[Prescription of psychotherapy provided by psychologists : a new role for general practitioners ?] / Prescription de psychothérapie dispensée par des psychologues : nouveau rôle des généralistes ?

This article focuses on the new model for prescribing psychotherapy provided by psychologists that has been in effect in Switzerland since July 1, 2022. Psychologists can now practice as independent providers with a prescription from a primary care physician for a given number of sessions. This new law, which should facilitate access to mental health care, introduces new administrative issues for general practitioners and transforms their relationship with their patients and psychologists. This phenomenon is part of a broader system of care that is changing and requires a great deal of adaptation on the part of front-line workers. Close collaboration between prescribing physicians, psychologists, psychiatrists and patients is therefore essential.

Cet article traite du modèle de prescription de psychothérapie prodiguée par les psychologues appliqué depuis le 1er juillet 2022 en Suisse. Les psychologues peuvent désormais exercer leurs activités en tant que prestataires indépendant-es sur ordonnance d'un-e médecin de premier recours, pour un nombre de séances donné. Cette loi, qui devrait faciliter l'accès aux soins de santé mentale, introduit de nouveaux enjeux administratifs pour les généralistes et transforme leur relation avec leurs patient-es et les psychologues. Ce phénomène s'inscrit plus globalement dans un système de soins qui change et demande beaucoup d'adaptation de la part des intervenants de première ligne. Une étroite collaboration entre médecins prescripteurs, psychologues, psychiatres et patient-es est désormais indispensable.

[REVIAC: ten years of advice for populations in vulnerable situations]. / REVIAC : dix ans de conseil pour les populations en situation de vulnérabilité.

The REVIAC device was designed ten years ago, with the aim of advising social workers in their efforts to support and reintegrate people in vulnerable situations. In this article, it will be a question of identifying the current issues and the challenges to be met for the future.

Le dispositif REVIAC a été conçu il y a dix ans dans le but de conseiller les assistants et assistantes sociales dans leurs démarches pour soutenir et réinsérer les personnes en situation de vulnérabilité. Dans cet article, il sera question de repérer les enjeux actuels et les défis à relever pour le futur.

A Cross-Sectional Study of the Prevalence and Determinants of Common Mental Health Problems in Primary Care in Switzerland.

Objective: This study investigated the prevalence of the most common mental health symptoms in a large primary care patient population and characterized their determinants. Methods: Data came from a 2015-16 cross-sectional study of a primary care population in Switzerland. An investigator presented the study to patients in waiting rooms, and 1,103 completed a tablet-based questionnaire measuring stress in daily life, sleep disorders and anxiety and depressive symptoms. Diagnoses and treatments were recorded. Results: Moderate-to-high anxiety and depressive symptoms concerned 7.7% of patients; 27.6% felt stressed at least once a week; 17.2% had severe sleep disorders. Sociodemographic determinants were associated with psychiatric symptoms: female sex, young age, and frequency of consultations with a GP. Participants taking psychotropics had high levels of mental distress. Conclusion: Even though most patients were regularly monitored by their GP, a significant number of mental health problems were found. GPs should be provided with concrete tools to manage these patients better. Collaboration with mental health specialists should be encouraged in primary care settings.

Psychiatric consultation in general practitioners' daily practice: a qualitative study on the experience of consultation-liaison psychiatry interventions in primary care settings in French-speaking Switzerland.

BACKGROUND: Mental disorders are frequent in primary care settings, which is challenging for primary care physicians. In Neuchâtel (Switzerland), a Consultation-Liaison psychiatrist integrated three primary care group practices, proposing both clinical interventions and supervisions/psychiatric training. Primary care physicians' experience regarding this collaboration was investigated. METHODS: A qualitative study was conducted. Three focus groups were organized in each primary care group practice involved in the project (10 primary care physicians participated in focus groups). Data were analysed with thematic content analysis. RESULTS: Six major themes emerged from our analysis, describing primary care physicians' collaboration with psychiatrists: 1) Impact on a difficult to reach and "reluctant to consult" population; 2) Fluidity of the intraprofessional collaboration; 3) Influence on the doctor-patient relationship; 4) Positive emotional experiences; 5) Psychiatric counselling and training; 6) Long-term prospects for the project. CONCLUSIONS: Consultation-Liaison psychiatrist's presence came as a relief for participating primary care physicians, facilitating accessibility to mental healthcare, introducing a common culture of care, and offering "in-situ" psychiatric training. Primary care physicians felt that their relationships with patients benefited from such interventions, being better able to deal with complex emotional experiences and found patients more confident regarding proposed care. Models of psychiatric intervention provided in primary care must establish settings of collaboration that reinforce relationships between primary care physicians, psychiatrists, and patients.

