[Prevention recommendations for transgender persons]. / Recommandations de prévention chez les personnes transgenres.

Transgender people are at risk of being in worse health than the cisgender population. On the one hand, they encounter specific health problems, mostly related to the impact of minority stress on their mental and somatic health. On the other hand, the preventive recommendations usually do not account for gender-affirming hormonal or surgical treatments that can alter their biologic or anatomic risk profile. The health of transgender people is an area in which research is yet sparse, professionals seldom trained, and where uncertainty remains. The aim of this review article is to summarize the current state of knowledge and propose recommendations for clinical practice.

Les personnes transgenres sont à risque d'avoir une moins bonne santé que la population cisgenre. D'une part, elles rencontrent des problématiques de santé spécifiques, majoritairement en lien avec l'impact du stress minoritaire sur leur santé mentale et somatique. D'autre part, les conseils de prévention habituels ne prennent que rarement en compte l'éventuel recours à des traitements hormonaux ou chirurgicaux d'affirmation de genre pouvant modifier les profils de risque sur les plans biologiques ou anatomiques. La prévention chez les personnes transgenres est une thématique pour laquelle la recherche est peu fournie, les professionnel-le-s peu formé-e-s et l'incertitude présente. Cet article a pour objectif de faire le point sur l'état actuel des connaissances et de proposer des recommandations pour la pratique clinique.

[Applying consent, in healthcare and beyond]. / Appliquer le consentement, dans les soins et au-delà.

Sexual violence constitutes a form of gender-based violence, to the extent that the victims are mainly women. Other groups of vulnerable people are also more affected, in particular gender and sexual diversity persons. Sexual and gender-based violence can also occur in healthcare. To respect the legal framework and people's rights, but also to promote safety and quality in healthcare, it is essential to obtain and respect consent. Consent must be informed, explicit, freely given, and reiterated throughout the consultation. This article reviews the concept of consent and offers practical tools for its application in healthcare.

Les violences sexuelles constituent une violence de genre, dans la mesure où les victimes sont principalement des femmes et les auteurs des hommes. D'autres groupes de personnes vulnérables sont également davantage concernés, en particulier les personnes de la diversité sexuelle et de genre. Ces violences sexuelles et de genre existent également dans les soins. Afin de respecter le cadre légal et les droits des personnes, mais aussi de favoriser des soins de qualité et en sécurité, il est primordial de recueillir et respecter le consentement. Celui-ci doit être éclairé, explicite, libre et réitéré tout au long de la consultation. Cet article fait le point sur le concept du consentement et offre des outils pratiques pour son application dans les soins.

[Teaching health equity in the French-speaking part of Switzerland : inventory in 2023]. / Enseignements sur l'équité en santé en Suisse romande : état des lieux en 2023.

The theme of health equity was for a long time absent or little addressed in the pre- and postgraduate teaching programs of universities and training university hospitals in Switzerland. This gap has gradually been filled by the development and provision of structured teaching on health equity, adapted to the needs of their target audiences. This article aims to highlight a selection of teachings that have emerged in recent years in the French-speaking part of Switzerland.

La thématique de l'équité en santé a été pendant longtemps absente ou peu abordée dans les programmes d'enseignement pré et post-gradué des universités et établissements hospitaliers de formation en Suisse. Cette lacune a été progressivement comblée par le développement et la mise à disposition de formations structurées portant sur l'équité en santé, adaptées aux besoins de leurs publics cibles. Cet article vise à mettre en avant une sélection d'enseignements qui ont vu le jour ces dernières années en Suisse romande.

[LGBTQIA+ people: care issues in the emergency department]. / Personnes LGBTQIA+ : enjeux de prise en charge aux urgences.

Visits to the emergency department are often a difficult time for LGBTQIA+ people, mainly because of the frequent discrimination in healthcare environments and the lack of knowledge of medical and nursing staff. This article begins by presenting some epidemiological features, before discussing specific issues such as contraception and fertility, hormone therapy, sexually transmitted infections, surgical complications, psychiatric pathologies, and traumatology, from the perspective of the emergency physician. Finally, suggestions for further reflection and improvement are proposed.

