Reflexivity and positionality applied to medical practice: a study on implicit gender bias with medical students in a Swiss university.

BACKGROUND: An array of evidence shows how the presence of implicit bias in clinical encounters can negatively impact provider-patient communication, quality of care and ultimately contribute to health inequities. Reflexive practice has been explored as an approach to identify and address implicit bias in healthcare providers, including medical students. At the Lausanne School of Medicine, a clinically integrated module was introduced in 2019 to raise students' awareness of gender bias in medical practice using a reflexivity and positionality approach. The purpose of this study is to describe the gender bias that were identified by medical students, analysing their types, places and modes of emergence during a clinical encounter. It further explores how positionality supported students' reflection on the way in which social position modulates their relationship to patients. METHODS: As part of the teaching activity, medical students individually reflected on gender bias in a specific clinical encounter by answering questions in their electronic portfolio. The questionnaire included a section on positionality. We qualitatively analysed the students' assignments (n=76), applying a thematic analysis framework. RESULTS: Medical students identified and described gender biases occurring at different moments of the clinical encounter (anamnesis (i.e. patient history), physical exam, differential diagnosis, final management). They causally associated these biases with wider social phenomena such as the gendered division of labour or stereotypes around sexuality and gender. Analysing students' reflections on how their position influenced their relationship with patients, we found that the suggested exercise revealed a major contradiction in the process of medical enculturation: the injunction to be neutral and objective erases the social and cultural context of patients and impedes an understanding of gender bias. CONCLUSION: Gender biases are present in the different steps of a clinical consultation and are rooted in broader gendered social representations. We further conclude that the tension between a quest for objectivity and the reality of social encounters should be made explicit to students, because it is constitutive of medical practice.

Interventions for smoking cessation in hospitalised patients.