Risk Perception Related to COVID-19 and Future Affective Responses Among Healthcare Workers in Switzerland: A Mixed-Methods Longitudinal Study.

Objectives: Whereas early findings suggest that risk perceptions related to COVID-19 affect psychological well-being in healthcare workers (HCWs), the temporal associations between these variables need to be clarified and HCWs lived experience further explored. This study proposes a mixed evaluation of COVID-19-related risk perception and affective responses among HCWs. Methods: A longitudinal mixed-method study was conducted. HCWs (N = 138) completed measures of COVID-19 risk perceptions, depression, anxiety, burnout and secondary traumatic stress (STS) at baseline and 6 months later. A subsample (n = 20) participated in semi-structured interviews exploring both risk perceptions and affective responses. Results: Main quantitative findings showed positive associations between worry to contaminate others and depression (IRR = 1.04, p < 0.05), anxiety (IRR = 1.03, p < 0.01), STS (b = 0.3, p < 0.05), and perceptions of lacking protection (IRR = 1.04, p < 0.05) with anxiety scores. Four themes emerged from the thematic content analysis: 1) life was turned upside down; 2) skills were put in quarantine; 3) dealing with patient discomfort; 4) balance to be found between protection and restrictions. Conclusion: These findings emphasize the importance to develop tailored interventions, such as group discussion sessions, to optimize risk perception and help manage uncertainty.

[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.

[Social integration income medical advisor : update in 2021]. / Dispositif de médecin-conseil pour le revenu d'insertion : état des lieux en 2021.

The social and professional measures suggested to beneficiaries of the Insertion Income have demonstrated their effectiveness. However, presence of mental disorders complicates their implementation, causing difficulties for both beneficiaries and social services. The integration of psychiatrist as medical advisors, as for the canton of Vaud, helps to support the role of medical advisors. Psychiatric intervention aims to strengthen the detection of mental conditions and to improve the relationship between the social worker and his·her beneficiary. The integration of a consultation-liaison psychiatry model in the role of medical consultant seems to bring undeniable advantages and avoidance of stigmatization and chronicization of mental disorders.

Les mesures d'insertion socioprofessionnelles proposées aux bénéficiaires du revenu d'insertion (RI) ont démontré leur efficacité. Cependant, la présence de troubles psychiques complexifie leur mise en place, engendrant des difficultés tant pour les bénéficiaires que pour les services sociaux. L'intégration de psychiatres dans l'équipe des médecins-conseils du RI, à l'instar du canton de Vaud, est une réponse pour y faire face. L'intervention psychiatrique vise ainsi à renforcer la détection des troubles psychiques et à améliorer la relation entre l'assistant·e social·e et son·sa bénéficiaire. L'intégration d'un modèle de psychiatrie de consultation-liaison dans le rôle de médecin-conseil semble apporter des avantages indéniables et permettrait également de lutter contre la stigmatisation et la chronicisation des troubles psychiques.

Coronavirus biopolitics: the paradox of France's Foucauldian heritage.

In this short paper we analyse some paradoxical aspects of France's Foucauldian heritage: (1) while several French scholars claim the COVID-19 pandemic is a perfect example of what Foucault called biopolitics, popular reaction instead suggests a biopolitical failure on the part of the government; (2) One of these failures concerns the government's inability to produce reliable biostatistical data, especially regarding health inequalities in relation to COVID-19. We interrogate whether Foucaldianism contributed, in the past as well today, towards a certain myopia in France regarding biostatistics and its relation to social inequalities in health. One might ask whether this very data could provide an appropriate response to the Foucauldian question: What kind of governance of life is the pandemic revealing to us?

