Background: Although interpersonal continuity is commonly assumed to be essential for care, some ... more Background: Although interpersonal continuity is commonly assumed to be essential for care, some patients prefer to attend a university outpatient clinic where physicians change regularly and interpersonal continuity of care is not ensured. Objectives: The aim of this exploratory study was to evaluate the differences between patients attending a university outpatient clinic and patients frequenting a private practice, explore their patterns of care-seeking and their understanding of continued care. Methods: We conducted a cross-sectional study of patients attending the university medical outpatient clinic (OC) in Lausanne, Switzerland and ten randomly selected private general practices (PP). Eligible patients were >30 years, Swiss nationals or long term residents, with one or more chronic conditions and attending the same practice for >3 years. They were asked to complete a questionnaire on sociodemographic data, use of medical resources and reasons for choosing and remaining at the same practice. Semi-structured interviews were conducted with a randomly selected subset of 26 patients to further explore their preferences. Results: 329 patient questionnaires were completed, 219 by PP and 110 by OC patients. OC patients tended to be of lower socioeconomic status than PP patients. The main reason for choosing a PP were personal recommendation, while a higher percentage of patients chose the OC because they could obtain a first appointment quickly. A higher percentage of PP patients accorded importance to physician communication skills and trust, whereas a higher percentage of OC patients favoured investigation facilities. Qualitative data suggested that although OC and PP patients reported different reasons for consulting, their expectations on the medical and relationship level were similar. Conclusion: Our study suggests that the two groups of patients belong to different social backgrounds, have different patterns of care-seeking and attach importance to different aspects of care continuity. However, patients' expectations and perceptions of the physician-patient relationship are similar.
Background: Physicians' explanatory models of commonly encountered clinical problems reflect not ... more Background: Physicians' explanatory models of commonly encountered clinical problems reflect not only formal medical training, but also personal and professional experience. In situations where formal training is absent, the clinical context of informal learning is likely to have an important influence on junior doctors' evolving knowledge and practice. Objectives: The purpose of this study was to explore junior doctors' explanatory models of somatisation in the absence of formal training, and in particular the influence of working with a large proportion of immigrants (asylum seekers and refugees) on their understanding and practice. Methods: Semi-structured interviews were conducted with all 14 junior doctors working at the Geneva University Hospitals general medicine outpatient clinic. Interviews explored junior doctors' definitions, understanding and management of somatisation. Interviews were tape-recorded, transcribed verbatim and analyzed for key themes. Results: In the absence of formal training, somatisation evoked considerable uncertainty and frustration in terms of diagnosis and management. Junior doctors' understanding of somatisation was heavily influenced by their contact with immigrant patients. They primarily attributed somatisation to psychosocial stresses related to migration and tended to label certain socio-cultural groups as more prone to somatisation than others. Conclusion: It is important to recognize that contextual factors have an important influence on physicians' evolving explanatory models for commonly encountered problems, especially in the absence of formal training. Results from this study suggest that formal training in management of somatisation should be offered in order to broaden junior doctors' understanding of somatisation and avoid cultural stereotyping.
Purpose: As the COVID-19 pandemic outbreak occurred, most structured clinical communication train... more Purpose: As the COVID-19 pandemic outbreak occurred, most structured clinical communication training were transformed from in-person to remote seminars. The aim of our study was to evaluate the usefulness and feasibility of online synchronous clinical communication training from both students' and tutors' perspectives. Patients and Methods: We conducted a cross-sectional study. Geneva Faculty of Medicine' 3rd year medical students and tutors involved in clinical communication were asked to respond to an online survey. Results: Eighty-five of 149 students and 15/16 tutors responded. Students highly valued both online seminars and reported little technical difficulty. They felt that tutors were well prepared and actively involved them in experiential learning. Tutors globally reported little technical difficulty and felt rather well prepared to do so online. Although both students and tutors preferred the in-person format, half of them could still consider using an online format in the future outside the pandemic but mentioned it required specific rules. Conclusion: Our results suggest that clinical communication can be taught and practiced online and that tutors can quickly adapt to such changes.
During their pre-clinical years, medical students are given the opportunity to practice clinical ... more During their pre-clinical years, medical students are given the opportunity to practice clinical skills with simulated patients. During these formative objective structured clinical encounters (OSCEs), tutors from various backgrounds give feedback on students' history taking, physical exam, and communication skills. The aim of the study was to evaluate whether the content and process of feedback varied according to the tutors' profile. During 2013, all 2(nd) and 3(rd) year medical students and tutors involved in three formative OSCEs were asked to fill in questionnaires, and their feedback sessions were audiotaped. Tutors were divided into two groups: 1) generalists: primary care, general internist and educationalist physicians 2) specialists involved in the OSCE related to their field of expertise. Outcome measures included the students' perceptions of feedback quality and utility and objective assessment of feedback quality. Participants included 251 medical students a...
