Dynamics of Students' Career Choice: a Conceptual Framework-Based Qualitative Analysis Focusing on Primary Care.

BACKGROUND: Increasing primary care's attractiveness as a career choice is an important task of socially accountable medical schools. Research has broadly studied influences on medical students' career choice. However, a deeper understanding of the processes behind career decision-making could support medical schools in their efforts to promote primary care careers. OBJECTIVE: To explore the dynamics of career choice during medical school with a focus on primary care, based on a previously developed conceptual framework. APPROACH: Qualitative study using a phenomenological, inductive-deductive approach DESIGN AND PARTICIPANTS: Individual interviews were conducted from May 2019 to January 2020 with 14 first-year postgraduate trainee physicians, graduates of the Faculty of Medicine in Geneva, Switzerland, purposively sampled based on their interest in primary care during undergraduate studies. The interview guide was developed to elicit narratives about career-related decision-making. Two authors coded the transcripts. Thematic analysis alternated with data collection until thematic saturation was reached. Emerging themes were discussed and refined within the research team. KEY RESULTS: Two main themes emerged: (1) developing professional identity, expressed as a changing professional image from unprecise and idealistic to concrete and realistic; priorities changed from content-based to lifestyle-based preferences; (2) individual trajectories of career-related decision-making, determined by different stages of refining professional interests; students navigated this process by employing various strategies, ranging from active exploration to passive behaviors. CONCLUSIONS: This study's narrative approach illustrates the dynamic nature of career choice and refines elements of a conceptual framework previously developed by the authors. Its findings underline the importance of exploration, for which personal experiences and observations of physicians' work are crucial. To advance efforts to make primary care a more attractive career, students must be sufficiently exposed to primary care in a safe and individualized environment and should be supported in all stages of their career choice process.

Multivariate pattern analysis of EEG reveals nuanced impact of negation on sentence processing in the N400 and later time windows.

The neurocognitive mechanism underlying negation processing remains controversial. While negation is suggested to modulate the access of word meaning, no such evidence has been observed in the event-related potential (ERP) literature on sentence processing. In the current study, we applied both univariate ERP and multivariate pattern analysis (MVPA) methods to examine the processing of sentence negation. We investigated two types of negative congruent/incongruent sentence pairs with truth-value evaluation (e.g., "A robin is a/not a bird") and without (e.g., "The woman reads a/no book"). In the N400 time window, ERPs consistently showed increased negativity for negative and incongruent conditions. MVPA, on the other hand, revealed nuanced interactions between polarity and congruency. In the later P600 time window, MVPA but not the ERPs revealed an effect of congruency, which may be functionally distinct from the N400 window. We further used cross-decoding to show that the cognitive processes underlying the N400 window for both affirmative and negative sentences are comparable, whereas in the P600 window, only for the truth sentences, negative sentences showed a distinct pattern from their affirmative counterparts. Our results thus speak for a more interactive, but nevertheless serial and biphasic, and potentially construction-specific processing account of negation. We also discuss the advantage of applying MVPA in addition to the classical univariate methods for a better understanding of the neurobiology of negation processing and language comprehension alike.

Effect of an app for promoting advance care planning and motivating patients to write their advance directives.

BACKGROUND: Accordons-nous, a smartphone app, was developed to support patients in the advance care planning (ACP) process. The app raises awareness and facilitates communication on this sensitive topic. It helps patients express their values and preferences for care and write their advance directives (AD). OBJECTIVE: Measure the impact of distributing Accordons-nous on patients' propensity to engage in the ACP process, compared with the distribution of a leaflet. A secondary objective was to test the effect of socio-demographic factors (age, health status, gender, level of education) on propensity to engage in ACP. METHODS: Pre-post randomized control study. Participants were patients approached in medical waiting rooms. They received the app (treatment) or an information leaflet (control). They responded to two questionnaires: one at recruitment and a second 3-4 weeks later. Improvement on four variables relevant to ACP was measured: reported contemplation of an event relevant to ACP; decision about treatment in case of that event; discussion about it with relatives or health care professionals; writing advance directives. Statistical analysis included between-group comparisons of pre-post differences with 2-sample tests for equality of proportions and logistic regression models. RESULTS: Four hundred seventy three participants were recruited and full responses obtained from 312. Overall, the intervention (control and treatment together) had a positive effect on the mean reported ACP engagement for all variables: new or renewed contemplation 54%; increase in decision 8%, discussion 11%, and writing 1%, compared to the baseline. Compared to the control (leaflet), the treatment group (app) had a larger effect size for all variables: between-group difference in contemplation + 11% (logistic regression, p = .05), decision + 1% (but p > .05 on this variable), discussion + 5% (p = .05), and writing AD + 5% (p = .03). Moreover, greater age was positively correlated with having written AD at inclusion (21% among retired compared to 2% among young adults) and with the propensity to write AD after our intervention (logistic regression, p = .001). Other factors tested (frequency of consultations, gender, level of education) had no effect on participants' ACP engagement. CONCLUSIONS: When distributed without specific counselling, the tool increased reported ACP engagement, although effect sizes remain modest. Further studies are needed to investigate whether the app could generate greater ACP engagement if used by professionals in dedicated ACP consultations.

