[Sex and gender issues in the organisation of tomorrow's medicine]. / Enjeux de sexe et de genre dans l'organisation de la médecine de demain.

Medicine is evolving with increasing feminization and the rise of part-time work. Women now outnumber men among graduates but are underrepresented in leadership roles and in the highest-paid specialties. To meet these economic and organisational challenges, this article proposes a number of courses of action. In addition to an overall increase in the number of medical training places to compensate for retirement and the development of interprofessional integrated care structures, support for academic promotion and management positions for women, as well as an increase in the financial value of professional and non-remunerated activities, are all solutions to be considered. These changes will ensure that medicine is inclusive, efficient and of high quality.

La médecine évolue avec une féminisation croissante et l'émergence de nouveaux modes de travail. Les femmes sont majoritaires parmi les diplômé-es mais sous-représentées aux postes de cadres et dans les spécialités à plus haut revenus. Pour répondre à ces défis économiques et organisationnels, cet article propose des pistes d'actions. En plus d'une augmentation globale des places de formation médicale pour pallier les départs en retraite et du développement de structures interprofessionnelles de soins intégrés, un soutien aux promotions académiques et aux positions de cadres pour les femmes ainsi qu'une revalorisation financière des activités professionnelles et non rémunérées sont autant de solutions à envisager. Ces changements assureront une médecine inclusive, de plus grande efficience et de qualité.

[The prescription: messenger between the person, the doctor's office, the nursing and pharmacy teams]. / L'ordonnance : messager entre la personne, le cabinet médical, l'équipe infirmière et la pharmacie. Introduction à la collaboration interprofessionnelle.

Interprofessional collaboration is essential to enhance quality of care and patient safety. It is clearly defined and requires the following 6 competencies: role clarification, teamwork, interprofessional conflict resolution, collaborative leadership, interprofessional communication and patient/client/family/community-centered care. Through different variations of a clinical scenario in primary care, we propose to demonstrate the importance of putting these skills into practice and to analyze the opportunities to reflect on the different types of interprofessional interactions depending on the complexity of the situation.

La collaboration interprofessionnelle est essentielle pour renforcer la qualité des soins et la sécurité des patient-e-s. Elle est clairement définie et requiert les 6 compétences suivantes : la clarification des rôles et des besoins de chacun, le travail d'équipe, la résolution des conflits, le leadership collaboratif, la communication interprofessionnelle et les soins centrés sur la personne, ses proches et la communauté. À travers différentes variantes d'un scénario clinique en soins primaires, nous proposons de démontrer l'importance d'utiliser ces compétences et d'analyser les opportunités de réfléchir aux différents types d'interactions interprofessionnelles en fonction de la complexité de la situation.

Centre de santé de soins primaires : à quoi ressemblera-t-il dans le futur ?

Poussé par les besoins croissants des patient·e·s et l'augmentation des différents professionnel·le·s de la santé, le lieu de travail du monde ambulatoire doit évoluer. La pandémie a montré que la digitalisation des pratiques, avec toutes les questions que cette transformation soulève, est l'un des aspects du futur qui s'ouvre. Mais elle n'est de loin pas le seul enjeu du centre de santé de demain. Prévention et promotion de la santé, santé intégrative, social, économie, architecture, durabilité : les défis sont multiples. Pour les matérialiser, la Revue Médicale Suisse, en partenariat avec Unisanté, organise un concours avec une vingtaine de jeunes médecins et professionnel·le·s de la santé entourés de douze tuteur·trice·s pour imaginer le centre de santé de demain. Le résultat sera présenté dans un show-room de 200 m2 aux Assises de la médecine romande le 4 novembre 2021.

Sex/gender bias in the management of chest pain in ambulatory care.

