Work week duration, work-family balance and difficulties encountered by female and male physicians: results from the French SESMAT study.

OBJECTIVE: France encounters difficulties attracting physicians to work in hospitals. Organisation at work and at home may be at the heart of the problem for female as well as for male physicians. PARTICIPANTS: A comprehensive questionnaire was filled out online by a representative sample of 1924 French hospital physicians. METHODS: We conducted gender bivariate and multivariate analysis of the risk factors for burnout and intent to leave the profession(ITL). RESULTS: ITL was declared by 17.4% of physicians. According to 41.3% of female physicians (FP), their profession was an obstacle to having children (versus 19.3% for male physicians (MP)). Major factors linked with burnout were Effort/Reward imbalance (FP adjOR = 5.09, MP adjOR = 5.93), Work-family conflicts (FP adjOR = 2.97, MP adjOR = 3.04), and Low quality of teamwork (FP adjOR = 1.82, MP adjOR = 2.68). Major factors linked with ITL were Low quality of teamwork (FP adjOR = 4.49, MP adjOR = 3.03), Patient-related burnout (FP adjOR = 2.10, MP adjOR = 2.35) and General burnout (FP adjOR = 1.85, MP adjOR = 1.45). CONCLUSIONS: Excessive job demands are linked with burnout and with work-family conflicts, conducting to difficulties in organising one's life in order to have and raise children. Potential solutions include facilitating teamwork in order to reduce departure, which increase workload on those who stay increasing their work family conflict.

Emergency physicians accumulate more stress factors than other physicians-results from the French SESMAT study.

INTRODUCTION: France is facing a shortage of available physicians due to a greying population and the lack of a proportional increase in the formation of doctors. Emergency physicians are the medical system's first line of defence. METHODS: The authors prepared a comprehensive questionnaire using established scales measuring various aspects of working conditions, satisfaction and health of salaried physicians and pharmacists. It was made available online, and the two major associations of emergency physicians promoted its use. 3196 physicians filled out the questionnaire. Among them were 538 emergency physicians. To avoid bias, 1924 physicians were randomly selected from the total database to match the demographic characteristics of France's physician population: 42.5% women, 57.5% men, 8.2% < 35 years old, 33.8% 35-44 years old, 34.5% 45-54 years old and 23.6% ≥ 55 years old. The distribution of physicians in the 23 administrative regions and by speciality was also precisely taken into account. This representative sample was used to compare subgroups of physicians by speciality. RESULTS: The outcomes indicate that the intent to leave the profession (ITL) was quite prevalent across French physicians and even more so among emergency physicians (17.4% and 21.4% respectively), and burnout was highly prevalent (42.4% and 51.5%, respectively). Among the representative sample and among emergency physicians, work-family conflict (OR=4.47 and OR=6.14, respectively) and quality of teamwork (OR=2.21 and OR=5.44, respectively) were associated with burnout in a multivariate analysis, and these risk factors were more prevalent among emergency physicians than other types. A serious lack of quality of teamwork appears to be associated with a higher risk of ITL (OR=3.92 among the physicians in the representative sample and OR=4.35 among emergency physicians), and burnout doubled the risk of ITL in multivariate analysis. CONCLUSIONS: In order to prevent the premature departure of French doctors, it is important to improve work-family balance, working processes through collaboration, multidisciplinary teamwork and to develop team training approaches and ward design to facilitate teamwork.

[Palliative care mobile team at a Parisian university hospital]. / Equipe mobile de soins palliatifs dans un hôpital universitaire parisien.

Ever since 1987 in France, palliative care is developing in hospitals through PCU and mobile teams. The arbitrary split between care and cure could find its origin in the history of the "cancer war" and in the lack of interest of doctors for patients at the end of their lives. The evolution of mindsets in modern societies goes together with the emergence of the individual, modifying at the same time the perception of pain. This concern for the one who suffers explains the strong requirement to relief pain and to attend the passing away persons. Death is a reality that one constantly tries to evacuate because it is disturbing and shows the limits of medicine. The mobile team within the hospital, including different health professionals, aims at preventing pain at each level of the disease, by a patient effort of awareness among the hospital teams.