BACKGROUND: In 2020, 32.6% of the world's population used tobacco. Smoking contributes to many illnesses that require hospitalisation. A hospital admission may prompt a quit attempt. Initiating smoking cessation treatment, such as pharmacotherapy and/or counselling, in hospitals may be an effective preventive health strategy. Pharmacotherapies work to reduce withdrawal/craving and counselling provides behavioural skills for quitting smoking. This review updates the evidence on interventions for smoking cessation in hospitalised patients, to understand the most effective smoking cessation treatment methods for hospitalised smokers. OBJECTIVES: To assess the effects of any type of smoking cessation programme for patients admitted to an acute care hospital. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was 7 September 2022. SELECTION CRITERIA: We included randomised and quasi-randomised studies of behavioural, pharmacological or multicomponent interventions to help patients admitted to hospital quit. Interventions had to start in the hospital (including at discharge), and people had to have smoked within the last month. We excluded studies in psychiatric, substance and rehabilitation centres, as well as studies that did not measure abstinence at six months or longer. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcome was abstinence from smoking assessed at least six months after discharge or the start of the intervention. We used the most rigorous definition of abstinence, preferring biochemically-validated rates where reported. We used GRADE to assess the certainty of the evidence. MAIN RESULTS: We included 82 studies (74 RCTs) that included 42,273 participants in the review (71 studies, 37,237 participants included in the meta-analyses); 36 studies are new to this update. We rated 10 studies as being at low risk of bias overall (low risk in all domains assessed), 48 at high risk of bias overall (high risk in at least one domain), and the remaining 24 at unclear risk. Cessation counselling versus no counselling, grouped by intensity of intervention Hospitalised patients who received smoking cessation counselling that began in the hospital and continued for more than a month after discharge had higher quit rates than patients who received no counselling in the hospital or following hospitalisation (risk ratio (RR) 1.36, 95% confidence interval (CI) 1.24 to 1.49; 28 studies, 8234 participants; high-certainty evidence). In absolute terms, this might account for an additional 76 quitters in every 1000 participants (95% CI 51 to 103). The evidence was uncertain (very low-certainty) about the effects of counselling interventions of less intensity or shorter duration (in-hospital only counselling ≤ 15 minutes: RR 1.52, 95% CI 0.80 to 2.89; 2 studies, 1417 participants; and in-hospital contact plus follow-up counselling support for ≤ 1 month: RR 1.04, 95% CI 0.90 to 1.20; 7 studies, 4627 participants) versus no counselling. There was moderate-certainty evidence, limited by imprecision, that smoking cessation counselling for at least 15 minutes in the hospital without post-discharge support led to higher quit rates than no counselling in the hospital (RR 1.27, 95% CI 1.02 to 1.58; 12 studies, 4432 participants). Pharmacotherapy versus placebo or no pharmacotherapy Nicotine replacement therapy helped more patients to quit than placebo or no pharmacotherapy (RR 1.33, 95% CI 1.05 to 1.67; 8 studies, 3838 participants; high-certainty evidence). In absolute terms, this might equate to an additional 62 quitters per 1000 participants (95% CI 9 to 126). There was moderate-certainty evidence, limited by imprecision (as CI encompassed the possibility of no difference), that varenicline helped more hospitalised patients to quit than placebo or no pharmacotherapy (RR 1.29, 95% CI 0.96 to 1.75; 4 studies, 829 participants). Evidence for bupropion was low-certainty; the point estimate indicated a modest benefit at best, but CIs were wide and incorporated clinically significant harm and clinically significant benefit (RR 1.11, 95% CI 0.86 to 1.43, 4 studies, 872 participants). Hospital-only intervention versus intervention that continues after hospital discharge Patients offered both smoking cessation counselling and pharmacotherapy after discharge had higher quit rates than patients offered counselling in hospital but not offered post-discharge support (RR 1.23, 95% CI 1.09 to 1.38; 7 studies, 5610 participants; high-certainty evidence). In absolute terms, this might equate to an additional 34 quitters per 1000 participants (95% CI 13 to 55). Post-discharge interventions offering real-time counselling without pharmacotherapy (RR 1.23, 95% CI 0.95 to 1.60, 8 studies, 2299 participants; low certainty-evidence) and those offering unscheduled counselling without pharmacotherapy (RR 0.97, 95% CI 0.83 to 1.14; 2 studies, 1598 participants; very low-certainty evidence) may have little to no effect on quit rates compared to control. Telephone quitlines versus control To provide post-discharge support, hospitals may refer patients to community-based telephone quitlines. Both comparisons relating to these interventions had wide CIs encompassing both possible harm and possible benefit, and were judged to be of very low certainty due to imprecision, inconsistency, and risk of bias (post-discharge telephone counselling versus quitline referral: RR 1.23, 95% CI 1.00 to 1.51; 3 studies, 3260 participants; quitline referral versus control: RR 1.17, 95% CI 0.70 to 1.96; 2 studies, 1870 participants). AUTHORS' CONCLUSIONS: Offering hospitalised patients smoking cessation counselling beginning in hospital and continuing for over one month after discharge increases quit rates, compared to no hospital intervention. Counselling provided only in hospital, without post-discharge support, may have a modest impact on quit rates, but evidence is less certain. When all patients receive counselling in the hospital, high-certainty evidence indicates that providing both counselling and pharmacotherapy after discharge increases quit rates compared to no post-discharge intervention. Starting nicotine replacement or varenicline in hospitalised patients helps more patients to quit smoking than a placebo or no medication, though evidence for varenicline is only moderate-certainty due to imprecision. There is less evidence of benefit for bupropion in this setting. Some of our evidence was limited by imprecision (bupropion versus placebo and varenicline versus placebo), risk of bias, and inconsistency related to heterogeneity. Future research is needed to identify effective strategies to implement, disseminate, and sustain interventions, and to ensure cessation counselling and pharmacotherapy initiated in the hospital is sustained after discharge.

Gender Bias in AI's Perception of Cardiovascular Risk.

The study investigated gender bias in GPT-4's assessment of coronary artery disease risk by presenting identical clinical vignettes of men and women with and without psychiatric comorbidities. Results suggest that psychiatric conditions may influence GPT-4's coronary artery disease risk assessment among men and women.

[Gender bias in clinical management : what can we do ?] / Biais de genre dans la prise en charge médicale : que faire ?

