Oncology clinicians' feelings towards patients presented in supervision: A pre-post assessment using the feeling word checklist.

OBJECTIVE: Clinical supervision of oncology clinicians by psycho-oncologists is an important means of psychosocial competence transfer and support. Research on this essential liaison activity remains scarce. The aim of this study was to assess the impact of supervision on oncology clinicians' feelings towards patients presented in supervision. METHODS: Oncology clinicians' (n = 23) feelings towards patients presented in supervision were assessed with the Feeling Word Checklist (FWC). The FWC was filled in by supervisees prior and after their supervision sessions (n = 91), which were conducted by experienced supervisors (n = 6). Pre- post-modification of feelings was evaluated based on a selection of FWC items, which were beforehand considered as likely to change in a beneficial supervision. Items were evaluated on session level using t-tests for dependent groups. Composite scores were calculated for feelings expected to raise and feelings expected to decrease and analysed on the level of supervisees. RESULTS: Feelings related to threats, loss of orientation or hostility such as "anxious", "overwhelmed", "impotent", "confused", "angry", "depreciated" and "guilty" decreased significantly after supervision, while feelings related to the resume of the relationship ("attentive", "happy"), a better understanding of the patient ("empathic"), a regain of control ("confident") and being "useful" significantly increased. Feeling "interested" and "calm" remained unchanged. Significant increase or decrease in the composite scores for supervisees confirmed these results. CONCLUSIONS: This study demonstrates modification of feelings towards patients presented in supervision. This modification corresponds to the normative, formative, and especially restorative function (support of the clinician) of supervision.

[When physicians and patients face the existential dimensions of illness]. / Quand médecins et patients-es sont confrontés-es aux dimensions existentielles de la maladie.

Our self-consciousness allows us to know that we exist and to situate ourselves in the world. However, self-consciousness also makes us realize that our existence is characterized by vulnerabilities, that we are individuals with experiences which cannot be experienced by the other and that we will not escape finitude. This selfconsciousness is usually in the background of our mind but may be brought to centre stage in case of illnesses which evolve toward death. Certain disciplines of medicine try to consider the existential dimensions of disease. The question remains what medicine can offer in such situations and why and for whom interventions to increase the well-being of patients under existential threat are proposed. An analysis of these developments needs to focus not only on patients, but also the clinician, medicine, and society.

La conscience de soi nous permet de savoir que nous existons dans le monde et de nous y situer. Elle nous fait aussi réaliser que notre existence est caractérisée par des vulnérabilités, que nous sommes des individus avec des expériences que personne ne peut vivre à notre place et que nous n'échapperons pas à la finitude. Cette conscience peut être propulsée sur le devant de la scène en cas de maladie évoluant vers la mort. Certaines disciplines de la médecine tentent ainsi d'en tenir compte. La question reste de savoir ce que le médecin peut véritablement offrir dans pareilles situations et pourquoi/pour qui des interventions auprès des patients sous menace existentielle sont proposées. Une lecture de ces développements implique de se centrer non seulement sur les patient-es, mais aussi sur les cliniciens-nes, la médecine et la société.

[Transidentites : the relevance of involving psychiatrists]. / Transidentités : pertinence de l'implication des psychiatres.

Psychiatrists play a crucial role in evaluating requests and treatment indications for individuals experiencing gender incongruence, while also providing support throughout the transition process. Their work involves addressing both the psychological and somatic aspects of this journey, facilitating the profound identity changes it entails.

Les psychiatres psychothérapeutes jouent un rôle essentiel pour évaluer les demandes et les indications au traitement des personnes souffrant d'incongruence de genre, et les accompagner dans leur parcours de transition. Leur travail permet d'intégrer les enjeux psychologiques et somatiques de ce cheminement et de soutenir les remaniements identitaires profonds qu'il implique.

The fragility of trust between patients and oncologists: A multiple case study.

