Has telemedicine come to fruition? Parents' and pediatricians' perceptions and preferences regarding telemedicine.

BACKGROUND: Telemedicine has increasingly become a viable option for patient care and may increase access to care. The aim of our study was to evaluate both parent and pediatrician perceptions, preferences, and acceptability regarding the use of different telemedicine modalities. METHODS: We conducted a cross-sectional survey of both parents and pediatricians in Geneva, Switzerland in 2021. The questionnaire focused on digital literacy, preferences, acceptability, advantages, and disadvantages regarding telemedicine (phone, email, video, and instant message). Descriptive statistics and comparisons of preferences and perceptions (Pearson Chi2 and logistic regression) were performed. RESULTS: Two hundred and twenty-two parents and 45 pediatricians participated. After face-to-face consultations, parents and pediatricians preferred the phone for simple medical advice, discussion of parameters, acute or chronic problems, and psychological support. Email was preferred for communication of results and prescription renewal. Main reasons for using telemedicine were avoiding travel and saving time. Disadvantages were lack of physical examination, technical problems, and unsuitability of the reason for consultation. CONCLUSIONS: Understanding the factors that influence acceptance and satisfaction with telemedicine is vital for its successful implementation. Convenience, quality of care, trust, strong pediatrician-parent relationships, technical reliability, user-friendliness, and privacy considerations play significant roles in shaping parent and pediatrician attitudes toward telemedicine. IMPACT: The COVID-19 pandemic spurred the expansion of the use of telemedicine in pediatric care. Few studies have addressed parent and pediatrician perceptions and preferences regarding telemedicine. Both parents and pediatricians consider certain telemedicine modalities (phone, email, video, and instant message) pertinent in only specific clinical situations. Advantages of telemedicine outweigh disadvantages with parents and pediatricians appreciating the increased access to care, time savings, and avoiding transport. However, the lack of a physical examination remains a significant disadvantage. Convenience, quality of care, trust, strong pediatrician-parent relationship, technical reliability, user-friendliness, and privacy considerations play significant roles in shaping attitudes towards telemedicine.

A gender biased hidden curriculum of clinical vignettes in undergraduate medical training.

OBJECTIVES: Medical education relies extensively on clinical vignettes, yet little attention has been given to what hidden curriculum they might convey. Our research aimed to identify whether the clinical vignettes used in pre-graduate medical education transmit gender stereotypes or gender biases. METHODS: We conducted a mixed quantitative and qualitative analysis of gender-related characteristics currently existing in clinical vignettes used for pre-graduate teaching and evaluation at the Geneva Faculty of Medicine. RESULTS: 2359 vignettes were identified, of which 955 met inclusion criteria. Patients' professions and family caregiver roles showed a strongly gendered distribution, as did the healthcare professions where male physicians and female nurses were the norm. Qualitative results identified widespread stereotyped gender roles and gender expression. CONCLUSION: Our study reveals that the clinical vignettes used in education and evaluation materials in pre-graduate medical education in Geneva convey a gender-biased hidden curriculum, which could negatively impact patient care and undermine equal opportunity for men and women. PRACTICE IMPLICATIONS: Active revision of the content and the form of clinical vignettes used in undergraduate medical education is needed using a gender lens. Based on rare gender neutral or gender transformative examples from our study, we propose guidelines for writing non-gender-biased vignettes.

Patients preferences for communication during video consultations.

Objective The aim of our simulation-based study was to explore patient preferences for physician behaviours in video consultations METHODS: We conducted an exploratory study in outpatient setting in Geneva, Switzerland.Patients were invited to watch two variations videos of six simulated physician communication behaviours (camera framing, gaze orientation, initial talk at the opening phase, privacy reminder, pauses, empathy)and to indicate which one they preferred RESULTS: 417 patients watched three different video-recorded encounters. Most patients preferred framing with both face and bust (50.7 %) versus face alone (21.8 %). They valued eye gazing towards the camera (42.9 %) versus eye gazing shifting between screen and camera (13 %). The social talk related to the connection quality was appreciated (43.1 % vs 17.1 %) as well as the privacy reminder (80.8 % vs 6.5 %). Patients preferred short rather than long pauses after physician's statements (63.9 vs 14.9 %) as well as expressive rather than neutral nonverbal behaviour (46.7 % vs 17.6 %). CONCLUSION: Our results confirm that patients prefer the use of video specific communication behaviours recommended by experts except for shifting eye gaze and long pauses after physician's statements. PRACTICE IMPLICATIONS: Given the increasing use of video consultations, video communication "best practices"should be systematically addressed in physician training.

