Daniela Leone

Cross-cultural adaptation of an innovative approach to learning about difficult conversations in healthcare.

Background: The Program to Enhance Relational and Communication Skills (PERCS) was developed at a large hospital in the United States to enhance clinicians’ preparedness to engage in difficult conversations. Aim: To describe the implementation of PERCS in an Italian hospital and assess the programs efficacy. Methods: The Italian PERCS program featured 4-h experiential workshops enrolling 10–15 interdisciplinary participants. The workshops were organized around the enactment and debriefing of realistic case scenarios portrayed by actors and volunteer clinicians. Before and after the workshop, participants rated their perceived preparation, communication and relational skills, confidence, and anxiety on 5-point Likert scales. Open-ended questions explored their reflections on the learning. T-tests and content analysis were used to analyze the quantitative and qualitative data, respectively. Results: 146 clinicians attended 13 workshops. Participants reported better preparation, confidence, and communication skills (p < 0.001) after the workshops. The program had a different impact depending on the discipline. Participants valued the emphasis on group feedback, experiential and interdisciplinary learning, and the patients perspective, and acquired: new communication skills, self-reflective attitude, reframed perspective, and interdisciplinary teamwork. Conclusion: PERCS proved culturally adaptable to the Italian context and effective in improving participants’ sense of preparation, communication skills, and confidence.

How Italian students learn to become physicians: A qualitative study of the hidden curriculum

Background: A great deal of what medical students learn in terms of behaviors, values, and attitudes related to their profession is conveyed by the hidden curriculum. Aim: To explore the messages conveyed by the hidden curriculum as perceived by third-year students of the Milan School of Medicine, Italy, following their first clinical internship. Method: Three group interviews were conducted. Students were asked to reflect on values, attitudes, and implicit rules they noticed during their internship experiences. Verbatim transcripts of the group interviews were analyzed through content analysis using Nvivo8. Results: Of the 81 students, 57 (70%) participated in the group interviews. Six themes were identified within the hidden curriculum: Physicians reassure and protect patients; power differential between physicians and patients; variable respect for patients; disease-centered medicine; respect for hierarchies; and delegation of patients’ emotional needs to nurses. Conclusions: Our findings suggest that the hidden curriculum has a strong cultural component. In our students’ experience, the hidden curriculum conveyed a paternalistic model of physician–patient relationships. Some of the messages conveyed by the actual hidden curriculum may compromise the standards formally taught in medical schools about doctor–patient relationships. Organizational culture change and student empowerment could be fostered to counteract the negative effects of the hidden curriculum.

To be or not to be: The patient's view of thrombophilia testing

INTRODUCTION The literature on the psychological effects of thrombophilia testing is unclear. Little is known about the complex world of significance subjects construct around the test. OBJECTIVE The study explored the peculiar network of implicit meanings that may be linked to the experience of being tested. MATERIALS AND METHODS The research was designed according to Interpretative Phenomenological Analysis (IPA). 19 patients were interviewed. Integral verbatim reports of the interviews were analyzed through an inductive process aimed at gaining a holistic understanding of the narratives. RESULTS Two main issues were identified, each with sub-issues: (1) the clinical problem: (1.1) unhealthy blood and (1.2) the family issue; (2) the test: (2.1) knowing for the sake of knowing; (2.2) knowing for the sake of doing; (2.3) not knowing. CONCLUSIONS The thrombophilia test is part of a larger network of meanings, where information about the test and its results seem to be lost. PRACTICE IMPLICATION The study suggests the importance of paying greater attention to the process of doctor-patient communication at the time of the test. The theme of being informed is important for patients, yet often they are not able to understand or retain the information they receive, increasing the risk of misunderstandings.

Inflammatory bowel diseases and psychological issues: A new approach for a systematic analysis of the academic debate

