Patients who attend a private practice vs a university outpatient clinic: how do they differ?

Although interpersonal continuity is commonly assumed to be essential for care, some patients prefer to attend a university outpatient clinic where physicians change regularly and interpersonal continuity of care is not ensured. The aim of this exploratory study was to evaluate the differences between patients attending a university outpatient clinic and patients frequenting a private practice, explore their patterns of care-seeking and their understanding of continued care. We conducted a cross-sectional study of patients attending the university medical outpatient clinic (OC) in Lausanne, Switzerland and ten randomly selected private general practices (PP). Eligible patients were >30 years, Swiss nationals or long term residents, with one or more chronic conditions and attending the same practice for >3 years. They were asked to complete a questionnaire on sociodemographic data, use of medical resources and reasons for choosing and remaining at the same practice. Semi-structured interviews were conducted with a randomly selected subset of 26 patients to further explore their preferences. 329 patient questionnaires were completed, 219 by PP and 110 by OC patients. OC patients tended to be of lower socioeconomic status than PP patients. The main reason for choosing a PP were personal recommendation, while a higher percentage of patients chose the OC because they could obtain a first appointment quickly. A higher percentage of PP patients accorded importance to physician communication skills and trust, whereas a higher percentage of OC patients favoured investigation facilities. Qualitative data suggested that although OC and PP patients reported different reasons for consulting, their expectations on the medical and relationship level were similar. Our study suggests that the two groups of patients belong to different social backgrounds, have different patterns of care-seeking and attach importance to different aspects of care continuity. However, patients' expectations and perceptions of the physician-patient relationship are similar.

Rauchentwohnung-- die zentrale Rolle der Arztinnen und Arzte [Smoking cessation--a central role for physicians]

Physicians are in a unique position to advice smokers to quit by the ability to integrate the various aspects of nicotine dependence. This review provides an overview of intervention with smokers presenting in a primary care setting. Strategies used for smoking cessation counseling differed according to patient's readiness to quit. For smokers who do not intend to quit smoking, physicians should inform and sensitize patients about tobacco use and cessation, especially by personalizing benefits to quit and challenging smokers 'beliefs. For smokers who are dissonant, physicians should use motivational strategies, such as discussing barriers to cessation and their solutions. For smokers ready to quit, the physician should show strong support, help set a quit date, prescribe pharmaceutical therapies for nicotine dependence, such as replacement therapy and/or bupropion, with instructions for use, and suggest behavioral strategies to prevent relapse.

Recursos i Restriccions de la Xarxa en Ciències de Biomèdiques

La xarxa Internet, entesa com un consorci format per usuaris, ordinadors, elements de comunicació, coneixements i aplicacions, és una innovació tecnològica que obre la porta a noves modalitats de treball i de relació entre les persones i les organitzacions en què estan agrupades. En el cas de les ciències biomèdiques, una gran part del seu èxit rau a oferir un substrat metodològic molt adient a la necessitat intrínseca de tractar dades i informacions i comunicar-les a d"altres professionals perquè la recerca progressi o a la societat per a difondre els coneixements. La medicina es beneficia en el mateix sentit, però l"impacte és mes gran, ja que hom pot preveure un canvi radical en el paradigma de l"actuació clínica. La clàssica relació metge-pacient haurà d"incorporar nous elements amb el grau de responsabilitat corresponent. Cal acceptar el fet d"Internet amb un esperit científic alhora suficientment crític per a copsar tots els beneficis que se"n poden obtenir i totes les restriccions i limitacions que per raons tècniques o ètiques s"hagin d"acceptar.

Helping medical students to acquire a deeper understanding of truth-telling.