[Collaboration in home care: first interprofessional ambulatory proximity network]. / Collaboration dans les soins à domicile : un réseau interprofessionnel ambulatoire de proximité.

While interprofessionality is indispensable to respond to home care current issues, its implementation in the practice is a real challenge. The Genevan domiciliary model (reference by a nurse, targeted areas of interventions, etc.) needs to integrate all the resources of proximity. For this purpose, an interprofessional ambulatory and of proximity care network (RIAP) was created, aiming at strengthening the exchanges physicians/nurses about shared patients. RIAP benefits from an encouraging first assessment. Learnings from this experience are used to refine the modeling of this type of proximity network.

Alors que l'interprofessionnalité est indispensable pour répondre aux enjeux actuels du maintien à domicile, sa mise en œuvre dans la pratique représente un véritable défi. Le modèle domiciliaire genevois actuel (référence infirmière, zones d'interventions ciblées, etc.) nécessite d'intégrer toutes les ressources de proximité. Pour ce faire, un réseau de soins interprofessionnel ambulatoire de proximité (RIAP) a été créé, visant au renforcement de l'interprofessionnalité et résolument ancré dans la proximité des différents acteurs. Le RIAP repose notamment sur la consolidation des échanges médecins/infirmières autour de patients communs. Le premier bilan du RIAP est encourageant. Les apprentissages tirés de cette expérience permettent d'affiner la modélisation de ce type de réseau de proximité.

[Eco-competences for a sustainable medical practice]. / Les écocompétences pour une pratique de soins durable en cabinet.

Climate and environmental changes require primary care physicians to adapt their practices. This article presents resources and actions contributing to reduce the impact of medical practice by implementing the CanMEDS competences in an environmental perspective.

Les changements climatiques et environnementaux nécessitent une adaptation des pratiques de soins des médecins de premier recours (MPR). Cet article a pour but de présenter des ressources et actions concrètes ancrées dans le cadre des compétences CanMEDS et permettant de réduire l'impact environnemental de la pratique médicale en cabinet.

[Deep vein thrombosis: new developments and recommendations for the primary care physician]. / Thrombose veineuse profonde : nouveautés et recommandations pour le médecin de premier recours.

The management of deep vein thrombosis is becoming more specific in terms of diagnostic methods and drug treatments. The use of the dichotomous Wells' score is now established. The indications for direct oral anticoagulants have expanded. Prevention and management of the post-thrombotic syndrome are based on compression socks. Their use is individualized and needs repeated assessments in time. This article presents the latest developments and outlines principles involved in the management of superficial, distal and deep vein thrombosis in primary care.

La prise en charge de la thrombose veineuse profonde se précise en termes de méthode diagnostique et de traitements médicamenteux. L'utilisation du score de Wells dichotomique s'est imposée et les indications des anticoagulants oraux se sont élargies. Le port de bas de compression pour la prévention et la prise en charge du syndrome post-thrombotique est maintenant individualisé et basé sur une évaluation répétée dans le temps. Cet article présente ces dernières nouveautés et expose les éléments nécessaires à la prise en charge des thromboses superficielles, distales et profondes en médecine de premier recours.

Students' intentions to practice primary care are associated with their motives to become doctors: a longitudinal study.