OBJECTIVES: This study aimed to explore in a naturalistic, real-life setting the dynamics of trust in oncological consultations. METHODS: Cases to study were purposively selected from a data set of audio-recorded and transcribed consultations between oncology physicians and patients with advanced cancer, and analyzed qualitatively. The analytical approach was deductive, relying on a thematic framework of dimensions of trust, and inductive, not restricted by this framework. RESULTS: The multiple case study approach allowed to identify factors, which play a role in the dynamics of trust. These factors are the number of treating physicians and how they communicate, continuity of care and the capital of trust, the hierarchical position of the physician and the physician's self-trust, and the patient's personality. SIGNIFICANCE OF RESULTS: The findings illustrate the importance to contextualize trust in the flow of oncological consultations and to conceive it comprehensively for each singular encounter between patients and clinicians.

[Psychiatric liaison: From yesterday to tomorrow]. / La liaison psychiatrique d'hier à demain.

This article reviews the genesis and development of liaison psychiatry, whose mission is (i) taking care for patients with psychiatric comorbidities (psychiatric consultation) and (ii) transferring knowledge and skills to somatic medicine and supporting clinicians in their practice (psychiatric liaison). We argue for a strengthening of psychiatric liaison and a consistent focus on the clinician as an object-subject of research, of training and of support. The following article will discuss the contribution of social sciences and quali-tative research to medicine and psychiatric liaison and outline the contours of a clinician-centered liaison model.

Ce premier article revient sur la genèse et le développement de la psychiatrie de liaison dont la mission est a) la prise en charge des patients atteints de comorbidités psychiatriques (consultation psychiatrique) et b) le transfert de savoir et de compétences vers le milieu somatique et le soutien des cliniciens dans leur pratique (liaison psychiatrique). Nous plaidons pour un renforcement de la liaison psychiatrique et une focalisation plus conséquente sur le clinicien comme objet-sujet de recherche, de ­formation et de soutien. Le second article* permettra de discuter l'apport des sciences sociales et de la recherche qualitative pour la médecine et la liaison psychiatrique, et d'esquisser les contours d'un modèle de liaison centré sur le clinicien.

[Towards a multilevel psychiatric liaison]. / Vers une liaison psychiatrique multi-niveaux.

The first of this pair of articles ends with the observation that -psychiatric liaison activity remains underdeveloped. Moreover, -psychiatric liaison is not based on sound empirical foundations and is not taught, which has had the consequence of putting it out of step with the transformations of medicine and the medical profession. In this second article, we discuss possible evolutions of psychiatric liaison and the role that social sciences can play in them. Both -articles are related to the creation of the first position of Professor in psychiatric liaison by the Faculty of Biology and Medicine of the University of Lausanne and the CHUV, a position held by a researcher from the social sciences.

Le premier de ce couple d'articles se termine sur l'observation que l'activité de liaison psychiatrique reste peu développée. En outre, la liaison psychiatrique ne repose pas sur des fondations empiriques solides et n'est pas enseignée, ce qui a eu pour conséquence de la mettre en décalage avec les transformations de la médecine et du métier de clinicien. Nous discutons dans ce second article des évolutions possibles de la liaison psychiatrique et du rôle que les sciences sociales peuvent y jouer. Les 2 articles ­sont en lien avec la création du premier poste de professeur en liaison psychiatrique créé par la Faculté de biologie et de médecine de l'université de Lausanne et le CHUV, poste occupé par une chercheuse issue des sciences sociales.

"You'll need to settle your affairs": How the subject of death is approached by oncologists and advanced cancer patients in follow-up consultations.

OBJECTIVES: This qualitative study aimed to investigate communication about death in consultations with patients undergoing chemotherapy with no curative intent. Specifically, we examined (i) how the topic of death was approached, who raised it, in what way, and which responses were elicited, (ii) how the topic unfolded during consultations, and (iii) whether interaction patterns or distinguishing ways of communicating can be identified. METHODS: The data consisted of 134 audio-recorded follow-up consultations. A framework of sensitizing concepts was developed, and interaction patterns were looked for when death was discussed. RESULTS: The subject of death and dying was most often initiated by patients, and they raised it in various ways. In most consultations, direct talk about death was initiated only once. We identified 4 interaction patterns. The most frequent consists of indirect references to death by patients, followed by a direct mention of the death of a loved one, and a statement of the oncologists aiming to skip the subject. SIGNIFICANCE OF RESULTS: Patients and oncologists have multiple ways of raising, pursuing, addressing and evacuating the subject of death. Being attentive and recognizing these ways and associated interaction patterns can help oncologists to think and elaborate on this topic and to facilitate discussions.

