Pictures as mementos after perinatal death: a case study.

BACKGROUND: The grieving process following perinatal loss caused by life-limiting conditions presents some particularities associated with the family's culture and the symbolic relationship with the deceased. OBJECTIVE: To reflect on the symbolic meaning attributed to mementos, particularly pictures taken immediately after birth. METHOD: Case study-a qualitative analysis of the data collected through semidirected interviews. RESULTS: Of the three women that took part in the study, one woman chose not to take a picture but opted to take home the hat with her son's name on it that was provided as a regular procedure for every birth at the maternity centre. During the interview, she questioned her decision. The two other women took pictures and still look at them affectionate. One of the women keeps the picture of her child in a shrine at home, thus attributing a symbolic religious meaning to the whole experience that alleviates her pain. CONCLUSION: The symbolic meaning attributed to pictures of the deceased can help parents process grief.

Family Conferences in Prenatal Palliative Care.

Background: Fetal malformations are diagnosed prenatally in nearly 3% of pregnancies, and ∼1.2% are major malformations. After prenatal diagnosis, it is imperative to consider families' values and to support their decision-making process. Prenatal palliative care is a growing field mainly based on family conferences. The prenatal care setting is unique and differs from postnatal and adult care. There are no descriptions of family conferences in prenatal palliative care. The descriptions of themes that emerge from the prenatal care conference charts may guide professionals in this delicate task, and help determine the causes of suffering and identify family values before the birth of the infant. Aim: To perform a content analysis of medical records of family conferences and to describe the main themes observed during prenatal palliative care follow-up after the diagnosis of a life-limiting fetal condition. Design: This is a retrospective study of medical records of family conferences from a perinatal palliative care group, the GAI group, between May 2015 and September 2016. Setting/Participants: Families with estimated perinatal mortality >50% and eligibility for follow-up at our tertiary fetal medicine center were enrolled. We included women who participated in at least one family conference with the GAI group and who had given birth at the clinic or delivered at another center and returned for the postnatal family conference. Results: Fifty women met the inclusion criteria. Five main themes and 18 categories emerged from the charts and are described in detail. A model of follow-up in prenatal palliative care is proposed based on the themes and categories identified. Conclusions: This analysis may guide health professionals who seek to better identify family needs and values and organize follow-up during prenatal palliative care.

Cross-Cultural Adaptation of the Communication Assessment Tool for Use in a Simulated Clinical Setting.

Construct: The Communication Assessment Tool (CAT) is a 14-item instrument developed in English to assess medical trainees' interpersonal communication skills from the patient's perspective in clinical settings. Background: Using validated instruments and simulated patients constitutes good practice in assessing doctor-patient communication. The CAT was designed for use in real practice, but has not yet been applied to assessing OB-GYN residents' delivery of bad news in Objective Structured Clinical Examination (OSCE) stations. This study aims to provide validity evidence for using the CAT to assess residents' interpersonal communication skills under difficult circumstances in a simulated clinical setting in Brazil. Approach: Cross-cultural adaptation comprised translation into Portuguese, synthesis of translations, and back-translation. Next, a committee of 10 external and independent experts rated the items for linguistic equivalence and relevance to the overall scale. Researchers used the expert ratings to produce a preliminary Brazilian-Portuguese version. This version was applied by four simulated patients to assess 28 OB-GYN residents completing two, 10-minute OSCE stations focused on delivering bad news. Item and scale content validity indices and internal-consistency reliability were calculated. Simulated patients were interviewed to clarify any doubt regarding the content and usability of the tool and their response process. Findings: Thirteen of the 14 items in the Brazilian-Portuguese version were considered "equivalent" by at least 70% of the experts. All items were considered relevant by 100% of the experts. The Item Content Validity Index ranged from .9 to 1, and the Scale Content Validity Index was .99. The instrument showed good reliability for both scenarios (Cronbach's alpha > .90). Simulated patients considered the CAT easy to understand and complete. Conclusions: This study provides validity evidence for using the Brazilian-Portuguese CAT in a simulated clinical environment to assess OB-GYN residents' delivery of bad news. Based on this study's findings, the OB-GYN Department organized an annual formative assessment for residents to improve their interpersonal communication skills. This version of the CAT may also be applicable to other specialties.

