[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.

Core stories of physicians on a Swiss internal medicine ward during the first COVID-19 wave: a qualitative exploration.

INTRODUCTION: The first COVID-19 wave (2020), W1, will remain extraordinary due to its novelty and the uncertainty on how to handle the pandemic. To understand what physicians went through, we collected narratives of frontline physicians working in a Swiss university hospital during W1. METHODS: Physicians in the Division of Internal Medicine of Lausanne University Hospital (CHUV) were invited to send anonymous narratives to an online platform, between 28 April and 30 June 2020. The analysed material consisted of 13 written texts and one audio record. They were examined by means of a narrative analysis based on a holistic content approach, attempting to identify narrative highlights, referred to as foci, in the texts. RESULTS: Five main foci were identified: danger and threats, acquisition of knowledge and practices, adaptation to a changing context, commitment to the profession, and sense of belonging to the medical staff. In physicians' narratives, danger designated a variety of rather negative feelings and emotions, whereas threats were experienced as being dangerous for others, but also for oneself. The acquisition of knowledge and practices focus referred to the different types of acquisition that took place during W1. The narratives that focused on adaptation reflected how physicians coped with W1 and private or professional upheavals. COVID-19 W1 contributed to revealing a natural commitment (or not) of physicians towards the profession and patients, accompanied by the concern of offering the best possible care to all. Lastly, sense of belonging referred to the team and its reconfiguration during W1. CONCLUSIONS: Our study deepens the understanding of how physicians experienced the pandemic both in their professional and personal settings. It offers insights into how they prepared and reacted to a pandemic. The foci reflect topics that are inherent to a physician's profession, whatever the context. During a pandemic, these foundational elements are particularly challenged. Strikingly, these topics are not studied in medical school, thus raising the general question of how students are prepared for the medical profession.

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.

Experiences of the medical profession: A qualitative study using narrative facilitators.

BACKGROUND: Physicians' narratives are means to approach and comprehend the practice of medicine, and physicians' embedment in their work and the healthcare context. OBJECTIVE: This study aimed to explore physicians' professional experiences and to examine how they are affected by factors related to their inner (psychological) and outer (institutional and social) worlds. METHODS: The study was designed as an exploratory qualitative study based on "narrative facilitators" (NF). Their goal is to encourage storytelling and to support the narrative process. The analytic approach was specific for each NF. RESULTS: Thirty-three physicians participated in the study. The findings showed a focus on the transformations of a profession, the need for physicians to adapt in terms of role and status, and their withstanding of conflicting projections from the public and patients (NF: press articles). The institutional context was described as not welcoming and impersonal (NF: photo-based story). When reacting to the quotes from their peers, participants showed a variety of un-patterned stances with respect to different aspects of medicine and the medical profession, illustrating heterogeneity with regard to professional attitudes and identities (NF: quotes from biographies/narrative accounts). Finally, findings also indicated that physicians often limited their narratives to a description of the materiality of the elements put into play (NF: blurred video sequences). CONCLUSION: Disenchanted physicians are not beneficial, neither for the patient nor for the health care system, and their feeling of being worn out may do harm and negatively affect themselves and their families.

[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 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.

Identifying complex patients in family medicine for potential benefit from a case manager: a short questionnaire derived from the INTERMED Self-Assessment (IMSA) questionnaire.

PURPOSE: To investigate how useful the Intermed-Self Assessment (IMSA) questionnaire and its components were for identifying which patient candidates would benefit most from case management (CM) in general practice. METHODS: The study was carried out in a group family medicine practice in Lausanne comprising seven GPs and four medical assistants, from February to April 2019. All the patients attending the practice between February and April 2019 were invited to complete the IMSA questionnaire. Additionally, their GPs were asked for their opinions on the potential benefits of each patient being assigned a case manager. Each IMSA item's value has been assessed as a predictor of GPs' opinions by using multivariate logistic models. A score including items retained as predictor was built. RESULTS: Three hundred and thirty one patients participated in the study (participation rate: 62%). Three items from the 20 item IMSA were sufficient to predict GPs' opinions about whether their patients could be expected to benefit if assigned a case manager. Those items addressed the patient's existing chronic diseases (item1), quality of life in relation to existing diseases (item 3), and their social situation (item 9). Using these three items as a score, a cut-off at 4 gave a sensitivity of 70% (ability to correctly identify patients who could benefit from a CM) and specificity of 73% (ability to correctly identify patients who should not benefit from a CM) and concerned about one patient in two. CONCLUSION: Identifying complex patients suitable for case management remains a challenge for primary care professionals. This paper describes a novel approach using a structured process of combining the results of standardized tools such as the one defined in this study, and the experience of the primary care team.

"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.

Le psychiatre comme «.