[Psychiatric liaison II: training]. / La liaison psychiatrique II : formation.

Training provided by liaison psychiatry has been considerably developed over the last decades. This article describes how " communication skills" training in oncology evolved to now address interpersonal dimensions of the medical encounter, the clinician's "inner" world and the context. We further present a so-called clinician-centered supervision, which aims to address the intra psychic issues of the clinician; the opportunities and precautions with this specific type of supervision are discussed. Focusing on the clinician facilitates and enriches the clinical encounter and improves medical care.

La formation dispensée par les psychiatres de liaison s'est considérablement développée ces dernières décennies. Cet article présente le cas des formations à la communication en oncologie, en détaillant pourquoi et comment elles ont évolué d'un enseignement centré sur des compétences en communication (skills) à un travail sur la dimension relationnelle de la rencontre, l'étude des mouvements intrapsychiques et une attention portée au contexte. Il décrit ensuite la supervision centrée sur la ou le clinicien·ne, utilisée aujourd'hui à titre exploratoire, en soulignant les opportunités et les précautions nécessaires à sa pratique. Ces exemples montrent en quoi une psychiatrie de liaison qui porte aussi son attention sur le ou la clinicien·ne facilite et enrichit la rencontre clinique et améliore les soins.

[Psychiatric liaison I : Clinical activities]. / La liaison psychiatrique I : clinique.

This series of three articles presents the evolutions of (1) the clinical activities of psychiatric liaison, illustrated by the PENbank project, (2) the training provided by psychiatric liaison clinicians, described by a recently developed clinician-centered supervision, and (3) research in psychiatric liaison, exemplified by four studies. Because it goes beyond traditional types of liaison interventions for clinicians, the PENbank may be considered a meta-liaison project. Indeed, the PENbank is an infrastructure (a data bank), which allows to collect, store on a long-term basis, and use physicians' narratives of experiences.

Cette série de 3 articles présente les évolutions de: 1) la clinique de la liaison psychiatrique, illustrée par le projet PENbank; 2) la formation par la liaison psychiatrique, au travers de l'exemple du développement d'un format de supervision centré sur les clinicien·nes et 3) la recherche en liaison psychiatrique, mise en lumière par 4 recherches récentes. La PENbank peut être comprise comme un projet de méta-liaison en ce qu'elle dépasse les formes traditionnelles d'intervention auprès des clinicien·nes et de soutien de l'activité clinique. En effet, la PENbank est une infrastructure (une banque de données) permettant le recueil et le stockage à long terme des récits d'expérience de médecins, ainsi que leur utilisation à différentes fins (visibilisation, restitution, recherche).

[Psychiatric liaison III: Research]. / La liaison psychiatrique III : recherche.

Liaison psychiatry consists of an activity of consultation for patients affected by somatic diseases and of an activity of liaison for clinicians. The liaison work can take different forms, such as teaching of patient-physician relationship, supervision or support. To illustrate psychiatric liaison research, we present four studies conducted in our service, which explore (a) the relations between medical students' mental health and their interpersonal competence, (b) the dreams of medical students and what they reveal of their subjectivities, (c) the stakes for primary care practitioners when asking for a specialist's consult, and (d) the situated clinical practice. These studies contribute to nourish psychiatric liaison, which can use their results for training or support of clinicians.

La psychiatrie de liaison comprend une activité de consultation auprès des patient·es en soins somatiques et une activité de liaison auprès des clinicien·nes. La liaison psychiatrique peut prendre des formes diverses, tels l'enseignement de la relation soignant·e-soigné·e, des supervisions ou le soutien d'équipe. Dans cet article, nous présentons 4 études menées dans notre service qui s'intéressent : a) aux liens entre la santé mentale des étudiant·es en médecine et leurs compétences interpersonnelles ; b) à leurs rêves et à ce qu'ils révèlent de leur subjectivité ; c) aux enjeux de l'appel aux spécialistes pour les médecins de premier recours et d) à la pratique clinique en situation. Ces études contribuent à nourrir le travail de liaison qui peut s'appuyer sur leurs résultats dans la formation et le soutien des soignant·es.

