Exploring how students think: a new method combining think-aloud and concept mapping protocols.

OBJECTIVES: A key element of medical competence is problem solving. Previous work has shown that doctors use inductive reasoning to progress from facts to hypotheses and deductive reasoning to move from hypotheses to the gathering of confirmatory information. No individual assessment method has been designed to quantify the use of inductive and deductive procedures within clinical reasoning. The aim of this study was to explore the feasibility and reliability of a new method which allows for the rapid identification of the style (inductive or deductive) of clinical reasoning in medical students and experts. METHODS: The study included four groups of four participants. These comprised groups of medical students in Years 3, 4 and 5 and a group of specialists in internal medicine, all at a medical school with a 6-year curriculum in France. Participants were asked to solve four clinical problems by thinking aloud. The thinking expressed aloud was immediately transcribed into concept maps by one or two 'writers' trained to distinguish inductive and deductive links. Reliability was assessed by estimating the inter-writer correlation. The calculated rate of inductive reasoning, the richness score and the rate of exhaustiveness of reasoning were compared according to the level of expertise of the individual and the type of clinical problem. RESULTS: The total number of maps drawn amounted to 32 for students in Year 4, 32 for students in Year 5, 16 for students in Year 3 and 16 for experts. A positive correlation was found between writers (R = 0.66-0.93). Richness scores and rates of exhaustiveness of reasoning did not differ according to expertise level. The rate of inductive reasoning varied as expected according to the nature of the clinical problem and was lower in experts (41% versus 67%). CONCLUSIONS: This new method showed good reliability and may be a promising tool for the assessment of medical problem-solving skills, giving teachers a means of diagnosing how their students think when they are confronted with clinical problems.

[Simple Horton's syndrome: modalities of treatment]. / La maladie de Horton simple: modalités thérapeutiques.

IN GENERAL: Corticosteroids remain the basis of treatment of Horton's syndrome, with prednisone the molecule of choice, since they improve the symptoms and considerably reduce the risk of blindness. Several clinical forms of the disease must be distinguished in order to specify the modalities of corticosteroid treatment and any eventual associated treatments. SIMPLE HORTON'S SYNDROME: The simple forms of the disease are defined by the absence of ocular involvement, the absence of clinical involvement of the large arteries, the absence of corticosteroid resistance and the absence of corticosteroid dependence (simple forms subsequently complicated). MODALITIES OF CORTICOSTEROID THERAPY: These simple forms justify an attack treatment with 0.7 mg/kg/d of prednisone although cortisone assaults do not have a specific justification. Initiation with lower daily doses of prednisone at 0.5/mg/kg or even less appear to expose the patient to a higher risk of progression of the disease, but merit assessment. SATELLITE QUESTIONS: The iatrogeneity of corticosteroids raises problems in corticosteroid dependent patients and those receiving prolonged attack treatment. The risk of cortisone-induced osteoporosis is particularly high during Horton's syndrome. There is still no prospective study specifying the indications for treatment of the disease with anticoagulants or platelet antiaggregants.

[Complicated Horton's syndrome: therapeutic modalities]. / La maladie de Horton compliquée: modalités thérapeutiques.

FORMS THAT RAISE THERAPEUTIC PROBLEMS: The complicated forms of Horton's syndrome regroup various situations: ocular involvement at the start, large vein involvement, corticosteroid resistance (rare), corticosteroid dependence preventing the reduction in the daily dose of prednisone to less than 15 mg, high rate of morbidity with prolonged corticosteroid therapy. GENERAL PRINCIPLES: The ocular forms and those with large vein involvement, require a minimal attack treatment with 1mg/kg/d of prednisone. Cortisone assaults are often prescribed despite the fact that their efficacy remains to be demonstrated. Curative treatment with heparin (calcic or of low molecular weight) should be prescribed for 5 to 7 days with later relay to a platelet anti-aggregant, without any randomised study having validated this proposition. THE CASE OF CORTICOSTEROID-DEPENDENCE: The iatrogenic risk of corticosteroids is high and alternative treatments should be proposed: azathioprine, methotrexate, dapsone or hydroxychloroquine. Osteoporosis is the most frequent complication of corticosteroid therapy and must be avoided by the administration of a biphosphonate.

[Giant cell arteritis after the age of 75]. / Maladie de Horton chez le sujet âgé de plus de 75 ans.

Despite its increasing incidence giant cell arteritis is not well detected in the elderly. Response to corticosteroid treatment is the same before and after the age of 75, but there are many steroid-induced side effects, particularly bone fractures, in the elderly. Therefore, it is important to reduce the corticosteroid load in elderly and frail people. In this cases, 0.3 to 0.5mg/kg, or 15 to 25mg daily prednisone-equivalent dose at start seems to be enough to prevent blindness in simple forms. This dose has to be rapidly reduced whenever the C-reactive protein remains moderately elevated. Moreover, an anti-agregant or anticoagulant treatment must be associated at the beginning of steroid treatment to prevent ischemic complications, as well as biphosphonates, which could prevent corticosteroid-induced osteoporosis.