Impact of Confinement in Patients under Long-Term Noninvasive Ventilation during the First Wave of the SARS-CoV-2 Pandemic: A Remarkable Resilience.

BACKGROUND: During the first wave of the SARS-CoV-2 pandemic in Switzerland, confinement was imposed to limit transmission and protect vulnerable persons. These measures may have had a negative impact on perceived quality of care and symptoms in patients with chronic disorders. OBJECTIVES: To determine whether patients under long-term home noninvasive ventilation (LTHNIV) for chronic respiratory failure (CRF) were negatively affected by the 56-day confinement (March-April 2020). METHODS: A questionnaire-based survey exploring mood disturbances (HAD), symptom scores related to NIV (S3-NIV), and perception of health-care providers during confinement was sent to all patients under LTHNIV followed up by our center. Symptom scores and data obtained by ventilator software were compared between confinement and the 56 days prior to confinement. RESULTS: Of a total of 100 eligible patients, 66 were included (median age: 66 years [IQR: 53-74]): 35 (53%) with restrictive lung disorders, 20 (30%) with OHS or SRBD, and 11 (17%) with COPD or overlap syndrome. Prevalence of anxiety (n = 7; 11%) and depressive (n = 2; 3%) disorders was remarkably low. Symptom scores were slightly higher during confinement although this difference was not clinically relevant. Technical data regarding ventilation, including compliance, did not change. Patients complained of isolation and lack of social contact. They felt supported by their relatives and caregivers but complained of the lack of regular contact and information by health-care professionals. CONCLUSIONS: Patients under LTHNIV for CRF showed a remarkable resilience during the SARS-CoV-2 confinement period. Comments provided may be helpful for managing similar future health-care crises.

[Medical consult before taking a plane: assessment and advice by the primary care physician]. / Consultation avant de prendre l'avion: evaluation et conseils par le médecin de premier recours.

Many of our patients travel by air. During the flight, they are exposed to specific physical conditions: decrease of the PaO2, increase of body gas volume and decrease in humidity. Depending on their illness, their tolerance to these conditions may vary. The primary care physician's role is to adequately counsel patients in order to ensure their security during and after the flight, as well as to prescribe additional therapies, when needed. Patients with a hypoxemic medical condition or patients that were recently operated deserve particular attention. Complications of common ear, nose and throat diseases should not be underestimated. Preventive recommendations for thromboembolic disease need to be addressed, while drug prophylaxis is not systematically recommended any more for patients with major thromboembolic risk factors.

Interpreter-mediated diabetes consultations: a qualitative analysis of physician communication practices.

BACKGROUND: Patient-provider communication, in particular physicians' ability to listen to their patients, and support them in making difficult lifestyle changes, is an essential component of effective diabetes care. Clinical communication around diabetes can be especially challenging when language barriers are present, and may contribute to poor diabetes management and outcomes. Clinicians need to be aware of and address potential communication difficulties associated with interpreter-mediated consultations. The purpose of our study was to explore how physicians communicate in interpreter-mediated consultations with diabetic patients, and how their communication behaviors may impact diabetes communication and care. METHOD: We analyzed transcripts from 8 audio recorded, outpatient consultations at the Basel University Hospital general medicine outpatient clinic involving Turkish-speaking patients, German-speaking physicians, and Turkish-German interpreters (both community interpreters and family members). RESULTS: Clinicians used closed questions when asking about symptoms and glucose control. When providing information and explanation, they spoke in long and complex speech turns. They often directed their speech to interpreters or became sidetracked by family members' questions or requests for information. Patients' participation in the consultation was minimal, and limited to brief answers to clinicians' questions. CONCLUSIONS: Clinicians need to be aware of common pitfalls that diminish patient-centeredness during interpreter-mediated consultations, and learn strategies to avoid them. Attention to established guidelines on triadic communication is recommended, as is hands-on training with interpreters.

Text-messaging versus telephone reminders to reduce missed appointments in an academic primary care clinic: a randomized controlled trial.