Health data show that there are differences in clinical management based on gender. One hypothesis is that these differences in management are not intentional discrimination but are the result of implicit and unconscious biases on the part of healthcare providers. These biases influence the clinical reasoning and practice of providers. This article, using clinical examples, illustrates how reflective practice is integrated into medical teaching in Lausanne to enable students to identify their biases, control them and ensure fair and relevant care. Students are also prompted to reflect on their social positionality, as thematising the power dynamics around knowledge and social interactions helps to better understand and prepare for medical practice.

Les données en santé font état de différences de traitement médical en fonction du genre. L'une des hypothèses est que ces différences de traitement ne sont pas des discriminations intentionnelles, mais relèvent de biais implicites et inconscients des soignant-e-s. Ces biais ont une influence sur les raisonnements et la pratique clinique des soignant-e-s. Cet article, à l'aide d'exemples cliniques, illustre comment la pratique réflexive est intégrée à l'enseignement en médecine à Lausanne afin de permettre aux étudiant-e-s d'identifier leurs biais, de les contrôler et d'assurer des soins équitables et pertinents. Il est également proposé aux étudiant-e-s de réfléchir à leur positionnement social, car thématiser les dynamiques de pouvoir autour des savoirs et des interactions sociales permet de mieux comprendre et préparer la pratique médicale.

[Autistic spectrum disorder in women : how does gender operate?] / Trouble du spectre de l'autisme au féminin : comment le genre opère-t-il ?

Autism spectrum disorder (ASD) is a common neurodevelopmental disorder, that affects both pediatric and adult populations and presents heterogeneously. The understanding of the clinical characteristics of ASD has expanded, in parallel with societal developments, including the integration of the notion of gender in medicine. It appears that individuals affected by this disorder, regardless of their age, are neither detected, diagnosed, nor followed or treated in the same manner depending on their gender. This article proposes to review current knowledge on ASD, its expression based on gender, factors influencing care, and the consequences for patients of exposure to gender bias.

Le trouble du spectre de l'autisme (TSA) est un trouble neurodéveloppemental fréquent. Il touche la population pédiatrique et adulte et se présente de manière hétérogène. La compréhension des caractéristiques clinique du TSA s'est étendue, en parallèle des évolutions sociétales, dont l'intégration de la notion de genre en médecine. Il apparaît que les personnes touchées par ce trouble, quel que soit leur âge, ne sont ni détectées, diagnostiquées, suivies ou traitées de manière identique selon leur genre. Cet article reprend les connaissances actuelles de l'expression du TSA en fonction du genre, et les conséquences pour les patient-e-s de l'exposition aux biais de genre.

Gender Inequalities in Citations of Articles Published in High-Impact General Medical Journals: a Cross-Sectional Study.

BACKGROUND: Besides the number of publications, the number of citations is another key metric often used to compare researchers with each other. While women researchers tend to have fewer publications than their men colleagues, the data is scarce for the number of citations. We aimed to determine whether there is a gender gap in citations. METHODS: We used Web of Science to retrieve the number of citations per year for all research articles and reviews published between January 2015 and December 2019 in fourteen high-impact general medical journals (impact factor > 5). We used Gender API to identify the gender of the first/last authors. We compared the results by gender using multivariable negative binomial regressions (adjusting for intra-cluster correlations within journals). RESULTS: The gender of the first/last author was determined for 13,218/13,350 (99%) and 11,894/12,026 (99%) articles, respectively. The proportion of women among first/last authors was 40% and 29%, respectively. The median number of citations per year was 5 (IQR = 11.3) for women and 6.8 (IQR = 17.8) for men for first authors (IRR = 1.5 [95% CI = 1.3-1.8], p value < 0.001), and 6 (IQR = 12.4) and 7.5 (IQR = 17.4) for last authors (IRR = 1.3 [95% CI = 1.2-1.5], p value < 0.001). Articles whose first and last authors were women were the least cited and those whose first and last authors were men were the most cited. CONCLUSION: In this cross-sectional study, we found that articles authored by women were cited less often than those authored by men. Further studies are needed to explore the reasons for these gender differences in article citations.