BACKGROUND: Medical schools can contribute to the insufficient primary care physician workforce by influencing students' career preferences. Primary care career choice evolves between matriculation and graduation and is influenced by several individual and contextual factors. This study explored the longitudinal dynamics of primary care career intentions and the association of students' motives for becoming doctors with these intentions in a cohort of undergraduate medical students followed over a four-year period. METHODS: The sample consisted of medical students from two classes recruited into a cohort study during their first academic year, and who completed a yearly survey over a four-year period from their third (end of pre-clinical curriculum) to their sixth (before graduation) academic year. Main outcome measures were students' motives for becoming doctors (ten motives rated on a 6-point scale) and career intentions (categorized into primary care, non-primary care, and undecided). Population-level flows of career intentions were investigated descriptively. Changes in the rating of motives over time were analyzed using Wilcoxon tests. Two generalized linear mixed models were used to estimate which motives were associated with primary care career intentions. RESULTS: The sample included 217 students (60% females). Career intentions mainly evolved during clinical training, with smaller changes at the end of pre-clinical training. The proportion of students intending to practice primary care increased over time from 12.8% (year 3) to 24% (year 6). Caring for patients was the most highly rated motive for becoming a doctor. The importance of the motives cure diseases, saving lives, and vocation decreased over time. Primary care career intentions were positively associated with the motives altruism and private practice, and negatively associated with the motives prestige, academic interest and cure diseases. CONCLUSION: Our study indicates that career intentions are not fixed and change mainly during clinical training, supporting the influence of clinical experiences on career-related choices. The impact of students' motives on primary care career choice suggests strategies to increase the attractivity of this career, such as reinforcing students' altruistic values and increasing the academic recognition of primary care.

[Self-care for anxiety in primary care]. / Anxiété en médecine générale : quels types d'autosoins proposer ?

Anxiety is a very common problem in primary care consultations. In addition to standard treatments (psychotropic medications and psychotherapy), many self-care techniques can improve patients' anxiety. A few explanations (psychoeducation) about the role of the autonomic nervous system in stress and anxiety can be helpful to motivate patients to experiment techniques that allow their body to relax and unwind, and to thus take care of themselves. Family doctors who have practiced some of these techniques for themselves can easily teach them to their patients, but they can also recommend face-to-face or Internet courses on the subject.

L'anxiété est un problème très courant dans les consultations de médecine générale. En complément aux traitements classiques (psychotropes et psychothérapie), de très nombreux autosoins (selfcare) peuvent amener un grand bénéfice aux patients anxieux. Quelques explications (psychoéducation) sur le rôle du système nerveux autonome dans le stress et l'anxiété aideront le médecin traitant à motiver son patient à expérimenter des techniques permettant le ressourcement de l'organisme et à s'autoriser à prendre soin de lui-même. Dans l'idéal, le médecin traitant sera capable d'enseigner certaines de ces techniques à ses patients, après les avoir expérimentées lui-même. De nombreux cours et démonstrations existent aussi sur internet ou en présentiel.

[Environmental impact of prescribing in family medicine - Example of simple urinary tract infection]. / Impact environnemental de la prescription en médecine de famille - Exemple de l'infection urinaire simple.

As the pharmaceutical industry keeps growing, the presence and impact of drug residues in water is becoming increasingly well documented. These end up in wastewater after human consumption, and then in surface water if they are not sufficiently removed in wastewater treatment plants, harming aquatic organisms even in minute quantities. Antibiotics and NSAIDs are the most worrying for the environment. We would recommend here a reduction in their prescription in urinary tract infections, considering that spontaneous healing occurs in half of the cases. We indicate more natural alternatives, with a reasonable level of safety despite a low level of evidence.

L'industrie pharmaceutique ne cesse de croître, tandis que la présence et l'impact des résidus médicamenteux dans les eaux sont de mieux en mieux documentés. Ces derniers se retrouvent dans les eaux usées après leur consommation par l'homme, puis dans celles de surface en l'absence d'une élimination suffisante dans les stations d'épuration, nuisant aux organismes aquatiques, même en quantités infimes. Les antibiotiques et les AINS sont les plus préoccupants pour l'environnement. Nous proposons ici une stratégie de réduction de leur prescription dans l'infection urinaire, en tenant compte d'une guérison spontanée dans la moitié des cas. Nous indiquons des alternatives plus naturelles avec un niveau de sécurité raisonnable malgré un niveau de preuve faible.