BACKGROUND: Increasing the attractiveness of primary care careers is a key step in addressing the... more BACKGROUND: Increasing the attractiveness of primary care careers is a key step in addressing the growing shortage of primary care physicians. The purpose of this review was to (1) identify interventions aimed at increasing the proportion of undergraduate medical students choosing a primary care specialty, (2) describe the characteristics of these interventions, (3) assess the quality of the studies, and (4) compare the findings to those of a previous literature review within a global context. METHODS: We searched MEDLINE, EMBASE, ERIC, CINAHL, PsycINFO, The Cochrane Library, and Dissertations & Theses A&I for articles published between 1993 and February 20, 2015. We included quantitative and qualitative studies reporting on primary care specialty choice outcomes of interventions in the undergraduate medical curriculum, without geographic restrictions. Data extracted included study characteristics, intervention details, and relevant outcomes. Studies were assessed for quality and strength of findings using a five-point scale. RESULTS: The review included 72 articles reporting on 66 different interventions. Longitudinal programs were the only intervention consistently associated with an increased proportion of students choosing primary care. Successful interventions were characterized by diverse teaching formats, student selection, and good-quality teaching. Study quality had not improved since recommendations were published in 1995. Many studies used cross-sectional designs and non-validated surveys, did not include control groups, and were not based on a theory or conceptual framework. DISCUSSION: Our review supports the value of longitudinal, multifaceted, primary care programs to increase the proportion of students choosing primary care specialties. Isolated modules or clerkships did not appear to be effective. Our results are in line with the conclusions from previous reviews and add an international perspective, but the evidence is limited by the overall low methodological quality of the included studies. Future research should use more rigorous evaluation methods and include long-term outcomes.
The aging of the population and the rising prevalence of chronic diseases mandate improved collab... more The aging of the population and the rising prevalence of chronic diseases mandate improved collaboration among different health professionals. Interprofessional training is one way to improve it, because it encourages health professionals to learn with, from and about one another and respects the integrity and contribution of each profession. Few medical or health professional schools develop such dimensions in their curricula, while postgraduate and continuous training seldom offer such opportunities. Institutional and political commitment may significantly contribute to the development of such dimensions in medical and other health profession education. Having a same mission, sharing responsibility for the team success, defining clear member roles and task, and communicating on a routine basis represent other key factors of success.
Somatisation is particularly challenging in multicultural contexts where patients and physicians ... more Somatisation is particularly challenging in multicultural contexts where patients and physicians often differ in terms of their illness-related beliefs and practices and health care expectations. This paper reports on a exploratory study aimed at better understanding how asylum seeker and refugee patients from the former country of Yugoslavia who were identified by their physicians as somatising make sense of their suffering. We conducted semi-structured interviews with 26 asylum seeker and refugee patients from the former country of Yugoslavia who attended the general medicine outpatient clinic of a Swiss teaching Hospital and were identified as presenting with somatisation. Interviews explored patients' illness perspectives and health care expectations. Interviews were audio taped, transcribed verbatim and analyzed to identify key themes in patients' narratives. Patients attributed the onset of symptoms to past traumatic experiences and tended to attribute their persistenc...
Residents' perceived needs in communication skills training are important to identify before ... more Residents' perceived needs in communication skills training are important to identify before designing context-specific training programmes, since learrners' perceived needs can influence the effectiveness of training. To explore residents' perceptions of their training needs and training experiences around communication skills, and whether these differ between residents training in inpatient and outpatient clinical settings. Four focus groups (FG) and a self-administered questionnaire were conducted with residents working in in- and outpatient medical service settings at a Swiss University Hospital. Focus groups explored residents' perceptions of their communication needs, their past training experiences and suggestions for future training programmes in communication skills. Transcripts were analysed in a thematic way using qualitative analytic approaches. All residents from both settings were asked to complete a questionnaire that queried their sociodemographics an...