PROBLEM: Truth-telling is an important component of respect for patients' self-determination, but in the context of breaking bad news, it is also a distressing and difficult task. INTERVENTION: We investigated the long-term influence of a simulated patient-based teaching intervention, integrating learning objectives in communication skills and ethics into students' attitudes and concerns regarding truth-telling. We followed two cohorts of medical students from the preclinical third year to their clinical rotations (fifth year). Open-ended responses were analysed to explore medical students' reported difficulties in breaking bad news. CONTEXT: This intervention was implemented during the last preclinical year of a problem-based medical curriculum, in collaboration between the doctor-patient communication and ethics programs. OUTCOME: Over time, concerns such as empathy and truthfulness shifted from a personal to a relational focus. Whereas 'truthfulness' was a concern for the content of the message, 'truth-telling' included concerns on how information was communicated and how realistically it was received. Truth-telling required empathy, adaptation to the patient, and appropriate management of emotions, both for the patient's welfare and for a realistic understanding of the situation. LESSONS LEARNED: Our study confirms that an intervention confronting students with a realistic situation succeeds in making them more aware of the real issues of truth-telling. Medical students deepened their reflection over time, acquiring a deeper understanding of the relational dimension of values such as truth-telling, and honing their view of empathy.

Sickness certification in primary care: a survey on views and practices among Swiss physicians.

QUESTIONS UNDER STUDY: Studies from several countries (Scandinavia, United Kingdom) report that general practitioners (GPs) experience problems in sickness certification. Our study explored views of Swiss GPs towards sickness certification, their practice and experience, professional skills and problematic interactions with patients. METHODS: We conducted an online survey among GPs throughout Switzerland, exploring behaviour of physicians, patients and employers with regard to sickness certification; GPs' views about sickness certification; required competences for certifying sickness absence, and approaches to advance their competence. We piloted the questionnaire and disseminated it through the networks of the five Swiss academic institutes for primary care. RESULTS: We received 507 valid responses (response rate 50%). Only 43/507 GPs experienced sickness certification as problematic per se, yet 155/507 experienced problems in sickness certification at least once a week. The 507 GPs identified estimating a long-term prognosis about work capacity (64%), handling conflicts with patients (54%), and determining the reduction of work capacity (42%) as problematic. Over 75% would welcome special training opportunities, e.g., on sickness certifications during residency (93%), in insurance medicine (81%), and conflict management (80%). CONCLUSION: Sickness certification as such does not present a major problem to Swiss GPs, which contrasts with the experience in Scandinavian countries and in the UK. Swiss GPs did identify specific tasks of sickness certification as problematic. Training opportunities on sick-leave certification and insurance medicine in general were welcomed.

Patients, médecins et internet [Patients, doctors and the internet].

The majority of the Swiss population uses the internet to seek information about health. The objective is to be better informed, before or after the consultation. Doctors can advise their information-seeking patients about high quality websites, be it medical portals or websites dedicated to a specific pathology. Doctors should not see the internet as a threat but rather as an opportunity to strengthen the doctor-patient relationship.

Patson Approach versus the Standard Approach for increasing breast reconstruction rates in women undergoing mastectomy. A randomized, controlled, open-label clinical trial

Breast cancer is the most prevalent neoplasm among women in the majority of countries worldwide. Breast cancer treatment include mastectomy which is associated to strong impact in women. Breast reconstruction is an option for many women to re-establish their body image and also to decrease psychological impact. However, breast reconstruction rates are low and many factors are involved in not undergoing breast reconstruction. Patient involvement in the decision-making process increases breast reconstruction rates and is associated to higher satisfaction and less anxiety and depression symptoms. More physician-patient relation and more education in terms of breast reconstruction are needed to achieve our objective. A new approach of medical care, called Patson Approach, is created in order to meet our goal with more patient involvement, as well as, physician and psychological counsellingObjective: to increase breast reconstruction rates in women who are candidates for breast reconstruction after mastectomy and are included in the Patson Approach compared to women included in the Standard ApproachMethods: the study design will be a randomized, controlled, open-label clinical trial. 62 patients will be recruited during two years and randomly divided in two groups, 31 will be included in the Standard Approach and 31 will be included in the Patson Approach. Preoperative and postoperative appointments are established in order to do a follow-up of the patients and collect all the data

