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Debriefing is a phase of synthesis and reflection that immediately follows a real-life or simulated situation. It is an essential educational step that forces the learners to reflect upon the thought processes that underlie their actions. Debriefing encourages a personal and collective reflection in order to remodel erroneous mental schemas and rectify actions done in context. Debriefing cannot be improvised; it requires a sound structure and regular practice in order to be truly effective. The debriefer must be considerate, choose appropriate learning objectives and dedicate ample time to the learners. Debriefing is focused on learning acquired in context-in other words, on the actions that were performed within a real-life or simulated clinical practice situation-and immediately follows the situation. After an initial phase of emotional release, the debriefer will help learners analyse their actions to identify their underlying rationale (contextualization), extract the overarching principles related to the lived situation in order to modify the rationale if needed (decontextualization) and assist the transfer of learning to real life (in the case of simulation) and to similar situations (recontextualization). A final summary of learning achieved during the training session concludes the debriefing. Debriefing is useful in any learning situation, including in internal medicine. Even if simulation is still underused in internal medicine, post-event debriefing can be implanted in our clinical services. Indeed, training our students and shaping them into healthcare professionals rest in no small part on hospital rotations where the intern is confronted with real-patient situations that are suitable to learning. Some in-hospital clinical encounters can be actively transformed into learning opportunities thanks to post-event debriefing, but can also passively morph into bad daily practice if no supporting action is implemented. Debriefing can thus provide an opportunity to develop non-technical skills in critical situations, or doctor-patient communication skills, within a team or between colleagues. These competencies are the hallmark of well-trained interns and are indispensable for the proper functioning of a care team. We will not develop the emotional and psychological management of debriefing in this article. We hope we will helpfully introduce as many of our colleagues as possible to the art of debriefing in most circumstances.

Problématique :Plusieurs mouvements tentent de reformuler les fondements d’une clinique en tant quepraxis, centrée sur un « agir-en-santé » : promotion de la santé, soins palliatifs, éducation thérapeutique du patient, médecine centrée sur le patient, courant du patient-partenaire, humanités et sciences humaines et sociales pour la santé, etc.. Ils s’efforcent d’apporter leurs contributions propres à la redéfinition de la santé et à sa traduction en tant qu’objet d’enseignement et d’apprentissage dans les curriculums de formation des professionnels de la santé.Exégèse :Les auteurs proposent la notion d’éthique des curriculums en santé pour désigner l’idée que les choix alternatifs relatifs aux conceptions de l’agir en santé, qui sous-tendent l’organisation des curriculums de formation des professionnels de la santé, devraient être rendus explicites au regard des dimensions constitutives d’un paradigme en philosophie des sciences (ontologique, épistémologique et méthodologique), dans le cadre de processus démocratiques de mise en projet.Conclusion :En lien avec une telle perspective, les auteurs argumentent qu’il est possible et nécessaire de caractériser l’agir professionnel en santé en tant que nouvel objet d’enseignement et d’apprentissage, au regard des trois dimensions, respectivement en privilégiant la centralité de l’action, en invitant à une rupture pragmatiste et à un élargissement gnoséologique et méthodologique, et en exploitant le concept de compétence à des fins didactiques et pédagogiques, dans le cadre de processus démocratiques de mise en projet, en favorisant une participation et une représentativité interdisciplinaires et interprofessionnelles. Une telle démarche est de nature éthique.