QUESTION UNDER STUDY/PRINCIPLES: Ambulatory care is a mandatory component of postgraduate trainin... more QUESTION UNDER STUDY/PRINCIPLES: Ambulatory care is a mandatory component of postgraduate training in general internal medicine. Academic outpatient clinics face challenges in training residents in terms of exposure to sufficient patient case-mix, diversity of clinical activities and continuity of care while fulfilling their mission to provide care to vulnerable populations. We report the development and evaluation of a new postgraduate curriculum in ambulatory care in Geneva, Switzerland, designed to overcome such challenges. METHODS/DESCRIPTION: The content of learning activities was adapted to core competencies and learning objectives. In the new 2-year curriculum, residents had their working week divided into 2½ days of continuity clinic over two years, and 2½ days of 6 to 12 months rotations (e.g., walk-in clinics). Team work was consolidated through the creation of subunits including an attending physician, 1-2 senior residents during one year and 6-to 8 residents, who met in bimonthly meetings with other health professionals. RESULTS/EVALUATION: In both local and national surveys, residents and senior residents expressed an overall global satisfaction with the new curriculum. Nursing and administrative staff were less satisfied, because of reduced residents' time in each unit. Interprofessional meetings were highly appreciated for both patient care and team building. Management of residents' absences became more complex. CONCLUSION: The new curriculum met its goals in gaining residents' satisfaction and in reinforcing interprofessional collaboration although management of human resources became more complex. It also gave insights into challenges to be addressed when disseminating a new curriculum, such as strong leadership, educational expertise and management skills and tools.
Background: Pain is a common complaint of patients attending walk-in clinics, but timely and appr... more Background: Pain is a common complaint of patients attending walk-in clinics, but timely and appropriate pain management is often lacking. Aim: To evaluate the impact of a multifaceted intervention on pain management. Design: Prospective interventional study. Methods: Three cross-sectional surveys were conducted: before, 4 months after and 14 months after a multifaceted intervention at the medical walk-in clinic of a university hospital. The intervention included both educational activities and structural changes. Use of recommended pain management procedures, pain relief and overall assessments of pain treatment and health professionals' attitudes were assessed using patient questionnaires, collected by mail. History of pain, records of pain intensity and use of pain medication were extracted from medical files. Results: We analysed 1409 medical files and 695 questionnaires of patients presenting with pain. Documentation of pain intensity and administration of pain medication at the walk-in clinic improved significantly 14 months after the intervention (7% vs. 53% and 17% vs. 27%, respectively, p < 0.001) and pain medication was more often administered by the oral route (14% vs. 23%, p < 0.001). However, no change was observed for complete pain relief (40% vs. 39%, p ¼ 0.92) or patients' overall assessments of pain management. Discussion: The intervention improved adherence to recommended procedures, even in the longer term, but did not result in better patient outcomes. Continuing efforts are needed to help health professionals improve pain management in outpatient care.
Background: Specific knowledge and skills are needed to work effectively with an interpreter, but... more Background: Specific knowledge and skills are needed to work effectively with an interpreter, but most doctors have received limited training. Self-assessed competency may not accurately identify training needs. Purposes: The purpose of this study is to explore the association between self-assessed competency at working with an interpreter and the ability to identify elements of good practice, using a written vignette. Methods: A mailed questionnaire was sent to 619 doctors and medical students in Geneva, Switzerland. Results: 58.6% of respondents considered themselves to be highly competent at working with a professional interpreter, but 22% failed to mention even one element of good practice in response to the vignette, and only 39% could name more than one. There was no association between self-rated competency and number of elements mentioned. Conclusions: Training efforts should challenge the assumption that working with an interpreter is intuitive. Evaluation of clinicians' ability to work with an interpreter should not be limited to self-ratings. In the context of large-scale surveys, written vignettes may provide a simple method for identifying knowledge of good practice and topics requiring further training.
Background: Lack of faculty training is often cited as the main obstacle to postgraduate teaching... more Background: Lack of faculty training is often cited as the main obstacle to postgraduate 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 outpatient medical services from the Geneva University Hospitals. Focus groups were audio taped, transcribed verbatim and analyzed in a thematic way using Maxqdaß 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.
Background: Methods are needed for assessing clinicians' cultural knowledge frameworks. Method: W... more Background: Methods are needed for assessing clinicians' cultural knowledge frameworks. Method: We used a mail survey containing four short clinical vignettes to explore respondents' ability to identify sociocultural factors affecting health and health care. Participants included 299 physicians working at the University Hospitals of Geneva, 156 private physicians, and all 134 local medical students in their clinical years. Twenty-one sociocultural ''domains'' were identified through inductive coding of responses. For each vignette, we obtained the sum of codes as a measure of the respondent's awareness of sociocultural factors that might affect care in this particular situation. As internal consistency was reasonably high (0.68), we computed a single total score as the sum of responses given to all four vignettes. Results: Reponses correlated with factors that might be expected to impact clinicians' awareness of sociocultural factors affecting care. Medical students, females, respondents who had received cultural competence training, those with greater interest in caring for immigrant patients, and those with high self-assessed skills at exploring psychosocial and migration-related issues scored higher on the vignettes. Conclusions: Brief clinical vignettes appear to be a relevant and feasible method for exploring physicians' knowledge of social and cultural factors affecting health and health care.
