Discovering clinical phronesis.

Phronesis is often described as a 'practical wisdom' adapted to the matters of everyday human life. Phronesis enables one to judge what is at stake in a situation and what means are required to bring about a good outcome. In medicine, phronesis tends to be called upon to deal with ethical issues and to offer a critique of clinical practice as a straightforward instrumental application of scientific knowledge. There is, however, a paucity of empirical studies of phronesis, including in medicine. Using a hermeneutic and phenomenological approach, this inquiry explores how phronesis is manifest in the stories of clinical practice of eleven exemplary physicians. The findings highlight five overarching themes: ethos (or character) of the physician, clinical habitus revealed in physician know-how, encountering the patient with attentiveness, modes of reasoning amidst complexity, and embodied perceptions (such as intuitions or gut feeling). The findings open a discussion about the contingent nature of clinical situations, a hermeneutic mode of clinical thinking, tacit dimensions of being and doing in clinical practice, the centrality of caring relations with patients, and the elusive quality of some aspects of practice. This study deepens understandings of the nature of phronesis within clinical settings and proposes 'Clinical phronesis' as a descriptor for its appearance and role in the daily practice of (exemplary) physicians.

Caring for patients with substance use disorders: a qualitative investigation of difficulties encountered by hospital-based clinicians.

Background: Caring for patients with substance use disorders (SUD) is held in low regard and many clinicians resist treating them. To address this situation, numerous research projects assessed training program gaps and professional attitudes. In contrast, this study explored the actual clinical difficulties that a variety of hospital-based professionals encounter when treating patients with SUD. Methods: Qualitative multiple method design including: (1) individual semi-structured interviews with SUD experts and educators; (2) video-elicited, cross self-confrontation interviews with clinicians working in a specialist addiction unit; (3) paired semi-structured interviews with clinicians working in non-specialist units. Participants were recruited within one university hospital. Data collected at stages (1) and (3) relied on an interview guide and were analyzed using conventional content analyses. Data collected at stage (2) consisted of discussions of video recorded clinical interviews and were analyzed based on a participatory approach. Results: Twenty-three clinicians from seven hospital units participated. Forty-four difficulties were reported that we classified into six categories: knowledge-based; moral; technical; relational; identity-related; institutional. We identified seven cross-category themes as key features of SUD clinical complexity: exacerbation of patient characteristics; multiplication of medical issues; hybridity and specificity of medical discipline; experiences of stalemate, adversity, and role reversal. Conclusions: Our study, providing a comprehensive analysis of the difficulties of caring for patients with SUD, reveals a highly challenging clinical practice for a diversity of healthcare providers. They represent a complementary approach to addressing resistance as an important feature of a complex clinical system, and valuable material to discussing professional preparedness.

[Psychiatric liaison III: Research]. / La liaison psychiatrique III : recherche.

Liaison psychiatry consists of an activity of consultation for patients affected by somatic diseases and of an activity of liaison for clinicians. The liaison work can take different forms, such as teaching of patient-physician relationship, supervision or support. To illustrate psychiatric liaison research, we present four studies conducted in our service, which explore (a) the relations between medical students' mental health and their interpersonal competence, (b) the dreams of medical students and what they reveal of their subjectivities, (c) the stakes for primary care practitioners when asking for a specialist's consult, and (d) the situated clinical practice. These studies contribute to nourish psychiatric liaison, which can use their results for training or support of clinicians.

La psychiatrie de liaison comprend une activité de consultation auprès des patient·es en soins somatiques et une activité de liaison auprès des clinicien·nes. La liaison psychiatrique peut prendre des formes diverses, tels l'enseignement de la relation soignant·e-soigné·e, des supervisions ou le soutien d'équipe. Dans cet article, nous présentons 4 études menées dans notre service qui s'intéressent : a) aux liens entre la santé mentale des étudiant·es en médecine et leurs compétences interpersonnelles ; b) à leurs rêves et à ce qu'ils révèlent de leur subjectivité ; c) aux enjeux de l'appel aux spécialistes pour les médecins de premier recours et d) à la pratique clinique en situation. Ces études contribuent à nourrir le travail de liaison qui peut s'appuyer sur leurs résultats dans la formation et le soutien des soignant·es.

The situated body: anorexia as a conflict of dwelling.

We commend Prof. Fuchs's analysis of anorexia as a conflict of embodiment. We find it important to underline the role of the environment. In particular, in reference to a study that will soon be published, we mention the difficulties patients experience in relation to their home.