L’annonce d’un décès au service des urgences : une étude qualitative

Nous cherchions à explorer les compétences que les intervenants du service des urgences (SU), des médecins et des infirmières travaillant en équipe dans des rôles complémentaires, ont développées dans la divulgation d‘un décès, pour éclairer l‘apprentissage de cette compétence de « Communicateur ». Nous avons utilisé des entrevues semi-dirigées et un échantillonnage non probabiliste de 8 intervenants. Nous avons analysé les entrevues à l‘aide de méthodes qualitatives reconnues. Le nombre total de présences de nos intervenants à une divulgation est estimé supérieur à 2000. Notre analyse a démontré qu‘ils utilisent une structure de divulgation uniforme. Néanmoins, ils repoussaient l‘utilisation d‘un protocole, parce que jugé trop rigide. La flexibilité et l‘empathie se sont révélées des qualités essentielles pour les intervenants. Nous représentons la visite de la famille comme un épisode de désorganisation/dysfonction qui se résorbe partiellement durant le séjour au SU. Nous proposons un modèle pédagogique qui est basé sur nos résultats.

L’anomie pharmaco-médicale. Compte-rendu de La prise de décision en éthique clinique : Perspectives micro, méso et macro, sous la direction de Yanick Farmer, Marie-Ève Bouthilier et Delphine Roigt

Compte-rendu / Review

Perspective maternelle de la consultation anténatale pour travail préterme : une approche relationnelle

Une femme à risque d’un accouchement prématuré vit un enjeu de santé très éprouvant et stressant ; elle sera souvent hospitalisée pour recevoir des traitements médicaux visant à prolonger la grossesse et améliorer le pronostic du bébé. Dans ce contexte, une consultation avec un néonatalogiste est demandée. Plusieurs associations professionnelles médicales ont émis des lignes directrices sur cette consultation, insistant sur le besoin d’informer les parents au sujet des complications potentielles de la prématurité pour leur enfant. Ces recommandations s’inspirent du point de vue médical, et très peu d’études ont examiné la perspective, les attentes et les besoins des parents à risque d’un accouchement prématuré. Ce projet de thèse a pour objectif de proposer un modèle de relation médecin-patient informé de la perspective maternelle de la consultation anténatale, pour développer une approche clinique répondant à leurs besoins. Afin d’examiner cette problématique de façon complète, un travail constant de va-et-vient a été effectué entre la recension de données empiriques et une réflexion normative bioéthique féministe. Un projet de recherche empirique a d’abord permis d’explorer les attentes et le vécu de ces femmes. Les participantes espéraient recevoir plus que de l’information sur les complications de la prématurité. Elles souhaitaient que le néonatologiste soit attentif à leur situation particulière et qu’il développe une relation de confiance avec elles, leur permettant d’explorer leurs futurs rôles de mères et les encourageant à formuler leurs propres questions. Le cadre théorique féministe d’autonomie relationnelle a ensuite permis de proposer une approche de soin qui sache répondre aux besoins identifiés par les patientes, tout en adressant des enjeux de pouvoir intrinsèques à la clinique, qui influencent la santé et l’autonomie de ces femmes. Cette approche insiste sur l’importance de la relation de soin en clinique, contrastant avec un modèle encourageant une vision réductrice de l’autonomie, dans laquelle un simple transfert de données scientifiques serait équivalent au respect de la norme médicolégale du consentement éclairé. Ce modèle relationnel propose des actions concrètes et pratiques, encourageant les cliniciens à entrer en relation avec chaque patiente et à considérer l’influence qu’ils exercent sur l’autonomie relationnelle de leurs patientes.

Measuring time series predictability using support vector regression

Most studies involving statistical time series analysis rely on assumptions of linearity, which by its simplicity facilitates parameter interpretation and estimation. However, the linearity assumption may be too restrictive for many practical applications. The implementation of nonlinear models in time series analysis involves the estimation of a large set of parameters, frequently leading to overfitting problems. In this article, a predictability coefficient is estimated using a combination of nonlinear autoregressive models and the use of support vector regression in this model is explored. We illustrate the usefulness and interpretability of results by using electroencephalographic records of an epileptic patient.

