75 research outputs found
Comment les mĂ©decins urgentologues raisonnent-ils au regard des spĂ©cificitĂ©s de leur cadre et leur mode dâexercice ?
Contexte : malgrĂ© les particularitĂ©s de lâenvironnement de pratique de la mĂ©decine dâurgence, il nâexiste pas de recherches spĂ©cifiquement menĂ©es sur la thĂ©matique du raisonnement clinique dans cette spĂ©cialitĂ©. Nous avons souhaitĂ© mieux comprendre comment les mĂ©decins urgentologues raisonnent dans le cadre de la prise en charge initiale des patients.
MĂ©thode : une posture Ă©pistĂ©mologique interprĂ©tative a Ă©tĂ© adoptĂ©e Ă travers un devis de recherche qualitatif de type ethnographique. Des entretiens ont Ă©tĂ© rĂ©alisĂ©s auprĂšs de mĂ©decins urgentologues experts, Ă lâissue de la prise en charge dâun patient rĂ©el. Ces entretiens reposaient notamment sur la visualisation de lâenregistrement vidĂ©o en perspective subjective situĂ©e, obtenu grĂące Ă l'usage d'une microcamĂ©ra fixĂ©e sur la tempe ou la branche de lunettes des praticiens.
RĂ©sultats : les hypothĂšses diagnostiques sont gĂ©nĂ©rĂ©es trĂšs prĂ©cocement par les mĂ©decins, parfois mĂȘme avant la rencontre avec le patient, sur la base de la prise en compte dâun nombre trĂšs limitĂ© dâinformations, pour certaines contextuelles. Cinq hypothĂšses Ă©taient en moyenne gĂ©nĂ©rĂ©es lors de la rencontre initiale et au moins une Ă©tait une hypothĂšse de gravitĂ©. Aucune nâĂ©tait formellement Ă©liminĂ©e ou validĂ©e sans rĂ©sultats dâexamens complĂ©mentaires. Un jugement prĂ©coce quant Ă la gravitĂ© de la situation permettait Ă©galement aux mĂ©decins dâorienter leurs intentions initiales vers des buts diagnostiques ou thĂ©rapeutiques. Les experts raisonnaient le plus souvent de maniĂšre intuitive. Ils prenaient en compte les spĂ©cificitĂ©s de leur environnement professionnel en Ă©tant, par exemple, vigilants au temps, au caractĂšre potentiellement Ă©volutif de lâĂ©tat clinique du malade et au devenir dâaval de celui-ci.
Conclusion : lâidentification du raisonnement clinique des mĂ©decins urgentologues offre des perspectives importantes en matiĂšre de pratique de la mĂ©decine dâurgence, et de formation des rĂ©sidents dans cette discipline. La mĂ©thode originale de recueil des donnĂ©es pourrait en outre ĂȘtre rĂ©exploitĂ©e dans le cadre de travaux ultĂ©rieurs
An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory
Context. Clinical reasoning plays a major role in the ability of doctors to make diagnoses and decisions. It is considered as the physician's most critical competence, and has been widely studied by physicians, educationalists, psychologists and sociologists. Since the 1970s, many theories about clinical reasoning in medicine have been put forward.Purpose. This paper aims at exploring a comprehensive approach: the “dual-process theory”, a model developed by cognitive psychologists over the last few years.Discussion. After 40 years of sometimes contradictory studies on clinical reasoning, the dual-process theory gives us many answers on how doctors think while making diagnoses and decisions. It highlights the importance of physicians’ intuition and the high level of interaction between analytical and non-analytical processes. However, it has not received much attention in the medical education literature. The implications of dual-process models of reasoning in terms of medical education will be discussed
Ethical Criteria for the Admission and Management of Patients in the ICU Under Conditions of Limited Medical Resources: A Shared International Proposal in View of the COVID-19 Pandemic
Introduction
The present pandemic has exposed us to unprecedented challenges that need to be addressed not just for the current state, but also for possible future similar occurrences. It is worth pointing out that discussions on the allocation of medical resources may not necessarily refer to an exception, but, unfortunately, to a regular condition for a large part of humanity (1). The criteria for admission to an Intensive Care Unit (ICU) setting generally take into account multiple factors. There must be a diagnostic and prognostic basis for the decisions made, considering both biological factors and patient values and wishes. Furthermore, the decision-making process should, whenever possible, respect the patient's advance directives as well as the relationship with the patient's family or attorney. Therapeutic neglect should be avoided.