The use of steroids in the management of inoperable intestinal obstruction in terminal cancer patients: do they remove the obstruction?

This multicentre, randomized double-blind study was undertaken to assess the efficacy of corticosteroids as a palliative treatment of intestinal obstruction due to advanced and incurable cancer. Thirty-one French palliative care units agreed to participate in the study and 12 actually recruited at least one patient. To be included, patients had to have an advanced cancer with a surgically inoperable bowel obstruction and to have received no specific anticancer therapy within the preceding 28 days. They had to fulfil at least three of the following criteria: vomiting at least twice a day; colicky abdominal pain; no flatus for 12 h or more; no stool for at least 4 days, faecal impaction being excluded; intestinal distension; air-fluid levels or absence of gas in the colon on an abdominal radiograph. Patients were randomized in three groups to receive either a placebo for 3 days (group A), or methylprednisolone 240 mg daily for 3 days (group B) or methylprednisolone 40 mg daily for 3 days (group C). Symptoms were assessed daily but success or failure of the treatment was assessed on day 4, according to the disappearance or persistence of symptoms. Fifty-eight patients were randomized, of whom 52 were able to be evaluated. Details of symptoms and associated treatments are described below. Of 40 patients without a nasogastric tube, symptoms were relieved in 68% of cases versus 33% among placebo-treated patients (P = 0.047). In 12 patients who had a nasogastric tube already in place, the results are less significant (60% versus 33% with P = 0.080). Because of the small sample size, no conclusions can be reached about the relative efficacy of low versus high-dose treatment regimes.

[Evaluation of cognitive disorders and screening of delirium in cancer patients receiving morphine. Comparison of the use of the Elementary Test of Concentration, Orientation and Memory (TELECOM)and of the Mini-Mental State Examination (MMSE)]. / Evaluation des troubles cognitifs et dépistage du delirium chez les patients cancéreux recevant de la morphine. Comparaison de l'utilisation du Test Elémentaire de Concentration, Orientation et Mémoire (TELECOM) et du Mini-Mental State Examination (MMSE).

OBJECTIVE: The Mini Mental State Examination (MMSE) is the gold standard cognitive test for screening delirium in cancer patients on opioids. But the MMSE is long and requires writing, reading and drawing from patients with various degrees of physical inability. Age and educational level affect the MMSE score. The Blessed Orientation-Memory-Concentration (BOMC) test is strictly oral and brief. This six item test is not affected by age or educational level. PATIENTS AND METHODS: We conducted a validation study of BOMC for screening delirium in cancer patients taking opioids. One physician examined 25 advanced cancer patients 34 times with MMSE and BOMC. Diagnosis of delirium was made by the same examiner according to the DSM IV criteria. The MMSE score was used for diagnosis of cognitive failure. RESULTS: Seventy-six percent of the patients completed the MMSE and 100% the BOMC. Scores of the two tests were correlated (0.71). An average 4 min 12 sec was gained with BOMC compared with MMSE. For a 10/11 cutoff, the BOMC had 83% sensitivity and 95% specificity for delirium diagnosis. Positive and negative predictive values were 91%. The time for the BOMC was correlated with BOMC score (0.6). A BOMC time of 3 min 20 sec had 91% sensitivity and specificity for delirium diagnosis. CONCLUSION: BOMC is more applicable than MMSE for screening delirium in cancer patients. The relationship between BOMC time and delirium deserves further investigations.

Physicians' recognition of the symptoms experienced by HIV patients: how reliable?

To assess how well physicians recognize common symptoms in HIV patients and identify factors associated with symptom recognition, a multicenter cross-sectional survey was performed in a random sample of 118 hospitalized and 172 ambulatory HIV patients, and their attending physicians. Patients' reports of 16 different symptoms were compared to physicians' reports of whether each symptom was present and/or specific treatments prescribed. Overall, fatigue, anxiety, skin problems, fever, and weight loss were more often recognized by physicians than other symptoms. Agreement between patients and physicians was poor to moderate, with Kappa statistics ranging from 0.17 (dry mouth) to 0.58 (fever). Recognition was independently more likely for ambulatory patients (adjusted odds ratio 1.69, P < 0.001) and for patients seen as sicker (adjusted odds ratio 1.88, P < 0.001). Appropriate symptom management requires improved symptom recognition. More systematic clinical examinations, including attentive patient interview, are needed.