The self-assessment INTERMED predicts healthcare and social costs of orthopaedic trauma patients with persistent impairments.

OBJECTIVE: To use the self-assessment INTERMED questionnaire to determine the relationship between biopsychosocial complexity and healthcare and social costs of patients after orthopaedic trauma. DESIGN: Secondary prospective analysis based on the validation study cohort of the self-assessment INTERMED questionnaire. SETTING: Inpatients orthopaedic rehabilitation with vocational aspects. SUBJECTS: In total, 136 patients with chronic pain and impairments were included in this study: mean (SD) age, 42.6 (10.7) years; 116 men, with moderate pain intensity (51/100); suffering from upper (n = 55), lower-limb (n = 51) or spine (n = 30) pain after orthopaedic trauma; with minor or moderate injury severity (severe injury for 25). MAIN MEASURES: Biopsychosocial complexity, assessed with the self-assessment INTERMED questionnaire, and other confounding variables collected prospectively during rehabilitation. Outcome measures (healthcare costs, loss of wage costs and time for fitness-to-work) were collected through insurance files after case settlements. Linear multiple regression models adjusted for age, gender, pain, trauma severity, education and employment contract were performed to measure the influence of biopsychosocial complexity on the three outcome variables. RESULTS: High-cost patients were older (+3.6 years) and more anxious (9.0 vs 7.3 points at HADS-A), came later to rehabilitation (+105 days), and showed higher biopsychosocial complexity (+3.2 points). After adjustment, biopsychosocial complexity was significantly associated with healthcare (ß = 0.02; P = 0.003; expß = 1.02) and social costs (ß = 0.03; P = 0.006, expß = 1.03) and duration before fitness-to-work (ß = 0.04; P < 0.001, expß = 1.04). CONCLUSION: Biopsychosocial complexity assessed with the self-assessment INTERMED questionnaire is associated with higher healthcare and social costs.

What symptoms tell us: A multiple case study of oncology consultations.

OBJECTIVES: While patients' symptom experiences have been widely investigated, there is a lack of contextualized studies investigating how symptoms circulate in the medical consultation, how patients present them, what they convey, how physicians respond, and how patients and physicians negotiate with each other to find ways to address them. The aim of this study is to explore patients and physicians handling of symptoms throughout oncological consultations with a multiple case study approach. METHODS: Five consultations, purposively selected from an existing dataset of audiotaped consultations with patients with advanced cancer, were analyzed by means of an inductive analytical approach based on a sensitive framework from the literature. RESULTS: Patients' symptoms showed multiple dimensions such as medical, cognitive, emotional, psychological, interactional, symbolic, experiential, and existential. SIGNIFICANCE OF RESULTS: Different symptom dimensions remained unnoticed and unaddressed in the consultations. The physician-centered symptom approach that was observed leads to consumed time and missed opportunities for relationship building with the patient. Physicians showed a lack of sensitivity regarding the multiple dimensions of symptoms. Based on the findings, strategies for a more comprehensive symptom approach can be conceived.

[When hotlines remain cold: Psychological support in the time of pandemic]. / Quand le téléphone ne chauffe pas : les hotlines psy en situation de pandémie.

In Switzerland and elsewhere, many psychological support hotlines were set up during the acute phase of the COVID-19 pandemic. Specialists in psychological first aid, in charge of developing and managing these hotlines, had to face an unknown situation, very different from the disasters for which they prepare themselves. Since the pandemic and the associated physical distancing were a potential threat to social cohesion, one could make the hypothesis that, by setting up hotlines, these professionals sought to reintroduce a form of proximity and to care for and cultivate the social connections among people. The pressure, feelings of emergency, anxious anticipation and expectation of the political authorities and the population may have favoured the development of these structures. Other factors certainly also played a role, such as the need to be useful and to exist as professional, or the need to act in order to reduce anxiety related to the pandemic. Altogether, these hotlines were little used, and their usefulness may be questioned. Similar phenomena have been observed - especially in the sanitary domain - with a multiplication of new offers, not always adjusted to specific identified needs, while health care services were on the same time under-used. Our observations plead against emergency responses in crisis situations and for reflecting on the measures to be put in place rather than to "act" them.