Having applied standard clinical evaluation criteria for the appropriate treatment of patients with COVID-19, including consideration of prognosis, if a hospital then finds itself unable to provide optimal treatment (e.g., due to a disproportion between the number of patients and the availability of beds, healthcare providers, ventilators, and drugs in the ICU), it becomes necessary to evaluate, case by case, how to achieve justice and the best possible good for the greatest number of patients. It is therefore mandatory to explore alternative solutions; these include increasing available beds and healthcare providers, implementing alternative, though suboptimal, approaches (where appropriate), transferring patients to other clinical units, etc. Making these decisions properly also involves the recovery of the political role of medicine and science (2). If the imbalance between needs and resources reaches a critical level, an emergency triage protocol, following the operational and ethical indications of âdisaster medicine,â should be activated. These have been deployed in major and serious natural (earthquakes or tsunamis for example) and technological (factory explosions, public transport accidents for example) disasters, as well as following terrorist attacks (3, 4). The question of the feasibility of developing a clinical evaluation algorithm to support the decision-making of the triage team remains open, though many such protocols have been written.
According to the above, we propose the following five ethical criteria for the triage of patients in conditions of limited resources, such as the COVID pandemic. They are the result of an interdisciplinary and intercultural dialogue between specialists from different disciplines. Several of the authors are working in the main epicenters of the crisis and currently are playing a central role in the bioethical, clinical, social and legal aspects of the management of the COVID-19 pandemic
How do emergency physicians make decisions in the context of their daily practice ?
Introduction : l'aptitude Ă prendre des dĂ©cisions est cruciale en mĂ©decine d'urgence. Notre Ă©tude avait pour objectif de mieux comprendre comment les mĂ©decins urgentistes prennent des dĂ©cisions. MĂ©thode : nous avons rĂ©alisĂ© une Ă©tude qualitative basĂ©e sur des entretiens semi-structurĂ©s avec des urgentistes. Les entretiens ciblaient la gestion d'une situation d'urgence courante. Ils reposaient sur la visualisation d'une vidĂ©o de l'activitĂ© enregistrĂ©e en perspective subjective situĂ©e. RĂ©sultats : plusieurs rĂ©sultats sont originaux. Nous avons en particulier montrĂ© le rĂŽle central jouĂ© par l'intuition dans la prise de dĂ©cisions. Par ailleurs, nous avons mis en Ă©vidence la façon dont les mĂ©decins urgentistes gĂ©nĂšrent et hiĂ©rarchisent les hypothĂšses diagnostiques. Conclusion : l'usage d'une approche mĂ©thodologique innovante nous a permis de mieux comprendre la façon dont les urgentistes prennent des dĂ©cisions, avec plusieurs implications pour la formation.Introduction: the ability to makes decisions is a crucial skill in emergency medicine. Our study aimed at revealing how and when emergency physicians make decisions during the patients' initial management. Methods : we carried out a qualitative research project based on semistructured interviews with emergency physicians. The interviews concerned management of an emergency situation during routine medical practice. They were associated with viewing the video recording of emergency situations ïŹlmed in an âown-point-of-viewâ perspective. RĂ©sults : many results are original. Specifically, we showed the major role played by intuition in the decision making process. Moreover, we revealed the way emergency physicians generate and evaluate diagnostic hypotheses. Conclusions : the use of an innovative research method allowed us to better understand the way emergency physicians make decisions in their everyday practice. Our results are associated with several implications for medical education
Comment les médecins urgentologues raisonnent-ils au regard des spécificités de leur cadre et de leur mode d'exercice ?