OBJECTIVE: Cardiovascular diseases (CVD) are the main cause of death worldwide and despite a higher prevalence in men, mortality from CVD is higher among women. Few studies have assessed sex differences in chest pain management in ambulatory care. The objective of this post hoc analysis of data from a prospective cohort study was to assess sex differences in the management of chest pain in ambulatory care. SETTING: We used data from the Thoracic Pain in Community cohort study that was realized in 58 primary care practices and one university ambulatory clinic in Switzerland. PARTICIPANTS: In total, 672 consecutive patients aged over 16 years attending a primary care practice or ambulatory care clinic with a complaint of chest pain were included between February and June 2001. Their mean age was 55.2 years and 52.5% were women. MAIN OUTCOME MEASURES: The main outcome was the proportion of patients referred to a cardiologist at 12 months follow-up. A panel of primary care physicians assessed the final diagnosis retained for chest pain at 12 months. RESULTS: The prevalence of chest pain of cardiovascular origin (n = 108, 16.1%) was similar for men and women (17.5% vs 14.8%, respectively, p = 0.4). Men with chest pain were 2.5 times more likely to be referred to a cardiologist than women (16.6% vs 7.4%, odds ratio: 2.49, 95% confidence interval: 1.52-4.09). After adjustment for the patients' age and cardiovascular disease risk factors, the estimates did not significantly change (odds ratio: 2.30, 95% confidence interval: 1.30-3.78). CONCLUSION: Although the same proportion of women and men present with a chest pain of cardiovascular origin in ambulatory care, there is a strong sex bias in their management. These data suggest that effort must be made to assure equity between men and women in medical care.

Patient-Centeredness as Physician Behavioral Adaptability to Patient Preferences.

A physician who communicates in a patient-centered way is a physician who adapts his or her communication style to what each patient needs. In order to do so, the physician has to (1) accurately assess each patient's states and traits (interpersonal accuracy) and (2) possess a behavioral repertoire to choose from in order to actually adapt his or her behavior to different patients (behavioral adaptability). Physician behavioral adaptability describes the change in verbal or nonverbal behavior a physician shows when interacting with patients who have different preferences in terms of how the physician should interact with them. We hypothesized that physician behavioral adaptability to their patients' preferences would lead to better patient outcomes and that physician interpersonal accuracy was positively related to behavioral adaptability. To test these hypotheses, we recruited 61 physicians who completed an interpersonal accuracy test before being videotaped during four consultations with different patients. The 244 participating patients indicated their preferences for their physician's interaction style prior to the consultation and filled in a consultation outcomes questionnaire directly after the consultation. We coded the physician's verbal and nonverbal behavior for each of the consultations and compared it to the patients' preferences to obtain a measure of physician behavioral adaptability. Results partially confirmed our hypotheses in that female physicians who adapted their nonverbal (but not their verbal) behavior had patients who reported more positive consultation outcomes. Moreover, the more female physicians were accurate interpersonally, the more they showed verbal and nonverbal behavioral adaptability. For male physicians, more interpersonal accuracy was linked to less nonverbal adaptability.

[Gender and disparities: the example of tobacco smoking]. / Genre et disparités: l'exemple du tabagisme.

Smoking prevalence is globally five times higher among men compared to women but this gap tends to decrease. Regarding health consequences of smoking, women tend to be more vulnerable than men. They are namely more at risk to present certain lung cancers and die of cardiovascular disease. While men are less prone to seek help for smoking cessation, women are less successful in their quit attempts and smoking cessation treatments are less effective among them. Interventions for smoking cessation and preventive measures tailored to gender specificities have the potential to improve management of smokers and decrease gender disparities in healthcare.

Finding the right interactional temperature: do colder patients need more warmth in physician communication style?

Being aware of which communication style should be adopted when facing more difficult patients is important for physicians; it can help prevent patient reactions of dissatisfaction, mistrust, or non-adherence that can be detrimental to the process of care. Past research suggests that less agreeable patients are especially critical towards, and reactive to, their physician's communication style, compared to more agreeable patients. On the basis of the literature, we hypothesized that less agreeable patients would react more negatively than agreeable patients to lower levels of affiliativeness (i.e., warmth, friendliness) in the physicians, in terms of satisfaction with the physician, trust in the physician, and determination to adhere to the treatment. Thirty-six general practitioners (20 men/16 women) working in their own practice in Switzerland were filmed while interacting with 69 patients (36 men/33 women) of different ages (M = 50.7; SD = 18.19; range: 18-84) and presenting different medical problems (e.g., back pain, asthma, hypertension, diabetes). After the medical interview, patients filled in questionnaires measuring their satisfaction with the physician, their trust in the physician, their determination to adhere to the treatment, and their trait of agreeableness. Physician affiliativeness was coded on the basis of the video recordings. Physician gender and dominance, patient gender and age, as well as the gravity of the patient's medical condition were introduced as control variables in the analysis. Results confirmed our hypothesis for satisfaction and trust, but not for adherence; less agreeable patients reacted more negatively (in terms of satisfaction and trust) than agreeable patients to lower levels of affiliativeness in their physicians. This study suggests that physicians should be especially attentive to stay warm and friendly with people low in agreeableness because those patients' satisfaction and trust might be more easily lowered by a cold or distant physician communication style.

