Skip to main content
SpringerLink
Log in

Comment les médecins urgentistes raisonnent-ils ? Synthèse des principaux résultats d’une recherche qualitative multicentrique et multidisciplinaire sur la prise de décision en médecine d’urgence

How do emergency physicians reason? A synthesis of the main results from a multicentric and multidisciplinary qualitative research on decision-making in emergency medicine

  • Article Original / Original Article
  • Published:
Annales françaises de médecine d'urgence

Résumé

Objectif

Nous en savons très peu sur la façon dont les médecins urgentistes raisonnent afin de prendre des décisions diagnostiques et thérapeutiques. Les erreurs de raisonnement sont pourtant à l’origine de la majorité des erreurs diagnostiques survenant dans le cadre de la pratique clinique. Cet article présente à l’attention des praticiens et des enseignants de médecine d’urgence les principaux résultats d’une vaste étude qui a réuni entre 2010 et 2015 une équipe internationale de chercheurs issus de plusieurs disciplines, avec pour objectif de modéliser l’expertise en médecine d’urgence.

Matériel et méthodes

Nous avons mené une recherche observationnelle prospective multicentrique basée sur une approche qualitative. Des entretiens ont été réalisés avec des médecins urgentistes experts jusqu’à saturation des données. Ils concernaient la prise en charge récente d’une situation d’urgence. Ils étaient sous-tendus par l’enregistrement vidéo de la situation selon le propre point de vue des médecins.

Résultats

Les médecins urgentistes interviewés utilisent essentiellement leur intuition, qui se forge très rapidement, sur la base de deux à quatre informations cliniques et contextuelles. Ils trouvent souvent le bon diagnostic avant même d’avoir rencontré le patient, mais attendent systématiquement les résultats des examens complémentaires pour en être certains. Ils sont loin d’être « objectifs » dans la façon dont ils traitent les données de leur environnement et craignent toujours le pire.

Conclusion

La modélisation de l’expertise en médecine d’urgence est susceptible d’aider les praticiens et les enseignants à mieux comprendre l’origine des erreurs de prise de décision dans le domaine de l’urgence.

Abstract

Objectives

Little is known about how emergency physicians reason in order to make diagnostic and therapeutic decisions. Yet, reasoning errors are the main cause of diagnostic errors in the context of the clinical practice. This article brings to the attention of emergency physicians and emergency medicine teachers the main results of a vast study carried out from 2010 to 2015 within a multidisciplinary team that brought together researchers from several countries. The project aimed at modeling expertise in emergency medicine.

Methods

We carried out a multicenter prospective observational study based on a qualitative approach. We conducted interviews with expert emergency physicians until data saturation. The interviews focused on the recent management of an emergency situation. They were underpinned by the video recording of the situation according to the physicians’ own point of view perspective.

Results

The interviewed emergency physicians mainly used their intuition, forged very early on the basis of two to four clinical and contextual data. They often generate the correct diagnostic even before meeting the patient, but systematically wait for the results of the complementary examinations to be certain. They are far from being “objective” when they deal with data from their environment and always worry about the worst.

Conclusion

The modeling of expertise in emergency medicine is likely to help practitioners and teachers to better understand the causes of decision-making errors in the field of emergency medicine.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Références

  1. Campbell S (2008) Patient safety and continuous quality improvement–A user’s guide. In: Croskerry P, Cosby KS, Schenkel SM, et al, Patient Safety in Emergency Medicine. Lippincott Williams & Wilkins, Philadelphie 12–22

    Google Scholar 

  2. Sandhu H, Carpenter C, Freeman K, et al (2006) Clinical decision making: opening the black box of cognitive reasoning. Ann Emerg Med 48:713–9

    Article  PubMed  Google Scholar 

  3. Pelaccia T, Tardif J, Triby E, et al (2011) Comment les médecins raisonnent-ils pour poser des diagnostics et prendre des décisions thérapeutiques ? Les enjeux en médecine d’urgence. Ann Fr Médecine Urgence 1:77–84