Inflammatory bowel disease (IBD) has received increasing attention in recent years within the literature, due to its incidence and prevalence. The pathogenesis of IBD is still unclear, but the research community is increasingly suggesting that psychological issues may play a role in its aetiology and in exacerbation of symptoms. However, the literature regarding the psychological factors associated with IBD remains controversial and fragmented. The aim of the present study is twofold: (1) to identify, through a bibliometric analysis, the current state of the ongoing scientific debate regarding the relationship between IBD and psychological/psychiatric factors; (2) to analyse, through a qualitative software-based thematic analysis, the main themes characterizing the literature on this topic from 1988 to 2012. This study highlighted increasing number of academic publications in recent years regarding the multiplicity of factors related to the disease process in IBD, thus confirming the growing interest in this issue. IBD is becoming increasingly recognized by the medical literature as being exacerbated by a multi-componential process that needs to be studied through a biopsychosocial theoretical perspective which ables to orient multidisciplinary healthcare organizations and clinical interventions aimed at addressing IBD patient needs at different levels. This study also sheds light on two possible theoretical perspectives through which the academic community has considered IBD: A biomedical point of view that addresses the need for an etiological explanation of IBD and a behavioural point of view that aims at describing the observable symptoms and measurable health outcomes of clinical interventions such as patient adherence and engagement in the care and treatment process.

Difficult encounters with a hemophilic patient: The inner perspective of physicians

This study aimed at exploring the hematologists’ internal representation of a difficult encounter with a hemophilic patient, using a written open format. Narrations were analyzed with Interpretative Phenomenological Analysis. Three main issues were identified, each with sub-issues: (1) Inside the relationship: to tell or not to tell, the balance between a normal life and a deviant medical condition, the guilt; (2) The borders of the professional role: professional values, the “do-it-all” doctor; and (3) The existential confrontation. This study reveals the deep involvement of physicians with their patients, at a professional level and, strongly, at a personal level. The experience of being so deeply involved should be considered in the continuing medical programs for physicians dealing with hemophilia.

Psychological distress, anger and quality of life in polycystic ovary syndrome: associations with biochemical, phenotypical andsocio-demographic factors

Abstract Objective: To investigate the association between polycystic ovary syndrome (PCOS) and psychological disturbances, including anger. To analyze whether the biochemical/phenotypical features of PCOS play a role in the type and severity of psychological disorders. Material and methods: This case–control study included 30 PCOS patients meeting NIH criteria and 30 non-PCOS women referring to Reproductive Medicine Unit for infertility. Complete clinical and biochemical screening and the self-reported psychological data [Symptom Check List 90-R (SCL-90-R); Short-Form Health Survey 36 (SF-36); and State-Trait Anger Expression Inventory-2 (STAXI-2)] were collected. Statistical analyses were performed with SPSS-21. Results: Compared with control women, women with PCOS reported significantly higher scores on SCL-90-R scales of somatization, anxiety, hostility, psychoticism, overall psychological distress and a number of symptoms. At STAXI-2, patients with PCOS scored higher in trait-anger and in the outward expression of anger, while lower in outward anger-control; PCOS patients had significantly lower scores on SF-36 scales of physical functioning and bodily pain. Hirsutism was directly associated with anxiety. Regarding the associations between phenotypical/biochemical features and psychological distress in PCOS patients, results showed that waist-to-hip ratio is inversely related to anxiety, psychoticism, hostility and to the indexes of psychological distress; such inverse relationship was also seen between plasmatic levels of testosterone and trait-anger, and between total cholesterol and hostility. Conclusions: Results were consistent with the previous literature on the well-being of PCOS women (in particular for anxiety and quality of life [QoL]) but failed to find evidence for depression. The relationship between psychological distress and the features of the syndrome highlighted the role of hirsutism. With respect to hyperandrogenemia, our data rejected its involvement in the elevated negative mood states and affects. Adopting an interdisciplinary approach in the PCOS patients’ care, anger showed to be common and deserves major consideration.

Breaking bad news in assisted reproductive technology: a proposal for guidelines

BackgroundThe issue of breaking bad news in assisted reproductive technology (ART) has been only partially explored by literature, and although some recommendations are available, specific guidelines are lacking. The present study aimed to explore the applicability of the oncologic SPIKES Protocol to the ART context.MethodsThirteen ART clinicians (7 gynecologists; 4 psychologists; 1 biologist; 1 obstetrician) completed the Critical Incidents Report (CIR) to describe the experience of delivering bad news in ART. The CIRs were first discussed with clinicians, then a focus group was created composed of 13 clinicians, one health communication expert and a patient to discuss the applicability of the six-step (SPIKES) Buckman Protocol to ART. The discussion was audiotaped, transcribed and analyzed with content analysis.ResultsThe SPIKES Protocol seems to fit ART consultations and participants found it practical and easy to understand. Some specificities were found for the ART context: the reiteration of bad news, the “patient” as a couple and the fact that ability to conceive is closely related to self-esteem, as well as to social and family identity. During the discussion of the SPIKES Protocol, participants highlighted the importance of: 1) providing a caring setting, by adding a reflection on the value of communication by phone; 2) exploring patients’ perceptions but also misinformation; 3) exploring patients’ desires and expectations, while balancing the need to be honest and clear; 4) applying Buckman’s suggestions for delivering information, and integrating clinical aspects with psychosocial ones; 5) managing and legitimizing patients’ emotions, in particular anger; 6) having a strategy for follow-up and supporting couples to make meaning of the ART experience.ConclusionThe proposal of a shared protocol for giving bad news in ART could be the starting point for training and experimental studies.

