Predictors of physicians' satisfaction with their management of uncertainty during a decision-making encounter with a simulated advanced stage cancer patient.

OBJECTIVES: To optimize their training, predictors of physicians' satisfaction with their management of uncertainty should be examined. This study investigated these predictors by using a simulated advanced stage cancer patient. METHODS: Physicians (n=85) rated their satisfaction with their management of uncertainty (Visual Analog Scale-100mm) after a decision-making encounter. Communication predictors were examined with the: Observing Patient Involvement scale (OPTION), Multidimensional analysis of Patient Outcome Predictions (MD.POP) and Communication Content Analysis Software (LaComm). Psychological predictors were assessed with the: Intolerance of Uncertainty Inventory (IUI), Physicians' Reactions to Uncertainty scale (PRU), Decisional Conflict Scale (DCS), and Jefferson Scale of Physician Empathy (JSPE). RESULTS: Physicians' satisfaction (mean=67mm; standard deviation=17mm) was not predicted by their communication, but by their anxiety due to uncertainty (PRU) (ß=-.42; p=<.001) and their perceived empathy (JSPE) (ß=.26; p=.009). These variables accounted for 25% of variance in physicians' satisfaction. CONCLUSIONS: Physicians' satisfaction with their management of uncertainty was not affected by their communication performance, but by their psychological characteristics. PRACTICE IMPLICATIONS: Training programs should increase physicians' awareness regarding the communication performance required in decision-making encounters under conditions of uncertainty.

Is it possible to improve the breaking bad news skills of residents when a relative is present? A randomised study.

BACKGROUND: Although patients with cancer are often accompanied by a relative during breaking bad news (BBN) consultations, little is known regarding the efficacy of training programmes designed to teach residents the communication skills needed to break bad news in a triadic consultation. METHODS: Residents were randomly assigned to a 40-h dyadic and triadic communication skills training programme (n=48) or a waiting list (n=47). A simulated BBN triadic consultation was audiotaped at baseline, and after training for the training group, and 8 months after baseline for the waiting list group. Transcripts were analysed using content analysis software (LaComm). A coder determined the moment of bad news delivery and the relative's first turn of speech regarding the bad news. A generalised estimating equation was used to evaluate residents' communication skills, BBN timing, and the relative's inclusion in the consultation. RESULTS: Ninety-five residents were included. After training, the duration of the pre-delivery phase was found to be longer for the trained residents (relative risk (RR)=3.04; P<0.001). The simulated relative's first turn of speech about the bad news came more often during the pre-delivery phase (RR=6.68; P=0.008), and was more often initiated by the trained residents (RR=19.17; P<0.001). Trained residents also used more assessment (RR=1.83; P<0.001) and supportive utterances (RR=1.58; P<0.001). CONCLUSION: This study demonstrates that a training programme that focuses on the practice of dyadic and triadic communication skills can improve the communication skills of the participating residents in a BBN triadic consultation. Such a training should be included in resident curriculum.

Quality of work life in doctors working with cancer patients.

BACKGROUND: Although studies have shown that medical residents experience poor psychological health and poor organizational conditions, their quality of work life (QWL) had not been measured. A new tool, the Quality of Work Life Systemic Inventory (QWLSI), proposes to fill the gap in the definition and assessment of this concept. AIMS: To confirm the convergent validity of the QWLSI, analyse Belgian medical residents' QWL with the QWLSI and discuss an intervention methodology based on the analysis of the QWLSI. METHODS: One hundred and thirteen medical residents participated between 2002 and 2006. They completed the QWLSI, the Maslach Burnout Inventory and the Job Stress Survey to confirm the correspondence between these three tools. RESULTS: Residents' low QWL predicted high emotional exhaustion (ß = 0.282; P < 0.01) and job stress (ß = 0.370; P < 0.001) levels, confirming the convergent validity. This sample of medical residents had an average QWL (µ = 5.8; SD = 3.1). However, their QWL was very low for three subscales: arrangement of work schedule (µ = 9; SD = 6.3), support offered to employee (µ = 7.6; SD = 6.1) and working relationship with superiors (µ = 6.9; SD = 5.3). CONCLUSIONS: The results confirm that the QWLSI can provide an indication of workers' health well-being and of organizational performance in different areas of work life. The problem factors found among Belgian medical residents suggest that prevention should focus on reduction of work hours, development of support and change in leadership style.

[Effectiveness of physical exercise in psychiatry: a therapeutic approach?]. / Efficacité de l'exercice physique en psychiatrie : une voie thérapeutique ?