    Article  Google Scholar 

  4. Brennan TA, Leape LL, Laird NM, et al (1991) Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 324:370–6

    CAS  PubMed  Google Scholar 

  5. Croskerry P, Abbass AA, Wu AW (2008) How doctors feel: affective issues in patients’ safety. Lancet 372:1205–6

    Article  PubMed  Google Scholar 

  6. Leape LL, Brennan TA, Laird N, et al (1991) The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 324:377–84

    CAS  PubMed  Google Scholar 

  7. Graber M (2005) Diagnostic errors in medicine: a case of neglect. Jt Comm J Qual Patient Saf Jt Comm Resour 31:106–13

    Google Scholar 

  8. Graber ML, Franklin N, Gordon R (2005) Diagnostic error in internal medicine. Arch Intern Med 165:1493–9

    Article  PubMed  Google Scholar 

  9. Croskerry P (2012) Perspectives on diagnostic failure and patient safety. Healthc Q Tor Ont 15(Spec No):50–6

    Article  Google Scholar 

  10. Payne VL, Crowley RS (2008) Assessing use of cognitive heuristic representativeness in clinical reasoning. AMIA Annu Symp Proc 2008:571–5

    PubMed Central  Google Scholar 

  11. Kachalia A, Gandhi TK, Puopolo AL, et al (2007) Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med 49:196–205

    Article  PubMed  Google Scholar 

  12. Croskerry P, Sinclair D (2001) Emergency medicine: A practice prone to error? CJEM 3:271–6

  13. Croskerry P (2000) The cognitive imperative: thinking about how we think. Acad Emerg Med 7:1223–31

    Article  CAS  PubMed  Google Scholar 

  14. Pelaccia T, Tardif J, Triby E, et al (2014) How and when do expert emergency physicians generate and evaluate diagnostic hypotheses? A qualitative study using head-mounted video cued-recall interviews. Ann Emerg Med 64:575–85

    Article  PubMed  Google Scholar 

  15. Pelaccia T, Tardif J, Triby E, et al (2015) Insights into emergency physicians’ minds in the seconds before and into a patient encounter. Intern Emerg Med 10:865–73

    Article  PubMed  Google Scholar 

  16. Pelaccia T, Tardif J, Triby E, et al (2015) From context comes expertise: how do expert emergency physicians use their knowwho to make decisions? Ann Emerg Med 67:747–51

    Article  PubMed  Google Scholar 

  17. Pelaccia T, Tardif J, Triby E, et al (2016) Do emergency physicians trust their patients? Intern Emerg Med 11:603–8

    Article  PubMed  Google Scholar 

  18. Knoblauch H (2005) Focused ethnography. Forum Qual Soc Res 6:44

    Google Scholar 

  19. Muecke MA (1994) On the evaluation of ethnographies. In: Morse JM, Critical issues in qualitative research methods. Sage, Thousand Oaks, CA, 187–209

    Google Scholar 

  20. Unsworth CA (2004) Clinical reasoning: how do pragmatic reasoning, worldview and client-centredness fit? Br J Occup Ther 67:10–9

    Article  Google Scholar 

  21. Omodei MM, Mc Lennan J, Wearing AJ (2005) How expertise is applied in real-world dynamic environments: head-mounted video and cued recall as a methodology for studying routines of decision-making. In: Betsch T, Haberstroh S, The routines of decision-making. Erlbaum, Mahwah, NJ, 271–88

    Google Scholar 

  22. Rix G, Biache MJ (2004) Enregistrement en perspective subjective située et entretien en re-situ subjectif: une méthodologie de la constitution de l’expérience. Intellectica 38:363–96

    Google Scholar 

  23. Unsworth CA (2001) Using a head-mounted video camera to study clinical reasoning. Am J Occup Ther 55:582–8

    Article  CAS  PubMed  Google Scholar 

  24. Choudhry NK, Fletcher RH, Soumerai SB (2005) Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med 142:260–73

    Article  PubMed  Google Scholar 

  25. Ericsson KA (2004) Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 79:S70–81

    Article  PubMed  Google Scholar 

  26. Friedman Z, Siddiqui N, Katznelson R, et al (2008) Experience is not enough: repeated breaches in epidural anesthesia aseptic technique by novice operators despite improved skill. Anesthesiology 108:914–20

    Article  PubMed  Google Scholar 

  27. Guest CB, Regehr G, Tiberius RG (2001) The lifelong challenge of expertise. Med Educ 35:78–81

    Article  CAS  PubMed  Google Scholar 

  28. Moulton CE, Regehr G, Mylopoulos M, Mac Rae HM (2007) Slowing down when you should: a new model of expert judgment. Acad Med 82:S109–16

    Article  PubMed  Google Scholar 

  29. Glaser BG, Strauss AL (1999) Discovery of grounded theory: strategies for qualitative research. Aldine Transaction, Piscataway, NJ