Breaking Bad News: A Study on Formal Training in a High-Risk Obstetrics Setting.

Background: Breaking bad news is a frequent task in high-risk obstetrics clinics. Few studies have examined the role of training in improving such a difficult medical task. Aim: To evaluate the influence of a training program on the participants' perceptions of bad news communication at a high-risk obstetrics center. Design: This prospective study was conducted at the Department of Obstetrics/Gynecology, Hospital das Clinicas, from March 2016 to May 2017. Setting/Participants: Maternal-fetal health specialists were invited to complete an institutional questionnaire based on the SPIKES protocol for communicating bad news before and after training. The training consisted of theoretical lectures and small group practice using role play. The questionnaire responses were compared using nonparametric tests to evaluate the differences in physicians' perceptions at the two timepoints. The questionnaire items were evaluated individually and in groups following the communication steps of the SPIKES protocol. Results: In total, 110 physicians were invited to participate. Ninety completed the pretraining questionnaire and 40 answered the post-training questionnaire. After training, there were significant improvements in knowing how to prepare the environment before delivering bad news (p = 0.010), feeling able to transmit bad news (p < 0.001), and to discuss the prognosis (p = 0.026), feeling capable of discussing ending the pregnancy (p = 0.003), and end-of-life issues (p = 0.007) and feeling confident about answering difficult questions (p = 0.004). The comparison of the grouped responses following the steps of the SPIKES protocol showed significant differences for "knowledge" (p < 0.001), "emotions," (p = 0.004) and "strategy and summary" (p = 0.002). Conclusion: The implementation of institutional training in breaking bad news changed the perception of the physicians in the communication setting.

Avaliação de Habilidades de Comunicação em Ambiente Simulado na Formação Médica: Conceitos, Desafios e Possibilidades / Assessment of Communication Skills in the Simulated Environment of Medical Training: Concepts, Challenges and Possibilities in Medical Education

RESUMO Na comunidade acadêmica internacional, a comunicação eficaz entre profissionais de saúde, pacientes e seus familiares é reconhecida como condição indispensável para a qualidade dos cuidados em saúde. No Brasil, as Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina estabelecem que o egresso deve ser preparado para se comunicar por meio de linguagem verbal e não verbal, com empatia, sensibilidade e interesse, promovendo o cuidado centrado na pessoa e uma relação horizontal e compartilhada com o paciente. Para alcançar esses objetivos, faz-se preciso a implementação de atividades curriculares que promovam o desenvolvimento dessa habilidade e avaliem a sua aquisição durante a graduação em Medicina. A habilidade em se comunicar adequadamente não pode ser aprendida apenas por observação e tende a declinar ao longo do curso. Recomenda-se que seu ensino se estenda de modo coerente a todos os níveis de formação, incluindo os internatos e programas de residência. Na avaliação de habilidades de comunicação, especialistas recomendam que seja instituída uma matriz que permita repetidas oportunidades de avaliação e feedback, reforçando o uso das habilidades mais básicas de entrevista até as mais complexas, como a comunicação de más notícias. Dessa maneira, para um ensino e avaliação eficientes, são necessários métodos e instrumentos com sólida fundamentação teórica. Atividades em ambiente simulado com a participação de pacientes padronizados têm sido amplamente utilizadas para o ensino e a avaliação dessa habilidade durante a consulta clínica. Nesse contexto, programas de desenvolvimento docente são fundamentais para que estratégias eficazes de ensino e avalição sejam implementadas e permitam ao futuro médico a aquisição de habilidades essenciais ao ético exercício profissional. Este artigo propôs-se a uma revisão narrativa sobre avaliação de habilidades de comunicação em ambiente simulado apresentando seus conceitos, desafios e possibilidades. Também aborda aspectos práticos para a organização desse tipo de avaliação.