Les visites aux urgences représentent souvent des moments difficiles pour les personnes LGBTQIA+, principalement en raison des discriminations particulièrement fréquentes dans les milieux de soins et du manque de connaissances du personnel médico-soignant. Cet article présente dans un premier temps quelques chiffres épidémiologiques, avant de discuter des enjeux spécifiques, comme la contraception et la fertilité, l'hormonothérapie, les infections sexuellement transmissibles, les complications opératoires, les pathologies psychiatriques ou la traumatologie, le tout sous le prisme de l'urgentiste. Enfin, des pistes de réflexion et d'amélioration sont proposées.

[Gender and sexual diversity medicine:ensuring equity in health care delivery]. / Médecine et diversité sexuelle et de genre : assurer l'équité dans les soins de santé.

The literature on the subject systematically shows that LGBTIQ+ people suffer from a worse health status than heterosexual and cisgender people. They are subject to more medical errors, discriminations, and delays in receiving care. They face many specific barriers in their access to care. Health institutions and health care professionals have the responsibility to adapt to the specific health needs of LGBTIQ+ people and to offer quality healthcare free from discrimination. This article highlights these barriers and proposes strategies to overcome them, both at individual and organisational levels.

Les études sur le sujet démontrent de manière systématique que les personnes LGBTIQ+ présentent un moins bon état de santé que la population hétérosexuelle et cisgenre. Elles sont plus souvent victimes d'erreurs médicales, de délais dans la prise en soins et de discrimination, et elles rencontrent des barrières spécifiques d'accès aux soins. Les institutions de santé et les professionnel-le-x-s y travaillant ont la responsabilité de s'adapter aux besoins de santé spécifiques aux personnes LGBTIQ+ afin de leur offrir des soins de qualité, inclusifs et libres de discrimination. Cet article a pour objectif de décrire ces barrières et de proposer des stratégies pour y remédier, tant au niveau individuel qu'organisationnel.

[New approaches to risk and the use of electronic tools in primary care medicine in 2021]. / Approches du risque et usage d'outils électroniques en médecine de premier recours en 2021.

Our selection of articles published in 2021 sheds light on topics related to risk, and to the use of electronic tools in primary care medicine. They cover blood pressure targets, telemonitoring, and the omega-3 fatty acid diet in the elderly and/or in patients with high cardiovascular risk. They present the role of primary care physicians in the management of patients with NAFLD, and in screening for domestic violence in all couples. They assess the risk of recurrence of a depressive episode after stopping antidepressant treatment. Finally, they discuss the place of apps to communicate with foreign-speaking patients and of vaping in smoking cessation.

Notre sélection d'articles parus en 2021 propose un éclairage sur des sujets en lien avec le risque chez nos patient·e·s et l'usage d'outils électroniques. Ils abordent le thème des cibles tensionnelles, du télémonitoring, et du régime riche en acides gras oméga 3 chez la personne âgée et/ou à haut risque cardiovasculaire. Ils présentent le rôle des médecins de premier recours dans la prise en charge de patient·e·s avec une stéatopathie métabolique, et dans le dépistage des violences conjugales dans tous les couples. Ils évaluent les risques de récidive d'épisode dépressif à l'arrêt d'un traitement antidépresseur. Enfin, ils discutent la place des applications pour la communication avec les patient·e·s allophones et du vapotage dans l'arrêt du tabac.

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.

[Bias in the consultation : What tools for the clinician ?] / Biais dans la consultation : quels outils pour le·la clinicien·ne ?

Implicit biases are a daily occurrence during medical consultations. Biases disrupt the clinical judgment and modify the attitude of the practitioner. They are a source of medical errors and they impact negatively all indicators of quality of care. Biases are rooted in collective stereotypes and individual prejudice and can contribute to sexual harassment and discrimination. Developing strategies to reduce stereotypes and their impact must be a part of any program targeting sexual harassment, sexism or discrimination of any kind. This article offers an understanding of the essence of biases, based on complex cognitive processes, and proposes strategies to increase awareness at the individual and collective level.

