[Interest of a psychosomatic approach Two example of what might be concealed behind gynecological symptoms]. / Intérêt de l'approche psychosomatique. Deux exemples de ce qui se cache derrière des symptômes en gynécologie.

Two situations found in everyday gynecological practice demonstrate how a trustworthy doctor-patient relationship is built. This relationship helps to uncover what is concealed behind physical symptoms, which can perturb daily life (couple, social, family life) beyond a purely medical approach. To understand what is really happening rarely leads to a rapid solution. A stable chronicity that does not involve too many treatments, including surgical ones, can already be considered a success.

Deux situations rencontrées en pratique gynécologique courante montrent comment se construit une relation médecin-patient de confiance. Cette relation permet de découvrir ensemble ce qui se cache derrière des symptômes physiques perturbant la vie quotidienne (vies de couple, sociale, familiale) au-delà de la rationalité médicale. La compréhension des enjeux réels débouche rarement sur une solution immédiate. Une chronicité stable sans trop de traitements, y compris chirurgicaux, est déjà un succès.

Views of healthcare professionals dealing with legal termination of pregnancy up to 12 WA in French-speaking Switzerland.

BACKGROUND: In 2002, by popular vote, Swiss citizens accepted to legalise termination of pregnancy (TOP), up to the 12th week of amenorrhoea (WA). As a result, the cantons formulated rules of application. In 2002, medical TOP was authorised. Health institutions then had to modify their procedures and practices. QUESTIONS UNDER STUDY/PRINCIPLES: What are the views of healthcare professionals on the modifications of procedures and practices implemented in French-speaking Switzerland? METHODS: Qualitative method: in-depth interviews with 77 healthcare professionals, including doctors, nurses and midwives, and sexual and reproductive health social workers. Voluntary participation. Thematic analysis with content analysis software. RESULTS: Most professionals have a balanced point of view on their practices. There is no point of view specific to each different category of professionals interviewed. They are unanimous on the elimination of the need for a second opinion. The points of view diverge on the usefulness of imposed waiting time to think before TOP, minors' access to TOP without parental consent, access to medical TOP and the right to refuse to practice TOP for personal reasons in public hospitals. CONCLUSIONS: The professionals do not question women's right to have TOP up to 12 WA, but they do diverge over procedures and practices. Institutional and cantonal cultures are probably behind these differences.

Clinical course in women undergoing termination of pregnancy within the legal time limit in French-speaking Switzerland.

BACKGROUND: In 2002, Swiss citizens voted to accept new laws legalising the termination of pregnancy (TOP) up to 12th week of pregnancy. As a result the cantons formulated rules of implementation. Health institutions then had to modify their procedures and practices. QUESTIONS UNDER STUDY/PRINCIPLES: One of the objectives of these changes was to simplify the clinical course for women who decide to terminate a pregnancy. Have the various health institutions in French-speaking Switzerland attained this goal? Are there differences between cantons? Are there any other differences, and if so, which ones? METHODS: Comparative study of cantonal rules of implementation. Study by questionnaire of what happened to 281 women having undergone a TOP in French-speaking Switzerland. Quantitative and qualitative method. RESULTS: The comparative legal study of the six cantonal rules of implementation showed differences between cantons. The clinical course for women are defined by four quantifiable facts: 1) the number of days delay between the woman's decision (first step) and TOP; 2) the number of appointments attended before TOP; 3) the method of TOP; 4) the cost of TOP. On average, the waiting time was 12 days and the number of appointments was 3. The average cost of TOP was 1360 CHF. The differences, sometimes quite large, are explained by the size of the institutions (large university hospitals; average-sized, non-university hospitals; private doctors' offices). CONCLUSIONS: The cantonal rules of implementation and the size of the health care institutions play an important role in these courses for women in French-speaking Switzerland.

Costs borne by families of children hospitalized in a pediatric intensive care unit: a pilot study.

QUESTION UNDER STUDY: Hospitalisation of a child in a paediatric intensive care unit (PICU) involves major stress for parents. They wish to stay at their child's bedside while at the same time giving the usual attention to their other children. The resultant out-of-pocket expenses have rarely been studied. METHODS: Over a 6-month period all the families of children hospitalised in our PICU for more than 4 days, speaking French and insured by our social security system, were eligible for inclusion. Participation was proposed only after diagnosis, treatment and prognosis had been determined. Costs were retrieved from a diary list of customised items and computed as the amount in excess of usual expenses until the end of the hospital stay. RESULTS: 117 children were hospitalised in our PICU for a total of 131 stays. The families of 16 fulfilled the inclusion criteria. One dropped out after a week at the parents' request. The children's age was 2.9 +/- 3.8 years and 67% were male. The majority had malformations (53%) or infections (33%). The total length of stay was 49 +/- 51 days, of which 24 +/- 41 were spent in the PICU. On average, parents spent CHF 86 +/- 31 every day, mainly on travel and meals. Over the entire hospital stay their expenses amounted to CHF 4,078 +/- 4,552. CONCLUSIONS: Direct out-of-pocket expenses for parents of children hospitalised in the PICU are considerable. Improvement in the social security system may be necessary to address this issue.

How do patients define "good" and "bad" doctors?