Objective: To explore the perception of dyspnoea in patients with severe chronic obstructive pulm... more Objective: To explore the perception of dyspnoea in patients with severe chronic obstructive pulmonary disease. Design: Cross-sectional study using mixed methods. Methods: Thirty-two patients with severe chronic obstructive pulmonary disease were included. Data collected included 3 health-related quality of life questionnaires (SF-36, St George and Maugeri respiratory questionnaires) and the Hospital Anxiety and Depression scale (HADS) to assess the impact of chronic obstructive pulmonary disease on quality of life and psychological functioning. Patients were then asked to draw their body and represent difficulties related to breathing. Drawings were coded and categorized. Patients' comments were transcribed. Results: HADS showed scores of depression and anxiety as high as 12.3 ± 2.6 and 9.3 ± 2.2, respectively; SF-36 subscales were severely affected, and the St Georges and Maugeri questionnaires indicated a high impact of chronic obstructive pulmonary disease (79 ± 13 and 60 ± 18, respectively). Drawings illustrated the pervasiveness of dyspnoea; patients' comments stressed breathlessness. Obstruction and tightening were salient, with a prominent representation of the head and internal structures, e.g. the lungs and the airways. Conclusion: Patients' drawings capture a global expression of illness experience. They provide insight into the heterogeneity of patients' perceptions, and allow acknowledgement of patients' representations and experiences. This may, in turn, help in gaining patients' participation in rehabilitation programmes or adherence to new medications.
The authors wish to thank Malik Babaker for his assistance in data collection, as well as all the... more The authors wish to thank Malik Babaker for his assistance in data collection, as well as all the busy residents who took time to answer our questions.
Despite the importance of appropriate inter-professional collaboration in healthcare, it is still... more Despite the importance of appropriate inter-professional collaboration in healthcare, it is still insufficiently taught in medical education. The aim of the study was to identify the relevant themes and competences related to inter-professional education and find a consensus on inter-professionalism among health professionals in the context of primary care, and the objective of a closer collaboration between the University of Applied Sciences Healthcare professionals, the Faculty of Sciences and the Faculty of Medicine in Geneva, Switzerland. Methods: A Delphi electronic survey was carried out in 2011. Invited participants comprised 12 categories of health professionals including practitioners, trainers and trainees from Switzerland. During the first round, practitioners working in primary care were asked to describe two personal situations of good and poor inter-professional collaboration. Trainers and trainees were asked to suggest themes and competences to be included in an "inter-professional" program. A first list of themes and competences for inter-professionalism collaboration was then extracted. During the second round, the same participants were asked to validate these lists. On the third round, participants were asked to prioritize them. Results: Seventy two participated to the first round and 43 to the third round. Patient communication, case management of chronic conditions, therapeutic patient education, health promotion and prevention, ethics and medication were the most important themes identified. "Defining, sharing tasks and responsibilities between professionals" was the most important competence. Sub analysis revealed that both themes and competences differed between health professional categories. Conclusions: The survey helped identify key themes and competencies needed to develop an interprofessional training program in the context of primary care and initiate collaboration among health professional educators in this field. Further research should explore to which extent the differences of perceptions observed between health professionals' relate more to their professional identify and the health care organization in Switzerland.
International Journal for Quality in Health Care, 2007
Background. While most recommended pain management practices have been developed for hospitalised... more Background. While most recommended pain management practices have been developed for hospitalised patients, little is known about their relevance for ambulatory patients presenting with acute pain. Objective. In this study, we explored the relationship between patients' reported use of recommended pain management practices and pain relief in outpatients. Mehtod. 703 adult patients who presented with pain at the medical walk-in clinic of the University Hospitals of Geneva, Switzerland, were included in a mailed cross-sectional survey. They completed a self-administered questionnaire with specific items on self reports of pain and pain management processes. Main outcome measures. Patient's self reports on pain and pain management processes. Results. Of the 703 patients presenting with pain, 40% reported complete pain relief after their visit at the medical walk-in clinic. After adjustment for age, sex, origin, general health and intensity of pain, patients' self-report of complete pain relief was associated with availability of medical doctors (OR ¼ 5.6; 95% CI 2.1-14.7 for excellent vs. poor availability), availability of nurses (OR ¼ 2.6; 95% CI 1.2-6.0 for excellent vs. poor availability), waiting ,10 min for pain medication (OR ¼ 4.6; 95% CI 2.2-9.8), regular assessment of pain (OR ¼ 1.7; 95% CI 1.02-2.7) and having received information about pain and its management (OR ¼ 3.0; 95% CI 1.8-4.9). Conclusions. Self-reported pain relief was associated with more frequent use of recommended pain management processes. These recommendations initially developed for hospitalized patients should also be encouraged for ambulatory care patients.