Explicações de crianças internadas sobre a causa das doenças: implicações para a comunicação profissional de saúde-paciente

Esta pesquisa pretendeu estudar o desenvolvimento cognitivo e as explicações sobre a causalidade das doenças em crianças hospitalizadas, particularmente a influência nas explicações da experiência com doenças e da escolaridade. Participaram da pesquisa cinqûenta crianças brasileiras internadas em um hospital público, com diferentes diagnósticos e idade variando entre cinco e nove anos. O desenvolvimento cognitivo e as concepções sobre as causas das doenças foram avaliados dentro de um referencial piagetiano. Como em estudos anteriores, as crianças processaram as informações numa seqüência cognitiva previsível. Entretanto, as crianças internadas mostraram atraso na aquisição da conservação, e explicações com poucos elementos subjetivos, sem referências à própria doença. As causas atribuídas às doenças foram similares às apontadas por crianças de outros países. Foi estatisticamente significativa a relação entre a complexidade das explicações e o número de internações. A maioria da amostra, independente da idade e nível cognitivo, atribuiu o adoecimento à desobediência, possível mecanismo adaptativo ao desamparo, resultado que parece trazer implicações a serem consideradas quando se abordam pacientes infantis.

Committees for ethics in research involving human subjects

In Brazil since October 1996 there have been guidelines for research involving human subjects. Now human subjects know when their treatment is part of research. Deceit is no longer tolerated. But is not enough to say we offer an explanation to the potential subject and we offer a choice before he or she is confronted with an informed consent form. As in all professional activity, scientific investigation needs social controls. In Brazil, the ultimate responsibility of an investigation lies on the investigator, but in every institution where research is carried out there is a Committee for Ethics in Research. All Committees are subordinated to the National Commission of Ethics in Research, which is submitted to the Brazilian Institute of Health. During 2005 around 17,000 protocols involving 700,000 human subjects were revised by 475 Committees distributed all over the country. Approximately 7,000 people are now working in these Committees.

Um dizer que fala de vida e morte: revelações e silêncios na comunicação sobre o diagnóstico do câncer

Um dos problemas enfrentados pelos médicos na assistência a doentes com câncer refere-se aos dilemas relacionados à comunicação sobre a doença, especialmente pela associação ainda presente no imaginário social à idéia de morte e sofrimento, conferindo ao diagnóstico uma importante dimensão simbólica. Interpretado como uma construção social, o tema do diagnóstico do câncer é analisado com base na experiência de médicos que atuam no Hospital Ophir Loyola (PA), referência estadual no tratamento do câncer, compreendendo um total de 20 informantes, que concordaram em participar de entrevistas cujo enfoque era a comunicação sobre o diagnóstico, incluindo o enunciado inicial da doença e as informações dele derivadas. Por meio de uma abordagem sócio-antropológica, são analisadas diferentes variáveis, do doente, do médico, da família e da doença, incluindo algumas particularidades referentes aos contextos público e privado. Os dados sugerem que a relação do médico com o doente é influenciada pela condição de classe, com determinantes sócio-históricos e culturais, que tornam a comunicação um fenômeno complexo, agravado pelo limitado acesso aos serviços de saúde, contribuindo para que grande parte dos doentes já cheguem ao Hospital sem possibilidade de cura. Os resultados obtidos evidenciaram que, na realidade pesquisada, a influência da família no processo de decisão foi relevante para determinar os limites entre o dizer e o não dizer sobre a doença, incluindo o enunciado do diagnóstico e do prognóstico. A perda da esperança foi freqüentemente citada como um requisito para a não divulgação de informações, especialmente nos casos em que a doença está em uma fase avançada, havendo um maior silenciamento à medida que a doença progride.