[Major change in asthma management]. / Changement majeur dans la prise en charge de l'asthme.

According to the latest recommendations, there is no longer place for the use of short-acting beta-2 agonist alone in chronic asthma treatment, due to an increased risk of severe exacerbations and exacerbation-related mortality. Current management of asthma is based on the use of inhaled corticosteroids in combination with formoterol as maintenance and as rescue treatment, thanks to the rapid and prolonged action of formoterol. General practitioners must evaluate, with the patient's collaboration, the treatable factors linked to poor asthma control. They should provide patients with a written treatment plan in order to help patients recognize and manage asthma exacerbation. The place of the pulmonary specialist is currently reserved for the advanced stages of the disease and in case of diagnostic doubt.

Selon les nouvelles recommandations, il n'y a plus de place pour l'utilisation des bêta-agonistes à courte durée d'action seuls dans le traitement de l'asthme chronique, en raison d'un risque accru d'exacerbations sévères et de mortalité. La prise en charge actuelle se base sur l'utilisation combinée de corticostéroïdes inhalés et de formotérol en traitement de fond mais également en traitement de secours, grâce à l'action à la fois rapide et prolongée du formotérol. Le/la généraliste doit évaluer, avec la collaboration du/de la patient-e, les facteurs modifiables liés au mauvais contrôle de l'asthme et lui fournir un plan de traitement afin qu'il/elle puisse reconnaître et gérer les symptômes d'une exacerbation d'asthme. La place du/de la spécialiste est réservée aux stades avancés de la maladie et en cas de doute lors de la pose du diagnostic.

[Use of non-pharmacological home remedies in ENT: research informs our practices and those of our patients]. / Emploi des remèdes de grand-mère en ORL : la recherche éclaire nos pratiques et celles de nos patients.

Upper respiratory tract infections (URTIs) are a common presenting condition in family medicine. The vast majority of URTIs are treated symptomatically with pharmacological or non-pharmacological treatments. This article presents some of the results of our research projects to compile a list of non-pharmacological home remedies to relieve symptoms such as sore throat, coughs and colds. Honey, thyme or lemon are often used by patients and considered to be effective. These remedies have few side-effects, and we therefore propose to include them in the range of treatments that can be proposed in family medicine.

Les infections des voies respiratoires supérieures (IVRS) constituent un motif de consultation fréquent en médecine de famille. La grande majorité des IVRS fait l'objet d'un traitement symptomatique pharmacologique ou non pharmacologique. Cet article se base sur une partie des résultats de nos projets de recherche pour constituer une liste de remèdes de grand-mère à proposer aux patients pour soulager des symptômes tels que les maux de gorge, la toux et le rhume. Le miel, le thym ou le citron sont souvent utilisés par les patients et considérés comme étant efficaces. Ces remèdes présentent peu d'effets indésirables et nous proposons donc de les intégrer dans l'arsenal thérapeutique en médecine de famille.

[Teaching planetary health in pregraduate medical curriculum in Switzerland]. / Enseigner la santé planétaire dans le curriculum médical prégradué en Suisse.

Environmental degradation, including climate change, is causing increasing threats to human health. To address these issues, health professionals, including future physicians, need to be educated in planetary health and sustainable healthcare. This article discusses possible content for pre-graduate education in planetary health and methods of implementation in the curriculum. It outlines several projects carried out in medical universities in Switzerland and underlines the effectiveness of students-led initiatives supported by faculties.

Les dégradations environnementales, dont les changements climatiques, font peser sur la santé humaine des menaces grandissantes. Pour répondre à ces enjeux, les professionnel-le-s de la santé, notamment les futur-e-s médecins, doivent être formé-e-s sur les approches de santé planétaire et de durabilité des soins. Cet article aborde les différents contenus à l'enseignement prégradué en santé planétaire et les méthodes d'implémentation dans le curriculum. Il présente plusieurs projets mis en place dans les facultés de médecine en Suisse et souligne l'efficacité des initiatives menées par les étudiant-e-s avec le soutien des institutions.

[COPD: Guidelines for primary care physicians]. / BPCO: recommandations pour les médecins de premiers recours.