[Detection and treatment of burnout by physicians of Unisanté]. / Repérage et prise en charge des patients en burnout par les médecins d'Unisanté.

Lacking diagnostic standards, the prevalence of Occupational Burnout (OB) remains uncertain. Unisanté aimed to evaluate its magnitude in its patients and to evaluate the medical practices related to OB in two of its departments, the Department of the Policlinics (DDP) and the Department of Occupational and Environmental Health (DSTE). An online survey has shown that 43/55 of the physicians participating in the survey have already diagnosed patients with OB in their practice. Two focus groups allowed to evaluate the interest and usefulness of a standardized diagnostic tool for physicians of the DDP and the DSTE. The tool turned out not to be appropriate in its present form, but this work allowed to sensitize physicians to OB and to clarify the recommendations for the screening and treatment of OB patients at Unisanté.

Faute de standard diagnostique, la prévalence de burnout professionnel (BP) reste incertaine. Unisanté a souhaité évaluer son ampleur dans sa patientèle et décrire les pratiques médicales en rapport au BP dans 2 de ses départements, le Département des policliniques (DDP) et le Département santé, travail et environnement (DSTE). Une enquête en ligne a montré que 43/55 médecins participant à l'étude ont déjà diagnostiqué des patients en BP dans leur pratique. Deux focus groups ont permis d'évaluer l'intérêt et l'utilité d'un outil diagnostique standardisé pour les médecins du DDP et du DSTE. L'outil s'est avéré peu adapté sous sa forme actuelle, mais ce travail a permis de sensibiliser les médecins au BP et de clarifier les recommandations de dépistage et de prise en charge des patients en BP à Unisanté.

[«â€ Group medical practices†¼ project†: collaboration between primary care medicine and institutional public psychiatry]. / Projet «â€ cabinets de groupe†¼â€ : collaboration entre médecine de premier recours et psychiatrie.

Collaboration between primary care medicine and psychiatry is a well-known challenge. In order to improve access to psychological care for patients undergoing primary care, the «â€…group medical practices ¼ project proposes a collaborative care model in which a psychiatrist employed by a public psychiatric institution integrates group medical practices in order to provide assistance to primary care physicians. It is thus able to evaluate patients directly in the practices and to offer supervision and consilium spaces to primary care physicians.

La collaboration entre la médecine de premier recours et la psychiatrie représente une difficulté bien connue. Pour améliorer l'accès aux soins psychiques des patients suivis en médecine de premier recours, le projet «â€…cabinets de groupe ¼ propose un modèle de soins collaboratifs dans lequel un psychiatre employé d'une institution psychiatrique publique intègre des cabinets de groupe afin d'apporter son aide aux médecins de premier recours (MPR). Il est ainsi en mesure, d'une part, d'évaluer les patients directement au sein des cabinets et, d'autre part, d'offrir des espaces de supervision et de consilium aux MPR.

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.

Protocol of a longitudinal study on the specific needs of Syrian refugee families in Switzerland.