Smoking Cessation in People With and Without Diabetes After Acute Coronary Syndrome.

INTRODUCTION: People with diabetes smoke at similar rates as those without diabetes, with cardiovascular consequences. Smoking cessation rates were compared between people with and without diabetes 1 year after an acute coronary syndrome (ACS). AIMS AND METHODS: People with ACS who smoked and were part of an observational prospective multicenter study in Switzerland were included from 2007 to 2017 and followed for 12 months. Seven-day point prevalence abstinence was assessed at 12 months follow-up. Association between diabetes and smoking cessation was assessed using multivariable-adjusted logistical regression model. RESULTS: 2457 people with ACS who smoked were included, the mean age of 57 years old, 81.9% were men and 13.3% had diabetes. At 1 year, smoking cessation was 35.1% for people with diabetes and 42.6% for people without diabetes (P-value .01). After adjustment for age, sex, and educational level, people with diabetes who smoked were less likely to quit smoking compared with people without diabetes who smoked (odds ratio [OR] 0.76, 95% confidence interval [CI] 0.59-0.98, P-value = .037). The multivariable-adjusted model, with further adjustments for personal history of previous cardiovascular disease and cardiac rehabilitation attendance, attenuated this association (OR 0.85, 95% CI 0.65-1.12, P-value = .255). Among people with diabetes, cardiac rehabilitation attendance was a positive predictor of smoking cessation, and personal history of cardiovascular disease was a negative predictor of smoking cessation. CONCLUSIONS: People with diabetes who smoke are less likely to quit smoking after an ACS and need tailored secondary prevention programs. In this population, cardiac rehabilitation is associated with increased smoking cessation. IMPLICATIONS: This study provides new information on smoking cessation following ACSs comparing people with and without diabetes. After an ACS, people with diabetes who smoked were less likely to quit smoking than people without diabetes. Our findings highlight the importance of tailoring secondary prevention to people with diabetes.

Women Are Underrepresented Among Authors of Retracted Publications: Retrospective Study of 134 Medical Journals.

We examined the gender distribution of authors of retracted articles in 134 medical journals across 10 disciplines, compared it with the gender distribution of authors of all published articles, and found that women were underrepresented among authors of retracted articles, and, in particular, of articles retracted for misconduct.

Smoking cessation and depression after acute coronary syndrome.

Smoking and depression are risk factors for acute coronary syndrome (ACS) that often co-exist. We investigated the evolution of depression according to smoking cessation one-year after ACS. Data from 1822 ACS patients of the Swiss multicenter SPUM-ACS cohort study were analyzed over a one-year follow-up. Participants were classified in three groups based on smoking status one-year post-ACS - continuous smokers, smokers who quit within the year, and non-smokers. Depression status at baseline and one-year was assessed with the Center for Epidemiologic Studies Depression scale (CES-D) and antidepressant drug use. A CES-D score ≥ 16 defined depression. A multivariate-adjusted logistic regression model was used to calculate odds ratios (OR) between groups. The study sample mean age was 62.4 years and females represented 20.8%. At baseline, 22.6% were depressed, 40.9% were smokers, and 47.5% of these quit smoking over the year post-ACS. In comparison to depressed continuous smokers, depressed smokers who quit had an adjusted OR 2.59 (95% confidence interval (CI) 1.27-5.25) of going below a CES-D score of 16 or not using antidepressants. New depression at one-year was found in 24.4% of non-depressed smokers who quit, and in 27.1% of non-depressed continuous smokers, with an adjusted OR 0.85 (95% CI 0.55-1.29) of moving to a CES-D score of ≥16 or using antidepressants. In conclusion, smokers with depression at time of ACS who quit smoking improved their depression more frequently compared to continuous smokers. The incidence of new depression among smokers who quit after ACS was similar compared to continuous smokers.

Cigarette smoking during pregnancy and adverse perinatal outcomes: a cross-sectional study over 10 years.