Chronic obstructive pulmonary disease (COPD) is common and should be suspected in any patient with chronic dyspnea, cough, or sputum with a history of exposure to tobacco or harmful particles. Spirometry is used for diagnosis. Full evaluation includes the severity of obstruction and clinical data, following the Global Initiative for Chronic Obstructive Lung Disease guidelines. Although the only treatments that have an impact on mortality are tobacco cessation, pulmonary rehabilitation and, for advanced disease, oxygen therapy, new symptomatic treatment have recently been made available. The duration of antibiotic and corticosteroid treatment for exacerbations has been shortened. The new diagnostic and management recommendations are summarized in this article.

La bronchopneumopathie chronique obstructive (BPCO) est fréquente et doit être suspectée chez tout patient présentant une dyspnée, une toux ou des expectorations chroniques avec une anamnèse d'exposition au tabac ou à des particules nuisibles. La spirométrie permet son diagnostic. Son évaluation se base sur la sévérité de l'obstruction et la clinique et tient compte des recommandations du guide de la Global Initiative for Chronic Obstructive Lung Disease. Bien que les seuls traitements impactant la survie soient l'arrêt du tabac, la réhabilitation respiratoire et tardivement l'oxygénothérapie, des nouveautés sont apparues dans l'arsenal thérapeutique symptomatique. La durée du traitement antibiotique et corticostéroïde des exacerbations est raccourcie. Les nouvelles recommandations diagnostiques et de prise en charge sont résumées dans cet article.

How Do Patients Want Us to Use the Computer During Medical Encounters?-A Discrete Choice Experiment Study.

BACKGROUND: Primary care physicians (PCPs) now widely use electronic health records (EHRs) during medical encounters. Experts in clinical communication issued recommendations for a patient-centered use of EHRs. However, they have never been validated by patients themselves. OBJECTIVE: To explore patients' preferences regarding physicians' EHR-related behaviors. DESIGN: Discrete choice experiment study. PATIENTS: French-speaking patients waiting for a medical consultation at two outpatient clinics in Geneva, Switzerland. MAIN MEASURES: We invited patients to watch videos displaying 2 or 3 variations of four specific EHR-related behaviors and asked them to indicate which one they preferred. EHR-related behaviors were (1) typing: continuous/intermittent/handwriting in biomedical or psychosocial focused consultations; (2) maintaining contact while typing: visual/verbal/both; (3) signposting the use of EHR: with/without; (4) position of physicians' hands and bust: on the keyboard and towards the patient/away from the keyboard and towards the patient/on the keyboard and towards the screen. KEY RESULTS: Three hundred thirty-six patients participated (response rate 61.4%). They preferred intermittent typing versus handwriting or continuous typing for biomedical issues (32.7%; 95% CI: 26.0-40.2% vs 31.6%; 95% CI: 24.9-39.0% or 14.9%; 95% CI: 10.2-21.1%) and psychosocial issues (38.7%; 95% CI: 31.6-46.3% vs 24.4% 95% CI: 18.4-31.5% or 17.9%; 95% CI; 12.7-24.4%). They favored visual and verbal contact (38.9%; 95% CI: 31.9-46.3%) over verbal (30.3%; 95% CI: 23.9-37.5%) or visual contact only (11.4%; 95% CI: 7.5-17.1%) while the doctor was typing. A majority preferred signposting the use of EHR versus no signposting (58.9%; 95% CI: 53.5-64.0% vs 34.8%; 95% CI: 29.9-40.1%). Finally, half of the patients (49.7%; 95% CI: 42.0-57.4%) favored the position with the physician's bust towards the patient and hands away from the keyboard. CONCLUSIONS: Our study shows that patients' preferences regarding EHR-related behaviors are in line with most experts' recommendations. Such recommendations should be more consistently integrated into under- and postgraduate communication skills training.

Understanding GPs' clinical reasoning processes involved in managing patients suffering from multimorbidity: A systematic review of qualitative and quantitative research.