The advent of simulation-based education has caused a renewed interest in feedback and debriefing. However, little attention has been given to the issue of transfer of learning from the simulation environment to real-life and novel situations. In this article, the authors discuss the importance of context in learning, based on the frameworks of analogical transfer and situated cognition, and the limitations that context imposes on transfer. They suggest debriefing strategies to improve transfer of learning: positioning the lived situation within its family of situations and implementing the metacognitive strategies of contextualizing, decontextualizing, and recontextualizing. In contextualization, the learners' actions, cognitive processes, and frames of reference are discussed within the context of the lived experience, and their mental representation of the situation and context is explored. In decontextualization, the underlying abstract principles are extracted without reference to the situation, and in recontextualization, those principles are adapted and applied to new situations and to the real-life counterpart. This requires that the surface and deep features that characterize the lived situation be previously compared and contrasted with those of the same situation with hypothetical scenarios ("what if"), of new situations within the same family of situations, of the prototype situation, and of real-life situations. These strategies are integrated into a cyclical contextualization, decontextualization, and recontextualization model to enhance debriefing.

Transfer is the ability to mobilize learnt knowledge and skills in new situations. In simulation-based learning, it is also the ability to use acquired knowledge and skills in real-life situations. While transfer should be the endpoint of learning, studies have shown that it is hard to achieve and does not readily occur without guidance. This chapter provides debriefing strategies to enhance transfer, based on the frameworks of analogical transfer and situated cognition. It describes the CDR model of debriefing which alternates contextualization (C), decontextualization (D), and recontextualization (R) to foster transfer of learning.

International audience

JOURNAL ARTICLE, SCOPUS: no.j, info:eu-repo/semantics/published

Contexte et problematique : L’evolution recente des programmes d’etudes amene a considerer l’approche par competences comme un nouveau cadre de reference en education, qui tente de depasser certaines limites de la pedagogie par objectifs. C’est dans ce contexte que l’integration du concept d’intelligence emotionnelle (IE) a la logique de l’approche pedagogique par competences dans les curriculums de formation en sante est interrogee. Objectifs : 1/ Reexaminer de facon critique plusieurs referentiels de competences (RC) revendiquant une prise en compte du champ de l’IE et degager quelques principes directeurs visant a les reformuler de facon plus explicite et plus precise en termes de competences emotionnelles (CE) visees, au regard des apports recents de la psychologie des emotions ; 2/ Verifier corollairement si la mise en correspondance analytique d’une taxonomie des CE en emergence et du cadre general de l’approche par competences integree (APCi) apporte des donnees qui contribuent a consolider reciproquement leurs validites de construit respectives. Materiel et methodes : Le travail s’inscrit dans le cadre d’une approche qualitative de nature interpretative et comprehensive et repond a une demarche d’analyse de contenu, qui exploite des donnees preexistantes dans une logique inductive deliberatoire. Quatre referentiels de competences (RC), issus de quatre institutions et elabores dans le cadre d’un travail methodique et systematique de planification de dispositifs de formation professionnelle en sante, ont constitue le materiau d’etude. Le travail d’analyse interpretative et de categorisation thematique du contenu des RC a exploite une grille d’analyse predeterminee, elaboree prealablement sur la base d’une etude ciblee de la litterature scientifique appropriee. Resultats : Les domaines et niveaux taxonomiques des CE sont globalement documentes mais parfois sur ou sous representes selon les RC. Certains enonces sont formules de facon insuffisamment explicite ou imprecise. Conclusion : La taxonomie provisoire des CE permet de categoriser adequatement les composantes des CE explicitees dans les RC. Il existe une reelle concordance entre la taxonomie provisoire des CE et l’APCi, qui consolide la validite de construit de l’une et de l’autre.

Resume En 1995, afin d’harmoniser l’enseignement universitaire des soins palliatifs en France, un diplome inter-universitaire (DIU) a ete construit en instaurant un reglement et un programme communs. Une etude qualitative s’interessant au processus pedagogique des DIU de soins palliatifs francais a ete menee en 2008 sous forme d’entretiens semidirectifs aupres de deux enseignants et de deux etudiants par ville universitaire. L’analyse des donnees met en evidence des disparites pedagogiques entre les differents sites, disparites en relation avec la question initiale portant sur la coherence entre l’enseignement dispense en 2008 et le document pedagogique initial de 1995. L’absence de references explicites a un modele pedagogique defini et travaille en commun a induit une interpretation et une mise en œuvre propre a chaque comite pedagogique universitaire.