BACKGROUND: It has been shown that active exposure to tobacco is associated with adverse pregnancy outcomes including, but not limited to, intrauterine fetal death, reduced fetal weight, and higher risk of preterm birth. We want to investigate these effects in a high-income country. METHODS: This cross-sectional study examined 20,843 pregnant women who delivered over 10 years at the Maternity Hospital of the Centre Hospitalier Universitaire Vaudois (CHUV) in Lausanne, Switzerland. The objective was to evaluate a dose-response relationship between daily cigarette use during pregnancy and possible adverse perinatal outcomes. The social and clinical characteristics as well as obstetric and neonatal outcomes were compared between the smoking and the non-smoking groups. Adjusted odds ratios (aOR) and trend analyses (ptrend) were calculated. RESULTS: Nineteen thousand five hundred fifty-four pregnant women met the inclusion criteria and 2,714 (13.9%) of them were smokers. Even after adjusting for confounding factors, smoking during pregnancy was associated with preterm birth, birthweight < 2500 g, intrauterine growth restriction, neonatal respiratory and gastrointestinal diseases, transfer to the neonatal intensive care unit, and neonatal intensive care unit admissions > 7 days. Intrauterine death and neonatal infection were associated with heavy smoking (≥ 20 cigarettes/day). Smoking appeared to be a protective factor for pre-eclampsia and umbilical cord arterial pH below 7.1. A significant trend (ptrend < 0.05) was identified for preterm birth, intrauterine growth restriction, birthweight < 2500 g, umbilical cord arterial pH below 7.1, transfers to our neonatal intensive care unit, and neonatal intensive care unit admissions more than 7 days. CONCLUSION: Cigarette smoking is associated with several adverse perinatal outcomes of pregnancy with a dose-dependent effect.

[Protection of pregnant and breastfeeding workers in Switzerland: a practical guide]. / Protection des travailleuses enceintes et allaitantes en Suisse : guide pratique.

Specific working conditions may endanger pregnant women's and their children's health. Switzerland has specific legislation for the protection of pregnant and breastfeeding employees. However, the implementation of these provisions presents important shortcomings. Attending physicians or gynaecologists-obstetricians who care for pregnant women have a central role in controlling the efficacy of protective measures put in place for their patients at work. What are the occupational exposures at risk and their health impact ? What are the collaboration with the different actors involved in the protection of maternity at work ? What steps should be taken if occupational dangers are identified? What tools can be used ? This article answers and explore these questions.

Certaines conditions de travail peuvent nuire à la santé des femmes enceintes et de leurs enfants. La Suisse dispose d'une législation spécifique pour la protection des employées enceintes et allaitantes. Or, l'application de ces dispositions est lacunaire. Les médecins traitants ou les gynécologues-obstétriciens qui suivent des femmes enceintes ont un rôle central dans le contrôle d'efficacité des mesures de protection prises pour leurs patientes au travail. Quels sont les expositions professionnelles à risque et leur impact sanitaire ? Quelles sont les collaborations avec les différents acteurs impliqués dans la protection de la maternité au travail ? Quelles démarches entreprendre en cas d'identification de dangers ? Quels outils peuvent être utilisés ? Cet article permet de répondre à ces questions et de les approfondir.

[Gender integration in the pregraduate medical curricula: now and then - pedagogic prospects]. / Intégrer le genre dans l'enseignement médical prégradué : actualités et perspectives pédagogiques.

Since a decade, the medical school of Lausanne, Switzerland, develops via the Gender and Medicine Unit a gender integration project in the pregraduate curricula through gender specific lessons and a transversal integration in pertinent disciplines. This article aims to present its progresses and to elaborate some future prospects.

Depuis une dizaine d'années, l'École de médecine de Lausanne développe un projet d'intégration du genre dans le cursus prégradué. L'Unité médecine et genre guide la création de cours spécifiques ainsi qu'une intégration transversale du genre dans les disciplines médicales pertinentes. Cet article a pour but de présenter l'avancée du projet et d'élaborer quelques perspectives d'avenir.

[Covid-19: how the pandemic revealed gender inequalities]. / Covid-19 : dans le genre on peut faire mieux !