Background: Although interpersonal continuity is commonly assumed to be essential for care, some ... more Background: Although interpersonal continuity is commonly assumed to be essential for care, some patients prefer to attend a university outpatient clinic where physicians change regularly and interpersonal continuity of care is not ensured. Objectives: The aim of this exploratory study was to evaluate the differences between patients attending a university outpatient clinic and patients frequenting a private practice, explore their patterns of care-seeking and their understanding of continued care. Methods: We conducted a cross-sectional study of patients attending the university medical outpatient clinic (OC) in Lausanne, Switzerland and ten randomly selected private general practices (PP). Eligible patients were >30 years, Swiss nationals or long term residents, with one or more chronic conditions and attending the same practice for >3 years. They were asked to complete a questionnaire on sociodemographic data, use of medical resources and reasons for choosing and remaining at the same practice. Semi-structured interviews were conducted with a randomly selected subset of 26 patients to further explore their preferences. Results: 329 patient questionnaires were completed, 219 by PP and 110 by OC patients. OC patients tended to be of lower socioeconomic status than PP patients. The main reason for choosing a PP were personal recommendation, while a higher percentage of patients chose the OC because they could obtain a first appointment quickly. A higher percentage of PP patients accorded importance to physician communication skills and trust, whereas a higher percentage of OC patients favoured investigation facilities. Qualitative data suggested that although OC and PP patients reported different reasons for consulting, their expectations on the medical and relationship level were similar. Conclusion: Our study suggests that the two groups of patients belong to different social backgrounds, have different patterns of care-seeking and attach importance to different aspects of care continuity. However, patients' expectations and perceptions of the physician-patient relationship are similar.
Background: Physicians' explanatory models of commonly encountered clinical problems reflect not ... more Background: Physicians' explanatory models of commonly encountered clinical problems reflect not only formal medical training, but also personal and professional experience. In situations where formal training is absent, the clinical context of informal learning is likely to have an important influence on junior doctors' evolving knowledge and practice. Objectives: The purpose of this study was to explore junior doctors' explanatory models of somatisation in the absence of formal training, and in particular the influence of working with a large proportion of immigrants (asylum seekers and refugees) on their understanding and practice. Methods: Semi-structured interviews were conducted with all 14 junior doctors working at the Geneva University Hospitals general medicine outpatient clinic. Interviews explored junior doctors' definitions, understanding and management of somatisation. Interviews were tape-recorded, transcribed verbatim and analyzed for key themes. Results: In the absence of formal training, somatisation evoked considerable uncertainty and frustration in terms of diagnosis and management. Junior doctors' understanding of somatisation was heavily influenced by their contact with immigrant patients. They primarily attributed somatisation to psychosocial stresses related to migration and tended to label certain socio-cultural groups as more prone to somatisation than others. Conclusion: It is important to recognize that contextual factors have an important influence on physicians' evolving explanatory models for commonly encountered problems, especially in the absence of formal training. Results from this study suggest that formal training in management of somatisation should be offered in order to broaden junior doctors' understanding of somatisation and avoid cultural stereotyping.
Purpose: As the COVID-19 pandemic outbreak occurred, most structured clinical communication train... more Purpose: As the COVID-19 pandemic outbreak occurred, most structured clinical communication training were transformed from in-person to remote seminars. The aim of our study was to evaluate the usefulness and feasibility of online synchronous clinical communication training from both students' and tutors' perspectives. Patients and Methods: We conducted a cross-sectional study. Geneva Faculty of Medicine' 3rd year medical students and tutors involved in clinical communication were asked to respond to an online survey. Results: Eighty-five of 149 students and 15/16 tutors responded. Students highly valued both online seminars and reported little technical difficulty. They felt that tutors were well prepared and actively involved them in experiential learning. Tutors globally reported little technical difficulty and felt rather well prepared to do so online. Although both students and tutors preferred the in-person format, half of them could still consider using an online format in the future outside the pandemic but mentioned it required specific rules. Conclusion: Our results suggest that clinical communication can be taught and practiced online and that tutors can quickly adapt to such changes.
During their pre-clinical years, medical students are given the opportunity to practice clinical ... more During their pre-clinical years, medical students are given the opportunity to practice clinical skills with simulated patients. During these formative objective structured clinical encounters (OSCEs), tutors from various backgrounds give feedback on students' history taking, physical exam, and communication skills. The aim of the study was to evaluate whether the content and process of feedback varied according to the tutors' profile. During 2013, all 2(nd) and 3(rd) year medical students and tutors involved in three formative OSCEs were asked to fill in questionnaires, and their feedback sessions were audiotaped. Tutors were divided into two groups: 1) generalists: primary care, general internist and educationalist physicians 2) specialists involved in the OSCE related to their field of expertise. Outcome measures included the students' perceptions of feedback quality and utility and objective assessment of feedback quality. Participants included 251 medical students a...