BACKGROUND: The ongoing Syrian civil war has led to massive population displacements, leading to the reorganization of the asylum policies of several countries. Accordingly, like other European countries, the Swiss government has recently chosen to implement a specific resettlement program. This program is characterized by the fact that the whole nuclear family is granted a work and residence permit upon arrival, and benefits from enhanced integration services. The aim of the present project is to evaluate the effects of the Swiss resettlement program, with a special focus on mental health, while adopting a family perspective. METHODS: The outcomes of 15 Syrian families taking part in this program will be compared to those of 15 Syrian families that came to Switzerland through other means (i.e., following the usual asylum procedure, which is much more stressful and time consuming). Each family member above 8 years old will be invited to participate to a 3-wave longitudinal survey concerning the resettlement process: upon arrival in the collective shelters, six and 12 months later. Questionnaires will be used for the evaluation of participants' mental health, risk behaviors, general health, romantic relationship, parent-child relationship, family functioning, parentification, social support, and social identities related to group belongingness. DISCUSSION: The findings of the present project will provide longitudinal information on Syrian refugees. A comprehensive approach will be adopted by screening potential difficulties that the sample may be faced with and potential strengths that participants may rely on. Accordingly, physical and mental health, as well as the quality of family functioning, the feeling of support and of belongingness to different groups will be evaluated. We will also compare the results of families who had the chance to immigrate through the Swiss resettlement program, to the results of families that did not. This comparison will allow the elaboration of hypotheses regarding adjusted asylum policies. Furthermore, it will enhance our knowledge regarding the impact of displacement on the family system. Indeed, although the role of the family for the well-being of adults and children has been established, surprisingly few studies have adopted this focus in the asylum field.

[From a different angle : supervision of general internal medicine practitioners by psychiatrists and its benefits]. / Déplacer le regard : apports de la supervision psychiatres/médecins généralistes.

The supervision of general internal medicine practitioners by psychiatrists is an opportunity to take a step back from the daily medical practice. In this article, we adopt an interdisciplinary perspective on these supervisory practices, combining a number of insights and perspectives from both psychiatry and sociology. We aim at initiating a broader and more rigorous reflection on such supervisions, which remain little theorized although they are clearly appreciated by those who benefit from them.

Les supervisions de médecins généralistes/internistes par des psychiatres sont l'occasion de prendre du recul par rapport à la clinique quotidienne. Dans cet article, nous adoptons une perspective interdisciplinaire sur ce dispositif, en mobilisant conjointement certains apports et perspectives issus de la psychiatrie et de la sociologie. L'enjeu est d'entamer une réflexion plus ample et rigoureuse sur ces pratiques de supervision qui, si elles sont manifestement appréciées de ceux qui en bénéficient, restent peu théorisées.

Difficult patient-doctor encounters in a Swiss university outpatient clinic: cross-sectional study.

INTRODUCTION: Previous research has shown that multiple factors contribute to healthcare providers perceiving encounters as difficult, and are related to both medical and non-medical demands. AIM: To measure the prevalence and to identify predictors of encounters perceived as difficult by medical residents. DESIGN AND SETTING: Cross-sectional study at the Department of Ambulatory Care and Community Medicine (DACCM), a university outpatient clinic with a long tradition of caring for vulnerable patients. METHOD: We identified difficult doctor-patient encounters using the validated Difficult Doctor-Patient Relationship Questionnaire (DDPRQ-10), and characterised patients using the patient's vulnerability grid, a validated questionnaire measuring five domains of vulnerability, both completed by medical residents after each encounter. We used a multiple linear regression model with the outcome variable as the DDPRQ-10 score, controlling for resident characteristics. PARTICIPANTS: We analysed 527 patient encounters performed by all 27 DACCM residents (17 women and 10 men). We asked each medical resident to evaluate 20 consecutive consultations starting on the same date. OUTCOME: One hundred and fifty-seven encounters (29.8%) were perceived as difficult. RESULTS: After adjusting for differences among residents, all five domains of the patient vulnerability grid were independently associated with a difficult encounter: frequent healthcare user; psychological comorbidity; health comorbidity; risky behaviours and a precarious social situation. CONCLUSION: Nearly a third of encounters were perceived as difficult by medical residents in our university outpatient clinic that cares for a high proportion of vulnerable patients. This represents twice the average ratio of difficult encounters in general practice. All five domains of patient vulnerability appear to have partial explanatory power on medical residents' perception of difficult patient encounters.

[Assumption of sincerity in medicine]. / Postulat de sincérité en médecine.

Medical practice is always embedded in time and space, whatever its scientific and technical progress could claim as universal truths. The postulate of sincerity is one those contextual elements but it has become so pervasive that a gloss of evidence surrounds it. This situation is at risk of loosing its depth, as much as its limits. By bringing closer together sincerity with more usual notions (transparency, confidence, uncertainty), one could get more insight into these matters of concern in medical practice.