ABSTRACT In the international academic community, effective communication between health professionals, patients, and their families are recognized as an indispensable condition for the quality of health care. In Brazil, the National Curriculum Guidelines for Undergraduate Medical Schools established that medical students should be prepared to communicate through verbal and non-verbal language, with empathy, sensitivity and interest, promoting patient-centered care, and a horizontal and shared relationship with the patient. To achieve these goals, it is necessary to implement curricular activities that promote the development of this skill and assess its acquisition during undergraduate medical school. Adequate communication skills cannot be learned by observation alone and tend to decline as medical students progress through their medical education. For the assessment of communication skills, experts recommend a framework that allows for repeated assessment and feedback opportunities, reinforcing the use of the most basic interviewing skills to the most complex ones, such as communicating bad news. Thus, for an efficient assessment, methods and instruments with a solid theoretical basis are necessary. Thus, activities in a simulated environment with the participation of standardized patients have been widely used for the teaching and assessment of these skills during the clinical consultation. In this context, faculty development programs are fundamental for effective teaching and assessment strategies to be implemented and allow the future doctors to acquire essential skills for their professional practice. This article proposes a narrative review of communication skills assessment in a simulated environment regarding its concepts, challenges, and possibilities. It also discusses practical aspects for the organization of this type of assessment.

Improving perinatology residents' skills in breaking bad news: A randomized intervention study / Aprimoramento das habilidades de residentes em perinatologia para comunicar más notícias: um estudo de intervenção randomizado

Abstract Objective Breaking bad news (BBN) is particularly difficult in perinatology. Previous research has shown that BBN skills can be learned and improved when taught and practiced. This project evaluated whether a structured training session would enhance perinatology residents' skills in BBN. Methods This was a randomized controlled intervention study with year 1 to 4 Perinatology residents from a medical school in Brazil, during the 2014/15 school year. A total of 61 out of 100 (61%) eligible residents volunteered to a structured training program involving communicating a perinatal loss to a simulated patient (SP) portraying the mother followed by the SP's immediatefeedback,bothvideo recorded. Later, residents were randomly assigned to BBN training based on a setting, perception, invitation, knowledge, emotion and summary (SPIKES) strategy with video reviews (intervention) or no training (control group). All residents returned for a second simulation with the same SP blinded to the intervention and portraying a similar case. Residents' performances were then evaluated by the SP with a checklist. The statistical analysis included a repeated measures analysis of covariance (RM-ANCOVA). Complementarily, the residents provided their perceptions about the simulation with feedback activities. Results Fifty-eight residents completed the program. The simulations lasted on average 12 minutes, feedback 5 minutes and SPIKES training between 1h and 2h30m. There was no significant difference in the residents' performances according to the SPs' evaluations (p = 0.55). The participants rated the simulation with feedback exercises highly. These educational activities might have offset SPIKES training impact. Conclusion The SPIKES training did not significantly impact the residents' performance. The residents endorsed the simulation with feedback as a useful training modality. Further research is needed to determine which modality is more effective.

Resumo Objetivo É uma tarefa particularmente difícil transmitir más notícias em perinatologia. Habilidades de comunicação podem ser aprendidas, ensinadas e praticadas. O presente estudo avalia se uma sessão de treinamento estruturado para comunicar más notícias ampliaria as habilidades dos residentes de perinatologia. Métodos Estudo de intervenção controlado e aleatorizado com residentes do 1° ao 4° ano do curso de perinatologia de uma faculdade de ciências médicas no ano letivo de 2014/15. Um total de 61 dos 100 residentes elegíveis (61%) voluntariaram-se para um programa de treinamento envolvendo comunicar uma perda perinatal para uma paciente simulada no papel da mãe, seguido do feedback imediato da atriz, ambos filmados. Posteriormente, os residentes foram aleatoriamente designados para um grupo de treinamento em más notícias baseado na estratégia SPIKES e revisão dos vídeos (intervenção) ou para um grupo-controle, sem treinamento. Todos os residentes retornaram numa segunda simulação análoga à primeira, com a mesma paciente simulada cega à intervenção. Avaliou-se as habilidades dos residentes segundo um checklist preenchido pela atriz. A análise estatística incluiu análise de covariância para medidas repetidas (ANCOVA-MR). Os residentes avaliaram a atividade de simulação com feedback. Resultados O programa foi completado por 58 residentes. As simulações duraram em média 12 minutos, o feedback 5 minutos, e o treinamento SPIKES entre 1h e 2,5h. Não houve diferença significativa nas atuações dos residentes segundo a paciente simulada (p = 0.55). Os residentes avaliaram a simulação com feedback positivamente. Essas atividades podem ter reduzido o impacto do treinamento SPIKES. Conclusão O treinamento SPIKES não teve impacto significativo na atuação dos residentes. Os residentes consideraram as simulações com feedback úteis. Mais pesquisas são necessárias para determinar qual modalidade é mais eficaz.