Les biais implicites sont quotidiens lors de la consultation médicale. Perturbant le jugement clinique et l'attitude des professionnel·le·s, ils peuvent être à l'origine d'erreurs médicales et avoir un impact négatif sur l'ensemble des indicateurs de qualité des soins. Les biais peuvent avoir pour source les stéréotypes ancrés dans la société ou les préjugés de chacun·e et aboutir à une forme de discrimination. L'élaboration de stratégies permettant de réduire les stéréotypes fait donc partie intégrante de la lutte contre le harcèlement sexuel et toutes sortes de discriminations. Cet article propose des outils de compréhension de l'essence des biais, basée sur des processus cognitifs complexes, et une gamme de stratégies offrant un renforcement de la prise de conscience à l'échelle individuelle et collective pour en diminuer l'impact.

[Covid-19: how the pandemic revealed gender inequalities]. / Covid-19 : dans le genre on peut faire mieux !

The SARS-CoV-2 pandemic has revealed inequalities between men and women and has deepened some existing disparities. While in Switzerland, more women than men have been infected, men have been at greater risk of developing complications and dying. A weaker immune response and more co-morbidities help to explain this poorer prognosis. Socially and economically, women have become more precarious as a result of less stable employment and greater involvement in domestic work. Domestic violence has increased and women's access to sexual and reproductive health services has become more difficult. Finally, women have been under-represented as research authors but also among experts in task forces and media.

La pandémie liée au SARS-CoV-2 a révélé des inégalités entre les hommes et les femmes et a creusé certaines disparités existantes. Si en Suisse les femmes sont plus nombreuses à avoir été infectées que les hommes, ces derniers ont eu un plus grand risque de décéder. Une réponse immunitaire moins performante et davantage de comorbidités contribuent à expliquer ce pronostic défavorable. Sur le plan social et économique, les femmes ont été davantage précarisées du fait d'emplois moins stables et d'une plus grande implication dans les tâches domestiques. La violence domestique a augmenté et l'accès des femmes aux services de santé sexuelle et reproductive a été plus difficile. Finalement, les femmes ont été sous-représentées comme autrices dans la recherche mais également parmi les expert·e·s dans les task forces et les médias.

Training junior faculty to become clinical teachers: The value of personalized coaching.

Background: Junior clinical faculty require institutional support in the acquisition of feedback and clinical supervision skills of trainees. We tested the effectiveness of a personalized coaching versus guided self-reflection format of a faculty development program at improving faculty skills and self-efficacy.Methods: Participants were evaluated both before and after the program using a four-station Objective Structured Teaching Exercise (OSTE). A gain-score analysis, one-way ANOVA, and paired t-tests were used to evaluate both groups. The impact on the learning environment was measured by resident ratings of the Maastricht Clinical Teaching Questionnaire.Results: One hundred and twenty-seven participants completed the study over a three-year period. Both groups had significant improvements in self-efficacy. Participants in the coaching group demonstrated superior performance in encouraging learner self-reflection, teaching effectiveness, verifying learner understanding, exploring feelings/needs, and defining learning objectives. Over a 5-year period, the overall institutional learning climate significantly improved concerning faculty role-modeling, coaching, articulation, and explorations skills.Conclusion: Offering a contextualized faculty-development program using OSTEs that provides multiple opportunities for feedback and is focused on creating a community of practice is an effective method to facilitate the transfer of skills to the clinical environment, supports teacher identity development, and favorably impacts the learning climate.

[Ethical questions regarding the medical care of adults with disabilities]. / Questions éthiques soulevées par la prise en charge médicale des adultes en situation de handicap.

Medical care of adults with disabilities, especially those with intellectual disabilities, can be ethically difficult. Several questions arise frequently. Can we administer a life-saving treatment that could impact negatively the patient's quality of life when the patient isn't able to give consent? During this Covid-19 period, can the use of chemical or physical restraints be considered as mistreatment, whereas the aim is to protect others? These are situations where the ethical question holds a central role. Although each clinical situation is unique, this article highlights, through four clinical cases, the ethical principles that should guide physicians in their decision-making process.

La prise en charge médicale des adultes en situation de handicap, notamment ceux souffrant de déficience mentale, peut se révéler difficile d'un point de vue éthique. Plusieurs questions se posent fréquemment. Peut-on proposer un traitement vital mais qui risque d'impacter la qualité de vie du patient sans pouvoir obtenir son consentement ? En période de Covid-19, l'utilisation de moyens de contention chimique ou physique peut-elle être considérée comme de la maltraitance alors qu'on cherche à protéger autrui ? Autant de situations où la question éthique prend une place centrale. Si chaque cas est évidemment différent, nous vous proposons, à travers quatre vignettes cliniques, de mettre en lumière les principes éthiques accompagnant le médecin dans son processus décisionnel.