La pratique médicale est toujours ancrée dans un temps et un lieu, quelles que soient les avancées scientifiques et techniques auxquelles elle a contribué et qui peuvent prétendre à une reconnaissance universelle. Le postulat de sincérité fait partie de ces déterminants contextuels, mais son statut contemporain « d'évidence ¼ risque de faire oublier sa profondeur, tout comme ses limites. En rapprochant la sincérité d'autres notions plus couramment évoquées (transparence, confiance, incertitude), nous verrons dans quelle mesure elle permet de les questionner à nouveaux frais.

[The hospital as space and as territory]. / L'hôpital comme espace et comme territoire.

Space is lived individually and collectively and can become a source of existential affectation, especially when the lived experience is modified by disease. The fact that the hospital is also a place of territorialisation can potentiate this affectation, with at times surprising consequences. We aim - based on a reflection about the relationship patients and clinicians establish with the territory of the hospital- to identify some psychological and existential issues at stake with regard to space as a social construction.

L'espace, sur le plan individuel et collectif, peut devenir une source d'affectation d'ordre existentiel, particulièrement lors d'une modification du vécu par la maladie. Le fait que l'hôpital soit aussi un lieu de territorialisation peut potentialiser cette affectation, avec des conséquences parfois surprenantes. Nous essaierons ­ à l'aide d'une réflexion sur le rapport des patients et soignants au territoire hospitalier ­ d'identifier quelques enjeux psychiques et existentiels que représente l'espace comme construction sociale.

[What remains of our Balints ?] / Que reste-t­il de nos Balint ?

In addition to providing psychiatric care to patients with somatic diseases, liaison psychiatry plays a role in the teaching of the relational aspects of medical practice. This series of three articles offers a critical reflection on this topic and examples of educational programs developed at Lausanne University Hospital. In the Department of Ambulatory Care and Community Medicine, an intervention inspired by Balint groups offers to residents in general internal medicine the possibility of working through their clinical experiences and their evolving professional identity.

En plus des soins psychiatriques qu'elle propose aux patients souffrant de problèmes somatiques, la psychiatrie de liaison joue un rôle important dans la formation aux aspects relationnels de la pratique médicale. Cette série de trois articles propose une réflexion critique sur ces enjeux et présente certaines des formations mises en place par le Service de psychiatrie de liaison du CHUV. Dans le cadre de la consultation de médecine générale de la Policlinique médicale universitaire, un dispositif inspiré des groupes Balint offre aux médecins assistants un espace pour élaborer leurs expériences cliniques et les transformations identitaires qui accompagnent leur formation. Nous espérons ainsi contribuer à former des médecins capables d'un retour réflexif sur leur pratique et conscients des enjeux personnels et sociétaux qu'elle mobilise.

[Toward the lived experience of the physician]. / Le médecin au centre: pour une approche de l'expérience vécue.

For manyyears, a major focus of interest has been the patient, in the context of a constantly changing society and increasingly complex medical practices. We propose to shift this focus on the physician, who is entangled in a similar, but less evident way. In these three articles, we explore, in succession, the lived experience of the contemporary physician, the ethos which brings together the medical community, and the education of the future physician, using research projects currently under way within the Service of Liaison Psychiatry at Lausanne University Hospital. In this first article, we particularly raise the question of what is the lived experience of the physician and sketch the outline of <> research.

[Three aspects of the medical ethos]. / Trois aspects de l'éthos médical.

For many years, a major focus of interest has been the patient, in the context of a constantly changing society and increasingly complex medical practices. We propose to shift this focus on the physician, who is entangled in a similar, but less evident way. In these three articles, we explore, in succession, the lived experience of the contemporary physician, the ethos which brings together the medical community, and the education of the future physician, using research projects currently under way within the Service of Liaison Psychiatry at Lausanne University Hospital. Here, we describe three aspects of the medical ethos shaping medicine and the physicians: pragmatism, scientific rationality, and the individualistic embodiment of clinical practice.