When physician-expressed uncertainty leads to patient dissatisfaction: a gender study.

CONTEXT: Communication guidelines often advise physicians to disclose to their patients medical uncertainty regarding the diagnosis, origin of the problem, and treatment. However, the effect of the expression of such uncertainty on patient outcomes (e.g. satisfaction) has produced conflicting results in the literature that indicate either no effect or a negative effect. The differences in the results of past studies may be explained by the fact that potential gender effects on the link between physician-expressed uncertainty and patient outcomes have not been investigated systematically. OBJECTIVES: On the basis of previous research documenting indications that patients may judge female physicians by more severe criteria than they do male physicians, and that men are more prejudiced than women towards women, we predicted that physician-expressed uncertainty would have more of a negative impact on patient satisfaction when the physician in question was female rather than male, and especially when the patient was a man. METHODS: We conducted two studies with complementary designs. Study 1 was a randomised controlled trial conducted in a simulated setting (120 analogue patients Analogue patients are healthy participants asked to put themselves in the shoes of real medical patients by imagining being the patients of physicians shown on videos); Study 2 was a field study conducted in real medical interviews (36 physicians, 69 patients). In Study 1, participants were presented with vignettes that varied in terms of the physician's gender and physician-expressed uncertainty (high versus low). In Study 2, physicians were filmed during real medical consultations and the level of uncertainty they expressed was coded by an independent rater according to the videos. In both studies, patient satisfaction was assessed using a questionnaire. RESULTS: The results confirmed that expressed uncertainty was negatively related to patient satisfaction only when the physician was a woman (Studies 1 and 2) and when the patient was a man (Study 2). CONCLUSIONS: We believe that patients have the right to be fully informed of any medical uncertainties. If our results are confirmed in further research, the question of import will refer not to whether female physicians should communicate uncertainty, but to how they should communicate it. For instance, if it proves true that uncertainty negatively impacts on (male) patients' satisfaction, female physicians might want to counterbalance this impact by emphasizing other communication skills.

[What shall I do with a patient with elevated liver tests?]. / Patient avec des tests hépatiques perturbés: que faire?

In this article you will find a short reminder on the lab tests of the hepatic function and of the hepatic diseases. It shall help treat a patient with elevated liver tests. We will distinguish between an elevation of the liver enzymes of more/equal 5x and less than 5x the norm. An elevation of more/equal 5x the norm of the liver enzymes requires a rapid work-up. When the elevation is less than 5x the norm, one can proceed in two steps. A life style modification can be proposed after excluding a viral hepatitis and a hemochromatosis. If the liver enzymes still remind elevated, rarer causes must be searched.

[Thoracic pain in primary care. Don't forget the patients without heart disease]. / Douteurs thoraciques en médecine ambulatoire. Sans oublier les patients qui n'ont "rien au coeur".

Thoracic pain in primary care. Don't forget the patients without heart disease Thoracic pain is a frequent medical complaint. Diagnostic and therapeutic guidelines have been developed and evaluated mostly in emergency and hospital settings. The primary care practitioner, as the emergency room doctor, has to identify quickly any severe condition needing urgent and highly specialized treatment. But in primary care, the process is not finished then! A patient with no vital and urgent problem still needs a diagnosis, information and adequate treatment. This review goes over the presentation of thoracic pain, the differential diagnoses and the challenge of treating such patients in ambulatory care.

A pair of monozygotic twins with anomalous pancreaticobiliary junction and pancreatitis.

The authors describe a pair of white 7-year-old monozygotic twin girls with the same anomaly of the pancreaticobiliary junction (APBJ), in whom the clinical presentation and disease evolution are slightly divergent. The pathogenesis and genetic control of the disease are discussed.