Understanding the clinical reasoning processes involved in the management of multimorbidity in an ambulatory setting: study protocol of a stimulated recall research.

BACKGROUND: Primary care physicians are at the very heart of managing patients suffering from multimorbidity. However, several studies have highlighted that some physicians feel ill-equipped to manage these kinds of complex clinical situations. Few studies are available on the clinical reasoning processes at play during the long-term management and follow-up of patients suffering from multimorbidity. This study aims to contribute to a better understanding on how the clinical reasoning of primary care physicians is affected during follow-up consultations with these patients. METHODS: A qualitative research project based on semi-structured interviews with primary care physicians in an ambulatory setting will be carried out, using the video stimulated recall interview method. Participants will be filmed in their work environment during a standard consultation with a patient suffering from multimorbidity using a "button camera" (small camera) which will be pinned to their white coat. The recording will be used in a following semi-structured interview with physicians and the research team to instigate a stimulated recall. Stimulated recall is a research method that allows the investigation of cognitive processes by inviting participants to recall their concurrent thinking during an event when prompted by a video sequence recall. During this interview, participants will be prompted by different video sequence and asked to discuss them; the aim will be to encourage them to make their clinical reasoning processes explicit. Fifteen to twenty interviews are planned to reach data saturation. The interviews will be transcribed verbatim and data will be analysed according to a standard content analysis, using deductive and inductive approaches. CONCLUSION: Study results will contribute to the scientific community's overall understanding of clinical reasoning. This will subsequently allow future generation of primary care physicians to have access to more adequate trainings to manage patients suffering from multimorbidity in their practice. As a result, this will improve the quality of the patient's care and treatments.

Medical students as feedback assessors in a faculty development program: Implications for the future.

Background: Little is known about simulated students' ability in assessing feedback received in Objective Structured Teaching Encounters (OSTEs). We aimed to assess to which extent students' perceptions matched objective analysis regarding quality of received feedback, to explore what elements of feedback they emphasized and what they learned about feedback.Methods: In this mixed-method study, 43 medical students participated as simulated residents in five OSTEs at Geneva University Hospitals. They assessed quality of feedback from faculty using a 15-item questionnaire and gave written/oral comments. Videotaped feedbacks were assessed using an 18-item feedback scale. During four focus groups, 25 students were asked about what they learned as feedback assessors.Results: 453 students' questionnaires and feedback scale were compared. Correlations were moderate for stimulating self-assessment (0.48), giving a balanced feedback (0.44), checking understanding (0.47) or planning (0.43). Students' feedback emphasized elements such as faculty's empathy or ability to give concrete advice. They reported that being a feedback assessor helped them to realize importance of making the learner active and that giving effective feedback required structure and skills.Conclusion: Medical students may identify quality of feedback. Involving them in OSTEs could be interesting to train them to become valid raters of supervisors' teaching skills.

Interprofessional collaborative reasoning by residents and nurses in internal medicine: Evidence from a simulation study.

Clinical reasoning has been studied in residents or nurses, using interviews or patient-provider encounters. Despite a growing interest in interprofessional collaboration, the notion of collaborative reasoning has not been well studied in clinical settings. Our study aims at exploring resident-nurse collaborative reasoning in a simulation setting. We enrolled 14 resident-nurse teams from a general internal medicine division in a mixed methods study. Teams each managed one of four acute case scenarios, followed by a stimulated-recall session. A qualitative, inductive analysis of the transcripts identified five dimensions of collaborative reasoning: diagnostic reasoning, patient management, patient monitoring, communication with the patient, and team communication. Three investigators (two senior physicians, one nurse) assessed individual and team performances using a five-point Likert scale, and further extracted elements supporting the collaborative reasoning process. Global assessment of the resident-nurse team was not simply an average of individual performances. Qualitative results underlined the need to improve situational awareness, particularly for task overload. Team communication helped team members stay abreast of each other's thoughts and improve their efficiency. Residents and nurses differed in their reasoning processes, and awareness of this difference may contribute to improving interprofessional collaboration. Understanding collaborative reasoning can provide an additional dimension to interprofessional education.

[Generic and biosimilar drug substitution: a panacea?]. / Médicaments génériques et biosimilaires: une panacée?

Drugs are the third largest source of expenditure under Switzerland's compulsory basic health insurance. Generics, the price of which should be at least 30 per cent less than the cost of the original drugs, can potentially allow substantial savings. Their approval requires bioequivalence studies and their use is safe, although some factors may influence patients' and physicians' acceptance. The increased substitution of biosimilar drugs for more expensive biotech drugs should allow further cost savings. In an attempt to extend the monopoly granted by the original drug patent, some pharmaceutical companies implement "evergreening" strategies including small modifications of the original substance for which the clinical benefit is not always demonstrated.