• Un portfolio est une collection organisee et cumulative de travaux et de reflexions d’un etudiant, qui rassemble des informations sur les competences qu’il a developpees au cours d’une periode plus ou moins longue d’apprentissage. • Le portfolio peut etre utilise comme soutien systematique du processus d’apprentissage et comme source d’information dans le cadre de la demarche evaluative. • L’utilisation du portfolio repond au souci d’aider l’etudiant a developper la composante metacognitive de la competence professionnelle, en modelisant et en le preparant a une pratique reflexive. • Le contenu et le format d’un portfolio peuvent varier en fonction des buts poursuivis et des contextes d’utilisation. Il comporte : une compilation de documents varies construits a partir des experiences professionnelles rencontrees par l’etudiant ; une synthese articulee des apprentissages developpes a partir de ce materiau. • Plusieurs categories de conditions specifiques de reussite d’une approche centree sur le portfolio ont ete identifiees : la supervision de l’etudiant par un mentorat adapte ; la structure du portfolio et les recommandations formulees aux etudiants ; les experiences et le materiel collige dans le portfolio; le type d’evaluation developpee a partir du portfolio. • Un dispositif centre sur le portfolio est potentiellement tres fecond mais vulnerable. Les principales menaces identifiees sont : le manque de temps ; la mauvaise qualite de la supervision pedagogique ; le manque de clarte des consignes de travail ; le caractere non explicite des criteres pris en compte pour l’evaluation du portfolio. • L’utilisation du portfolio en tant que support d’evaluation sommative fait l’objet de questions non resolues. Celles-ci concernent : l’influence d’une evaluation sommative sur la nature et la qualite des apprentissages documentes dans le portfolio ; les qualites psychometriques de l’evaluation du portfolio. Des etudes exploratoires cherchent a operationnaliser des criteres de rigueur alternatifs issus de la recherche qualitative.

• Plusieurs courants conceptuels ont contribue graduellement a l’elaboration des principes de ce qu’il est aujourd’hui convenu de denommer « paradigme d’apprentissage ». Ces apports sont ceux de la psychologie humaniste, du courant de la « pedagogie d’adulte », de la perspective socio-cognitiviste (ou constructiviste) et de l’approche inspiree par la « demarche-qualite ». • Les principes du paradigme d’ apprentissage privilegient les competences contextualisees, appreciees a partir de tâches professionnelles completes, complexes et signifiantes, en enchâssant l’evaluation au sein des activites d’enseignement et d’apprentissage et en mobilisant autour des apprentissages des etudiants la communaute des enseignants. • Un tel cadre conceptuel semble particulierement adapte au developpement d’un programme de formation medicale initiale post gradue. Une experience concernant une revision curriculaire d’un programme de residanat de medecine generale est presentee et illustree.

• L’ evaluation des apprentissages est un processus qui consiste a recueillir des informations relatives a ces apprentissages, a les interpreter afin de porter un jugement de valeur, dans le but de prendre une decision. • Compte tenu du role central de l’ evaluation dans la dynamique enseignement-apprentissage, il importe fondamentalement de se preoccuper de la coherence du dispositif d’ evaluation avec les orientations conceptuelles du programme de formation. • Les pratiques pedagogiques issues du modele de « l’enseignant qui enseigne a l’ etudiant » sont plus souvent associees a une approche evaluative qui privilegie la mesure des apprentissages a partir de comportements observables, dans des tâches standardisees ; les pratiques pedagogiques issues du modele de « l’etudiant qui apprend individuellement, a partir des questions qu’il s’est posees, en interaction avec le pro fesseur » sont plus souvent associees a une approche evaluative qui privilegie des sources d’ informations plus eclectiques concernant les apprentissages, recueillies lors de tâches authentiques et complexes, integrees aux activites d’enseignement et d’ apprentissage. • Plusieurs recommandations generales meritent d’ etre prises en compte lors du developpement d’un dispositif d’ evaluation ; anticiper les consequences previsibles du dispositif mis en oeuvre sur les apprentissages des etudiants ; delimiter ce qui doit etre evalue en raison de sa pertinence par rapport aux competences visees plutot qu’en raison de sa facilite a etre mesure ; selectionner des modalites d’ evaluation qui renseignent valablement sur le niveau de performance reellement attendu des etudiants ; exposer les etudiants a un nombre et a une variete suffisants de situations d’ evaluation ; developper des dispositifs d’ evaluation utilisant des methodes et des instruments que l’on maitrise, dont on connait les forces et les limites, compatibles avec les allocations en ressources du programme de formation et acceptes par les acteurs concernes ; rendre explicite aux etudiants, des le debut de la sequence d’enseignement et d’ apprentissage, la nature des tâches d’ evaluation et les criteres pris en compte pour la correction et/ou pour la determination de la reussite.