BACKGROUND: Most consultations in primary care involve patients suffering from multimorbidity. Nevertheless, few studies exist on the clinical reasoning processes of general practitioners (GPs) during the follow-up of these patients. The aim of this systematic review is to summarise published evidence on how GPs reason and make decisions when managing patients with multimorbidity in the long term. METHODS: A search of the relevant literature from Medline, Embase, PsycINFO, and ERIC databases was conducted in June 2019. The search terms were selected from five domains: primary care, clinical reasoning, chronic disease, multimorbidity, and issues of multimorbidity. Qualitative, quantitative, and mixed-methods studies published in English and French were included. Quality assessment was performed using the Mixed Methods Appraisal Tool. RESULTS: A total of 2 165 abstracts and 362 full-text articles were assessed. Thirty-two studies met the inclusion criteria. Results showcased that GPs' clinical reasoning during the long-term management of multimorbidity is about setting intermediate goals of care in an ongoing process that adapts to the patients' constant evolution and contributes to preserve their quality of life. In the absence of guidelines adapted to multimorbidity, there is no single correct plan, but competing priorities and unavoidable uncertainties. Thus, GPs have to consider and weigh multiple factors simultaneously. In the context of multimorbidity, GPs describe their reasoning as essentially intuitive and seem to perceive it as less accurate. These clinical reasoning processes are nevertheless more analytical as they might think and rooted in deep knowledge of the individual patient. CONCLUSIONS: Although the challenges GPs are facing in the long-term follow-up of patients suffering from multimorbidity are increasingly known, the literature currently offers limited information about GPs' clinical reasoning processes at play. GPs tend to underestimate the complexity and richness of their clinical reasoning, which may negatively impact their practice and their teaching.

Shifting palliative care paradigm in primary care from better death to better end-of-life: a Swiss pilot study.

BACKGROUND: Patients suffering from advanced cancer often loose contact with their primary care physician (PCP) during oncologic treatment and palliative care is introduced very late. The aim of this pilot study was to test the feasibility and procedures for a randomized trial of an intervention to teach PCPs a palliative care approach and communication skills to improve advanced cancer patients' quality of life. METHODS: Observational pilot study in 5 steps. 1) Recruitment of PCPs. 2) Intervention: training on palliative care competencies and communication skills addressing end-of-life issues. 3) Recruitment of advanced cancer patients by PCPs. 4) Patients follow-up by PCPs, and assessment of their quality of life by a research assistant 5) Feedback from PCPs using a semi-structured focus group and three individual interviews with qualitative deductive theme analysis. RESULTS: Eight PCPs were trained. Patient recruitment was a challenge for PCPs who feared to impose additional loads on their patients. PCPs became more conscious of their role and responsibility during oncologic treatments and felt empowered to take a more active role picking up patient's cues and addressing advance directives. They developed interprofessional collaborations for advance care planning. Overall, they discovered the role to help patients to make decisions for a better end-of-life. CONCLUSIONS: While the intervention was acceptable to PCPs, recruitment was a challenge and a follow up trial was not deemed feasible using the current design but PCPs reported a change in paradigm about palliative care. They moved from a focus on helping patients to die better, to a new role helping patients to define the conditions for a better end-of-life. TRIAL REGISTRATION: The ethics committee of the canton of Geneva approved the study (2018-00077 Pilot Study) in accordance with the Declaration of Helsinki.

[Teaching conflicts of interest with industry as a « role model ¼]. / Enseigner les conflits d'intérêts avec l'industrie ­ l'importance du « modèle de rôle ¼.

General practitioners should be trained to teach their student about conflicts of interest with the private sector. Beyond the common issues linked to biomedical research and publications, the daily repercussions of these conflicts of interest on medical practice and prescribing must be recognized, whether it be about medical representatives, gifts, or continuing medical education. Only with a complete understanding of these daily challenges to professional ethics will it be possible to represent an appropriate "role model" for students.

Les médecins de famille doivent savoir enseigner aux étudiantes les enjeux concrets des conflits d'intérêts avec l'industrie. S'il est essentiel de connaître en amont l'importance de ces conflits dans la recherche et les publications biomédicales, il est tout aussi crucial de mesurer les implications pratiques de conflits rencontrés dans la pratique quotidienne, qu'il s'agisse de rendez-vous avec les représentantes médicauxales, de cadeaux offerts par l'industrie, ou encore de financement privé pour la formation continue. C'est par la connaissance de ces influences quotidiennes et la mise en œuvre d'un code de conduite strict dans leur pratique que les médecins de famille, comme « modèles de rôle ¼ possibles, peuvent transmettre une approche déontologique solide aux étudiantes sur la question des conflits d'intérêts avec l'industrie.

