Christophe Samuel Luthy

Clinical supervisors' perceived needs for teaching communication skills in clinical practice

Background: Lack of faculty training is often cited as the main obstacle to post-graduate teaching in communication skills. Aims: To explore clinical supervisors’ needs and perceptions regarding their role as communication skills trainers. Methods: Four focus group discussions were conducted with clinical supervisors from two in-patient and one out-patient medical services from the Geneva University Hospitals. Focus groups were audio taped, transcribed verbatim and analyzed in a thematic way using Maxqda© software for qualitative data analysis. Results: Clinical supervisors said that they frequently addressed communication issues with residents but tended to intervene as rescuers, clinicians or coaches rather than as formal instructors. They felt their own training did not prepare them to teach communication skills. Other barriers to teach communication skills include lack of time, competing demands, lack of interest and experience on the part of residents, and lack of institutional priority given to communication issues. Respondents expressed a desire for experiential and reflective training in a work-based setting and emphasised the need for a non-judgmental learning atmosphere. Conclusions: Results suggest that organisational priorities, culture and climate strongly influence the degree to which clinical supervisors may feel comfortable to teach communication skills to residents. Attention must be given to these contextual factors in the development of an effective communication skills teaching program for clinical supervisors.

Collaborative Quality Improvement to Manage Pain in Acute Care Hospitals

OBJECTIVE Collaborative quality improvement programs have been successfully used to manage chronic diseases in adults and acute lung complications in premature infants. Their effectiveness to improve pain management in acute care hospitals is currently unknown. The purpose of this study was to determine whether a collaborative quality improvement program implemented at hospital level could improve pain management and overall pain relief. DESIGN To assess the effectiveness of the program, we performed a before-after trial comparing patients self-reported pain management and experience before and after program implementation. We included all adult patients hospitalized for more than 24 hours and discharged either to their home or to a nursing facility, between March 1, 2001 and March 31, 2001 (before program implementation) and between September 15, 2005 and October 15, 2005 (after program implementation). SETTING A teaching hospital of 2,096 beds in Geneva, Switzerland. PATIENTS All adult patients hospitalized for more than 24 hours and discharged between 1 to 31 March 2001 (before program) and 15 September to 15 October 2005 (after program implementation). INTERVENTIONS Implementation of a collaborative quality improvement program using multifaceted interventions (staff education, opinion leaders, patient education, audit, and feedback) to improve pain management at hospital level. OUTCOME MEASURES Patient-reported pain experience, pain management, and overall hospital experience based on the Picker Patient Experience questionnaire, perceived health (SF-36 Health survey). RESULTS After implementation of the program only 2.3% of the patients reported having no pain relief during their hospital stay (vs 4.5% in 2001, P=0.05). Among nonsurgical patients, improvements were observed for pain assessment (42.3% vs 27.9% of the patients had pain intensity measured with a visual analog scale, P=0.012), pain management (staff did everything they could to help in 78.9% vs 67.9% of cases P=0.003), and pain relief (70.4% vs 57.3% of patients reported full pain relief P=0.008). In surgical patients, pain assessment also improved (53.7.3% vs 37.6%) as well as pain treatment. More patients received treatments to relieve pain regularly or intermittently after program implementation (95.1% vs 91.9% P=0.046). CONCLUSION Implementation of a collaborative quality improvement program at hospital level improved both pain management and pain relief in patients. Further studies are needed to determine the overall cost-effectiveness of such programs.

Difficulties of residents in training in end-of-life care. A qualitative study

Residents in training are first-line physicians in hospital settings and they are in the process of developing knowledge and mastering clinical skills. They have to confront complex tasks calling upon their personal background, professional identity and relationships with the patients. We conducted a qualitative study investigating the difficulties they perceive in end-of-life care. In all, 24 consecutive residents were presented with a written query asking them to indicate the difficulties they identify in the management of patients hospitalised for end-of-life care. Their responses were submitted to content analysis. Physicians’ mean age was 28 ± 2.2 years, 37% were women, average postgraduate training duration was 2.5 ± 1.3 years. Content analysis elicited eight categories of difficulties: abitily to provide adequate explanations, understand the patients’ needs, have sufficient theoretical knowledge, avoid flight, avoid false reassurance, manage provision of time, face one’s limits as a physician and be able to help despite everything. Residents’ responses showed that they identify the complexity of care in terminally-ill patients early in their training. Their responses pointed to the ‘right distance’ in-between getting involved and preserving oneself as a dimension of major importance.