[Enterococcal infections: from simple to most complex]. / Infections à entérocoques: du plus simple au plus complexe...

Enterococci are microorganisms with a remar- kable ability to adapt to their environment. Two species have a significant clinical implication, Enterococcus faecalis and Enterococcus faecium. The risk factors for colonization and infection must be recognized, including prior treatment with antibiotics such as cephalosporins or quinolones. Because of their native resistance to several classes of antibiotics and the increase of acquired resistance to penicillins, the initial empiric treatment of a severe infection in a patient at risk of enterococcal infection often includes a glycopeptide. A restriction in the empirical use of cephalosporins or quinolones and a targeted antibiotic therapy following receipt of the antibiogram are essential to prevent the emergence of enterococcal strains and especially vancomycin-resistant enterococci.

Association between burnout and stigma in physicians.

BACKGROUND: Physicians suffering from burnout are more likely to develop depression, substance dependence, and cardiovascular diseases, which can affect their practices. Stigmatization is a barrier to seeking treatment. This study aimed to understand the complex links between burnout among medical doctors and the perceived stigma. METHODS AND FINDINGS: Online questionnaires were sent to medical doctors working in five different departments of the Geneva University Hospital. The Maslach Burnout Inventory (MBI) was used to assess burnout. The Stigma of Occupational Stress Scale in Doctors (SOSS-D) was used to measure the three stigma dimensions. Three hundred and eight physicians participated in the survey (response rate: 34%). Physicians with burnout (47%) were more likely to hold stigmatized views. Emotional exhaustion was moderately correlated with perceived structural stigma (r = 0.37, P < .001) and weakly correlated with perceived stigma (r = 0.25, P = 0.011). Depersonalization was weakly correlated with personal stigma (r = 0.23, P = 0.04) and perceived other stigma (r = 0.25, P = 0.018). CONCLUSION: These results suggest the need to adjust for existing burnout and stigma management. Further research needs to be conducted on how high burnout and stigmatization impact collective burnout, stigmatization, and treatment delay.

[Antibiotic prophylaxis in liver cirrhosis]. / Antibioprophylaxie de la péritonite bactérienne spontanée.

Bacterial infections are frequent and severe complications in patients with cirrhosis. Spontaneous bacterial peritonitis (SBP) is the most common infection in such patients. The risk of recurrence at one year after a first episode of SBP is higher than 70% and hospital mortality is estimated between 30-50%. Therefore, there is growing interest in antibiotic prophylaxis (ATP) in these patients. Risk factors for the occurrence of SBP include low protein level in ascitis, a history of previous SBP and an episode of gastrointestinal bleeding. In all three situations, the indication of ATP, reviewed in this paper, is recognized and improves survival.

[Albumin infusion for paracentesis in patients with cirrhosis: dogma or evidence?]. / Administration d'albumine lors de paracentèse évacuatrice dans la cirrhose: dogme ou évidence?

Large-volume paracentesis is the procedure of choice for refractory or symptomatic ascitis. However, there is a risk for Post-paracentesis Circulatory Dysfunction (PCD) leading to hyponatremia, renal failure, or worsening portal hypertension. PCD may be effectively prevented by volume expanders, essentially albumin, administered during and after the procedure, but the data regarding the impact of this treatment on mortality are still limited. For this reason, there is a debate about the true clinical benefit of preventing PCD, explaining some variations among published guidelines. The efficacy of molecules other than albumin is still under study but none has shown real superiority so far.

[Critical pathway for community-acquired pneumonia]. / Itinéraire clinique et pneumonie acquise à domicile.

A clinical pathway is a methodological tool for standardizing medical practice, improving the quality and efficiency of care delivery, and enhancing the diffusion of evidence-based medicine. Despite the fact that a majority of trials have shown that the use of clinical pathways improves certain specific outcomes such as length of stay or complications, the overall impact of these pathways in the clinical setting has yet to be documented. In the setting of community-acquired pneumonia, a few observational and one large randomized trial have shown positive effects on various outcomes. We describe in this article the clinical pathway for community-acquired pneumonia developed at our institution.

Clinical supervisors' perceived needs for teaching communication skills in clinical practice.