BACKGROUND: Telephone or text-message reminders have been shown to significantly reduce the rate of missed appointments in different medical settings. Since text-messaging is less resource-demanding, we tested the hypothesis that text-message reminders would be as effective as telephone reminders in an academic primary care clinic. METHODS: A randomized controlled non-inferiority trial was conducted in the academic primary care division of the Geneva University Hospitals between November 2010 and April 2011. Patients registered for an appointment at the clinic, and for whom a cell phone number was available, were randomly selected to receive a text-message or a telephone call reminder 24 hours before the planned appointment. Patients were included each time they had an appointment. The main outcome was the rate of unexplained missed appointments. Appointments were not missed if they were cancelled or re-scheduled before or independently from the intervention. We defined non-inferiority as a difference below 2% in the rate of missed appointments and powered the study accordingly. A satisfaction survey was conducted among a random sample of 900 patients (response rate 41%). RESULTS: 6450 patients were included, 3285 in the text-message group and 3165 in the telephone group. The rate of missed appointments was similar in the text-message group (11.7%, 95% CI: 10.6-12.8) and in the telephone group (10.2%, 95% CI: 9.2-11.3 p = 0.07). However, only text message reminders were cost-effective. No patient reported any disturbance by any type of reminder in the satisfaction survey. Three quarters of surveyed patients recommended its regular implementation in the clinic. CONCLUSIONS: Text-message reminders are equivalent to telephone reminders in reducing the proportion of missed appointments in an academic primary care clinic and are more cost-effective. Both types of reminders are well accepted by patients.

[Prescription of physical therapy by the physician]. / Prescription de physiothérapie au cabinet médical.

The physical therapist is an essential actor of the medical management of patients with osteo-articular problems. After an initial evaluation, based on the information provided by the prescribing physician, he provides a "physiotherapeutic diagnosis" in terms of deficiency. He then proposes a number of passive and active techniques and may teach the patient exercises to practice at home. This article outlines prescription information for the physician, describes the main techniques used by the physical therapist and makes prescription recommendations for common osteo-articular problems.

[General internal medicine: important articles about ambulatory care published in 2010]. / Médecine interne générale: articles importants pour la pratique ambulatoire en 2010.

This review of articles published in 2010 covers the new role of dabigatran in atrial fibrillation, the lack of efficacy on pain of chondroïtine/ glucosamine in knee arthrosis, the risk of thrombosis with antipsychotics, the increase cardiovascular risk in case of migraine with aura and the insufficient prescription of adjuvant chemotherapy in elderly with colon cancer. Authors also highlight public health topics such as the association of poor oral hygiene and increased cardiovascular risk, the positive effect of opioid substitution therapy by primary care practitioners on mortality, the high frequency of prenatal violence on pregnant women and the negative impact of financial constraint on the risk of hospitalization.

Reduction of missed appointments at an urban primary care clinic: a randomised controlled study.

BACKGROUND: Missed appointments are known to interfere with appropriate care and to misspend medical and administrative resources. The aim of this study was to test the effectiveness of a sequential intervention reminding patients of their upcoming appointment and to identify the profile of patients missing their appointments. METHODS: We conducted a randomised controlled study in an urban primary care clinic at the Geneva University Hospitals serving a majority of vulnerable patients. All patients booked in a primary care or HIV clinic at the Geneva University Hospitals were sent a reminder 48 hrs prior to their appointment according to the following sequential intervention: 1. Phone call (fixed or mobile) reminder; 2. If no phone response: a Short Message Service (SMS) reminder; 3. If no available mobile phone number: a postal reminder. The rate of missed appointment, the cost of the intervention, and the profile of patients missing their appointment were recorded. RESULTS: 2123 patients were included: 1052 in the intervention group, 1071 in the control group. Only 61.7% patients had a mobile phone recorded at the clinic. The sequential intervention significantly reduced the rate of missed appointments: 11.4% (n = 122) in the control group and 7.8% (n = 82) in the intervention group (p < 0.005), and allowed to reallocate 28% of cancelled appointments. It also proved to be cost effective in providing a total net benefit of 1846. - EUR/3 months. A satisfaction survey conducted with 241 patients showed that 93% of them were not bothered by the reminders and 78% considered them to be useful. By multivariate analysis, the following characteristics were significant predictors of missed appointments: younger age (OR per additional decade 0.82; CI 0.71-0.94), male gender (OR 1.72; CI 1.18-2.50), follow-up appointment >1 year (OR 2.2; CI: 1.15-4.2), substance abuse (2.09, CI 1.21-3.61), and being an asylum seeker (OR 2.73: CI 1.22-6.09). CONCLUSION: A practical reminder system can significantly increase patient attendance at medical outpatient clinics. An intervention focused on specific patient characteristics could further increase the effectiveness of appointment reminders.