The SARS-CoV-2 pandemic has revealed inequalities between men and women and has deepened some existing disparities. While in Switzerland, more women than men have been infected, men have been at greater risk of developing complications and dying. A weaker immune response and more co-morbidities help to explain this poorer prognosis. Socially and economically, women have become more precarious as a result of less stable employment and greater involvement in domestic work. Domestic violence has increased and women's access to sexual and reproductive health services has become more difficult. Finally, women have been under-represented as research authors but also among experts in task forces and media.

La pandémie liée au SARS-CoV-2 a révélé des inégalités entre les hommes et les femmes et a creusé certaines disparités existantes. Si en Suisse les femmes sont plus nombreuses à avoir été infectées que les hommes, ces derniers ont eu un plus grand risque de décéder. Une réponse immunitaire moins performante et davantage de comorbidités contribuent à expliquer ce pronostic défavorable. Sur le plan social et économique, les femmes ont été davantage précarisées du fait d'emplois moins stables et d'une plus grande implication dans les tâches domestiques. La violence domestique a augmenté et l'accès des femmes aux services de santé sexuelle et reproductive a été plus difficile. Finalement, les femmes ont été sous-représentées comme autrices dans la recherche mais également parmi les expert·e·s dans les task forces et les médias.

[Gender in medicine: what contribution to medical practice? Eight selected narratives]. / Le genre en médecine : quels apports pour la pratique ? Huit témoignages choisis.

In this article, we report abstracts of eight interviews, showing how clinicians use their interest in gender in their everyday practice. Clinicians report that being acquainted with a person interested by the question of gender raises their own awareness about the subject. In practice, they notice biased acquisition of knowledge due to non-inclusion of gender in research on one hand, and influence of gender stereotypes on clinical care on the other hand. Gender also influenced carriers. Some interviewed clinicians expressed they wished for more training, to reduce inequalities attributable to gender.

Dans cet article, nous rapportons de brefs extraits de 8 entrevues avec des clinicien·ne·s sensibilisé·e·s au genre, dans le but d'illustrer comment un intérêt pour ce domaine peut influencer la pratique quotidienne. Les personnes interrogées expliquent que le fait d'avoir un·e proche intéressé·e au genre les a rendues attentives à ce sujet. Dans leur pratique, elles disent avoir conscience de biais liés, d'une part, à l'acquisition des connaissances médicales ne tenant pas compte du genre et, d'autre part, à des stéréotypes de genre menant à une pratique médicale inégalitaire. Le genre a aussi un effet sur leurs carrières. Certaines personnes interrogées souhaiteraient bénéficier de plus de formation afin de diminuer les inégalités dues au genre.

Gender awareness among medical students in a Swiss University.

BACKGROUND: Gender is an important social determinant, that influences healthcare. The lack of awareness on how gender influences health might lead to gender bias and can contribute to substandard patient care. Our objectives were to assess gender sensitivity and the presence of gender stereotypes among swiss medical students. METHODS: A validated scale (N-GAMS - Nijmegen Gender Awareness in Medicine Scale), with 3 subscores assessing gender sensitivity (GS) and gender stereotypes toward patients (GRIP) and doctors (GRID) (ranging from 1 to 5), was translated into French and was distributed to all medical students registered at the University of Lausanne, Switzerland in April-May 2017. Reliability of the three subscales was assessed calculating the alpha Cronbach coefficient. Mean subscales were calculated for male and female students and compared using two sample t-tests. A linear model was built with each subscale as a dependent variable and students' sex and age as covariables. RESULTS: In total, 396 students answered the N-GAMS questionnaire, their mean age was 22 years old, 62.6% of them were women. GS and GRID sub-scores were not significantly different between female and male students (GS 3.62 for women, 3.70 for men, p = 0.27, GRID 2.10 for women, 2.13 for men, p = 0.76). A statistically significant difference was found in the GRIP subscale, with a mean score of 1.83 for women and 2.07 for men (p < 0.001), which suggests a more gender stereotyped opinion toward patients among male students. A trend was observed with age, gender sensibility increased (p < 0.001) and stereotypes decreased (GRIP p = 0.04, GRID p = 0.02) with students getting older. CONCLUSION: Medical students' gender sensitivity seems to improve throughout the medical curriculum, and women students have less stereotypes towards patients than men do. The implementation of a gender-sensitive teaching in the medical curriculum could improve students' knowledge, limit gender bias and improve patients' care.