Improving Perinatology Residents' Skills in Breaking Bad News: A Randomized Intervention Study.

OBJECTIVE: Breaking bad news (BBN) is particularly difficult in perinatology. Previous research has shown that BBN skills can be learned and improved when taught and practiced. This project evaluated whether a structured training session would enhance perinatology residents' skills in BBN. METHODS: This was a randomized controlled intervention study with year 1 to 4 Perinatology residents from a medical school in Brazil, during the 2014/15 school year. A total of 61 out of 100 (61%) eligible residents volunteered to a structured training program involving communicating a perinatal loss to a simulated patient (SP) portraying the mother followed by the SP's immediate feedback, both video recorded. Later, residents were randomly assigned to BBN training based on a setting, perception, invitation, knowledge, emotion and summary (SPIKES) strategy with video reviews (intervention) or no training (control group). All residents returned for a second simulation with the same SP blinded to the intervention and portraying a similar case. Residents' performances were then evaluated by the SP with a checklist. The statistical analysis included a repeated measures analysis of covariance (RM-ANCOVA). Complementarily, the residents provided their perceptions about the simulation with feedback activities. RESULTS: Fifty-eight residents completed the program. The simulations lasted on average 12 minutes, feedback 5 minutes and SPIKES training between 1h and 2h30m. There was no significant difference in the residents' performances according to the SPs' evaluations (p = 0.55). The participants rated the simulation with feedback exercises highly. These educational activities might have offset SPIKES training impact. CONCLUSION: The SPIKES training did not significantly impact the residents' performance. The residents endorsed the simulation with feedback as a useful training modality. Further research is needed to determine which modality is more effective.

OBJETIVO: É uma tarefa particularmente difícil transmitir más notícias em perinatologia. Habilidades de comunicação podem ser aprendidas, ensinadas e praticadas. O presente estudo avalia se uma sessão de treinamento estruturado para comunicar más notícias ampliaria as habilidades dos residentes de perinatologia. MéTODOS: Estudo de intervenção controlado e aleatorizado com residentes do 1° ao 4° ano do curso de perinatologia de uma faculdade de ciências médicas no ano letivo de 2014/15. Um total de 61 dos 100 residentes elegíveis (61%) voluntariaram-se para um programa de treinamento envolvendo comunicar uma perda perinatal para uma paciente simulada no papel da mãe, seguido do feedback imediato da atriz, ambos filmados. Posteriormente, os residentes foram aleatoriamente designados para um grupo de treinamento em más notícias baseado na estratégia SPIKES e revisão dos vídeos (intervenção) ou para um grupo-controle, sem treinamento. Todos os residentes retornaram numa segunda simulação análoga à primeira, com a mesma paciente simulada cega à intervenção. Avaliou-se as habilidades dos residentes segundo um checklist preenchido pela atriz. A análise estatística incluiu análise de covariância para medidas repetidas (ANCOVA-MR). Os residentes avaliaram a atividade de simulação com feedback. RESULTADOS: O programa foi completado por 58 residentes. As simulações duraram em média 12 minutos, o feedback 5 minutos, e o treinamento SPIKES entre 1h e 2,5h. Não houve diferença significativa nas atuações dos residentes segundo a paciente simulada (p = 0.55). Os residentes avaliaram a simulação com feedback positivamente. Essas atividades podem ter reduzido o impacto do treinamento SPIKES. CONCLUSãO: O treinamento SPIKES não teve impacto significativo na atuação dos residentes. Os residentes consideraram as simulações com feedback úteis. Mais pesquisas são necessárias para determinar qual modalidade é mais eficaz.

Breaking Bad News Training Program Based on Video Reviews and SPIKES Strategy: What do Perinatology Residents Think about It? / Programa de treinamento para comunicação de más notícias baseado em revisão de vídeos e na estratégia SPIKES: o que pensam os residentes de perinatologia?