[Physicians, their practice, and the institution : to adapt or to situate oneself ?] / Le médecin, sa clinique et l'institution : s'adapter ou se situer ?

The context of the clinical encounter, and more generally of the practice of medicine, has effects on physicians. For example, it shapes their opinions, discourses, and ultimately their behaviors. The context may also directly impact physicians, sometimes affecting their physical and mental health. Numerous interventions, provided within and outside the institution, are targeting these effects. The question we raise in this article is: should physicians adapt to, or should they rather situate themselves within, their context. This question leads us to discuss reflexivity and reflexivity training.

Le contexte du médecin, « ce qui entoure ¼ la rencontre clinique et, plus globalement, sa pratique, produit des effets sur lui, par exemple en orientant, déterminant et modelant ses opinions, ses discours et sa conduite. Ces effets peuvent se révéler délétères et atteindre les médecins dans leur santé physique et psychique. De nombreuses interventions et formations sont aujourd'hui ciblées sur ces effets et proposées dans et hors institution. La question que nous posons dans cet article est de savoir si les médecins doivent apprendre à s'adapter à leur contexte ou, plutôt, à s'y situer. Cela nous amène à traiter du processus de réflexivité et des formations à la réflexivité.

[The physician, the clinical practice, and the institution: the suicidal patient]. / Le médecin, sa clinique et l'institution: le cas du patient suicidaire.

Patients and their clinical predicaments have an impact on clinicians (that psychoanalysis frames as countertransference), but also on medical institutions. Suicidal patients provide a potent illustration of such phenomena. At the individual level, they evoke intense, often negative affective reactions. At the institutional level, they are also « difficult ¼ patients, who often do not conform to the classical, « expected ¼ sick role. This can result in policies too focused on risk assessment and strict procedures, potentially detrimental to proper care. To prevent such defensive attitudes, institutions should provide clinicians an environment in which they are able to work through their relationships with patients, but also with the medical profession and institutions.

Parallèlement à ce qu'ils éveillent chez les cliniciens ­ les psychanalystes parlent de contre-transfert ­, les patients ont des effets sur l'institution. La suicidalité en fournit un bon exemple. Au niveau individuel, la rencontre avec les patients suicidaires suscite des affects intenses et souvent négatifs. Au niveau institutionnel, ces patients, difficiles, rappellent les suicides passés et leurs effets traumatiques; ils peuvent être ambivalents vis-à-vis des soins et ne se conforment pas au rôle « attendu ¼ des malades. En réaction, on peut observer des mouvements délétères, comme le développement de procédures trop focalisées sur l'évaluation du risque. Pour les prévenir, l'institution doit offrir aux cliniciens qui la font et la soignent un cadre pour penser leur relation aux patients, au métier et à l'institution elle-même.

Undergraduate training in breaking bad news: A continuation study exploring the patient perspective.

OBJECTIVE: This paper reports on the continuation of an initial study that demonstrated the effectiveness, as rated by experts, of an undergraduate training in breaking bad news (BBN) using simulated patient (SP) and individual feedback. The current study aimed to further explore whether such an individualized training approach also has positive effects from the perspective of the patient, using the analogue patient (AP) methodology. METHODS: A subsample of 180 videotaped interviews with SPs were selected from the existing data set (N = 332), consisting of 60 pre- and post-training interviews of students benefiting from the individualized approach (intervention group) and 60 post-training interviews of students having small-group SP training and collective supervision (comparison group). Sixty-eight APs-healthy untrained observers-were asked to view the videotaped interviews while "putting themselves in the patient's shoes" and evaluate satisfaction, trust, liking, and the competence of medical students. RESULTS: The intervention group students improved significantly from pre- to post-training on several dimensions evaluated by the APs: patient satisfaction, trust in the student, liking of the student, and perceived medical competence. Increased AP satisfaction was related to different changes in students' communication behavior between pre- and post-training: increase in positive talk, emotional responsiveness, biomedical and psychosocial information, and biomedical counseling. There was no significant between-group difference at post-training. CONCLUSIONS: AP evaluation showed significant improvement between pre- and post-training. This result provides additional and complementary evidence of the positive effects of individualized training in BBN from the AP perspective, a proxy of (real) patients.