Our objective was to study the interaction between major histocompatibility complex (MHC) class II and T-cell receptor (TCR) alleles in the recognition of extractable nuclear antigen-derived peptides in 32 patients with systemic lupus erythematosus and 173 of their family members. MHC genes were analyzed using sequence specific oligonucleotides, and TCR beta-chain gene polymorphism using restriction fragment-length polymorphism. One dominant peptide (as defined by enzyme-linked immunosorbent assay autoantibody reactivity) was identified in each antigen studied: peptide 1-20 in Sm-D, peptide 35-58 in U1-RNP-A, and peptide 304-324 in the Ro/SSA 60 Kd protein. None of the MHC class II and TCR beta haplotypes was directly associated with any of the autoantibodies. Twenty-six subjects had antibodies to the peptide Sm-D1-20; nine of them were DRB1*0101/DQB1*0501. Among subjects with this haplotype, the number of responders was higher (p0.028, p corrected, pc = 0.336) in those with the 2-25-9 TCR beta haplotype than in the remainder. Conversely, the number of DRB1*04/DQB1*0302 responders was lower (p0.030, pc = 0.360) among subjects with the 23-20-9 TCR beta haplotype than in those without. The odds ratios (OR) were 4.23 and 0.21, respectively. Of the 54 subjects positive for anti-U1-RNP-A 35-38, 13 were DRB1*0101/DQB1*0501 and eight DRB1*04/DQB1*0302. The percentage of responders was higher (p0.041, pc = 0.492, OR = 3.48) in the former group of subjects with the 2-25-9 TCR beta haplotype, and lower (p0.02, pc = 0.024, OR = 0.09) in the latter with the 23-20-9 TCR beta haplotype. Three of the 12 anti Ro/SSA 60Kd 304-324-positive subjects were DRB1*0101/DQB1*0501. All had the 2-25-9 TCR beta haplotype (p0.046, pc = 0.552, OR = 6.29) and none the 23-20-9 (p0.031, pc = 0.372, OR = 0.10). The same combinations of genes were associated with high/low response toward the three peptides. These data provide evidence for an interplay of the MHC class II and TCR beta alleles in the control of specific autoantibody response to well-defined nuclear Ag peptides.

Cord blood and fetal liver B cells were immortalized using Epstein-Barr virus, and IgM antibodies from the resulting lines and clones were examined for their binding to a variety of auto-antigens and micro-organisms by ELISA and fluorescence assays. Auto-antigens tested included Fc of IgG, ssDNA and dsDNA, cardiolipin, histones 1-4, collagens type I and II, thyroglobulin, cytoskeletal components, and a tissue section screen. Of 71 cell lines tested, all but 19 showed some autoreactivity. All 32 fetal liver lines reacted to some self-antigens. In cord blood clones, 16 out of 26 bound to auto-antigens. Many of the clones reacted with more than one auto-antigen and were 'polyreactive'. Some of the cord blood clones bound to extracts of micro-organisms, showing specificity for both endogenous and exogenous antigens. The high frequency of CD5+ B cells in the cord blood (greater than 50%) and fetal liver (greater than 70%) argues for many of these clones being derived from this subset. Therefore, our data support the concept that many 'early' B cells produce polyreactive IgM which can bind to a variety of different auto-antigens and micro-organisms. These IgM antibodies are similar to those described by others as 'natural antibodies'.