Abstract Objective Resident doctors usually face the task to communicate bad news in perinatology without any formal training. The impact on parents can be disastrous. The objective of this paper is to analyze the perception of residents regarding a training program in communicating bad news in perinatology based on video reviews and setting, perception, invitation, knowledge, emotion, and summary (SPIKES) strategy. Methods We performed the analysis of complementary data collected from participants in a randomized controlled intervention study to evaluate the efficacy of a training program on improving residents' skills to communicate bad news. Data were collected using a Likert scale. Through a thematic content analysis we tried to to apprehend the meanings, feelings and experiences expressed by resident doctors in their comments as a response to an open-ended question. Half of the group received training, consisting of discussions of video reviews of participants' simulated encounters communicating a perinatal loss to a "mother" based on the SPIKES strategy. We also offered training sessions to the control group after they completed participation. Twenty-eight residents who were randomized to intervention and 16 from the control group received training. Twenty written comments were analyzed. Results The majority of the residents evaluated training highly as an education activity to help increase knowledge, ability and understanding about breaking bad news in perinatology. Three big categories emerged fromresidents' comments: SPIKES training effects; bad news communication in medical training; and doctors' feelings and relationship with patients. Conclusions Residents took SPIKES training as a guide to systematize the communication of bad news and to amplify perceptions of the emotional needs of the patients. They suggested the insertion of a similar training in their residency programs curricula.

Resumo Objetivo Médicos residentes, em geral, enfrentam a tarefa de comunicarmás notícias em perinatologia sem um treino formal prévio. O impacto nos pais pode ser desastroso. O objetivo deste artigo é analisar as percepções dos residentes sobre um programa de treinamento para a comunicação de más notícias em perinatologia baseado na revisão de vídeos e na estratégia SPIKES. Métodos Analisamos os dados complementares coletados dos participantes de um estudo de intervenção controlado e aleatorizado que avaliou a eficácia de umprograma de treinamento para ampliar as habilidades dos residentes em comunicarmás notícias. Os dados foram coletados utilizando um questionário em escala Likert. Através da análise temática de conteúdos buscamos apreender os significados, sentimentos e experiências descritos nos comentários dos residentes em resposta a uma questão aberta avaliando o treinamento. Metade do grupo recebeu treinamento, que consistiu de discussões do vídeo da consulta simulada de cada participante em que ele comunicava uma perda perinatal para uma "mãe" baseado na estratégia SPIKES. Ofereceu-se treinamento também para o grupo controle após encerraram sua participação na pesquisa. Vinte e oito residentes aleatorizados para a intervenção e 16 do grupo controle receberam treinamento. Vinte comentários escritos foram analisados. Resultados A maioria dos residentes avaliou o treinamento como uma ótima atividade educativa para ajudá-los a aumentar conhecimento, habilidades e compreensão sobre o processo de comunicar más notícias em perinatologia. Três grandes categorias emergiram dos comentários: Efeitos do treinamento SPIKES, comunicação de más notícias no treinamento médico; e os sentimentos dos médicos e sua relação com os pacientes. Conclusão Residentes de perinatologia entenderam o treinamento SPIKES como um guia para sistematizar a comunicação de más notícias e ampliar suas percepções sobre as necessidades emocionais dos pacientes. Eles sugeriram que treinamentos similares fossem inseridos nos currículos dos programas de residência.

Breaking Bad News Training Program Based on Video Reviews and SPIKES Strategy: What do Perinatology Residents Think about It?