Exploring Clinical Practice and Developing Clinician Self-Reflection Through Cross Self-Confrontation Methodology: An Application Within an Addiction Medicine Unit.

Use of the methodology of cross self-confrontation (CSC) is limited in the field of healthcare and in the context of clinical practice. We applied this methodology within an addiction medicine unit of a university hospital, as part of an exploration of addiction-related clinical difficulties. Cross self-confrontation was used according to a 3-phase design based on video recorded clinical interviews with pairs of nurses and medical doctors. The article reports and discusses the application of CSC in a specific clinical context and illustrates the methodological process through one result. Findings suggest two major strengths of CSC in the context of clinical practice research and education: (1) the capacity to elicit tacit knowledge from daily clinical practice and (2) the ability to enhance self-reflection by questioning professionals both individually and collectively. Further use of CSC in nursing surroundings and clinical settings should be encouraged.

[Physicians, their practice, and the institution : to adapt or to situate oneself ?] / Le médecin, sa clinique et l'institution : s'adapter ou se situer ?

The context of the clinical encounter, and more generally of the practice of medicine, has effects on physicians. For example, it shapes their opinions, discourses, and ultimately their behaviors. The context may also directly impact physicians, sometimes affecting their physical and mental health. Numerous interventions, provided within and outside the institution, are targeting these effects. The question we raise in this article is: should physicians adapt to, or should they rather situate themselves within, their context. This question leads us to discuss reflexivity and reflexivity training.

Le contexte du médecin, « ce qui entoure ¼ la rencontre clinique et, plus globalement, sa pratique, produit des effets sur lui, par exemple en orientant, déterminant et modelant ses opinions, ses discours et sa conduite. Ces effets peuvent se révéler délétères et atteindre les médecins dans leur santé physique et psychique. De nombreuses interventions et formations sont aujourd'hui ciblées sur ces effets et proposées dans et hors institution. La question que nous posons dans cet article est de savoir si les médecins doivent apprendre à s'adapter à leur contexte ou, plutôt, à s'y situer. Cela nous amène à traiter du processus de réflexivité et des formations à la réflexivité.

[The physician, the clinical practice, and the institution: the suicidal patient]. / Le médecin, sa clinique et l'institution: le cas du patient suicidaire.

Patients and their clinical predicaments have an impact on clinicians (that psychoanalysis frames as countertransference), but also on medical institutions. Suicidal patients provide a potent illustration of such phenomena. At the individual level, they evoke intense, often negative affective reactions. At the institutional level, they are also « difficult ¼ patients, who often do not conform to the classical, « expected ¼ sick role. This can result in policies too focused on risk assessment and strict procedures, potentially detrimental to proper care. To prevent such defensive attitudes, institutions should provide clinicians an environment in which they are able to work through their relationships with patients, but also with the medical profession and institutions.

Parallèlement à ce qu'ils éveillent chez les cliniciens ­ les psychanalystes parlent de contre-transfert ­, les patients ont des effets sur l'institution. La suicidalité en fournit un bon exemple. Au niveau individuel, la rencontre avec les patients suicidaires suscite des affects intenses et souvent négatifs. Au niveau institutionnel, ces patients, difficiles, rappellent les suicides passés et leurs effets traumatiques; ils peuvent être ambivalents vis-à-vis des soins et ne se conforment pas au rôle « attendu ¼ des malades. En réaction, on peut observer des mouvements délétères, comme le développement de procédures trop focalisées sur l'évaluation du risque. Pour les prévenir, l'institution doit offrir aux cliniciens qui la font et la soignent un cadre pour penser leur relation aux patients, au métier et à l'institution elle-même.

Differences and similarities in instant countertransference towards patients with suicidal ideation and personality disorders.

BACKGROUND: Previous findings showed that suicidal patients elicit mostly negative countertransference such as distress, hopelessness, feelings of inadequacy, and apprehension, and that a concurrent personality disorder is associated with more feelings of entrapment and mistreatment, among other adverse reactions. No studies were however conducted on instant countertransference (iCT), i.e., after a single encounter, for example in an emergency setting. We aimed to evaluate the impact of suicidal ideations, self-harm and presence of personality disorders on instant Countertransference (iCT). METHODS: Caregivers rated their iCT with two validated and standardized questionnaires after a first emergency or outpatient consultation. Suicidal ideation, self-harm and personality disorders were tested as predictors for iCT in a multivariate and multilevel analysis. RESULTS: Thirty caregivers rated their iCT towards 321 patients. Personality disorders and suicidal ideation, but neither recent nor past history of self-harm, predicted iCT. Common iCT included tension, lack of self-confidence and feeling of being tied. iCT specifically associated with suicidal ideation included distress, lack of hope, confusion, and sense that the patient's life had little worth. In contrast, iCT towards patients with personality disorders suggested tension in the therapeutic relationship (low affiliation with patient, anger, disappointment, devaluation). LIMITATIONS: Caregiver's characteristics were not considered in the analysis. Furthermore, while countertransference also includes unconscious phenomena, only conscious iCT was assessed. CONCLUSIONS: Patients with suicidal ideation and personality disorders elicit common but also specific negative iCT. Mental health institutions need to devote specific resources (such as clinical supervision and training) to help caregivers manage their iCT.