INTRODUCTION: There is a general belief that physical activity and exercise have positive effects on mood and anxiety. Intervention studies describe an anxiolytic and antidepressive effect of exercise in healthy subjects and patients. However, the majority of published studies have substantial methodological inconsistencies. Our review of the literature showed the importance of distinguishing three items in studies regarding efficacy of physical exercise in psychiatry: operationalisation of concepts (duration, frequency, intensity, type of exercise), the type of disorder, the diagnosis, and exploratory hypotheses. The aim of this article is to demonstrate that physical exercise in the psychiatry department contributes to the improvement of the mental health of in-hospital patients. METHODS: Sociodemographical data, the diagnosis and the physical exercise (duration, distance, type and frequency) of 283 in-hospital patients in the psychiatry department were listed. Physical exercise (cycling, long walks, short walks, soft and hard gymnastics) included in a database has been proposed to patients for many years in this hospital. After their hospitalisation, the members of the medical staff (20 persons) evaluated the patients on a visual analogic scale from 1 to 10 related to the improvement of their mental health. No experimental manipulation was made. SUBJECTS: One hundred and twenty-eight men, mean age: 45.67 years (± 13.59) exhibited the following disorders: major depressive disorder (117), anxious disorders (25), alcoholic addiction (85), toxicomania (10), psychotic decompensation (33), bipolar disorder (3) and others (10). Patients practised at least one exercise during their hospitalisation, mean duration of 15.93 (± 9.18) working days. The frequency of physical exercises per patient was 5.65 (± 6.20). The improvement of each patient was evaluated around six times (6.16 ± 3.83). The average amelioration score for all the patients was close to 50% (4.99 ± 1.65). RESULTS: Correlations between the improvement of mental health and participation in physical exercises were all significant (frequency: r=0.228; P<0.001; duration: r=0.236; P<0.001; distance: r=0.201, P=0.001). In comparison with psychotic patients, drug addiction and alcoholic, depressive patients showed greater interest in physical exercise. This is similar for anxious disorders. According to the results, two groups were created regarding their improvement (cut out point: 5.08). We observed that patients suffering from major depression considerably improved thanks to physical exercise (P=0.048), spent more time practising (P=0.037) and walked or cycled greater distances (P=0.038). Finally, cycling (frequency: P=0.008; distance: P=0.016; duration: P=0.011) and "hard" gymnastics were the physical exercises which optimized the results. DISCUSSION: Physical exercise is correlated with the improvement of mental health. The practice of physical exercise depends on the mental disorder. People suffering from major depressive disorder benefit more from physical exercise than other groups. Cycling and "hard" gymnastics are both exercises to be proposed in every programme. CONCLUSION: To practice physical exercise during hospitalisation in a psychiatric department has a positive influence on the symptomatology, and contributes to the improvement of mental health.

Is it possible to improve residents breaking bad news skills? A randomised study assessing the efficacy of a communication skills training program.

BACKGROUND: This study aims to assess the efficacy of a 40-h training programme designed to teach residents the communication skills needed to break the bad news. METHODS: Residents were randomly assigned to the training programme or to a waiting list. A simulated patient breaking bad news (BBN) consultation was audiotaped at baseline and after training in the training group and 8 months after baseline in the waiting-list group. Transcripts were analysed by tagging the used communication skills with a content analysis software (LaComm) and by tagging the phases of bad news delivery: pre-delivery, delivery and post-delivery. Training effects were tested with generalised estimating equation (GEE) and multivariate analysis of variance (MANOVA). RESULTS: The trained residents (n=50) used effective communication skills more often than the untrained residents (n=48): more open questions (relative rate (RR)=5.79; P<0.001), open directive questions (RR=1.71; P=0.003) and empathy (RR=4.50; P=0.017) and less information transmission (RR=0.72; P=0.001). The pre-delivery phase was longer for the trained (1 min 53 s at baseline and 3 min 55 s after training) compared with the untrained residents (2 min 7 s at baseline and 1 min 46 s at second assessment time; P<0.001). CONCLUSION: This study shows the efficacy of training programme designed to improve residents' BBN skills. The way residents break bad news may thus be improved.

Comparisons between psychotropic drugs: must the risk of side effects dictate our practices?

OBJECTIVES: Recently, SOHO and CATIE's studies in the field of schizophrenic disorders asserted that molecules apparently showing the most side-effects are not only the most effective but also lead to the least changes in treatments. Can we generalise this assertion to other domains of pharmacological treatments, such as in mood and anxiety disorders? And, more generally, do we possess information about comparison between different types of molecules in these different fields. METHODS: Review of the literature (medline-psycinfo-psycarticles) addressing these three psychiatric disorders, and comparing efficacy of treatments, or cost-effectiveness studies. RESULTS: Although there is a plethora of publications about the efficacy of given molecules vs. placebo, studies comparing molecules are scarce, and studies on cost-effectiveness in natural environments are even more scarce. Independently of the type of disorders under study, the last few years' efforts to completely limit side effects seem to have resulted in a loss of efficacy. Moreover, the previously held hypothesis suggesting that the fewer the side effects, the lesser the need to change treatment has not been confirmed. The duration of a treatment is more dependent upon its efficacy than on other variables. CONCLUSIONS: Clinicians cannot determine the absence of noxiousness of a molecule as their primary criterion of choice. In contrast, they should carefully balance side effects and efficacy. In Psychiatry, there is a lack of studies about cost-effectiveness in natural environments.