Objective Resident doctors usually face the task to communicate bad news in perinatology without any formal training. The impact on parents can be disastrous. The objective of this paper is to analyze the perception of residents regarding a training program in communicating bad news in perinatology based on video reviews and setting, perception, invitation, knowledge, emotion, and summary (SPIKES) strategy. Methods We performed the analysis of complementary data collected from participants in a randomized controlled intervention study to evaluate the efficacy of a training program on improving residents' skills to communicate bad news. Data were collected using a Likert scale. Through a thematic content analysis we tried to to apprehend the meanings, feelings and experiences expressed by resident doctors in their comments as a response to an open-ended question. Half of the group received training, consisting of discussions of video reviews of participants' simulated encounters communicating a perinatal loss to a "mother" based on the SPIKES strategy. We also offered training sessions to the control group after they completed participation. Twenty-eight residents who were randomized to intervention and 16 from the control group received training. Twenty written comments were analyzed. Results The majority of the residents evaluated training highly as an education activity to help increase knowledge, ability and understanding about breaking bad news in perinatology. Three big categories emerged from residents' comments: SPIKES training effects; bad news communication in medical training; and doctors' feelings and relationship with patients. Conclusions Residents took SPIKES training as a guide to systematize the communication of bad news and to amplify perceptions of the emotional needs of the patients. They suggested the insertion of a similar training in their residency programs curricula.

Objetivo Médicos residentes, em geral, enfrentam a tarefa de comunicar más notícias em perinatologia sem um treino formal prévio. O impacto nos pais pode ser desastroso. O objetivo deste artigo é analisar as percepções dos residentes sobre um programa de treinamento para a comunicação de más notícias em perinatologia baseado na revisão de vídeos e na estratégia SPIKES. Métodos Analisamos os dados complementares coletados dos participantes de um estudo de intervenção controlado e aleatorizado que avaliou a eficácia de um programa de treinamento para ampliar as habilidades dos residentes em comunicar más notícias. Os dados foram coletados utilizando um questionário em escala Likert. Através da análise temática de conteúdos buscamos apreender os significados, sentimentos e experiências descritos nos comentários dos residentes em resposta a uma questão aberta avaliando o treinamento. Metade do grupo recebeu treinamento, que consistiu de discussões do vídeo da consulta simulada de cada participante em que ele comunicava uma perda perinatal para uma "mãe" baseado na estratégia SPIKES. Ofereceu-se treinamento também para o grupo controle após encerraram sua participação na pesquisa. Vinte e oito residentes aleatorizados para a intervenção e 16 do grupo controle receberam treinamento. Vinte comentários escritos foram analisados. Resultados A maioria dos residentes avaliou o treinamento como uma ótima atividade educativa para ajudá-los a aumentar conhecimento, habilidades e compreensão sobre o processo de comunicar más notícias em perinatologia. Três grandes categorias emergiram dos comentários: Efeitos do treinamento SPIKES, comunicação de más notícias no treinamento médico; e os sentimentos dos médicos e sua relação com os pacientes. Conclusão Residentes de perinatologia entenderam o treinamento SPIKES como um guia para sistematizar a comunicação de más notícias e ampliar suas percepções sobre as necessidades emocionais dos pacientes. Eles sugeriram que treinamentos similares fossem inseridos nos currículos dos programas de residência.

A Qualitative Study on the Practice of Yoga for Women with Pain-Associated Endometriosis.

OBJECTIVES: To understand the meaning women with pain-associated endometriosis attribute to yoga practice regarding their physical and emotional state at the beginning of the practice; pain management by integrating body and mind; secondary benefits of the practice of yoga, such as self-knowledge, self-care, and autonomy; and the role of the yoga group as psychosocial support. DESIGN: Qualitative study conducted simultaneously with a randomized clinical trial. SETTING: Public university hospital in southeastern Brazil between August 2013 and December 2014. PARTICIPANTS: Fifteen women with pain-associated endometriosis who practiced yoga for 8 weeks. INTERVENTION: After completing the twice-a-week program, all women participated in a single, semi-structured interview. Interviews were recorded and transcribed verbatim, and thematic analyses were performed. OUTCOME MEASURES: The main themes of analysis were women's expectations regarding the practice of yoga, physical and emotional state of women at the beginning of yoga practice, control and pain management through the integration of body and mind, secondary benefits, acquisition of self-knowledge and autonomy, and the role of yoga group as psychosocial support. RESULTS: All participants reported that yoga was beneficial to control pelvic pain. They related that they were aware of the integration of body and psyche during yoga practice and that this helped in the management of pain. Women said they had identified a relationship between pain management and breathing techniques (pranayama) learned in yoga and that breathing increased their ability to be introspective, which relieved pain. The participants have developed greater self-knowledge, autonomy, and self-care and have reduced the use of pain and psychiatric medications. They created ties among themselves, suggesting that the yoga group allowed psychosocial support. CONCLUSIONS: Bodily and psychosocial mechanisms to control pain were identified in women with endometriosis. To reach such control, it is crucial that mind and body integrative techniques are learned.