[Medical crisis, clinical engagement]. / Crise médicale, engagement clinique.

Medicine is changing, and so are the causes of dissatisfaction among physicians. In a broader context characterized by the dominance of an economic rationality, in which medicine is shaped by the phenomenon of acceleration typical of modernity, we argue, in this brief article, that clinical practice is based on an engagement involving a form of suspension of the flow of time. Engagement is thereby an essential dimension of medicine, and is proposed as a lasting foundation of clinical practice.

La médecine change et avec elle, les raisons de l'insatisfaction des médecins. Dans un contexte où prévaut notamment une logique de type économique et où le métier de médecin est marqué par l'accélération caractéristique de la modernité, nous avançons dans ce bref article de réflexion que la clinique se fonde sur un engagement impliquant une forme de suspension du temps. L'engagement constitue ainsi une dimension essentielle du métier médical et potentiellement un socle durable de la clinique.

Collusion in palliative care: an exploratory study with the Collusion Classification Grid.

OBJECTIVE: Collusion is a largely unconscious, dynamic bond, which may occur between patients and clinicians, between patients and family members, or between different health professionals. It is widely prevalent in the palliative care setting and provokes intense emotions, unreflective behavior, and negative impact on care. However, research on collusion is limited due to a lack of conceptual clarity and robust instruments to investigate this complex phenomenon. We have therefore developed the Collusion Classification Grid (CCG), which we aimed to evaluate with regard to its potential utility to analyze instances of collusion, be it for the purpose of supervision in the clinical setting or research. METHOD: Situations of difficult interactions with patients with advanced disease (N = 10), presented by clinicians in supervision with a liaison psychiatrist were retrospectively analyzed by means of the CCG. RESULT: 1) All items constituting the grid were mobilized at least once; 2) one new item had to be added; and 3) the CCG identified different types of collusion. SIGNIFICANCE OF RESULTS: This case series of collusions assessed with the CCG is a first step before the investigation of larger samples with the CCG. Such studies could search and identify setting-dependent and recurrent types of collusions, and patterns emerging between the items of the CCG. A better grasp of collusion could ultimately lead to a better understanding of the impact of collusion on the patient encounter and clinical decision-making.

[A relationship under the influence : collusive phenomena in clinics]. / Une relation sous influence : phénomènes collusifs en Clinique.

Collusion is a mostly unconscious phenomenon occurring in the therapeutic relationship, which can be commonly identified in psychiatry but more generally in medicine. Collusion is especially present in circumstances in which the effects of disease and its treatments have a heavy impact on patients and caregivers, and where the stakes are existential. Collusion is triggered by unresolved psychological problems, for example, loss, intimacy or control, which are shared by the patient and the clinician. Collusion, if unrecognized, can seriously hamper the clinician-patient relationship and the care of the patient.

La collusion est un phénomène inconscient survenant dans la relation thérapeutique, observable en psychiatrie, mais aussi en médecine. Elle se manifeste surtout dans les domaines où les effets de la maladie et des traitements pèsent lourdement sur les patients et les cliniciens et où les enjeux sont existentiels. L'origine d'une collusion se situe dans des problèmes psychologiques non résolus, en lien avec des thématiques comme la perte, l'intimité ou le contrôle, qui sont partagés par le clinicien et son patient. La collusion, si elle n'est pas reconnue, peut sérieusement entraver la relation clinique et avoir des conséquences négatives sur la prise en charge.

An empirical and philosophical exploration of clinical practice.