[Groin hernia in female patients: sex-specific management]. / Hernie inguino-fémorale chez les femmes†: spécificités de prise en charge.

Groin hernia in women is an entity whose clinical manifestations can be quite subtle, and which therefore risks to go unnoticed. Imaging studies by ultrasound or dynamic CT/MRI is strongly recommended in case of a clinical doubt. Optimal treatment consists of laparoscopic surgery, even in oligosymptomatic patients, because the risk of incarceration, and subsequent morbidity and mortality is high especially in cases of femoral hernia, which are frequent and often overlooked in women. During pregnancy, the risk of developing a groin hernia is very low (around 0,1%) and a wait-and-see attitude is to be preferred as much as possible, except in the case of an acute complication (incarceration).

Chez les femmes, la hernie du pli de l'aine est une entité dont les manifestations cliniques peuvent être subtiles, majorant son risque de passer inaperçue. Un bilan d'imagerie, par échographie, voire scanner ou imagerie par résonance magnétique dynamique, est fortement conseillé en cas de doute clinique. Le traitement optimal consiste en une chirurgie par abord laparoscopique, même chez les patientes oligosymptomatiques, car le risque d'incarcération et de morbimortalité est élevé, surtout en cas de hernie fémorale, fréquente et souvent méconnue chez les femmes. Durant la grossesse, le risque de développer une hernie de l'aine est très faible (de l'ordre de 0,1 %) et une attitude attentiste est à privilégier au maximum, sauf en cas de complication aiguë (incarcération).

[Reflexivity during medical internships†: how to think about gender in clinical practice]. / Pratique réflexive dans les cours-blocs de médecine ambulatoire ou comment penser le genre en clinique.

Gender bias in medicine negatively interfere with the medical care of both men and women, which can lead to risks for patients as well as health inequalities. Unisanté has launched a pilot project to integrate reflexivity by students at the Medical School of the University of Lausanne on the influence of gender in clinical practice, using an electronic portfolio. The clinical vignettes presented and discussed in this article illustrate this reflective work and the main biases and stereotypes encountered: pain management, assessment of the psychosocial context, management of domestic violence, screening for chlamydia infection and discussion of a contraceptive method.

Les biais de genre en médecine interfèrent négativement avec la prise en charge médicale tant des hommes que des femmes, ce qui peut entraîner des risques pour les patient·e·s et des inégalités de santé. Unisantéaa lancé un projet pilote visant à intégrer l'approche réflexive par les étudiant·e·s de l'École de médecine de l'Université de Lausanne (UNIL) sur l'influence du genre dans la pratique clinique, en utilisant un portfolio électronique. Les vignettes cliniques présentées et discutées dans cet article illustrent ce travail réflexif et les principaux biais et stéréotypes rencontrés : la prise en charge de la douleur, l'évaluation du contexte psychosocial, la prise en charge des violences au sein du couple, le dépistage d'une infection à Chlamydia ainsi que la discussion d'une méthode de contraception.

Biomedical risk assessment as an aid for smoking cessation.