BACKGROUND: Increasing the attractiveness of primary care careers is a key step in addressing the... more BACKGROUND: Increasing the attractiveness of primary care careers is a key step in addressing the growing shortage of primary care physicians. The purpose of this review was to (1) identify interventions aimed at increasing the proportion of undergraduate medical students choosing a primary care specialty, (2) describe the characteristics of these interventions, (3) assess the quality of the studies, and (4) compare the findings to those of a previous literature review within a global context. METHODS: We searched MEDLINE, EMBASE, ERIC, CINAHL, PsycINFO, The Cochrane Library, and Dissertations & Theses A&I for articles published between 1993 and February 20, 2015. We included quantitative and qualitative studies reporting on primary care specialty choice outcomes of interventions in the undergraduate medical curriculum, without geographic restrictions. Data extracted included study characteristics, intervention details, and relevant outcomes. Studies were assessed for quality and strength of findings using a five-point scale. RESULTS: The review included 72 articles reporting on 66 different interventions. Longitudinal programs were the only intervention consistently associated with an increased proportion of students choosing primary care. Successful interventions were characterized by diverse teaching formats, student selection, and good-quality teaching. Study quality had not improved since recommendations were published in 1995. Many studies used cross-sectional designs and non-validated surveys, did not include control groups, and were not based on a theory or conceptual framework. DISCUSSION: Our review supports the value of longitudinal, multifaceted, primary care programs to increase the proportion of students choosing primary care specialties. Isolated modules or clerkships did not appear to be effective. Our results are in line with the conclusions from previous reviews and add an international perspective, but the evidence is limited by the overall low methodological quality of the included studies. Future research should use more rigorous evaluation methods and include long-term outcomes.
The aging of the population and the rising prevalence of chronic diseases mandate improved collab... more The aging of the population and the rising prevalence of chronic diseases mandate improved collaboration among different health professionals. Interprofessional training is one way to improve it, because it encourages health professionals to learn with, from and about one another and respects the integrity and contribution of each profession. Few medical or health professional schools develop such dimensions in their curricula, while postgraduate and continuous training seldom offer such opportunities. Institutional and political commitment may significantly contribute to the development of such dimensions in medical and other health profession education. Having a same mission, sharing responsibility for the team success, defining clear member roles and task, and communicating on a routine basis represent other key factors of success.
Somatisation is particularly challenging in multicultural contexts where patients and physicians ... more Somatisation is particularly challenging in multicultural contexts where patients and physicians often differ in terms of their illness-related beliefs and practices and health care expectations. This paper reports on a exploratory study aimed at better understanding how asylum seeker and refugee patients from the former country of Yugoslavia who were identified by their physicians as somatising make sense of their suffering. We conducted semi-structured interviews with 26 asylum seeker and refugee patients from the former country of Yugoslavia who attended the general medicine outpatient clinic of a Swiss teaching Hospital and were identified as presenting with somatisation. Interviews explored patients' illness perspectives and health care expectations. Interviews were audio taped, transcribed verbatim and analyzed to identify key themes in patients' narratives. Patients attributed the onset of symptoms to past traumatic experiences and tended to attribute their persistenc...
Residents' perceived needs in communication skills training are important to identify before ... more Residents' perceived needs in communication skills training are important to identify before designing context-specific training programmes, since learrners' perceived needs can influence the effectiveness of training. To explore residents' perceptions of their training needs and training experiences around communication skills, and whether these differ between residents training in inpatient and outpatient clinical settings. Four focus groups (FG) and a self-administered questionnaire were conducted with residents working in in- and outpatient medical service settings at a Swiss University Hospital. Focus groups explored residents' perceptions of their communication needs, their past training experiences and suggestions for future training programmes in communication skills. Transcripts were analysed in a thematic way using qualitative analytic approaches. All residents from both settings were asked to complete a questionnaire that queried their sociodemographics an...