BACKGROUND: Previous empirical work among physicians has led us to propose that clinical practice is experienced by clinicians as an engagement-in-the-clinical-situation. In this study, we pursue our exploration of clinical practice 'on its own terms' by turning to the experience of patients. METHODS: Phenomenological analysis of in-depth individual interviews with 8 patients. RESULTS: We describe the patient experience as a set of three motifs: the shock on the realization of the illness, the chaos of the health care environment, and the anchor point provided by an engaged physician. We draw on Heidegger's notion of solicitude to show that patients are actively ascertaining the physician's engagement in their care. CONCLUSIONS: These findings lead us to question the classical "dual discourse" of medicine that offers a dichotomous account of clinical practice as the addition of care to cure, art to science, humanism to technique, and person to medical case. We found no such distinctions in our empirical investigation of clinical practice. Rather, in our synthesis, practice appears as a unitary experience. The physician's solicitude for the patient entrains engagement in the clinical situation. Moreover, the solicitous, engaged physician constitutes an anchor point for the patient.

Engagement and practical wisdom in clinical practice: a phenomenological study.

In order to understand the lived experiences of physicians in clinical practice, we interviewed eleven expert, respected clinicians using a phenomenological interpretative methodology. We identified the essence of clinical practice as engagement. Engagement accounts for the daily routine of clinical work, as well as the necessity for the clinician to sometimes trespass common boundaries or limits. Personally engaged in the clinical situation, the clinician is able to create a space/time bubble within which the clinical encounter can unfold. Engagement provides an account of clinical practice as a unitary lived experience. This stands in stark contrast to the prevailing notion, referred to as a dual discourse, that describes medicine as the addition of humanism to science. Drawing on Aristotle's notion of phronesis and Sartre's definition of the situation, we illustrate how this novel perspective entwines clinical practice, the person of the clinician, and the clinician's situation.

[The « Osler ¼ group : a new opportunity to think about « becoming a physician ¼]. / Le groupe « Osler ¼ : une nouvelle opportunité pour réfléchir sur le « devenir médecin ¼.

Issues of professionalism and professional identity formation, particularly amongst young doctors, have been the object of increasing attention. This is explained in part by the evolution of the hospital environment (specialization, shorter stays), as well as by the prevalence of physician burnout and suicide. In this context, the CHUV implemented a pilot project within the department of internal medicine aiming to support its residents in the construction of their professional identity. The Osler group convened 10 residents led by an attending physician and a senior resident from the internal medicine department as well as an attending physician of the liaison psychiatry department. The experience has been a success, with residents describing clear benefits of the group.

Les enjeux de professionnalisme et d'identité professionnelle chez les médecins font l'objet d'un intérêt croissant, en raison des évolutions du milieu hospitalier (spécialisation, raccourcissement de la durée de séjour) ainsi que de phénomènes comme le burn-out ou le suicide. C'est dans ce contexte que le CHUV a mis en place un projet pilote dans le Service de médecine interne (SMI) pour soutenir les médecins assistants dans la construction de leur identité professionnelle, valoriser la transmission de l'expérience clinique et leur offrir un espace de parole et d'échange. Le groupe « Osler ¼ a ainsi réuni dix assistants pour des rencontres animées par un médecin cadre et une cheffe de clinique du SMI, ainsi qu'un médecin cadre du Service de psychiatrie de liaison. L'expérience a été un succès, les assistants exprimant clairement les bienfaits du groupe, notamment quant à leur rapport au métier.

[Addiction-related clinical practice in hospital setting : from specialization to responsibilization]. / La clinique des addictions en milieu hospitalier : entre spécialisation et responsabilisation.

Over the past two years, the Swiss Institute for Postgraduate and Further Education in Medicine has implemented a new certification in addiction medicine and an in-depth training in addiction psychiatry and psychotherapy. These developments contribute to the recognition of a specialty and the training of a new generation of specialized clinicians. This context leads to the question of the role and the skills to be passed on to non-specialists when taking care of drug addiction. This article focuses on the importance of preparing non-specialized clinicians in the hospital setting and presents two prerequisites for improving their training: to explore clinicians' field experience and to make the individual and institutional actors aware of their responsibility.

Au cours des deux dernières années, l'ISFM (Institut suisse pour la formation médicale postgraduée et continue) a établi le cadre d'une nouvelle certification en médecine de l'addiction et d'une formation approfondie en psychiatrie et psychothérapie des addictions. Ces développements contribuent à la reconnaissance d'une spécialité et à la formation d'une nouvelle génération de cliniciens spécialistes. Dans ce contexte, se pose la question du rôle et des compétences à transmettre aux non-spécialistes, notamment à l'hôpital, pièce maîtresse de la prise en charge des personnes souffrant d'un problème d'addiction aux substances. Cet article décrit l'importance de préparer les cliniciens non spécialistes sur le terrain hospitalier et évoque deux prérequis à l'amélioration de leur préparation : explorer les expériences de terrain et responsabiliser les acteurs.