[Psychiatry in the time of pandemic†: forging new ways without getting lost]. / La psychiatrie face à la pandémie†: se réinventer sans se perdre.

Coronavirus pandemic challenges mental health care providers in different ways. At an individual level, they have to adapt their clinical practice and consider specific issues of teleconsultations to address patient's needs. At a population level, dedicated interventions (e.g. hotlines, health professionals' support) have to strike a balance between «â€…pathologizing ¼ people's reactions and trivializing the psychological effects of a pandemic. Finally, psychiatric leaders must be able to advise decision-makers on mental-health policy and communication.

La pandémie de coronavirus oblige les soignants en santé mentale à réinventer leur manière de travailler et à penser de nouveaux cadres thérapeutiques, les patients réagissant de manière singulière à cette situation extraordinaire. Sur un plan populationnel, les interventions envisagées (e.g. hotlines, soutien aux professionnels et aux équipes) doivent trouver un équilibre entre une «â€…psychiatrisation ¼ des vécus d'ordre existentiel et une banalisation des effets psychologiques d'une pandémie. Sur les plans institutionnel et politique, la psychiatrie peut conseiller les décideurs quant aux impacts psychologiques et à la communication.

[Medical crisis, clinical engagement]. / Crise médicale, engagement clinique.

Medicine is changing, and so are the causes of dissatisfaction among physicians. In a broader context characterized by the dominance of an economic rationality, in which medicine is shaped by the phenomenon of acceleration typical of modernity, we argue, in this brief article, that clinical practice is based on an engagement involving a form of suspension of the flow of time. Engagement is thereby an essential dimension of medicine, and is proposed as a lasting foundation of clinical practice.

La médecine change et avec elle, les raisons de l'insatisfaction des médecins. Dans un contexte où prévaut notamment une logique de type économique et où le métier de médecin est marqué par l'accélération caractéristique de la modernité, nous avançons dans ce bref article de réflexion que la clinique se fonde sur un engagement impliquant une forme de suspension du temps. L'engagement constitue ainsi une dimension essentielle du métier médical et potentiellement un socle durable de la clinique.

[Role of the psychiatrist-psychotherapist in the assessment and treatment of gender dysphoria]. / Rôle du psychiatre-psychothérapeute dans la prise en charge de la dysphorie de genre.

This article is the result of the joint work of psychiatrists-psychotherapists working with patients with gender dysphoria (children, adolescents and adults) in Lausanne and Geneva university hospitals. It emphasizes the importance of their clinical interventions when hormone therapy and sex reassignment surgery are requested.

Cet article est issu d'une collaboration entre les psychiatres-psychothérapeutes et les pédopsychiatres-psychothérapeutes intervenant dans les deux consultations universitaires spécialisées pour la dysphorie de genre en Suisse romande et illustre l'importance de leur intervention dans la prise en charge des personnes qui sollicitent des traitements médicochirurgicaux de réassignation sexuelle.

Moving toward the next generation of communication training in oncology: The relevance of findings from qualitative research.

OBJECTIVE: The critics and recommendations for communication training in oncology call for new ideas, which may contribute to designing the next generation of training. The aim of this work was to search the literature on communication in oncology for empirically grounded observations that might be useful for the development of training approaches. METHODS: The approach consists of identifying findings that might serve as cues for the design of the next generation of training. The literature search strategy allowed the inclusion of 68 articles. RESULTS: Findings of the articles showed that multiple factors shape clinical communication: the functions and effects of information provision, the relational and interactional aspects of communication, its patient- and context-related dimensions, and the intrapsychic and context-related barriers hampering the patient encounter that clinicians are facing. CONCLUSION: A way to reach all oncologists and to provide training centred on the singular needs of participants is a shift in the focus of training from communication tasks or communication-related situations to the clinician. PRACTICE IMPLICATIONS: Training should focus on the competencies and qualities to be developed by clinicians, such as being flexible, able to adapt to the singular patient, sensitive to interactional aspects of communication, which influence the clinical encounter.