    Google Scholar 

  30. Green J (2009) Qualitative methods for health research, 3rd revised edition. SAGE Publications Ltd, Los Angeles

    Google Scholar 

  31. Pope C, Ziebland S, Mays N (2000) Analysing qualitative data. BMJ 320:114–6

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Miles MB, Huberman M (1994) Qualitative data analysis: an expanded sourcebook, 2nd revised edition. SAGE Publications Inc, Thousand Oaks

    Google Scholar 

  33. Pelaccia T, Tardif J, Triby E, Charlin B (2011) An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory. Med Educ Online, 16

  34. Hogarth RM (2010) Educating intuition. University Of Chicago Press, Chicago

    Google Scholar 

  35. Durning S, Artino AR, Pangaro L, et al (2011) Context and clinical reasoning: understanding the perspective of the expert’s voice. Med Educ 45:927–38

    Article  PubMed  Google Scholar 

  36. Croskerry P (2009) Context is everything or how could I have been that stupid? Healthc Q 12:e171–6

    Article  PubMed  Google Scholar 

  37. Croskerry P, Cosby KS (2009) Patient safety in emergency medicine. Lippincott Williams & Wilkins, Philadelphia

    Google Scholar 

  38. Elstein AS, Schulman LS, Sprafka SA (1978) Medical problem solving: an analysis of clinical reasoning. Harvard University Press, Cambridge, MA

    Book  Google Scholar 

  39. Schwartz A, Elstein AS (2008) Clinical reasoning in medicine. In: Higgs J, Jones MA, Loftus S, et al, Clinical reasoning in the health professions. Butterworth-Heinemann, Oxford, 223–34

    Google Scholar 

  40. Norman G (2005) Research in clinical reasoning: past history and current trends. Med Educ 39:418–27

    Article  PubMed  Google Scholar 

  41. Gruppen LD, Frohna AZ (2002) Clinical reasoning. In: Norman GR, van der Vleuten CP, Newble DI, International handbook of research in medical education. Kluwer Academic, Boston, 205–30

    Chapter  Google Scholar 

  42. Woods NN (2007) Science is fundamental: the role of biomedical knowledge in clinical reasoning. Med Educ 41:1173–7

    Article  PubMed  Google Scholar 

  43. Ericsson KA, Simon HA (1993) Protocol analysis: verbal reports as data. A Bradford Book, Cambridge, MA

    Google Scholar 

  44. Britten N (1995) Qualitative interviews in medical research. BMJ 311:251–3

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Service d’aide médicale urgente du Bas-Rhin, hôpitaux universitaires de Strasbourg, 70 rue de l’Engelbreit, F-67200, Strasbourg, France

    T. Pelaccia

  2. Centre de formation et de recherche en pédagogie des sciences de la santé (CFRPS), Faculté de médecine de Strasbourg, Université de Strasbourg, 4 rue Kirschleger, F-67085, Strasbourg, France

    T. Pelaccia

  3. Département de pédagogie, Faculté d’éducation, Université de Sherbrooke, 2500 boulevard de l’Université, QC J1K 2R1, Québec, Canada

    J. Tardif

  4. Faculté des sciences de l’éducation, université de Strasbourg, 7 rue de l’Université, F-67000, Strasbourg, France

    E. Triby

  5. Département de médecine d’urgence, hôpital universitaire d’Amiens, 1 place Victor Pauchet, F-80054, Amiens, France

    C. Ammirati

  6. SAMU 94, hôpital Henri-Mondor, AP-HP, 51 avenue du Maréchal de Lattre de Tassigny, F-94000, Créteil, France

    C. Bertrand

  7. Centre for Medical Education, McGill University, 1100 Pine Avenue West, QC H3A 2T5, Montréal, Québec, Canada

    V. Dory

  8. Centre de pédagogie appliquée aux sciences de la santé (CPASS), Faculté de médecine, université de Montréal, QC H3T 1J4, Montréal, Québec, Canada

    B. Charlin

Authors
  1. T. Pelaccia
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. Tardif
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. E. Triby
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. C. Ammirati
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. C. Bertrand
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. V. Dory
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. B. Charlin
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to T. Pelaccia.

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Pelaccia, T., Tardif, J., Triby, E. et al. Comment les médecins urgentistes raisonnent-ils ? Synthèse des principaux résultats d’une recherche qualitative multicentrique et multidisciplinaire sur la prise de décision en médecine d’urgence. Ann. Fr. Med. Urgence 7, 153–158 (2017). https://doi.org/10.1007/s13341-017-0729-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13341-017-0729-1

Mots clés

Keywords

Search

Navigation