Julien Carretier

La place du patient dans la médecine factuelle

Medical practice has undergone a significant evolution over the last decade due to two important factors: (1) the theory and practice of Evidence-Based Medicine (EBM) has become widely established; (2) the relationship between health-care professionals and patients or clients has been profoundly modified. In this review, we discuss the heterogeneity and variability of patient preference and the need to develop a doctor-patient relationship, which facilitates shared decision-making in preference to previous models based on patient information without choice and paternalistic attitudes. Thus, this modern concept of care based on EBM shifts the focus of interest from the disease entity itself to that of the patient suffering from a disease. The patient has a right to information concerning his illness; this information helps the patient to participate in medical decisions through the laying out of clinical practice guidelines. These aspects of the patients role in care management are illustrated by a national program in the field of oncology which empower the patient in the decisions arrived at by a multi-disciplinary oncology team.

Mise au pointLa place du patient dans la médecine factuelleThe patient's role in evidence-based medicine

Medical practice has undergone a significant evolution over the last decade due to two important factors: (1) the theory and practice of Evidence-Based Medicine (EBM) has become widely established; (2) the relationship between health-care professionals and patients or clients has been profoundly modified. In this review, we discuss the heterogeneity and variability of patient preference and the need to develop a doctor-patient relationship, which facilitates shared decision-making in preference to previous models based on patient information without choice and paternalistic attitudes. Thus, this modern concept of care based on EBM shifts the focus of interest from the disease entity itself to that of the patient suffering from a disease. The patient has a right to information concerning his illness; this information helps the patient to participate in medical decisions through the laying out of clinical practice guidelines. These aspects of the patients role in care management are illustrated by a national program in the field of oncology which empower the patient in the decisions arrived at by a multi-disciplinary oncology team.

Developing a Return to Work Intervention for Breast Cancer Survivors with the Intervention Mapping Protocol: Challenges and Opportunities of the Needs Assessment

Return to work (RTW) is an important step for breast cancer survivors (BCSs). However, they face many barriers that affect particularly women with low socioeconomic status (SES). Health care, workplace, and insurance actors lack knowledge and collaborate poorly. No intervention to date has proven effective to reduce social disparities in employment after breast cancer. The intervention mapping (IM) protocol is being used in France to develop, implement, and evaluate an intervention to facilitate and sustain RTW after breast cancer [FAciliter et Soutenir le retour au TRAvail après un Cancer du Sein (FASTRACS) project]. The research question of this study was to elicit the needs for RTW after breast cancer from various stakeholders’ point of view. The aim of this study was to describe the process and the preliminary results of the needs assessment of the FASTRACS project. Different methods were followed to (a) establish and work with a planning group and (b) conduct a needs assessment to create a logic model of the problem. A planning group was organized to gather the stakeholders with the research team. A review of the literature and indicators was conducted to identify the magnitude of the problem and the factors influencing RTW. A qualitative inquiry was conducted with 12 focus groups and 48 individual semi-structured interviews to explore the needs and experience of the stakeholders. The results of these tasks were the proposition of a charter of partnership to structure the participative process, a review of the scientific evidence and indicators, and the description by the stakeholders of their needs and experience. Many stakeholders disagreed with the concept of “early intervention.” They advocated for a better support of BCSs during their RTW, emphasized as a process. Anticipation, intersectoral collaboration, and workplace accommodation were mentioned to fit the needs of the BCS and their environment. A logic model of the problem was elaborated from these data. The ability of the model to consider specific characteristics of women with low SES is discussed, with a view to developing the FASTRACS intervention through the next steps of the IM protocol.

Moving towards shared decision making in the physician-patient encounter in France: State of the art and future prospects

In this paper we present the evolution of shared decision making since the mid-nineties in terms of legislation, official statements and guidelines. We outline the goals and declarations of the French Ministry of Health and the French National Authority for Health, for whom informing patients and shared decision-making are central concerns. Finally, we discuss research projects and clinical initiatives in shared decision-making in France and provide a general overview of progress and barriers to progress.

Adaptation d’une approche nutritionnelle dans le contexte du cancer du sein : points de vue croisés des personnes malades et des professionnels de santé