Cognitive Load and Self-Determination Theories Applied to E-Learning: Impact on Students' Participation and Academic Performance.

BACKGROUND: Emergency clerkships expose students to a stressful environment that require multiple tasks, which may have a direct impact on cognitive load and motivation for learning. To address this challenge, Cognitive Load Theory and Self Determination Theory provided the conceptual frameworks to the development of a Moodle-based online Emergency Medicine course, inspired by real clinical cases. METHODS: Three consecutive classes (2013-2015) of sixth-year medical students (n = 304) participated in the course, during a curricular and essentially practical emergency rotation. "Virtual Rounds" provided weekly virtual patients in narrative format and meaningful schemata to chief complaints, in order to simulate real rounds at Emergency Unit. Additional activities such as Extreme Decisions, Emergency Quiz and Electrocardiographic challenge offered different views of emergency care. Authors assessed student´s participation and its correlation with their academic performance. A survey evaluated students´ opinions. Students graduating in 2015 answered an online questionnaire to investigate cognitive load and motivation. RESULTS: Each student produced 1965 pageviews and spent 72 hours logged on. Although Clinical Emergency rotation has two months long, students accessed the online course during an average of 5.3 months. Virtual Rounds was the most accessed activity, and there was positive correlations between the number of hours logged on the platform and final grades on Emergency Medicine. Over 90% of students felt an improvement in their clinical reasoning and considered themselves better prepared for rendering Emergency care. Considering a Likert scale from 1 (minimum load) to 7 (maximum load), the scores for total cognitive load were 4.79±2.2 for Virtual Rounds and 5.56±1.96 for real medical rounds(p<0,01). CONCLUSIONS: A real-world inspired online course, based on cognitive and motivational conceptual frameworks, seems to be a strong tool to engage students in learning. It may support them to manage the cognitive challenges involved in clinical care and increase their motivation for learning.

Relato da história da inserção e evolução do atendimento psicológico a bebês e suas famílias em uma Unidade de Neonatologia / The history of the inception and evolution of psychological care for infants and their families in a Neonatal Unit

OBJETIVO: Este artigo apresenta o histórico de atuação de uma psicóloga na área de Neonatologia e sua evolução, desde as primeiras tentativas de mudar certas rotinas da unidade para que favorecessem a humanização do atendimento até a sua completa inserção na equipe multidisciplinar. São descritas em detalhes as atuações específicas junto aos bebês e suas famílias no contexto da internação hospitalar, com o intuito de auxiliar os profissionais de saúde que trabalham na área de implementação de programas afins. DESCRIÇÃO DO CASO: Relato da história de inserção e da evolução do trabalho de uma psicóloga na equipe de Neonatologia do Centro de Atenção Integral à Saúde da Mulher (CAISM) da Universidade Estadual de Campinas (Unicamp), num período de dez anos (1993 a 2003). Descrevem-se as atividades específicas da Psicologia, o embasamento teórico dos programas desenvolvidos na unidade e os recursos técnicos utilizados no atendimento à clientela. COMENTÁRIOS: O saber específico do psicólogo pode ser estendido a toda a equipe, favorecendo ações de prevenção em Saúde Mental, principalmente a proteção da relação mãe-bebê. Além disso, pode ser disseminado, ganhar relevância e fazer parte do cotidiano de todas as unidades de terapia neonatais.

OBJECTIVE: This article describes the evolution of a psychologist's work in a Neonatal Care Unit, from simple interventions that changed certain routines to foster humanization of care, to the complete integration of this professional into the multidisciplinary neonatal team. Detailed descriptions of the work's implementation in the hospital setting offer health professionals of the field a model for similar programs. CASE DESCRIPTION: The history of the inception and evolution of a psychologist's work at the Neonatal Care Unit of Universidade Estadual de Campinas in a ten-year period (1993 to 2003) was described. Specific activities developed within this period have been described, as well as the theory supporting every action. The base techniques utilized within this time frame are also commented. COMMENTS: The specificity of the psychologist's knowledge can be extended to other health professionals of the same field, promoting preventive mental health measures, especially actions that benefit the bonding between mothers and their babies. It could also be disseminated, grow in importance, and become routine in every neonatal care unit.