[Cross glances on the videoconsultation]. / Regards croisés sur la vidéoconsultation.

The covid-19 outbreak prompted many health care providers to use video consultation for the first time. While it is particularly useful in times of pandemic, a number of patients wish to continue using video consultation as it allows easy access to their physician. However, many physicians may be uncomfortable communicating with new technologies and without performing a traditional physical examination. Training in communication and virtual physical examination in telemedicine appears to be necessary, making it possible to make videoconsultation sustainable into daily practice while guaranteeing quality of care.

La crise liée au Covid-19 a poussé de nombreux soignants à utiliser pour la première fois la vidéoconsultation. Si celle-ci est particulièrement utile en temps de pandémie, elle est également sollicitée au quotidien par certains patients, leur permettant un contact facilité avec leur médecin. Pourtant, ce dernier est parfois peu à l'aise pour communiquer avec les nouvelles technologies et du fait de l'absence d'examen physique traditionnel. Une formation à la communication et à l'examen physique virtuel en vidéoconsultation apparaît nécessaire, permettant d'inscrire la télémédecine dans la pratique quotidienne tout en garantissant une prise en charge de qualité.

[Knowing how to deliver healthcare is now as important as having medical knowledge]. / Savoir délivrer les soins est -désormais aussi important que d'avoir -les -connaissances médicales.

Traditionally, the doctor has focused his efforts on mastering medical knowledge. Given the challenges facing him, the medical institutions and the society, it becomes clear that his concern must also be about how this medical knowledge hits the patients and the general population. Knowing how to deliver our care is now as important as having the medical knowledge ! In this article, we present new models of healthcare delivery that we implemented or plan to implement in Geneva, Switzerland.

Traditionnellement, le médecin a concentré ses efforts sur la maîtrise de la connaissance médicale. Face aux enjeux qui se présentent à lui, aux institutions et à la société, il devient évident que sa préoccupation doit également se porter sur la façon dont cette connaissance médicale atteint les patients et la population en général. Savoir délivrer nos soins est désormais aussi important que d'avoir les connaissances médicales ! Dans cet article, nous présentons des nouveaux modèles de soins de santé que nous avons mis en œuvre ou prévoyons de mettre en œuvre à Genève, en Suisse.

Vulnerability in the clinic: case study of a transcultural consultation.

Discrimination and inequalities in healthcare can be experienced by many patients due to many characteristics ranging from the obviously visible to the more subtly noticeable, such as race and ethnicity, legal status, social class, linguistic fluency, health literacy, age, gender and weight. Discrimination can take a number of forms including overt racist statement, stereotyping or explicit and implicit attitudes and biases. This paper presents the case study of a complex transcultural clinical encounter between the mother of a young infant in a highly vulnerable social situation and a hospital healthcare team. In this clinical setting, both parties experienced difficulties, generating explicit and implicit negative attitudes that heightened into reciprocal mistrust, conflict and distress. The different factors influencing their conscious and unconscious biases will be analysed and discussed to offer understanding of the complicated nature of human interactions when faced with vulnerability in clinical practice. This case vignette also illustrates how, even in institutions with long-standing experience and many internal resources to address diversity and vulnerability, cultural competence remains a constant challenge.

The relevance of clinical ethnography: reflections on 10 years of a cultural consultation service.