QUESTION UNDER STUDY/PRINCIPLES: Ambulatory care is a mandatory component of postgraduate trainin... more QUESTION UNDER STUDY/PRINCIPLES: Ambulatory care is a mandatory component of postgraduate training in general internal medicine. Academic outpatient clinics face challenges in training residents in terms of exposure to sufficient patient case-mix, diversity of clinical activities and continuity of care while fulfilling their mission to provide care to vulnerable populations. We report the development and evaluation of a new postgraduate curriculum in ambulatory care in Geneva, Switzerland, designed to overcome such challenges. METHODS/DESCRIPTION: The content of learning activities was adapted to core competencies and learning objectives. In the new 2-year curriculum, residents had their working week divided into 2½ days of continuity clinic over two years, and 2½ days of 6 to 12 months rotations (e.g., walk-in clinics). Team work was consolidated through the creation of subunits including an attending physician, 1-2 senior residents during one year and 6-to 8 residents, who met in bimonthly meetings with other health professionals. RESULTS/EVALUATION: In both local and national surveys, residents and senior residents expressed an overall global satisfaction with the new curriculum. Nursing and administrative staff were less satisfied, because of reduced residents' time in each unit. Interprofessional meetings were highly appreciated for both patient care and team building. Management of residents' absences became more complex. CONCLUSION: The new curriculum met its goals in gaining residents' satisfaction and in reinforcing interprofessional collaboration although management of human resources became more complex. It also gave insights into challenges to be addressed when disseminating a new curriculum, such as strong leadership, educational expertise and management skills and tools.
Background: Pain is a common complaint of patients attending walk-in clinics, but timely and appr... more Background: Pain is a common complaint of patients attending walk-in clinics, but timely and appropriate pain management is often lacking. Aim: To evaluate the impact of a multifaceted intervention on pain management. Design: Prospective interventional study. Methods: Three cross-sectional surveys were conducted: before, 4 months after and 14 months after a multifaceted intervention at the medical walk-in clinic of a university hospital. The intervention included both educational activities and structural changes. Use of recommended pain management procedures, pain relief and overall assessments of pain treatment and health professionals' attitudes were assessed using patient questionnaires, collected by mail. History of pain, records of pain intensity and use of pain medication were extracted from medical files. Results: We analysed 1409 medical files and 695 questionnaires of patients presenting with pain. Documentation of pain intensity and administration of pain medication at the walk-in clinic improved significantly 14 months after the intervention (7% vs. 53% and 17% vs. 27%, respectively, p < 0.001) and pain medication was more often administered by the oral route (14% vs. 23%, p < 0.001). However, no change was observed for complete pain relief (40% vs. 39%, p ¼ 0.92) or patients' overall assessments of pain management. Discussion: The intervention improved adherence to recommended procedures, even in the longer term, but did not result in better patient outcomes. Continuing efforts are needed to help health professionals improve pain management in outpatient care.
Background: Specific knowledge and skills are needed to work effectively with an interpreter, but... more Background: Specific knowledge and skills are needed to work effectively with an interpreter, but most doctors have received limited training. Self-assessed competency may not accurately identify training needs. Purposes: The purpose of this study is to explore the association between self-assessed competency at working with an interpreter and the ability to identify elements of good practice, using a written vignette. Methods: A mailed questionnaire was sent to 619 doctors and medical students in Geneva, Switzerland. Results: 58.6% of respondents considered themselves to be highly competent at working with a professional interpreter, but 22% failed to mention even one element of good practice in response to the vignette, and only 39% could name more than one. There was no association between self-rated competency and number of elements mentioned. Conclusions: Training efforts should challenge the assumption that working with an interpreter is intuitive. Evaluation of clinicians' ability to work with an interpreter should not be limited to self-ratings. In the context of large-scale surveys, written vignettes may provide a simple method for identifying knowledge of good practice and topics requiring further training.
Background: Lack of faculty training is often cited as the main obstacle to postgraduate teaching... more Background: Lack of faculty training is often cited as the main obstacle to postgraduate 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 outpatient medical services from the Geneva University Hospitals. Focus groups were audio taped, transcribed verbatim and analyzed in a thematic way using Maxqdaß 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.
Background: Methods are needed for assessing clinicians' cultural knowledge frameworks. Method: W... more Background: Methods are needed for assessing clinicians' cultural knowledge frameworks. Method: We used a mail survey containing four short clinical vignettes to explore respondents' ability to identify sociocultural factors affecting health and health care. Participants included 299 physicians working at the University Hospitals of Geneva, 156 private physicians, and all 134 local medical students in their clinical years. Twenty-one sociocultural ''domains'' were identified through inductive coding of responses. For each vignette, we obtained the sum of codes as a measure of the respondent's awareness of sociocultural factors that might affect care in this particular situation. As internal consistency was reasonably high (0.68), we computed a single total score as the sum of responses given to all four vignettes. Results: Reponses correlated with factors that might be expected to impact clinicians' awareness of sociocultural factors affecting care. Medical students, females, respondents who had received cultural competence training, those with greater interest in caring for immigrant patients, and those with high self-assessed skills at exploring psychosocial and migration-related issues scored higher on the vignettes. Conclusions: Brief clinical vignettes appear to be a relevant and feasible method for exploring physicians' knowledge of social and cultural factors affecting health and health care.