RésuméLe centre de lutte contre le cancer Léon-Bérard (Lyon, France) s’est engagé dans l’adaptation d’une approche nutritionnelle pour les patientes atteintes de cancer du sein, leur proposant un suivi diététique et des séances d’activité physique adaptée pendant leurs traitements. Cela soulève plusieurs problématiques concernant les barrières et facilitateurs à sa mise en place. Une étude qualitative par focus groups conduits avec des femmes atteintes d’un cancer du sein, en cours de chimiothérapie ou à distance de la maladie, et des professionnels de santé impliqués dans la prise en charge de ces patientes a été réalisée afin d’identifier et d’analyser, de leurs points de vue, les barrières et facilitateurs d’un tel dispositif. Le rôle de l’information et de l’accompagnement des patientes engagées dans un tel dispositif a été identifié comme un facteur prioritaire d’adhésion. La notion de motivation des patientes s’exprime dans les deux corpus comme un déterminant prioritaire de participation. L’importance des liens sociaux impliqués dans les attitudes d’adhésion ou de refus est également mise en exergue par les patientes. Cette étude centrée sur les patientes et les praticiens suggère des pistes d’amélioration et des éléments de structuration susceptible de s’inscrire dans une démarche d’éducation thérapeutique nutritionnelle pour les femmes atteintes d’un cancer du sein.AbstractThe French Cancer Center Léon-Bérard (Lyon, France) is committed to the adaptation of a nutritional approach for breast cancer patients, offering a dietary monitoring and physical activity sessions during their treatments. This raises several issues regarding the barriers and facilitators to its implementation. A qualitative study using focus groups with women with breast cancer undergoing chemotherapy or beyond treatment, and health professionals, was conducted in order to identify and analyze their views, barriers, and facilitators of such a program. The role of information and support for recipient patients has been identified as a priority factor for their involvement. The concept of patient motivation is expressed in both groups as a primary determinant of participation. The importance of social ties in accession or refusal attitudes to participate in the program is also highlighted by breast cancer patients. This study suggests ways of improving and structuring elements on diet and physical activity sessions that could be part of a therapeutic education approach for breast cancer patients.

Former les élu(e)s territoriaux à la santé-environnement : une action pilote en région Rhône-Alpes

Les repercussions de l’environnement sur la sante sont des preoccupations de sante humaine et sante publique faisant l’objet de plans nationaux et regionaux et de conferences environnementales. Bien que de nombreux enjeux touchent de pres les missions des elu(e)s territoriaux, le champ de la sante-environnement et leurs responsabilites associees demeurent pour eux difficiles a apprehender.Pour repondre a ces questionnements et developper la formation en sante-environnement, le Conseil regional Rhone-Alpes, l’Agence regionale de sante (ARS) Rhone-Alpes et la Direction regionale de l’environnement, de l’amenagement et du logement (DREAL) Rhone-Alpes ont soutenu une action-pilote de formation des elus territoriaux dans le cadre du deuxieme Plan regional sante-environnement Rhone-Alpes. Cette action, confiee au Centre de lutte contre le cancer Leon-Berard et a l’association Reseau environnement sante, s’est deroulee en deux parties : 1) une etude pour mieux connaitre les attentes et besoins des parties prenantes sur la base de l’analyse de 24 entretiens individuels menes aupres de personnalites, elus et cadres des institutions concernees et d’un auto-questionnaire anonyme envoye a un echantillon de 338 elus des territoires rhonalpins, conseillers regionaux, departementaux, maires, tires au sort a partir de la liste des 3 379 elus de la region ; 2) l’elaboration et la mise en œuvre d’une journee-pilote de sensibilisation-formation des elus.L’ensemble des resultats met en evidence un interet tres net des elus pour la sante-environnement et confirme le besoin de formation. Ils s’estiment insuffisamment informes sur le sujet (70 %), ne connaissent pas le deuxieme Plan regional (pres de 100 %), se sentent en grande majorite concernes par la thematique (82 %), mais considerent que celle-ci est mal prise en compte dans les politiques locales (79 %).Cette action pilote apporte des arguments supplementaires et des propositions pour developper la formation en sante-environnement des elus territoriaux. Leur formation a un role determinant, notamment du fait de leur pouvoir decisionnel et de leurs liens de proximite avec la population.

Pour un partage du savoir et la construction d’une nouvelle relation entre les malades et leurs proches

En tant que pratique sociale, la medecine est une sphere d’activite en evolution. Sous le joug de la demande sociale, la relation medecin-patient est en mutation, passant progressivement du modele « paternaliste » traditionnel, dans lequel le medecin decide du traitement, au paradigme ideal participatif d’une decision medicale partagee. Nee des mouvements de malades, approfondie par des reflexions sur les relations entre science et democratie (1, 2), cette evolution a fait emerger les besoins des patients, confirmes par diverses enquetes portant sur leurs preferences et sur les obstacles a leur information et a leur participation.

Patient involvement in French Lung cancer guidelines: A qualitative study

7603 Background: Clinical Practice Guidelines (CPGs) are increasingly used and regarded as mandatory references for clinical decisions and patient centered cancer care. Discrepancies between recommendations and patient’s preferences have been found to be an important factor of non-compliance with CPGs. To improve the quality and efficiency of cancer CPGs, the French Standards, Options and Recommendations (SOR) program has adapted methods validated in other settings to involve patients in the development of guidelines. Objective: To assess barriers and facilitators of involving patients in the Guideline Development Group (GDG) for a CPG on treatment of early-stage non-small cell lung cancer (NSCLC). Methods: Qualitative study (January 2006 to March 2007) combining 8 direct observations of GDG meetings and 12 semi-directive interviews with the participating patients and experts. Results: The barriers and facilitators indentified could be grouped into four categories (see table). Conclusion: Our observations...