BACKGROUND: Lack of faculty training is often cited as the main obstacle to post-graduate teaching in communication skills. AIMS: To explore clinical supervisors' needs and perceptions regarding their role as communication skills trainers. METHODS: Four focus group discussions were conducted with clinical supervisors from two in-patient and one out-patient medical services from the Geneva University Hospitals. Focus groups were audio taped, transcribed verbatim and analyzed in a thematic way using Maxqda software for qualitative data analysis. RESULTS: Clinical supervisors said that they frequently addressed communication issues with residents but tended to intervene as rescuers, clinicians or coaches rather than as formal instructors. They felt their own training did not prepare them to teach communication skills. Other barriers to teach communication skills include lack of time, competing demands, lack of interest and experience on the part of residents, and lack of institutional priority given to communication issues. Respondents expressed a desire for experiential and reflective training in a work-based setting and emphasised the need for a non-judgmental learning atmosphere. CONCLUSIONS: Results suggest that organisational priorities, culture and climate strongly influence the degree to which clinical supervisors may feel comfortable to teach communication skills to residents. Attention must be given to these contextual factors in the development of an effective communication skills teaching program for clinical supervisors.

[Update in hospital medicine 2008]. / Médecine interne hospitalière.

This paper summarizes several important studies published during the previous year that have an impact on the practice of inpatient internal medicine, because they either modify or reinforce current practices. The selected domains include cardiovascular disease, for example the management of hypertension in very old patients, the effects of blockade of the renin-angiotensin-aldosterone system, and the use of biomarkers in cardiology; neurovascular pathology, specifically the prognosis of transient ischemic attacks and some aspects of cardioembolic stroke due to atrial fibrillation. Other topics include pneumonia prognosis, the management of ascitis fluid or of septic shock, and methodology.

Influence of age on the cost-effectiveness of diagnostic strategies for suspected pulmonary embolism.

BACKGROUND: Age has a marked effect on the diagnostic yield of D-dimer measurement and lower limb compression ultrasonography (CUS) in patients with suspected pulmonary embolism (PE), suggesting that specific diagnostic strategies may be needed in elderly patients. OBJECTIVE: To evaluate the cost-effectiveness of including D-dimer and CUS in the workup of PE, with particular attention to patient age. SUBJECTS AND METHODS: We analyzed data from two recent outcome studies that enrolled 1721 consecutive outpatients with suspected PE. Both studies used a sequential diagnostic strategy that included assessment of clinical probability, D-dimer measurement, CUS, and helical computed tomography (hCT). A decision analysis model was created for analyzing cost-effectiveness according to six classes of age. The main outcome measures were 3-month quality-adjusted expected survival and costs per patient managed. RESULTS: All strategies were equally safe, with variations in the 3-month survival never exceeding 0.5% as compared to the most effective strategy. D-dimer measurement was highly cost-saving under the age of 80 years. Above 80 years, the cost-sparing effect of D-dimer was diminished, but not completely abolished. Inclusion of CUS increased the costs of diagnostic strategies irrespective of age. Results were unchanged over a wide range of the variables of interest (costs, sensitivity, and specificity of the tests). CONCLUSIONS: Diagnostic strategies using D-dimer are less expensive. The cost-sparing effect of D-dimer is reduced but not abolished above 80 years, suggesting that adapting specific diagnostic strategies in elderly outpatients is not mandatory. CUS is costly, and only marginally improves the safety of diagnostic strategies for PE.

[Update in hospital internal medicine 2006]. / Médecine interne hospitalière: nouveautés en 2006.

This paper summarizes several important studies published during the previous few years that have an impact on the practice of inpatient internal medicine, because they either modify or reinforce current practices. Selected domains include management of community-acquired pneumonia, diagnosis and treatment of stroke, diagnostic and therapeutic aspects in cardiology, an update on diagnostic strategies for pulmonary embolism and various therapeutic novelties.

Assessing clinical competence: a pilot project to evaluate the feasibility of a standardized patient -- based practical examination as a component of the Swiss certification process.

