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.

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.

The relationship between medical students' empathy, mental health, and burnout: A cross-sectional study.

OBJECTIVE: To investigate how medical students' empathy is related to their mental health and burnout. METHODS: This cross-sectional study included 886 medical students from curriculum years 1-6. The cognitive, affective, and behavioural dimensions of empathy were measured with self-report questionnaires and an emotion recognition test. Regressions were used to test the relationship between the empathy dimensions, depressive symptoms, anxiety, and burnout as well as the influence of curriculum year and gender. RESULTS: Cognitive and behavioural empathy were significantly related to less mental health issues and burnout, whereas affective empathy was related to more mental health issues and burnout. Students in later curriculum years reported less mental health issues and burnout than students in earlier years, whereas no systematic difference could be observed for empathy. Female students reported more mental health issues and burnout as well as higher empathy, except for behavioural empathy for which male students scored higher. CONCLUSIONS: The cognitive, affective, and behavioural dimensions of empathy were differently related to the mental health and burnout of medical students. Students presenting mental health issues or burnout might have more difficulty to adapt their behaviour in social situations and keep a certain distance when taking others' perspective.

"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 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.

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.

[The gender paradox in suicide : some explanations and much uncertainty]. / Le paradoxe du genre dans le suicide : des pistes explicatives et pas mal d'incertitudes.

Men die more by suicide than women, but women attempt suicide more frequently. Gender does indeed shape suicidal ideas and behaviors. Due to differences in the way men express their suffering, men's depression may be underdiagnosed and undertreated. Furthermore, regarding suicidal behaviors, men use more lethal suicide methods than women. Their suicidal process seems also to progress more rapidly, which is probably related to their frequent substance use. Clinicians and researchers should consider these differences in their approach, without reducing men and women to their gender.

Le paradoxe du genre dans le suicide renvoie au fait que les hommes se suicident plus que les femmes, alors que ces dernières font plus de tentatives de suicide. Ce phénomène s'expliquerait par l'influence du genre dans ce qui détermine les idées et les conduites suicidaires. Des manifestations différentes de la souffrance psychologique pourraient d'abord conduire à un défaut de reconnaissance des dépressions masculines. Ensuite, au niveau même des comportements suicidaires, les hommes optent pour des moyens plus létaux et l'évolution de leur processus suicidaire est plus rapide, entre autres en lien avec le fait qu'ils consomment plus fréquemment des substances. Les cliniciens et les chercheurs devraient prendre ces différences en considération dans leur approche, sans réduire hommes et femmes à leur appartenance de genre.

[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.

[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.

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.

How physicians make sense of their experience of being involved in hospital users' complaints and the associated mediation.

BACKGROUND: The growing interest in hospital users' complaints appears to be consistent with recent changes in health care, which considers the patient's voice a valuable information source to improve health care. Based on the assumption that the clinicians' lived experience is an essential element of health care and to neglect it may have serious consequences, this study aimed to explore how physicians experience hospital users' complaints and the associated mediation process. METHODS: A qualitative analysis of experience narrative interviews. Fourteen physicians concerned by complaints which resulted in a mediation provided a comprehensive narrative of their experience with the complaints center. Data were analyzed with Interpretative Phenomenological Analysis (IPA). Interviews were analyzed inductively and iteratively to explore how physicians make sense of their experience. RESULTS: The analysis of the physicians' narratives revealed that being the object of a complaint and to enter a process of mediation is a specific experience of which some physicians benefited and others felt psychologically weakened. The causes of the complaints were at times considered by physicians to be related to medical malpractice, but more often to communicational and relational difficulties, unrealistic expectations of patients, physicians' attitudes, or the lack of a coherent care plan. The analysis of their narratives revealed that physicians showed a need for reconsidering and elaborating on the reason(s) leading to the complaint, and on the expectations patients/relatives may have had towards medicine and health care professionals. This may be interpreted as an attempt to assign their meaning, such meaning having the potential to ease the distress associated with the experience of complaints. CONCLUSION: Most physicians appeared more aware of the communicational and relational aspects of care after experiencing a complaint situation; however, prior to the complaint, physicians seem to have underestimate these issues, and when they acknowledge that the complaint originated in psychological aspects of care, they still consider it not relevant, since not related to clinical decision-making and management. Mediation as providing the opportunity to restore the clinical relationship should be encouraged at an institutional level as well as support of health care professionals by means of individual or group supervision.

General practitioners referring patients to specialists in tertiary healthcare: a qualitative study.

BACKGROUND: There is a large and unexplained variation in referral rates to specialists by general practitioners, which calls for investigations regarding general practitioners' perceptions and expectations during the referral process. Our objective was to describe the decision-making process underlying referral of patients to specialists by general practitioners working in a university outpatient primary care center. METHODS: Two focus groups were conducted among general practitioners (10 residents and 8 chief residents) working in the Center for Primary Care and Public Health (Unisanté) of the University of Lausanne, in Switzerland. Focus group data were analyzed with thematic content analysis. A feedback group of general practitioners validated the results. RESULTS: Participating general practitioners distinguished two kinds of situations regarding referral: a) "clear-cut situations", in which the decision to refer or not seems obvious and b) "complex cases", in which they hesitate to refer or not. Regarding the "complex cases", they reported various types of concerns: a) about the treatment, b) about the patient and the doctor-patient relationship and c) about themselves. General practitioners evoked numerous reasons for referring, including non-medical factors such as influencing patients' emotions, earning specialists' esteem or sharing responsibility. They also explained that they seek validation by colleagues and postpone referral so as to relieve some of the decision-related distress. CONCLUSIONS: General practitioners' referral of patients to specialists cannot be explained in biomedical terms only. It seems necessary to take into account the fact that referral is a sensitive topic for general practitioners, involving emotionally charged interactions and relationships with patients, colleagues, specialists and supervisors. The decision to refer or not is influenced by multiple contextual, personal and clinical factors that dynamically interact and shape the decision-making process.

Individual Supervision to Enhance Reflexivity and the Practice of Patient-Centered Care: Experience at the Undergraduate Level.

This article reports on what is at work during individual supervision of medical students in the context of teaching breaking bad news (BBN). Surprisingly, there is a relative lack of research and report on the topic of supervision, even though it is regularly used in medical training. Building on our research and teaching experience on BBN at the undergraduate level, as well as interviews of supervisors, the following key elements have been identified: learning objectives (e.g., raising student awareness of structural elements of the interview, emotion (patients and students) handling), pedagogical approach (being centered on student's needs and supportive to promote already existing competences), essentials (e.g., discussing skills and examples from the clinical practice), and enhancing reflexivity while discussing specific issues (e.g., confusion between the needs of the patient and those of the student). Individual supervision has been identified as crucial and most satisfactory by students to provide guidance and to foster a reflexive stance enabling them to critically apprehend their communication style. Ultimately, the challenge is to teach medical students to not only connect with the patient but also with themselves.