Uncertainty is a fundamental aspect of medical practice, necessitating incorporation into undergraduate medical training. The integrative model of uncertainty tolerance (UT) developed by Hillen and ...Han serves as a comprehensive framework for exploring clinical uncertainty. While studies have extensively examined UT dimensions, including sources, responses, and moderators, the factors influencing the perception of uncertainty stimuli remain underexplored. However, students' ability to perceive uncertainty and their approach to uncertain stimuli play a crucial role in enabling them to develop adaptive responses to uncertainty, necessary for their comfort in these situations. Defining uncertainty as a metacognitive state suggests significant variability in its perception among individuals and within an individual over time. Moreover, several studies have demonstrated the substantial influence of various individual and contextual factors on how individuals perceive and respond to uncertainty. In this paper, the authors present multiple hypotheses to address the question of whether students genuinely perceive uncertainty stimuli when they should. The authors argue that students' personal relationship with their knowledge is essential in their ability to identify clinical uncertainty, particularly concerning the limits of medical knowledge. Therefore, they propose that an academic culture fostering doubt, through exposing students to a variety of perspectives, would enhance their ability to identify uncertainty zones in a clinical situation at an early stage. Drawing on Dewey's situational theory, the authors emphasize the importance of better understanding, in a work setting, the influence of contextual and situational characteristics on individual perceptions of uncertainty. In line with this idea, ethnographic studies would offer valuable insights into identifying the relationship between the students, their work environment, and their perception of clinical uncertainty.
Abstract Background The risk of venous thromboembolism (VTE) during warm autoimmune hemolytic anemia (wAIHA) is apparent in several published series. Unlike proximate disorders (autoimmune ...thrombocytopenia, non-immune hemolytic diseases) little is known about the presentation and risk factors for VTE in this setting. Objective To determine the frequency, presentation and risk factors for VTE associated with wAIHA. Methods We performed a single center retrospective study of adult patients (> 18 years) followed for wAIHA between 2009 and 2013. VTE risk factors were systematically assessed. The characteristics of patients with or without VTE were compared. VTE presentation and precipitating factors were analyzed. The Padua VTE risk score was calculated in each case. Results Forty patients were included. wAIHA was idiopathic in 24 patients (60%). Twelve patients (30%) had Evans syndrome. Mean lowest hemoglobin level was 6.6 g/dl 3.7–11.5. Eight patients (20%) presented VTE after the appearance of wAIHA, at a mean age of 52.5 years. All patients had pulmonary embolus, associated with a deep venous thrombosis in 4 cases. At the time of VTE 7/8 patients had frank hemolysis (median hemoglobin level: 7 g/dL) and 6/8 were outpatients with a low Padua VTE risk score. The frequency of usual VTE risk factor was similar in cases and controls. By contrast, lowest hemoglobin level was significantly lower in patients that experienced VTE (5.3 vs 7.2 g/dL, p = 0.016). During the first episode of wAIHA, patients with concurrent VTE had a more pronounced anemia (5.3 vs 7.4 g/dL, p = 0.026). At the time of VTE, anemia was more severe when no other precipitating factor was present (6 vs 8.9 g.dL, p = 0.04). Conclusion In our cohort, 20% of patients with wAIHA presented VTE. The vast majority of VTE occurred during severe hemolytic flares and were not attributable to usual VTE risk factors. VTE prophylaxis is advisable in any patient admitted for wAIHA, irrespective of Padua VTE risk score. Prophylaxis also seems reasonable for outpatients with marked hemolysis.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Uncertainty in inherent to every aspects of medical practice. As the concept of uncertainty in healthcare is still to explore, deciphering the determinants and the roots of this uncertainty would ...benefit from the insights of various disciplines, such as epistemology, sociology, mathematics, or philosophy. The urgent need to improve physician's ability to cope with uncertainty, has been recently highlighted by the COVID-19 pandemic. Besides, the concept of uncertainty tolerance has been proposed, and could serve as a relevant basis for approaching uncertainty, in medical education. Thus, we propose at first to discuss the uncertainty tolerance framework from Hillen et al. Then, from an educational perspective, we outline some avenues regarding how uncertainty tolerance could be thought, in a competence-based approach, and discuss several educational activities, which have proven efficient in promoting uncertainty tolerance among medical practitioners abroad.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPUK, ZAGLJ, ZRSKP
Uncertainty arises when information is not sufficient to predict the prognosis or the outcome following an intervention. It is omnipresent in medical daily practice, and will follow each practitioner ...all along his career. The communication or merely even the feeling of uncertainty is frequently perceived as a negative experience. Nevertheless, rather than a sign of weakness, feeling uncertain reflects a dynamic state of self-reassessment which should be experienced by each doctor involved in providing his patients with the best care. Furthermore, uncertainty may lead to disastrous consequences for practitioners who have not been properly prepared to it, involving the sphere of emotions (stress, anxiety, burn-out) as well as the behavioral field (misdiagnosis, excessive testing, impaired communication…). A growing number of observations, clinical or educational studies, supports the idea that learning uncertainty should be a critical prerequisite to a valuable medical practice. Through this literature review, we propose herein a conceptual glance on uncertainty. Then, we expose some sources of uncertainty in daily practice and teaching, its consequences, and the main factors that contribute to the wide variety of the individual relationship with uncertainty. We finally aim to prompt a global reflexion, falling within an uncertainty competency-based education approach, assuming that our obligation to professionalize the students necessitates making them skilled in dealing with uncertainty.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPUK, ZAGLJ, ZRSKP
Background: The goal of this study was to examine the impact of subjective and physiological stress responses on medical students' diagnostic reasoning and communication skills.