Factors that influence cancer patients' anxiety following a medical consultation: impact of a communication skills training programme for physicians.

BACKGROUND: No study has yet assessed the impact of physicians' skills acquisition after a communication skills training programme on the evolution of patients' anxiety following a medical consultation. This study aimed to compare the impact, on patients' anxiety, of a basic communication skills training programme (BT) and the same programme consolidated by consolidation workshops (CW), and to investigate physicians' communication variables associated with patients' anxiety. PATIENTS AND METHODS: Physicians, after attending the BT, were randomly assigned to CW or to a waiting list. The control group was not a non-intervention group. Consultations with a cancer patient were recorded. Patients' anxiety was assessed with the State Trait Anxiety Inventory before and after a consultation. Communication skills were analysed according to the Cancer Research Campaign Workshop Evaluation Manual. RESULTS: No statistically significant change over time and between groups was observed. Mixed-effects modelling showed that a decrease in patients' anxiety was linked with screening questions (P = 0.045), physicians' satisfaction about support given (P = 0.004) and with patients' distress (P < 0.001). An increase in anxiety was linked with breaking bad news (P = 0.050) and with supportive skills (P = 0.013). No impact of the training programme was observed. CONCLUSIONS: This study shows the influence of some communication skills on the evolution of patients' anxiety. Physicians should be aware of these influences.

Impact of medical specialists' locus of control on communication skills in oncological interviews.

Although is it widely recognised that physicians' characteristics could influence their communication styles, no empirical evidence is currently available. No studies are available on the impact of physicians' locus of control (LOC) on their communication skills. LOC is a generalised belief regarding the extent to which life outcomes are controlled by an individual's actions (internal LOC) or by external forces such as luck, fate or other individuals (external LOC). It was hypothesised that physicians with external LOC would take more into account others' concerns than physicians with internal LOC and would consequently use more appropriate assessment, informative and supportive functions. A total of 81 medical specialists were assessed in a simulated interview and a clinical interview. Communication skills were rated according to the Cancer Research Campaign Workshop Evaluation Manual. LOC was assessed using the Rotter I-E scale. Communication skills of the upper and lower quartiles of physicians in respect of their scores on this scale were compared using Student's t-test. Results show that physicians with external LOC give more appropriate information than physicians with internal LOC in simulated interviews (P=0.011) and less premature information than physicians with internal LOC in clinical interviews (P=0.015). This result provides evidence that physicians' LOC can influence their communication styles in oncological interviews and in particular the way they provide information to the patient.

[Clinical and pathophysiological contribution of event-related potentials used to study migraine headache]. / Intérêts clinique et physiopathologique des potentiels évoqués cognitifs dans la migraine.

Event-related potentials are electric brain manifestations evoked by mental activities. This neurophysiological technique is able to describe temporal succession of cognitive processing and allows to measure the neurobiological correlates of each cognitive activity. The evoked potentials of the oddball paradigm and the Contingent Negative Variation (CNV) are also concerned by clinical applications in neuropsychiatry, in neurology and in psychopharmacology. In the case of migraine, the studies with CNV recorded between migraine attacks are characterized by two major phenomena, cerebral hyperreactivity and lack of habituation to repetitive stimuli. From cognitive point of view, this can be interpreted as a difficulty from migraine sufferers to adapt their information-processing to environmental constraints. From neurological point of view, this trouble is related with dysregulation of norepinephrin and serotonin ascending pathways. Studies with the oddball paradigm potentials remain non consistent. The mismatch between different methodologies could explain such a lack of consistency. The neurophysiological studies have contributed to new physiopathological hypothesis of migraine. Those hypothesis reveal that a shift in the brain metabolic homeostasis could be the common factor of migraine attacks. The clinical contribution of event-related potentials is of little use in the diagnosis of migraine. But two purposes have been suggested: the differential diagnosis between common migraine and tension-type headaches and the monitoring of beta-blocking agents prophylaxis.

[Breast cancer and its psychological approach: family, others, chance and...me]. / Le cancer du sein et son approche psychologique: la famille, les autres, la chance et ... moi.

Since several years already, the scientific literature evoked the psycho-oncological perspective in the psychotherapeutic treatment of the patient suffering of a malignant mammary pathology. The objective of this article is to insist on some characteristics of personality inherent to the individual that suffers of a malignant mammary pathology. Comparing three groups of women (malignant mammary pathology--n = 51, benign mammary pathology--n = 71 and a group controls--n = 30), a set of questionnaires relating to locus of control and to the close circle--family and couple--has been managed. Results indicate that the woman suffering of a breast cancer is less "intern", consider that her health depends on factor "luck" and wish less cohesion and therefore more of distance within her couple and her family.