Platelet transfusions in advanced hematological malignancies: a position paper.

Treatment of patients with advanced-stage hematological malignancies (HM) includes frequent transfusions. Given present limited hospital budgets, administrative pressure is increasing on hematology services to limit the cost of these transfusions. An expert multidisciplinary panel involved in hematology formed a working party to draw up a series of proposals, including definitions of advanced stage disease and the indications for platelet transfusion. Their proposals included: (a) Platelet transfusions are indicated for the treatment of bleeding caused by low platelet counts; (b) Patients should receive full information, including the basic criteria for platelet transfusion; (c) Doctors should be trained to assess whether or not platelet transfusions are urgently required; and (d) The practice of home transfusions should be encouraged.

[Demand for the stopping of chronic hemodialysis. Apropos of 1 case]. / Demande d'arrêt d'hémodialyse chronique. A propos d'une observation.

We reported a case of a 69 years old woman who requested stopping long-term dialysis. She did not suffer a serious medical deterioration, except a worsening quality of life. After a global evaluation (medical, psychologic and social), several propositions to increase her state of life done. Nine months later, she persisted in her request. She was admitted in a palliative care unit, and death occurred 4 days later. A medical, juridic, ethic discussion and a literature review are proposed about this difficult medical problem.

The Palliative Care Centre of Hôtel-Dieu Hospital.

In 1989, two affiliations of Centre de Soins Palliatifs were created by the Assistance Publique-Hôpitaux de Paris, the largest medical complex in Europe. At Hôtel-Dieu de Paris, a mobile team from Soins Palliatifs was formed. The members were recruited from hospital services in order to help the team in the care and support of patients with advanced diseases. A description of the service, team activities (care, formation, teaching and research) is proposed.

[Indications of analgesia with absolute alcohol or phenol for intractable pain in thoracic and abdominal cancerous pathology (author's transl)]. / La neurolyse chimique (alcool ou phénol). Ses indications à visée antalgique en pathologie cancéreuse thoraco-abdominale.

This work analyzes the results of 88 blocks for intractable pain in thoracic and abdominal malignant diseases. Results and duration of analgesia are compared in regard to the localization of pain and to the use of alcohol or phenol. Best analgesic results are obtained in the pelvic pains and especially in the colorectal pains. The analgesic results and the duration of analgesia are poorer since the spinal nerves to block are higher, there are only 50 p. cent of good results in the thoracic region. Analgesic results are the same with alcohol or phenol, but duration of analgesia seems to be longer with phenol. The two routes of administration, subarachnoid or epidural, seem to give equal results. Motor paralysis of the bladder or the rectum may occur, especially in the low pelvic localizations and these complications justify careful selection of the indication.

[A comparison of anaesthetic awakening with out-patients treated by maxillo-facial surgery using 4 different anaesthetic techniques (author's transl)]. / Le réveil anesthésique obtenu en chirurgie ambulatoire maxillo-faciale. Comparaison des résultats obtenus avec quatre techniques d'anesthésie différentes.

To estimate and compare the awakening period following 4 different anaesthetic techniques (enflurane and halothane and two intraveinous anaesthetic substances: propanidide and althesin), the authors examined 120 outpatients who had undergone maxillo-facial surgery distributed over 4 sample groups of 30 each. A statistical analysis of the responses to psycho-dianostic tests has not enabled the authors to decide which anaesthetic ambulatory technique is preferable.

[Headaches and subarachnoïd anaesthesia. Prevention by new technique (author's transl)]. / Céphalées et rachi-anesthésie. Prévention par une modification de la technique.

The authors study the influence of a new subarachnoïd anasthesia technique on the incidence of headaches. A statistical survey is carried out on two homogeneous samples of patients who had undergone urologic surgery.