Method: A prospective ...randomized quantitative study was undertaken, looking at ambulatory consultations in internal medicine. On the first day (baseline day), volunteer year 6 students (n = 41) participated in a simulated ambulatory consultation with standardized patients (SPs). On the second day (study day), one week later, they were randomly assigned to two groups: a low stress (n = 20) and a high stress (n = 21) simulated ambulatory consultation. Stress was measured using validated questionnaires and salivary cortisol. The SPs assessed the students' reasoning and communication. The students completed assessments of their clinical reasoning after the consultations.
Results: Although stress measures were all significantly higher in the high-stress condition (all p < 0.05), no differences were found in diagnostic accuracy and justification scores. However, correlational analyses revealed a negative correlation between multiple-stress measures and the students' ability to generate arguments for differential diagnoses.
Conclusion: Stress was associated with impairments in clinical reasoning, of a nature typically suggestive of premature closure.
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DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Many factors can contribute to the risk of venous thrombosis observed in hemolytic diseases. Some mechanisms are related to hemolysis by itself, while others seem more specific to each disease. ...Despite recent advances in the quantification of this risk and in understanding its physiopathology, the association of hemolysis with venous thrombosis is often unknown. The purpose of this general review is to clarify the main pro-thrombotic mechanisms during hemolysis and to synthesize the clinical data currently available. We will focus on the main types of hemolytic pathologies encountered in current practice, namely paroxysmal nocturnal hemoglobinuria, hemoglobinopathies, auto-immune hemolytic anemia and thrombotic microangiopathies.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPUK, ZAGLJ, ZRSKP
We report the fabrication and the characterization of the refractometric and thermo-optical properties of a quasi-one-dimensional waveguide photonic crystal-a strong, 76-/spl mu/m-long Bragg grating. ...The transmission spectra (around 660 nm) of the structure have been measured as a function of both the cladding refractive index and the temperature. The transmission stopband was found to shift by 0.8-nm wavelength for either a cladding refractive index change of 0.05 or a temperature change of 120 K. The steep stopband edges provide a sensitive detection method for this band shift, by monitoring the transmitted output power.
(1) To evaluate the corticosteroid sparing effect of an initial intravenous (i.v.) pulse of methylprednisolone (MP) in the treatment of simple forms of giant cell arteritis (GCA). (2) To analyze ...corticosteroid response, steroid related side effects, and GCA complications.
Patients received a 240 mg i.v. pulse of MP followed by 0.7 mg/kg/day oral prednisone (Group 1) or 0.7 mg/kg/day prednisone without an i.v. pulse (Group 2, controls), or a 240 mg i.v. pulse of MP followed by 0.5 mg/kg/day prednisone (Group 3). Corticosteroid dosage was reduced after normalization of 2 biological inflammatory variables to obtain half-dosage after 4 weeks in Groups 1 and 2 and 20 mg/day after 2 weeks in Group 3. Tapering was systematically attempted from the 6th month of treatment.
One hundred sixty-four patients were included in the trial (1992-96). Cumulative doses of corticosteroids after one year were identical for all groups (p = 0.39). No significant differences were observed in the time required for normalization of C-reactive protein, corticosteroid resistance (13.5%), and corticosteroid related side effects (39% of patients; p = 0.37). Corticosteroid resistant patients received larger doses and showed a high risk of GCA related complications (p = 0.02).
MP pulses have no significant longterm, corticosteroid sparing effects in the treatment of simple forms of GCA and should be limited to complicated forms. Moreover, corticosteroid resistance is a real risk factor for GCA complications.
In France, at the end of the sixth year of medical studies, students take a national ranking examination including progressive clinical case-based multiple-choice questions (MCQs). We aimed to ...evaluate the ability of these MCQs for testing higher-order thinking more than knowledge recall, and to identify their characteristics associated with success and discrimination.
