. Literature suggests that residents aiming to practice in a teaching institution should receive support for the development of teaching competencies as much as they do for medical competencies, but there is limited data on how to recognize teacher identity development in residents. Our study focused on the manifestations of teacher identity development in a group of senior residents in a four-week optional pedagogy rotation. In particular, we were interested in seeing teacher identity development towards the end of the residency program, at a time when clinician identity begins to consolidate.  Methods: A qualitative and exploratory approach guided our study design. Participants were internal medicine residents, (from Yr4 to Yr6) at University of Montréal, who intended working in a university setting and were interested in developing a teaching project. Focus groups were held at three separate moments: 1) before rotation, 2) after rotation and, 3) six months after rotation. Direct content analysis was chosen to analyze our findings. Results: We observed the emergence and the evolution of teacher identity and furthermore, we identified six development pathways, which underpin the development of teacher professional identity: 1) From awkward and stereotyped usage to mastery of concepts and teaching techniques, 2) From the reproduction of implicit norms of the clinical setting to the establishment of pedagogical norms 3) From the feeling of powerlessness in teaching to a feeling of mastery and taking initiatives 4) From teaching intuitively to reasoning pedagogically 5) From a teacher based paradigm to the discovery of the learner-centered paradigm and 6) From an emerging identity as a clinician to the simultaneous construction of twin identities: clinician and teacher. Six development indicators providing operational cues to help recognize different facets of teacher identity development were then identified. Conclusion: The identity development pathways allowed us to gain deeper insights about how teacher identity develops in internal medicine residents toward the end of a pedagogical rotation. It is our hope that these findings will help educators recognize and support the development of teacher identity in their residents

« Ils sont carrément incurables » : comment les métaphores des cliniciens enseignants révèlent leur malaise dans la gestion des difficultés de raisonnement clinique de leurs internes

Contexte : Les directives concernant la gestion systématique des difficultés de raisonnement clinique chez les internes ne sont pas toujours appliquées sur le terrain. Les formations aux habiletés requises pourraient ne pas suffire si les représentations des cliniciens enseignants font obstacle à leur mise en œuvre. But : Explorer les représentations des cliniciens enseignants au sujet de la gestion des difficultés de raisonnement clinique (rôle, normes, auto-efficacité). Trianguler les données d’une précédente analyse thématique de groupes de discussion focalisée. Sujets/matériel/méthodes : Vingt-six cliniciens enseignants en Belgique et en Suisse ont participé à quatre groupes de discussion focalisée. Une analyse systématique des métaphores a été menée par les deux auteurs et les résultats comparés à ceux de l’analyse thématique. Résultats : Les métaphores utilisées révèlent la préséance des normes cliniques sur les normes pédagogiques ainsi qu’une vision idéalisée du déroulement normal de l’internat. Les difficultés de raisonnement clinique étaient autant de grains de sable dans l’engrenage de la pratique clinique. Ces métaphores sont cohérentes avec une conception de l’internat comme un compagnonnage classique mais mettent au jour les limites de ce modèle lorsqu’il s’agit de gérer des internes en difficulté. Les métaphores évoquaient divers degrés d’implication relationnelle avec les internes. Seule celle de l’entraîneur sportif suggérait une implication compatible avec une saine relation pédagogique. Conclusion : Changer la culture pédagogique d’une institution nécessite des activités visant le développement d’une identité d’enseignant. Réfléchir aux métaphores utilisées serait une manière de stimuler ce développement