BACKGROUND: A possible strategy for increasing smoking cessation rates could be to provide smokers with feedback on the current or potential future biomedical effects of smoking using, for example, measurement of exhaled carbon monoxide (CO), lung function, or genetic susceptibility to lung cancer or other diseases. OBJECTIVES: The main objective was to determine the efficacy of providing smokers with feedback on their exhaled CO measurement, spirometry results, atherosclerotic plaque imaging, and genetic susceptibility to smoking-related diseases in helping them to quit smoking. SEARCH METHODS: For the most recent update, we searched the Cochrane Tobacco Addiction Group Specialized Register in March 2018 and ClinicalTrials.gov and the WHO ICTRP in September 2018 for studies added since the last update in 2012. SELECTION CRITERIA: Inclusion criteria for the review were: a randomised controlled trial design; participants being current smokers; interventions based on a biomedical test to increase smoking cessation rates; control groups receiving all other components of intervention; and an outcome of smoking cessation rate at least six months after the start of the intervention. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We expressed results as a risk ratio (RR) for smoking cessation with 95% confidence intervals (CI). Where appropriate, we pooled studies using a Mantel-Haenszel random-effects method. MAIN RESULTS: We included 20 trials using a variety of biomedical tests interventions; one trial included two interventions, for a total of 21 interventions. We included a total of 9262 participants, all of whom were adult smokers. All studies included both men and women adult smokers at different stages of change and motivation for smoking cessation. We judged all but three studies to be at high or unclear risk of bias in at least one domain. We pooled trials in three categories according to the type of biofeedback provided: feedback on risk exposure (five studies); feedback on smoking-related disease risk (five studies); and feedback on smoking-related harm (11 studies). There was no evidence of increased cessation rates from feedback on risk exposure, consisting mainly of feedback on CO measurement, in five pooled trials (RR 1.00, 95% CI 0.83 to 1.21; I2 = 0%; n = 2368). Feedback on smoking-related disease risk, including four studies testing feedback on genetic markers for cancer risk and one study with feedback on genetic markers for risk of Crohn's disease, did not show a benefit in smoking cessation (RR 0.80, 95% CI 0.63 to 1.01; I2 = 0%; n = 2064). Feedback on smoking-related harm, including nine studies testing spirometry with or without feedback on lung age and two studies on feedback on carotid ultrasound, also did not show a benefit (RR 1.26, 95% CI 0.99 to 1.61; I2 = 34%; n = 3314). Only one study directly compared multiple forms of measurement with a single form of measurement, and did not detect a significant difference in effect between measurement of CO plus genetic susceptibility to lung cancer and measurement of CO only (RR 0.82, 95% CI 0.43 to 1.56; n = 189). AUTHORS' CONCLUSIONS: There is little evidence about the effects of biomedical risk assessment as an aid for smoking cessation. The most promising results relate to spirometry and carotid ultrasound, where moderate-certainty evidence, limited by imprecision and risk of bias, did not detect a statistically significant benefit, but confidence intervals very narrowly missed one, and the point estimate favoured the intervention. A sensitivity analysis removing those studies at high risk of bias did detect a benefit. Moderate-certainty evidence limited by risk of bias did not detect an effect of feedback on smoking exposure by CO monitoring. Low-certainty evidence, limited by risk of bias and imprecision, did not detect a benefit from feedback on smoking-related risk by genetic marker testing. There is insufficient evidence with which to evaluate the hypothesis that multiple types of assessment are more effective than single forms of assessment.

Weight gain after smoking cessation: more data to refute concerns.

Take home figure.

Modeling empathy as synchrony in clinician and patient vocally encoded emotional arousal: A failure to replicate.

Empathy is a well-defined active ingredient in clinical encounters. To measure empathy, the current gold standard is behavioral coding (i.e., trained coders attribute overall ratings of empathy to clinician behaviors within an encounter), which is labor intensive and subject to important reliability challenges. Recently, an alternative measurement has been proposed: capturing empathy as synchrony in vocally encoded arousal, which can be measured as the mean fundamental frequency of the voice (mean F0). This method has received preliminary support by one study (Imel, Barco, et al., 2014). We aimed to replicate this study by using 2 large samples of clinical interactions (alcohol brief motivational interventions with young adults, N = 208; general practice consultations, N = 204). Audio files were segmented to identify respective speakers and mean F0 was measured using speech signal processing software. All sessions were independently rated by behavioral coders using 2 validated empathy scales. Synchrony between clinician and patient F0 was analyzed using multivariate multilevel models and compared with high and low levels of empathy derived from behavioral coding. Findings showed no support for our hypothesis that mean F0 synchrony between clinicians and patients would be higher in high-empathy sessions. This lack of replication was consistent for both clinical samples, both behavioral coding instruments, and using measures of F0 synchrony occurring at both the session-level and minute-level. We considered differences in culture and language, patients' characteristics, and setting as explanations for this failure to replicate. Further replication testing and new developments regarding measurement methods and modeling are needed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).