PURPOSE: advances in the assessment of clinical competence have prompted medical schools and licensing authorities to complement written and oral tests with practical ones. The purposes of this project were to (1) determine how clinical competencies not effectively addressed on the present Swiss federal examinations can be assessed adequately on a standardised patient-based practical examination (SCE) and (2) evaluate the SCE validity, reliability and feasibility. METHOD: a bilingual, three-hour standardised patient-based clinical examination was pilot tested in 2003 with 48 volunteered fifth and sixth-year students from the five Swiss medical schools. All students took the same eight 15-minute patient cases. To ensure the test content validity, test cases were selected by a multi-disciplinary and -institutional committee of clinical faculty on the basis of predefined exam blueprint criteria and in reference to the Swiss catalogue of learning objectives. RESULTS: moderate correlations between the SCE and the existing Federal final written examinations (0.46) and the newly pilot-tested structured oral examination or SOE (0.56) [3] suggested that they were complementary to one another and that each might emphasise aspects of the clinical competence which others might not. The reliability (a coefficient) of the SCE scores ranged from 0.73 to 0.77. CONCLUSIONS: limited experiences gathered throughout the SCE pilot project demonstrated its feasibility. Preliminary results suggested that SCE scores had a good level of construct validity and reliability and seemed to complement scores obtained on the final certification written examinations and the newly tested SOE. These results, however, need to be further confirmed with larger samples studies.

[Empiric therapy of community-acquired pneumonia: a transatlantic controversy]. / Antibiothérapie des pneumonies acquises à domicile--une controverse transatlantique.

North American and European guidelines for empiric antimicrobial therapy of community-acquired pneumonia differ. This stems from a different mechanism of pneumococcal resistance to macrolides, and a different perception of the need to cover atypical germs. For mild cases, two recent meta-analyses conclude that this coverage is not associated with any benefit. For more severe pneumonias, data are scarce and experts generally recommend wide coverage. Except for particular situations, the new fluoroquinolones should not represent the first-line therapy because of rapidly growing resistance to these antibiotics.

[Primary prevention of gastroduodenal ulcer: what is the evidence?]. / Prévention primaire de l'ulcère gastro-duodénal: quelles évidences?

Primary prevention of gastroduodenal ulcer and its major complication, gastrointestinal bleeding, has been studied mainly in the intensive care environment. Proton pump inhibitors (PPIs), H2-receptor antagonists and sucralfate have proved effective. By extension, PPIs are inappropriately prescribed in a variety of clinical situations. In contrast, they are probably underused in patients chronically treated by nonsteroidal anti-inflammatory drugs. This article reviews the situations in which an increased ulcer risk justifies primary prevention. Validated prophylactic options are also addressed.

[Leukotriene-modifiers in asthma treatment]. / Les antileucotriènes dans le traitement de l'asthme.

This review aims to evaluate the efficacy of the leukotriene modifiers in the different stages and subgroups of asthma. In mild asthma, they bring some improvement as monotherapy, but less than inhaled steroids. In moderate asthma, leukotriene modifiers associated with inhaled steroids seem to offer a slight advantage over placebo. No evidence of additional effect has been published in severe asthma. Exercice- and aspirin-induced asthma are particulary responsive to leukotriene modifiers. This treatment may also play a role in acute asthma. In practice, it is possible to select patients who benefit from those molecules. If only these "responders" are treated, leukotriene modifiers are an adequate treatment, easy to use and well tolerated.

Prevention of stroke recurrence with presumed paradoxical embolism.

Paradoxical cerebral embolism (PCE) through a patent foramen ovale (PFO) should be considered as a cause of ischemic stroke, particularly in young patients without an alternative cause for stroke. PCE is even more important that it is potentially treatable. However, PCE remains often presumed because it rests upon the rarely demonstrated findings of a deep venous thrombosis and a thrombus lodged in the PFO. Recent studies have shown a rather low stroke recurrence rate in patients with PFO and stroke but suggest that some subgroups of patients with a higher stroke recurrence risk-exist according clinical, echocardiographical and radiological characteristics. For these subgroups, it seems that a more invasive treatment should be required. There are four therapeutic options; antiaggregants, anticoagulation, transcatheter closure of PFO, and surgical closure of PFO. However, these treatments have yet to be evaluated in clinical trials.

The Patient Findings Questionnaire: one solution to an important standardized patient examination problem.

PURPOSE: To describe the Patient Findings Questionnaire (PFQ) and compare its scores and pass/fail decisions with those obtained from standardized patient (SP) examination checklists. METHOD: Checklists and PFQs were used to assess data acquisition by 790 second-year medical students. PFQs were composed of multiple-choice items designed to determine whether examines had acquired key historical patient information. RESULTS: At the item level, the two measurement methods yielded the same decisions about data acquisition on 88% of observed occasions. Most discrepancies (74%) involved SPs rating examinees as having elicited information when the examinee was unable to answer the associated PFQ item. At the test level, the two instruments yielded the same pass/fail decision on a large majority of occasions. CONCLUSIONS: The PFQ and checklist yielded similar data acquisition scores and decisions at the item and test levels. Replacement of the checklist with the PFQ should result in examinees' behaving in a way more consistent with recommended interviewing practices.