Résumé Contexte. En Suisse, dans les situations de demandes de suicide assisté, le psychiatre est mis dans une position de « gatekeeper ¼ lorsqu'on lui demande de se prononcer sur la capacité de discernement et sur l'existence d'un éventuel trouble psychiatrique interférant avec cette capacité et qui empêcherait les patients d'accéder à cet acte. OBJECTIF: L'étude explore les motifs des demandes de suicide assisté formulées par des patients hospitalisés dans un service somatique du Centre hospitalier universitaire Vaudois ainsi que les enjeux auxquels le psychiatre fait face. Méthode. L'étude se base sur une analyse rétrospective des rapports psychiatriques, concernant 18 patients de 65 ans ou plus qui ont fait une demande de suicide assisté. Nous avons identifié dans le matériel des motifs manifestes mais aussi des éléments latents, en prenant pour cadre la théorie de l'attachement et une lecture psychodynamique orientée autour des concepts de Moi idéal, Idéal du moi et Surmoi. Résultats. Différentes catégories de motifs de recours au suicide assisté ont été identifiées dans les demandes des patients. Au niveau latent, des indices d'attachement sécure et insécure, de sentiments sous-jacents de honte et d'abandon et plus rarement de culpabilité ont été relevés. Outre des limites liées à l'état du patient, le rôle de gatekeeper a un impact sur les possibilités d'aborder ou d'utiliser ces éléments de manière thérapeutique avec le patient. CONCLUSION: Le psychiatre mis dans un rôle de gatekeeper face au suicide assisté est dans une position peu confortable. Il est amené à penser comment tenir ce rôle tout en demeurant psychiatre de liaison. Abstract Background. In Switzerland, psychiatrists sometimes assume the role of gatekeepers when patients request assisted suicide, evaluating the patient's discernment and the existence of a possible psychiatric disorder interfering with the capacity to discern. OBJECTIVES: Our study explores the motifs of requests for assisted suicide made by patients hospitalized in a somatic service of Lausanne University Hospital and the challenges faced by the psychiatrist as gatekeeper. METHOD: We conducted a retrospective analysis of psychiatric reports concerning 18 patients aged 65 years or older who had requested assisted suicide. We aimed to identify both manifest and latent motifs in the patients' accounts, referring to the attachment theory and a psychodynamic analysis based on the concepts of the Ideal ego, the Ego ideal and the Superego. RESULTS: Different categories of motifs for assisted suicide requests were expressed by the patients. We also found indications of insecure and secure attachment, and underlying feelings of shame and abandonment, more rarely of guilt. In addition to limitations related to the patient's condition, the gatekeeper position limits the possibilities of addressing these issues or using them therapeutically with the patient. CONCLUSION: The psychiatrist' role as a gatekeeper in assisted suicide is uncomfortable. He or she must think about how to assume this role while remaining being a liaison psychiatrist.

[Bio-Psycho-Social Needs Assessment in Family Medicine: Acceptability of the Intermed Self-Assessment]. / Evaluation des besoins bio-psycho-sociaux en médecine de famille: acceptabilité de l'INTERMED Self-Assessment.

Bio-Psycho-Social Needs Assessment in Family Medicine: Acceptability of the Intermed Self-Assessment Abstract. In view of the increasing number of patients with somato-psychic comorbidities, a tool for identifying complex patients such as the INTERMED self-assessment (IMSA) would prove useful in family medicine. An observational study was conducted in a practice with seven general practitioners to evaluate the acceptability of patients to fill in this questionnaire in the waiting room. The IMSA was quickly completed and well accepted by patients, who found the questions easy to understand and relevant to their health. The waiting room environment didn't seem to hinder the process. The majority of participants deemed useful that their doctor received the data from the questionnaire. The IMSA could be implemented in the practice to detect certain psycho-social fragilities at an early stage.

Résumé. Face à l'augmentation du nombre de patients présentant des comorbidités somato-psychiques, un outil d'identification des patients complexes tel que L'INTERMED self-assessment (IMSA) s'avèrerait utile en médecine de famille. Afin d'évaluer l'acceptabilité des patients de remplir ce questionnaire dans la salle d'attente de leur médecin, une étude observationnelle a été menée durant neuf semaines dans un cabinet regroupant sept généralistes. L'IMSA, rapide à remplir, est bien accepté par les patients qui jugent les questions faciles à comprendre et pertinentes pour leur santé. L'environnement de la salle d'attente ne semble pas être un obstacle. La majorité des participants estime utile que leur médecin reçoive les informations du questionnaire. L'IMSA pourrait être implémenté au cabinet pour détecter certaines fragilités psycho-sociales précocement.

Observational study of suicide in Switzerland: comparison between psychiatric in- and outpatients.

AIMS OF THE STUDY: In Switzerland, suicide is a major cause of years of potential life lost. Among people who died by suicide, a significant number suffered from mental illness and were treated by psychiatric care institutions. Psychiatric patients are thus a specific target for suicide prevention. Based on data from a clinical committee reviewing every death by suicide of psychiatric patients in the Canton of Vaud (Switzerland), this observational study aimed to gain knowledge on sociodemographic and clinical characteristics of psychiatric patients who died by suicide by comparing in- and outpatients. METHODS: Sociodemographic and clinical characteristics of patients who died by suicide in our department from January 2007 to December 2019 were analysed. In- and outpatients were compared. RESULTS: The sample included 153 patients (64.7% males, n = 99). Three quarters (76.4%, n = 81) of the patients had at least one previous suicide attempt. In- and outpatients did not differ significantly in terms of sociodemographics data, psychiatric diagnosis or method of suicide. Almost all (97.2%) of the outpatients had at least one past psychiatric hospitalisation. We found gender disparities for several variables and a lower male/female suicide ratio than in the general Swiss population. Seventy-two percent of the outpatients (n = 49) had a last personal contact with clinicians less than a week before their suicide and 38.8 % of those less than 24 hours (28% of outpatients, n = 19). CONCLUSIONS: Patients dying by suicide present most of the time a serious psychiatric history. In- and outpatients seem to have a similar clinical and sociodemographic profile and suicide prevention should thus not be addressed differently in these two groups. The time between death of outpatients and last contact with a therapist was shorter than expected.

[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 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 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.