We analysed the 72 progressive clinical cases taken by the students in the years 2016–2019, through an online platform.
A total of 72 progressive clinical cases (18 for each of the 4 studied years), corresponding to 1059 questions, were analysed. Most of the clinical cases (n=43, 60%) had 15 questions. Clinical questions represented 89% of all questions, whereas basic sciences questions accounted for 9%. The most frequent medical subspecialties were internal medicine (n=90, 8%) and infectious diseases (n=88, 8%). The most frequent question types concerned therapeutics (26%), exams (19%), diagnosis (14%), and semiology (13%). Level 2 questions (“understand and apply”) accounted for 59% of all questions according to the Bloom's taxonomy. The level of Bloom's taxonomy significantly changed over time with a decreasing number of level 1 questions (“remember”) (P=0.04). We also analysed the results of the students among 853 questions of training ECNi. Success and discrimination significantly decreased when the number of correct answers increased (P<0.0001 both). The success, discrimination, mean score, and mean number of discrepancies did not differ according to the diagnosis, exam, imaging, semiology, or therapeutic type of questions.
Progressive clinical case-based MCQs represent an innovative way to evaluate undergraduate students.
Les questions à réponses multiples (QRM) sont utilisées depuis longtemps pour évaluer les étudiants en médecine. Les dossiers progressifs (DP), dont le principe est basé sur une situation clinique suivie de 12 à 17 QRM où l’étudiant ne peut retourner en arrière, ont été créés en 2016 pour les premières épreuves classantes nationales informatisées (ECNi).
Nous avons analysé les 72 DP passés par les étudiants aux ECNi 2016–2019 sur une plateforme en ligne, ainsi que 60 DP passés pour des ECNi d’entraînement inter-facultaire.
Pour l’étude des ECNi, 72 DP (18 pour chacune des 4 années étudiées), correspondant à 1059 questions, ont été analysés. La plupart des DP (n=43, 60%) comportaient 15 questions. Les questions cliniques représentaient 89% de toutes les questions, tandis que les questions des sciences fondamentales représentaient 9%. Les sous-spécialités médicales les plus fréquentes étaient la médecine interne (n=90, 8%), et les maladies infectieuses (n=88, 8%). Les types de questions les plus fréquents concernaient la thérapeutique (26%), les examens (19%), le diagnostic (14%), et la sémiologie (13%). Les questions de niveau 2 (« comprendre et appliquer »), selon la taxonomie de Bloom, représentaient 59% des questions. Nous avons constaté que le niveau des questions selon la taxonomie de Bloom a évolué entre 2016 et 2019 avec un nombre décroissant de questions de niveau 1 (« connaître ») (p=0,04). Nous avons observé que le succès aux QRM et leur potentiel de discrimination diminuaient significativement lorsque le nombre de bonnes réponses augmentait (p<0,0001). Le succès, la discrimination, le score moyen et le nombre moyen de divergences ne différaient pas selon le type de questions (diagnostic, examens, imagerie, la sémiologie ou le type de questions thérapeutiques).
Les DP basés sur des situations cliniques représentent une façon innovante d’évaluer et classer les étudiants de second cycle.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPUK, ZAGLJ, ZRSKP
Abstract Background The thrombogenic burden of immobilization remains unknown especially in the medical setting. Most of epidemiological studies estimating the link between risk factors and venous ...thromboembolism (VTE) have not been designed to evaluate immobilization. The aim of this work was to estimate the risk of VTE in medical bedridden patients by a systematic review and a meta-analysis. Methods A research on PUBMED and EMBASE was carried out to retrieve case-control and cohort studies showing the proportion of bedridden patients with or without VTE. Included studies were assigned in six groups according to the following criteria: 1) their design (cohort or case-control), 2) the targeted population (with or without suspicion of VTE) and 3) the medical setting (ambulatory or hospital). Odd-Ratios and Relative Risk for case-control and cohort studies were calculated using a random effect method. Heterogeneity and publication bias were statistically assessed by the I2 statistics and funnel plots with Egger's tests. Results 43 studies were included (24181 patients). The pooled RR ranged from 1.46 to 2.77 in the subgroups of cohort studies (n = 36) with an overall RR of 1.86 (1.61-2.14; P < 0.001). The pooled OR were 2.79 and 2.47 in the two subgroups of case-control studies (n = 7), both statistically significant (overall OR: 2.52; 1.70-3.74; P < 0.001). Heterogeneity through studies was demonstrated in four subgroups. Publication bias was only observed in one subgroup. Conclusions Among medical patients, immobilization increases the risk of VTE. Nevertheless, a specific role of underlying conditions can not be excluded.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPUK
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