QUESTIONS UNDER STUDY: Knowledge of hospital patients' perceptions of doctors' qualities is limited. The purpose of this study was to explore hospital patients' definitions of "good" and "bad" doctors. METHODS: Semi-structured interviews conducted with 68 consecutive hospital patients. The questions explored the characteristics of good/bad doctors. Responses were subjected to content analysis. RESULTS: The patients' mean age was 72.7 (+/- 15) years; 61% were female. Content analysis produced 9 categories connoted positively/negatively; the mean number of categories/patient response was 2.4 (+/- 1.3), ranging from 1-6. Sensitivity/insensitivity to feelings were in the forefront, together with the importance of the relational dimension and the need to provide treatment tailored to the patient's needs. Patients' responses emphasised "bad" doctors' use of medicine as self-serving and not serving the patient. CONCLUSION: This qualitative enquiry made it possible to gather information on the patients' expectations or beliefs outside physicians' or health researchers' pre-established categories. It emphasised that acknowledging possible areas of uncertainty may be less threatening for the doctor's image than exhibiting scientific proficiency unadapted to the patient's expectations and needs.

Exploring the major difficulties perceived by residents in training: a pilot study.

OBJECTIVES: To assess residents' difficulties during the first year of residency. In contrast to previous studies that mainly used structured questionnaires, a qualitative procedure was applied. METHODS: Twenty-four consecutive first-year residents in internal medicine were asked to "Please identify two to three major difficulties or concerns related to your practice of medicine within this hospital". The answers were submitted to content analysis performed by three independent researchers. Inter-rater agreement was high (kappa coefficient = 0.92). Disagreements were solved by consensus. RESULTS: Physicians' characteristics: female 37%, mean age 28 +/- 2.2 years, mean duration of postgraduate training 2.5 +/- 1.3 years. Total number of answers: 122, average answers/resident 5.1 +/- 1.3. Nine categories were extracted from content analysis: communication problems at the workplace, feelings of not being respected, constraints of collaborative work, experiencing the gap between medical school and clinical care, work overload, responsibility towards and emotional investment in patients, worries about career plans, and lack of theoretical knowledge. Residents expressed major difficulties in communicating with and being respected by seniors and peers in particular, and hospital staff in general. They also voiced problems in coping with emotions, either their own or those of their patients. CONCLUSIONS: The residents' responses stressed the complexity of blending the requirements of the physician's role when instrumental/cognitive knowledge is not sufficient to deal with problems requiring personal and relational dimensions. Learning to combine medical knowledge and practice necessitates helping students/residents identify and deal with the constraints of these requirements.

Contraceptive practice before and after termination of pregnancy: a prospective study.

This study is part of a larger prospective research program focusing on termination of pregnancy (TOP). One hundred and three women requesting TOP were interviewed before the intervention and 6 months later using open and closed questions and psychological tests. This paper focuses on contraceptive practices before and after abortion. The analysis took into account specific aspects of contraceptive practices and patients' behaviors. The aims were to assess: the level of women's knowledge and practice of contraception at the time of request for a TOP; the behavioral modifications following professional counseling 6 months after TOP; the influence of psychological and sexual factors, and those linked to the women's use of contraception. Most women (n = 101) had already used recommended contraception. During the cycle that had resulted in pregnancy, more than half (n = 58) had used recommended contraception and one third had not used any contraception. Six months later, 86 women used recommended contraception, and 17 did not. The majority of women reported changes in their contraceptive methods (n = 82). Most changes were within recommended methods. The women (n = 10) who continued to practice unprotected intercourse post-TOP were slightly older, satisfied with their sexual relations with their partner, often involved in a long-term and good relationship. During post-TOP period, it is essential to take into account the psychological dynamics involved in the choice of contraceptive methods. Counseling should emphasize not only protection against an unwanted pregnancy but also protection against sexually transmitted diseases, which is often perceived as a less important issue following TOP.

[Sexual life, future of the couple, and contraception after voluntary pregnancy termination. Prospective study in Geneva (Switzerland) with 103 women]. / Vie sexuelle, devenir du couple et contraception après IVG. Etude prospective réalisée à Genève (Suisse) auprès de 103 femmes.

OBJECTIVE: Study the impact of termination of pregnancy on women sexuality, contraceptive behaviour and couple relationship. DESIGN: Prospective qualitative and quantitative study. SUBJECTS: 103 women requiring induced abortion by vacuum aspiration who were interviewed one to three weeks before the operation and again six months later. The interview was performed by a questionnaire including open and closed questions and psychological tests (Locke-Wallace and Horowitz' IES). RESULTS: A majority of women (n = 101) had already used contraception. During the cycle that had resulted in pregnancy, more than a half (n = 58) had actually used contraception and 1/3 had not use any contraception at all. Six months later, the majority (n = 86) used contraception, while only 16 did not. Condom was only rarely used (n = 11). After termination of pregnancy, 14 couples of 84 separated. The majority of women (n = 72) did not report changes in their sexual behaviour. On the other hand, 1/5 of women presented a decrease in sexual desire and orgasm troubles. About 1/3 described psychosomatic symptoms, but a majority (n = 92) was not traumatised. CONCLUSIONS: The great majority of women seems to tolerate well the termination of pregnancy. A minority presents sexual dysfunction, psychosomatic symptoms, which persist six months after intervention. As per contraception, the majority of women does protect herself from pregnancy but a percentage still does not protect itself at all or only in a noneffective or less effective way. After termination of pregnancy, the issue of protection from AIDS and sexuality-transmitted diseases seems to be less important.