[The use of Advance Care Planning in primary care medicine]. / Utilisation du projet de soins anticipé en médecine de premier recours.

The ambulatory management of end-of-life patients is often a complex and delicate process for general practitioners. It is often difficult for them to tackle the question of the end of life and even more so to plan for it. The Advance Care Planning (ACP) aims overall to anticipate the end of life of patients and to ensure that their choices are respected, thereby improving their quality of life at the end of life. General practitioners could therefore benefit from a tool inspired by the ACP, in an outpatient context. This article presents such a tool, built in the form of a grid: now included in an electronic file used by more than 1'500 general practitioners, we hope that this document will be used for the future improvement of the ACP approach by general practitioners with their patients.

La prise en charge ambulatoire des patients en fin de vie est un processus souvent complexe et délicat pour les médecins généralistes. Il leur est, en effet, souvent difficile d'aborder la question de la fin de vie et encore plus de la planifier. Le projet de soins anticipé (PSA) vise globalement à anticiper la fin de vie des patients et à veiller au respect de leurs choix, améliorant de ce fait leur bien-être en fin de vie. Les médecins généralistes pourraient donc bénéficier d'un outil inspiré du PSA, dans un contexte ambulatoire. Cet article présente un tel outil, construit sous forme de grille : maintenant incluse dans un dossier informatique utilisé par plus de 1500 médecins en Suisse romande, nous espérons que ce document servira à l'amélioration future de l'approche du PSA par les généralistes avec leurs patients.

[Pedagogical Quality Cercle: a new tool for ambulatory clinical supervisors]. / Cercle de qualité pédagogique : un nouvel outil pour les clinicien·ne·s enseignant·e·s en médecine ambula.

Supervisors in clinical practice need to engage in continuous education so as to acquire the appropriate pedagogical tools to continue improving their teaching abilities. A new monthly « Pedagogical Quality Cercle ¼ (PQC) has recently been developed to provide a virtual and innovative exchange of practices focused on supervisors' difficulties during clinical placements. The article presents the conceptual framework of PQC and their teaching communities of practice and gives an example of a typical exchange between PQC facilitators and clinical teachers during a session. Future developments of CQP sessions are discussed to show how they will contribute to the improvement of the teaching skills of clinical supervisors in French-speaking Switzerland.

La tâche pédagogique des clinicien·ne·s enseignant·e·s en cabinet (CEC) entraîne une nécessité de formation continue. Ceci afin de s'approprier les outils adéquats pour porter son stagiaire vers une autonomie croissante tout en reconnaissant les points d'amélioration du superviseur comme de l'apprenant. Le cercle de qualité pédagogique (CQP) proposé par l'Institut universitaire de médecine de famille et de l'enfance est un nouvel espace ­ virtuel mais dynamique ­ d'échange de pratiques orienté sur les difficultés de supervision des CEC. Nous présentons les bases théoriques du CQP avec ses avantages en cours de stage et proposons un exemple concret d'échange entre modérateurs et CEC. Nous précisons enfin le futur des CQP qui permettra d'élargir la formation des CEC romands.

[Intensive psychosocial medicine in primary care : some practical tools]. / Médecine psychosociale intensive au cabinet : quelques outils pratiques.

The psychosocial crisis is a frequent problem. Because of its complexity and variable nature, it can exceed the resources (administrative, communication) available to the family doctor in his daily practice. It requires specific tools in order to take care of the patient as a whole and identify the main issues. This article details some of these tools such as time management, communication and networking, that allow the practitioner to identify risk situations and manage care for these complex patients during the acute phase of the crisis, as well as in the long term through an often multidisciplinary care.

La crise psychosociale est un problème fréquent. Du fait de sa complexité et de sa nature variable, elle peut dépasser les ressources (administratives, communicationnelles) dont dispose le médecin de famille dans sa pratique quotidienne. Elle nécessite des outils spécifiques afin de prendre en charge le patient dans sa globalité et d'identifier les problématiques principales. Cet article détaille certains de ces outils, tels que la gestion du temps, la communication et le travail en réseau, qui permettent d'identifier les situations à risque et de prendre en charge ces patients complexes lors de la phase aiguë de la crise, mais également sur le long terme à travers une prise en charge souvent multidisciplinaire.