BACKGROUND: Training health professionals in culturally sensitive medical interviewing has been widely promoted as a strategy for improving intercultural communication and for helping clinicians to consider patients' social and cultural contexts and improve patient outcomes. Clinical ethnography encourages clinicians to explore the patient's explanatory model of illness, recourse to traditional and alternative healing practices, healthcare expectations and social context, and to use this information to negotiate a mutually acceptable treatment plan. However, while clinical ethnographic interviewing skills can be successfully taught and learned, the "real-world" context of medical practice may impose barriers to such patient-centered interviewing. Creating opportunities for role modeling and critical reflection may help overcome some of these barriers, and contribute to improved intercultural communication in healthcare. We report and reflect on a retrospective analysis of 10 years experience with a "cultural consultation service" (CCS) whose aim is to provide direct support to clinicians who encounter intercultural difficulties and to model the usefulness of clinical ethnographic interviewing for patient care. METHODS: We analyzed 236 cultural consultation requests in order to identify key patient, provider and consultation characteristics, as well as the cross cultural communication challenges that motivate health care professionals to request a cultural consultation. In addition, we interviewed 51 clinicians about their experience and satisfaction with the CCS. RESULTS: Requests for cultural consultations tended to involve patient care situations with complex social, cultural and medical issues. All patients had a migration background, two-thirds spoke French less than fluently. In over half the cases, patients had a high degree of social vulnerability, compromising illness management. Effective communication was hindered by language barriers and undetected or underestimated patient/provider differences in health-related knowledge and beliefs. Clinicians were highly satisfied with the CCS, and appreciated both the opportunity to observe how clinical ethnographic interviewing is done and the increased knowledge they gained of their patients' context and perspective. CONCLUSIONS: A cultural consultation service such as ours can contribute to institutional cultural competence by drawing attention to the challenges of caring for diverse patient populations, identifying the training needs of clinicians and gaps in resource provision, and providing hands-on experience with clinical ethnographic interviewing.

Learning to use electronic health records: can we stay patient-centered? A pre-post intervention study with family medicine residents.

BACKGROUND: The Electronic Health Record (EHR) is now widely used in clinical encounters. Because its use can negatively impact the physician-patient relationship, several recommendations on the "patient-centered" use of the EHR have been published. However, the impact of training to improve EHR use during clinical encounters is not well known. The aim of this study was to assess the impact of training on residents' EHR-related communication skills and explore whether they varied according to the content of the consultation. METHODS: We conducted a pre-post intervention study at the Primary Care Division of the Geneva University Hospitals, Switzerland. Residents were invited to attend a 3-month training course that included 2 large group sessions and 2-4 individualized coaching sessions based on videotaped encounters. Outcomes were: 1) residents' perceptions regarding the use of EHR, measured through a self-administered questionnaire and 2) objective use of the EHR during the first 10 min of patient encounters. Changes in practice were measured pre and post intervention using the Roter interaction analysis system (RIAS) and EHR specific items. RESULTS: Seventeen out of 27 residents took part in the study. Participants used EHR in about 30% of consultations. After training, they were less likely to consider EHR to be a barrier to the physician-patient relationship, and felt more comfortable using the EHR. After training, participants increased the use of signposting when using the EHR (pre: 0.77, SD 1.69; post: 1.80, SD3.35; p 0.035) and decreased EHR use when psychosocial issues appeared (pre: 24.5% and post: 9.76%, p < 0.001). CONCLUSIONS: This study suggests that training can improve residents' EHR-related communication skills, especially in situations where patients bring up sensitive psychosocial issues. Future research should focus on patients' perceptions of the relevance and usefulness of such skills.

Quality in practice: integrating routine collection of patient language data into hospital practice.

QUALITY PROBLEM: Timely identification of patients' language needs can facilitate the provision of language-appropriate services and contribute to quality of care, clinical outcomes and patient satisfaction. INITIAL ASSESSMENT: At the University Hospitals of Geneva, Switzerland, timely organization of interpreter services was hindered by the lack of systematic patient language data collection. CHOICE OF SOLUTION: We explored the feasibility and acceptability of a procedure for collecting patient language data at the first point of contact, prior to its hospital-wide implementation. IMPLEMENTATION: During a one-week period, receptionists and triage nurses in eight clinical services tested a new procedure for collecting patient language data. Patients were asked to identify their primary language and other languages they would be comfortable speaking with their doctor. Staff noted patients' answers on a paper form and provided informal feedback on their experience with the procedure. EVALUATION: Registration staff encountered few difficulties collecting patient language data and thought that the two questions could easily be incorporated into existing administrative routines. Following the pilot test, two language fields with scroll-down language menus were added to the electronic patient file, and the subsequent filling-in of these fields has been rapid and hospital wide. LESSONS LEARNED: Our experience suggests that routine collection of patient language data at first point of contact is both feasible and acceptable and that involving staff in a pilot project may facilitate hospital-wide implementation. Future efforts should focus on exploring the sensitivity and specificity of the proposed questions, as well as the impact of data collection on interpreter use.