La compréhension de l'antibiothérapie chez des étudiants et des étudiantes en médecine : Enjeux didactiques et sociaux

Résumé

Des recherches récentes indiquent une recrudescence importante de la résistance bactérienne aux antibiotiques ; cette résistance semble être provoquée, du moins en partie, par des comportements inadéquats des médecins au regard de la prescription d'antibiotiques. Quelles sont les causes de ces comportements : sont‐ce les contraintes du milieu hospitalier, les pression des patients ou la compréhension inappropriée de l'antibiothérapie ? C'est vers cette dernière hypothèse que s'oriente notre recherche en investiguant du côté des représentations. Un questionnaire ouvert comportant quatre cas cliniques réalistes a été distribué à 50 étudiants en médecine finissant leur cours préclinique. Notre objet d'étude se situe donc entre le savoir théorique et le savoir d'action en contexte réel. Il leur était demandé de répondre en termes scientifiquement acceptables et de façon vulgarisée à un patient fictif, de façon à pouvoir étudier la mobilisation et l'adaptation des concepts selon les contextes et l'interlocuteur (Vergnaud, 1994). Nos résultats indiquent que 80 % des futurs médecins adopteraient déjà des comportements incompatibles avec les règles de prévention de la résistance microbienne telles qu'enseignées dans les cours d'infectiologie ; de plus, les futurs médecins établissent peu de liens entre les concepts définissant l'antibiothérapie et ils ne semblent pas comprendre le phénomène de résistance d'une façon globale ou systémique. L'enseignement médical devrait donc en premier lieu être ciblé, puisque même avant tout contact avec la pratique et ses enjeux de pouvoir, les futurs médecins présentent déjà des lacunes importantes au regard de leur compréhension des concepts reliés à la prévention de la résistance microbienne.

Executive Summary

The last several years have witnessed a proliferation of antibiotic‐resistant strains of bacteria. Various competing hypotheses have attempted to explain the speed with which multi‐resistance has spread: intensive use of antibiotics, use of broad spectrum antibiotics, systematic failure to use antibiograms, patient pressure on doctors to prescribe antibiotics, poor monitoring of antibiotic treatments, and the use of antibiotics in veterinary medicine and animal feed. It is worth noting that several of the potential solutions put forward in the literature assign a major role to doctors (Acar & Courvalin, 1998). This study focuses on examining, from a cognitive and non‐sociological point of view (social pressure and power issues), whether the representations elicited from future doctors are consistent with their acting to prevent microbial resistance subsequent to receiving instruction on the subject in their medical classes.

The design of the data‐production methods and of the data analysis drew on theoretical frameworks for social representations, as well as those developed by Vergnaud (1986). Using an open‐ended questionnaire, we chose to study the representations of concepts related to antibiotic therapy that were devised by future doctors (n = 50). We wanted to investigate whether these future doctors would make use of the concept of resistance if they were confronted with realistic clinical cases (that is, likely to occur in a hospital setting). We chose a qualitative data processing and analysis method (L'Écuyer, 1990), based on a combined categorization model.

Although the responses of these future doctors were in keeping with standardized or canonical knowledge, they evidenced little in the way of elaboration and made do with repeating almost textually the contents of infectiology course notes. These doctors‐to‐be were, it seemed, aware of the uselessness of antibiotics for treating viral diseases, but while they generally mentioned this fact to fictional patients, few actually explained why. It appears that, while the interviewees had been made aware of resistance, as a rule, they did not have a comprehensive view of the associated mechanisms or the risky behaviours that should be avoided. This shortcoming, in tandem with the constraints of the hospital setting, merits further consideration. Fewer than 20% of the subjects appear to have adopted a treatment compatible with preventing resistance. These preliminary results strongly suggest that future doctors have a poor grasp of microbial resistance when they graduate from medical school. Moreover, some medical students already appeared to be adopting behaviours incompatible with the prevention of microbial resistance, prior even to their having had any contact with medical practice, having encountered the constraints of the public health sector, or having experienced pressure from patients and pharmaceutical companies.

Thus, the question arises of how best to foster the development, in future doctors, of a more systematic vision of medical concepts. Various avenues are open: studies of clinical cases; role playing in which these concepts can be brought into play from a range of different perspectives and involve a variety of stakeholders, and contexts; teamwork encouraging the emergence of various points of view; and the formulation of pressure situations and power issues likely to be encountered in practice. In addition to improving the methods of educating future doctors, it would also be appropriate to deal with this problem from a variety of angles—i.e., political, social, educational, ethical, and economic.