CONTEXT The last 10 years have represented a period of significant reform within both the health care and education systems in France. In terms of its workforce, France faces a shortage of doctors, particularly in primary care. METHODS This paper examines the French medical curriculum, student selection, licensure and continuing medical education and discusses the challenges currently facing French medical faculties. RESULTS The French medical curriculum is defined nationally, with methods adapted at medical school level. There has been some uptake of innovative methods such as problem-based learning, skills-based teaching and performance-based assessment. However, traditional didactic teaching of scientific medicine and the apprenticeship model remain dominant. France uses a unique method of selection, which is the subject of much debate. Following a general year, medical students are subject to a selection examination that permits only a small number to continue studies. Similarly, at the end of medical school, a written test is used to rank students for the purpose of matching to specialty training. France has no national colleges or licensing authorities and thus authorisation to practise rests on the diploma delivered by each faculty of medicine. From 2005, continuing medical education became compulsory for all doctors. It includes the evaluation of medical practice. CONCLUSIONS French faculties of medicine face several challenges, including: rising numbers of students without a commensurate growth in the number of faculty members; an increasing emphasis on multidisciplinary health care; a drive towards mandatory continuing education and performance-based outcomes, and the development of national selection examinations that are knowledge-based.

International audience; OBJECTIVE: To achieve a common strategy in the event of a suspected venous thromboembolism. DESIGN: A multifaceted intervention, combining an audit strategy and implementation of local guidelines: phase 1, the first step, consisted of a 6-month audit to identify dysfunction; during phase 2, intervention, local guidelines were formulated by a working group and then implemented; phase 3 consisted of a re-audit over a 6-month period following the intervention. SETTING: A tertiary hospital, France. PARTICIPANTS: 419 patients with suspected venous thromboembolism in phase 1; 287 patients with suspected pulmonary embolism in phase 3. RESULTS: First phase: a dysfunction was observed in three of five criteria under study: (i) the diagnostic procedure lasted more than 48 hours in 114 patients (27.2%); (ii) no anticoagulant therapy at the time of suspicion in 116 patients (27.7%); (iii) an inconclusive lung scan without further testing in the event of a suspected pulmonary embolism in 40 patients (14%); the intervention phase was thus restricted to the management of suspected pulmonary embolism; similar results were found during the phase 3 re-audit. CONCLUSION: No improvement in the diagnostic work-up in the event of a suspected pulmonary embolism was observed following this multifaceted intervention.

Summary The diagnosis of tuberculous meningitis is difficult, especially when there is no extrameningial disease, because the direct examination of the cerebral spinal fluid (CSF) is often negative and the results from culture of Mycobacterium tuberculosis may take 3 to 8 weeks to become available. The morbidity and mortality remain high. So meningitis with a lymphocytic pleiocytosis and a low glucose level of CSF enjoins initiating antituberculous therapy. A pleiocytosis consisting predominantly of polymorphonuclear leucocytes in the CSF is well recognized in the early stages of the treatment, but its apearance later is hardly reported and suggests several hypotheses. We report a new case of later cytological change during antituberculous therapy.

Resume Les aerosols de pentamidine sont un mode preferentiel de prophylaxie de la pneumocystose pulmonaire chez les patients infectes par le virus de l'immunodeficience humaine. Ils sont exceptionnellement responsables d'effets secondaires graves, du fait du faible passage systemique du produit. Nous rapportons un nouveau cas d'intolerance glucidique aigue spontanement resolutive dans les suites d'un tel aerosol.