[Psychological approach to different skin diseases: life events and tendency to complain]. / Approche psychologique de différentes dermatoses: événements de vie et propension à se plaindre.

BACKGROUND: For nearly two decades, dermatology has associated with psychology to find a better way to care for dermatology conditions. A scientific trend called psychosomatics is creating a link between dermatology and psychology. OBJECTIVE: The purpose of this article was to examine two concepts closely linked to psychodermatology (life events and tendency to complain) and to emphasize the difference between factors playing a role in the onset of certain skin diseases (psoriasis, alopecia areata, benign tumors, eczema). RESULTS: We found that psoriasis patients have a greater tendency to complain than people with the other disease. This point to the importance of taking emotions into account when studying psoriasis. We also found that life events play a role in the onset of psoriasis and alopecia areata. Moreover, these events were anterior by more than 12 months in alopecia patients. CONCLUSION: We propose exploring emotions in psoriasis patients and life events over the prior year in alopecia areata patients.

[Improving doctor's communication skills in oncology: review and future perspectives]. / Améliorer les stratégies de communication des médecins en oncologie: état des lieux et perspectives futures.

The aim of this review is to discuss the different communication skills training designed to physician interactions with cancer patients. The development of medicine and chronic cancer treatments indicates the need to improve communication skills that combine appropriate assessment, information and support. Literature shows however that numerous factors may jeopardize the mastery of those skills. As a consequence, initiatives have been made to improve oncologists' communication skills. The objectives of those training programs are to improve patients' as well as the medical staffs' quality of life. A critical review of objectives and used techniques (theorical information, case discussion, role playing, feed-back) is presented here. This review includes also the discussion about training module integrating several techniques. This review shows the efficacy of experiential techniques as well as participative techniques. The results of available studies are finally emphasizing two difficulties: the maintenance and the consolidation of the various skills acquired over time and their successful transfer to the clinical practice.

["Psychogenesis" of cancer: between myths, misuses and reality]. / <> du cancer: entre mythes, abus et réalité.

Since a long time, hypothesis of links between psychological factors and cancer, have been established in our culture. So far, numerous researches have tempted to indicate stress, coping facing the disease, depression or "type C" personality as factors participating to the onset and/or the course of the cancer. A review of those studies, mainly retrospective, has mostly brought debated results, as well as prospective researches including large sample of population or people awaiting a diagnosis; therefore making old-fashioned every area strictly "psychogenetic" of cancer at first sight. Explicative indirect hypothesis are suggested by the psychoneuroendocrinoimmunology. Various researches in this field proved that external factors such as stress, depression or social support have significative influences on components of the immune system which in turn influence the onset and/or the course of the cancer. The links between psychological factors and cancer are extremely complex, bringing numerous biological, psychological or even sociological systems in interactions. Then psychoneuroendocrinoimmunology constitutes an early interdisciplinary way of mediation, capable of account for the connections between psychology and cancer.

[For or against peridural analgesia?: a psychological approach based on the parturient's needs]. / Pour ou contre la péridurale?: une approche psychologique de la demande de la parturiente.

The present study investigates why some women, before and during delivering, request peridural analgesia or, on the contrary, refuse it. On the basis of a literature review and of an empiricial study involving 57 women, a psychological differentiation is attempted to discriminate users from non-users of peridural analgesia. Pain perceptions, health locus of control, when internal (IHLC), family and couple adaptability appear to be discriminating factors. Our results indicate a higher chance locus of control (externality) in non-users then in users, as well as a more rigid couple functioning. The incidence of Internal Health Locus of Control of pain perception is outlined.

[Psychiatric complication of organ transplantation]. / Complications psychiatriques des greffes d'organes.

The authors have reviewed the literature with a view to trying to establish the psychiatric disorders associated with organ transplantation and open up a discussion of the psychodynamics involved. Psychiatric complications fall roughly into 4 categories, namely those specific to the 3 stages of transplantation, i.e. whether the patient is awaiting a transplant, has recently received a transplant or is in the post-transplantation stage, and those associated with the underlying psychopathology of long-term illness.

Adolescence and diagnostics.

The major diagnostic categories (schizophrenia, borderline disorder, depression) are reviewed and the difficulties in applying this "adult" classification to adolescence are noted. The reasons for these are numerous, i.e., history of the discovery of diseases, the similarities in psychodynamic functioning between the pathological and the "normal" in adolescence, and prognosis which varies depending on age. How, then, does one distinguish between the pathological and the normal at this age, and is the concept of crisis at all useful?