Objective: To explore the perception of dyspnoea in patients with severe chronic obstructive pulm... more Objective: To explore the perception of dyspnoea in patients with severe chronic obstructive pulmonary disease. Design: Cross-sectional study using mixed methods. Methods: Thirty-two patients with severe chronic obstructive pulmonary disease were included. Data collected included 3 health-related quality of life questionnaires (SF-36, St George and Maugeri respiratory questionnaires) and the Hospital Anxiety and Depression scale (HADS) to assess the impact of chronic obstructive pulmonary disease on quality of life and psychological functioning. Patients were then asked to draw their body and represent difficulties related to breathing. Drawings were coded and categorized. Patients' comments were transcribed. Results: HADS showed scores of depression and anxiety as high as 12.3 ± 2.6 and 9.3 ± 2.2, respectively; SF-36 subscales were severely affected, and the St Georges and Maugeri questionnaires indicated a high impact of chronic obstructive pulmonary disease (79 ± 13 and 60 ± 18, respectively). Drawings illustrated the pervasiveness of dyspnoea; patients' comments stressed breathlessness. Obstruction and tightening were salient, with a prominent representation of the head and internal structures, e.g. the lungs and the airways. Conclusion: Patients' drawings capture a global expression of illness experience. They provide insight into the heterogeneity of patients' perceptions, and allow acknowledgement of patients' representations and experiences. This may, in turn, help in gaining patients' participation in rehabilitation programmes or adherence to new medications.
The authors wish to thank Malik Babaker for his assistance in data collection, as well as all the... more The authors wish to thank Malik Babaker for his assistance in data collection, as well as all the busy residents who took time to answer our questions.
Despite the importance of appropriate inter-professional collaboration in healthcare, it is still... more Despite the importance of appropriate inter-professional collaboration in healthcare, it is still insufficiently taught in medical education. The aim of the study was to identify the relevant themes and competences related to inter-professional education and find a consensus on inter-professionalism among health professionals in the context of primary care, and the objective of a closer collaboration between the University of Applied Sciences Healthcare professionals, the Faculty of Sciences and the Faculty of Medicine in Geneva, Switzerland. Methods: A Delphi electronic survey was carried out in 2011. Invited participants comprised 12 categories of health professionals including practitioners, trainers and trainees from Switzerland. During the first round, practitioners working in primary care were asked to describe two personal situations of good and poor inter-professional collaboration. Trainers and trainees were asked to suggest themes and competences to be included in an "inter-professional" program. A first list of themes and competences for inter-professionalism collaboration was then extracted. During the second round, the same participants were asked to validate these lists. On the third round, participants were asked to prioritize them. Results: Seventy two participated to the first round and 43 to the third round. Patient communication, case management of chronic conditions, therapeutic patient education, health promotion and prevention, ethics and medication were the most important themes identified. "Defining, sharing tasks and responsibilities between professionals" was the most important competence. Sub analysis revealed that both themes and competences differed between health professional categories. Conclusions: The survey helped identify key themes and competencies needed to develop an interprofessional training program in the context of primary care and initiate collaboration among health professional educators in this field. Further research should explore to which extent the differences of perceptions observed between health professionals' relate more to their professional identify and the health care organization in Switzerland.
International Journal for Quality in Health Care, 2007
Background. While most recommended pain management practices have been developed for hospitalised... more Background. While most recommended pain management practices have been developed for hospitalised patients, little is known about their relevance for ambulatory patients presenting with acute pain. Objective. In this study, we explored the relationship between patients' reported use of recommended pain management practices and pain relief in outpatients. Mehtod. 703 adult patients who presented with pain at the medical walk-in clinic of the University Hospitals of Geneva, Switzerland, were included in a mailed cross-sectional survey. They completed a self-administered questionnaire with specific items on self reports of pain and pain management processes. Main outcome measures. Patient's self reports on pain and pain management processes. Results. Of the 703 patients presenting with pain, 40% reported complete pain relief after their visit at the medical walk-in clinic. After adjustment for age, sex, origin, general health and intensity of pain, patients' self-report of complete pain relief was associated with availability of medical doctors (OR ¼ 5.6; 95% CI 2.1-14.7 for excellent vs. poor availability), availability of nurses (OR ¼ 2.6; 95% CI 1.2-6.0 for excellent vs. poor availability), waiting ,10 min for pain medication (OR ¼ 4.6; 95% CI 2.2-9.8), regular assessment of pain (OR ¼ 1.7; 95% CI 1.02-2.7) and having received information about pain and its management (OR ¼ 3.0; 95% CI 1.8-4.9). Conclusions. Self-reported pain relief was associated with more frequent use of recommended pain management processes. These recommendations initially developed for hospitalized patients should also be encouraged for ambulatory care patients.
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Papers by Noelle Perron