Use of a computer-based simulated consultation tool to assess whether doctors explore sociocultural factors during patient evaluation.

RATIONALE, AIMS AND OBJECTIVES: The delivery of patient-centred care to diverse populations requires that doctors identify sociocultural factors that may affect care. We adapted a computer-based simulated consultation tool and tested its utility for assessing whether doctors explore sociocultural factors during a patient evaluation, and whether they include such information in their case conclusions and follow-up recommendations. METHODS: We developed two detailed patient 'stories' that involved sociocultural issues that doctors needed to identify and consider for adequate clinical management. They were incorporated into an existing 'Virtual Internet Patient Simulation' (VIPS) program designed to test clinical reasoning skills. Doctors and medical students (n = 618) were invited to access the program via Internet. For each consultation, participants were assigned a sociocultural score, corresponding to the number of sociocultural domains explored. Scores were then compared with subjective ratings of participants' performance by expert doctors. RESULTS: 118 respondents completed at least one virtual consultation (19%), 92 conducted both. The mean number of sociocultural dimensions explored by doctors (i.e. sociocultural score) was 3.9 (standard deviation 2.6) for case 1, and 5.2 (standard deviation 2.3) for case 2. The two sociocultural scores were moderately correlated (Spearman r = 0.65, P < 0.001). Sociocultural scores correlated positively with experts' subjective ratings of participants' performance (Spearman r = 0.84 for case 1 and 0.78 for case 2, both P < 0.001). CONCLUSIONS: The adapted computer-based simulated consultation tool provided a feasible means to assess doctors' exploration of sociocultural issues during a clinical evaluation. Further validation of this method should be conducted by comparing VIPS results with other skills assessment methods such as objective structured clinical examination or direct observation of clinical performance.

GPs' strategies in intercultural clinical encounters.

BACKGROUND: In North America and Europe, patients and physicians are increasingly likely to come from non-Western cultural backgrounds. The expectations of these patients may not match those of physicians. OBJECTIVE: To identify strategies used by GPs with patients from cultures other than their own. METHODS: We conducted a qualitative inductive study based on 25 semi-structured interviews with family physicians practising in Montreal, Canada. We elicited physicians' strategies when dealing with patients from a cultural background different from their own. We began by asking physicians to describe an encounter they found difficult and one they found easy. RESULTS: Physicians reported three types of strategies: (i) insistence on patient adaptation to local beliefs and behaviours; (ii) physician adaptation to what he or she assumed patients wanted; and (iii) negotiation of a mutually acceptable plan. Individual physicians did not adopt the same strategy in all situations. Their choice of strategy depended on the topic. When dealing with issues they felt deeply about, such as the autonomy of women, many physicians insisted on patient adaptation. Physicians used a patient-centred model of care, but had no framework to elicit information about patients' culture. CONCLUSIONS: A patient-centred model of care enables physicians to consult effectively despite a wide range of cultural differences between themselves and their patients. However, their lack of a conceptual framework for addressing cultural difference prevents systematic data collection and consideration of challenges to respect for individual autonomy. Physician training should include the provision of an explicit conceptual framework for approaching patients from a different culture.

Explaining medically unexplained symptoms.

Patients with medically unexplained symptoms comprise from 15% to 30% of all primary care consultations. Physicians often assume that psychological factors account for these symptoms, but current theories of psychogenic causation, somatization, and somatic amplification cannot fully account for common unexplained symptoms. Psychophysiological and sociophysiological models provide plausible medical explanations for most common somatic symptoms. Psychological explanations are often not communicated effectively, do not address patient concerns, and may lead patients to reject treatment or referral because of potential stigma. Across cultures, many systems of medicine provide sociosomatic explanations linking problems in family and community with bodily distress. Most patients, therefore, have culturally based explanations available for their symptoms. When the bodily nature and cultural meaning of their suffering is validated, most patients will acknowledge that stress, social conditions, and emotions have an effect on their physical condition. This provides an entree to applying the symptom-focused strategies of behavioural medicine to address the psychosocial factors that contribute to chronicity and disability.