Abordagem psicológica em obstetrícia: aspectos emocionais na gravidez, parto e puerpério / Psycological approach in obstetrics: emotional aspects of pregnancy, childbirth and puerperium

A necessidade de compreender os aspectos psicológicos que permeiam o período grávido-puerperal torna-se cada vez mais reconhecida no âmbito do atendimento à saúde reprodutiva da mulher, tendo-se em vista, principalmente, os esforços no Brasil relacionados à humanização do parto. Ao se pensar nesses termos psicológicos e contextualizá-los a uma prática de atendimento clínico, constrói-se uma referência que permite a reflexão e a reconstrução do conhecimento para os profissionais da área. O objetivo deste artigo é apresentar uma revisão sucinta dos aspectos emocionais mais observados no pré-natal, parto e puerpério, e em situações de intercorrências gestacionais. São sugeridas formas possíveis de abordagem dessas situações que favoreçam a elaboração dos problemas mais emergentes dessa fase de vida da gestante e de seu companheiro, oferecendo à equipe de saúde a possibilidade de uma abordagem mais ampla, integrada e gratificante.

Cuidados paliativos em neonatologia: implementação de um programa multiprofissional / Palliative Care in Neonatology - Implementation of a Multi-Professional Program

Avanços tecnológicos em medicina perinatal têm melhorado dramaticamente a sobrevida dos recém-nascidos, inclusive os prematuros extremos e dos bebês com malformação congênita grave. Assim, os neonatos de mau prognóstico e seus familiares suscitam uma nova abordagem pela equipe de atendimento neonatal. O objetivo deste artigo é relatar a experiência do grupo de cuidados paliativos neonatais do CAISM/UNICAMP dos procedimentos iniciais até a discussão de protocolos assistenciais de acolhimento ao óbito, atendimento em sala de parto e seguimento durante a internação em unidade de terapia intensiva neonatal do bebê criticamente doente e seus familiares. Também é apresentado um caso atendido no serviço para ilustrar o artigo.

Interrupção legal em gestações com fetos portadores de patologias letais: aspectos epidemiológicos e emocionais / Legal abortion in pregnancies with lethal fetal abnormalities: epidemiological and emotional aspects

Analisar aspectos epidemiológicos e emocionais nos casos de interrupção legal de gestações de fetos portadores de malformações incompatíveis com sobrevida neonatal, atendidos no Programa de Medicina Fetal (PMF) do Centro de Atenção Integral à Saúde da Mulher (CAISM) - UNICAMP entre 1995 e 1999; investigar as gestações levadas a termo nas mesmas circunstâncias. Estudo retrospectivo e documental a partir dos prontuários de 153 gestantes atendidas no PMF com diagnóstico pré-natal de anomalias fetais incompatíveis com a vida. Variáveis estudadas: idade, estado civil, idade gestacinal (IG) de admissão, antecedentes gestacionais, planejamento da atual gestação, patologia fetal. Setenta pacientes (45,7 por cento) optaram pela interrupção da gravidez (grupo A) e 83 (54,3 por cento) pela continuidade (grupo B). Distribuição dos tipos de anomalia diagnosticados; anencefalia (43,2 por cento), patologia renal (22,2 por cento), malformações múltiplas (7,2 por cento), trissomia do cromossomo 18 (11,7 por cento), trissomia do cromossomo 13 (5,9 por cento), displasias esqueléticas (6,5 por cento) e gemelidade incompleta (3,2 por cento). Faixa etária das pacientes: 16 a 43 anos. A freqüência de primigestas e multíparas foram semelhantes. As interrupções autorizadas ocorreram entre o 2º e o 3º trimestre gestacional. A IG e o tipo de patologia fetal foram significativamente determinantes na opção (p=0,03 e p<0,001, respectivamente). Importância do diagnóstico precoce de malformações. A possibilidade de interrupção pode representar um fator tranqüilizador.