Aspects psychologiques de la fibromyalgie

Centre d’evaluation et de traitement de la douleur, division de pharmacologie et toxicologie cliniques,Hopitaux Universitaires de Geneve, 1211 Geneve 14, SuisseRecu le 2 janvier 2003 ; accepte le 2 janvier 2003Mots cles : Fibromyalgie ; Psychopathologie ; Somatisation ; Catastrophisme ; StigmatisationKeywords: Fibromyalgia; Psychopathology; Somatization; Catastrophizing; Stigma

Douleurs rebelles et ébranlements traumatiques

RésuméII n’est pas rare que les douleurs attribuées à un traumatisme évoluent vers un processus de chronicisation, voire d’invalidation, alors même que l’événement initial n’a entraîné que des séquelles objectivement minimes. Dans la pratique, l’attribution des douleurs à un événement traumatique doit être recherchée et l’expérience subjective du patient soigneusement explorée. Une étude menée chez des patients fibromyalgiques est présentée comme exemple. Elle révèle la fréquence des attributions traumatiques de la douleur et ouvre la réflexion sur les liens entre douleurs chroniques et traumatismes.SummaryThe attribution of pains to a traumatic event is often associated with a risk of chronification. The causal attribution of pain to such an event should be explored. The summary of a study involving fibromyalgia patients is presented here. It shows the high prevalence of traumatic events in the narratives of these patients and the association made with the onset of pain, leading to considerations about the link between chronic pain and trauma.

Bedside or not bedside: Evaluation of patient satisfaction in intensive medical rehabilitation wards

Background Concerns that bedside presentation (BsP) rounds could make patients uncomfortable led many residency programs to move daily rounds outside the patients’ room (OsPR). We performed a prospective quasi-experimental controlled study measuring the effect of these two approaches on patient satisfaction. Methods Patient satisfaction was measured using the Picker questionnaire (PiQ). Results are expressed in problematic percentage scores scaled from 0 = best-100 = worst. During three months, 3 wards of a 6 ward medical rehabilitation division implemented BsP and 3 control wards kept their usual organization of rounds. In total, 90 patients of each group were included in the study and completed the PiQ. Results Socio-clinical characteristics were similar in both groups: mean age = 67 years (SD = 13), mean Charlson comorbidity index = 8.6 (2.4); mean length of stay = 22 days (12). During their stay, patients in the BsP units had a mean of 14.3 (8) BsP rounds and 0.5 (0.8) OsPR; control patients had a mean of 0.9 (0.7) BsP and 14.8 (7.3) OsPR (p<0.0001). Patients in BsP units reported lower problematic scores regarding coordination of care (39% vs 45%, p = 0.029), involvement of family/friends (29 vs 41%, p = 0.006) and continuity/transition (44% vs 54%, p = 0.020); two questions of the PiQ had worse scores in the BsP: trust in nurses (46.7% vs 30 %, p = 0.021) and recommendation of the institution (61.1% vs 44.4%. p = 0.025). No worsening in dimensions such as respect for patient preferences was seen. Conclusions BsP rounds influenced the patient-healthcare professionals’ encounter. These rounds were associated with improved patient satisfaction with care, particularly regarding interprofessional collaboration and discharge planning.

Douleur et culture: quelques questions de méthode liées à la mesure de la dimension culturelle

RésuméLes relations entre douleur et culture soulèvent le problème de l’interaction complexe de facteurs biologiques, psychologiques, culturels et sociaux dans la perception et l’expression de la douleur. Elles posent également la question de la manière dont l’expérience douloureuse peut être traduite et communiquée dans le cadre d’une relation thérapeutique. Les questions qui se posent dans le domaine des rapports entre douleur et groupes sociaux et culturels sont donc multiples et de divers ordres. S’il s’agit bien sûr de savoir quelle est l’influence de ces variables sur la perception de la douleur et sur la réponse à la douleur, la question se pose cependant en premier lieu de savoir ce que recouvre la référence à la «culture» des individus. Cet article propose un bref survol de quelques interrogations que soulève cette dimension «culturelle».SummaryThe relations between pain and culture underline the problem of a complex interaction between biological, psychological, cultural and social factors in the perception of and response to pain. They also raise the issue of the ways pain may be expressed in a therapeutical relationship. Investigating the relations between pain and variables such as cultural and social aspects thus addresses various dimensions. The matter at stake is of course to know how these variables influence pain perception and pain responses. However, the question of the contents and meaning of the «cultural» variables(s) is of utmost importance. This article reviews some of the issues related to the «cultural» dimension.