Introduction: the ability to makes decisions is a crucial skill in emergency medicine. Our study aimed at revealing how and when emergency physicians make decisions during the patients' initial management. Methods : we carried out a qualitative research project based on semistructured interviews with emergency physicians. The interviews concerned management of an emergency situation during routine medical practice. They were associated with viewing the video recording of emergency situations ïŹlmed in an âown-point-of-viewâ perspective. RĂ©sults : many results are original. Specifically, we showed the major role played by intuition in the decision making process. Moreover, we revealed the way emergency physicians generate and evaluate diagnostic hypotheses. Conclusions : the use of an innovative research method allowed us to better understand the way emergency physicians make decisions in their everyday practice. Our results are associated with several implications for medical education.Introduction : l'aptitude Ă prendre des dĂ©cisions est cruciale en mĂ©decine d'urgence. Notre Ă©tude avait pour objectif de mieux comprendre comment les mĂ©decins urgentistes prennent des dĂ©cisions. MĂ©thode : nous avons rĂ©alisĂ© une Ă©tude qualitative basĂ©e sur des entretiens semi-structurĂ©s avec des urgentistes. Les entretiens ciblaient la gestion d'une situation d'urgence courante. Ils reposaient sur la visualisation d'une vidĂ©o de l'activitĂ© enregistrĂ©e en perspective subjective situĂ©e. RĂ©sultats : plusieurs rĂ©sultats sont originaux. Nous avons en particulier montrĂ© le rĂŽle central jouĂ© par l'intuition dans la prise de dĂ©cisions. Par ailleurs, nous avons mis en Ă©vidence la façon dont les mĂ©decins urgentistes gĂ©nĂšrent et hiĂ©rarchisent les hypothĂšses diagnostiques. Conclusion : l'usage d'une approche mĂ©thodologique innovante nous a permis de mieux comprendre la façon dont les urgentistes prennent des dĂ©cisions, avec plusieurs implications pour la formation
How do emergency physicians make decisions in the context of their daily practice ?
Introduction : l'aptitude Ă prendre des dĂ©cisions est cruciale en mĂ©decine d'urgence. Notre Ă©tude avait pour objectif de mieux comprendre comment les mĂ©decins urgentistes prennent des dĂ©cisions. MĂ©thode : nous avons rĂ©alisĂ© une Ă©tude qualitative basĂ©e sur des entretiens semi-structurĂ©s avec des urgentistes. Les entretiens ciblaient la gestion d'une situation d'urgence courante. Ils reposaient sur la visualisation d'une vidĂ©o de l'activitĂ© enregistrĂ©e en perspective subjective situĂ©e. RĂ©sultats : plusieurs rĂ©sultats sont originaux. Nous avons en particulier montrĂ© le rĂŽle central jouĂ© par l'intuition dans la prise de dĂ©cisions. Par ailleurs, nous avons mis en Ă©vidence la façon dont les mĂ©decins urgentistes gĂ©nĂšrent et hiĂ©rarchisent les hypothĂšses diagnostiques. Conclusion : l'usage d'une approche mĂ©thodologique innovante nous a permis de mieux comprendre la façon dont les urgentistes prennent des dĂ©cisions, avec plusieurs implications pour la formation.Introduction: the ability to makes decisions is a crucial skill in emergency medicine. Our study aimed at revealing how and when emergency physicians make decisions during the patients' initial management. Methods : we carried out a qualitative research project based on semistructured interviews with emergency physicians. The interviews concerned management of an emergency situation during routine medical practice. They were associated with viewing the video recording of emergency situations ïŹlmed in an âown-point-of-viewâ perspective. RĂ©sults : many results are original. Specifically, we showed the major role played by intuition in the decision making process. Moreover, we revealed the way emergency physicians generate and evaluate diagnostic hypotheses. Conclusions : the use of an innovative research method allowed us to better understand the way emergency physicians make decisions in their everyday practice. Our results are associated with several implications for medical education
Vers une perspective sociocognitiviste de lâĂ©tude du raisonnement clinique pour mieux capter lâexpertise. Un Ă©clairage particulier Ă partir de lâĂ©tude du raisonnement en mĂ©decine dâurgence
ProblĂ©matique : Le raisonnement clinique est lâune
des thématiques de recherche les plus prolifiques dans le domaine
de lâĂ©ducation mĂ©dicale. Il a essentiellement Ă©tĂ© Ă©tudiĂ© selon une perspective
cognitiviste, qui a conduit Ă lâĂ©mergence des principaux concepts
et thĂ©ories qui guident aujourdâhui nos pratiques dâenseignement.
Depuis plusieurs années, une perspective complémentaire, de nature
sociocognitiviste, tend Ă prendre de lâimportance. Elle permet dâapprĂ©hender
le raisonnement comme le fruit dâinteractions entre un individu
et son environnement. ExégÚse : Des travaux réalisés en médecine
dâurgence selon cette perspective ont permis de mettre en Ă©vidence
lâinfluence quâont les autres soignants et les patients sur le raisonnement
clinique des mĂ©decins. Les rĂ©sultats ont fait lâobjet dâune prĂ©sentation
Ă lâoccasion de la troisiĂšme ConfĂ©rence internationale de MontrĂ©al
sur le raisonnement clinique, dont cette tribune est un résumé
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