State of the Art: Psychotherapeutic Interventions Targeting the Psychological Factors Involved in IBD

The present article aims to review the literature on the relationship between psychology and inflammatory bowel disease (IBD). In particular, the first section is dedicated to explore the role of psychological factors in the etiopathology of the disease, its development and the efficacy of treatments, while the second analyzes existing literature on the role of psychological interventions in the care of IBD patients. Although the role of psychological factors in IBD appears controversial, literature seems to distinguish between antecedents of the disease (stress and lifestyle behavior), potential mediators of disease course (family functioning, attachment style, coping strategies, and illness perception), outcomes of IBD and concurrent factors (anxiety, depression and quality of life). Four types of psychological interventions are described: Stress management, Psychodynamic, Cognitive behavioral and Hypnosis based. Data on the role and efficacy of psychological interventions in IBD patients show little evidence both on reduction of the disease activity and benefits on psychological variables. Psychological interventions seem to be beneficial in the short term especially for adolescents. The importance of considering the connections between psychology and IBD from a broader perspective reflecting the complexity of the phenomenon at multiple levels is discussed.

Satisfaction for quality of life : a comparison of patient and occupational therapist perspectives

Abstract Objective: To verify whether the patients satisfaction with quality of life (QoL) is similar to or different from the occupational therapists perception of the patients satisfaction. Materials and methods: Each patient enrolled was given the Satisfaction Profile (SAT-P) questionnaire to be filled out personally; the same questionnaire, the SAT-P, was given to the respective occupational therapist who was asked to fill it out by evaluating the patients satisfaction as perceived by the therapist. A descriptive statistic was applied for socio-demographic data to describe the cohort. Differences between patient and therapist answers to the SAT-P were evaluated using a t-test. Results: 12 occupational therapists and 69 patients participated in the study. A significant difference between occupational therapist and patient was found for Factor II (physical functioning) (p = 0.048) and for Factor V (social functioning) (p = 0.011). The comparison of patient and therapist mean scores showed that therapists had a tendency to underestimate patient satisfaction levels for all factors except Factor IV. Discussion: The results showed similarities between the therapist and the patients view of the patients satisfaction with QoL, confirming occupational therapy as a client-centred discipline. However, as far as physical functioning is concerned, it is possible that the professional makes an “a priori” judgement, considering the objective clinical data regardless of the patients subjective experience of his/her illness.

Talking about sex: a qualitative study on the physician's inner experience

The study aimed to explore clinicians’ subjective difficulties related to talking with patients about sexuality. Forty-four physicians were recruited during a one-day congress about erectile dysfunction, where they were asked to write a narrative about an episode in which they found themselves in difficulty talking with a patient about sex. Narratives were analyzed using Interpretative Phenomenological Analysis. Four main issues with sub-issues arose from the data: 1. What: cognitive contents and emotions; 2. How: talking about sex, the problem of language; 3. As if: the metaphoric view of the profession; 4. Who: me as a man. Clinical and educational implications are discussed. L’obiettivo del presente lavoro e quello di esplorare le difficolta dei clinici nel par-lare con i pazienti di tematiche riguardanti la sessualita. Quarantaquattro medici sono stati reclutati durante una giornata di congresso sulla disfunzione erettile, du-rante la quale e stato chiesto loro di scrivere una narrazione su un episodio in cui si sono trovati in difficolta a parlare di sesso con il paziente. Le narrazioni sono state analizzate utilizzando l’Analisi Interpretativa Fenomenologica. Dall’analisi dei dati sono emerse quattro tematiche principali, con relative sotto-tematiche: 1. Cosa: contenuti cognitivi ed emozioni; 2. Come: parlare di sesso, il problema del linguaggio; 3. Come se: la prospettiva metaforica della professione; 4. Chi: io come uomo. Le implicazioni cliniche e formative dei risultati sono state infine discusse.