[Twelve tips for a good medical consultation in primary care.] / Dodici suggerimenti per una buona consultazione medica nelle cure primarie.

BACKGROUND: The recent pandemic has brought into sharper focus the need, long emphasised in the scientific literature, for a change in primary care that goes beyond the limits of the hyper-specialisation constitutive of Western health systems. While the direction of the cultural and organisational change that needs to be developed is well outlined, little is written about the competencies and values that physicians must acquire in order to shape a new and coherent organisation of services. The patient encounter is the frame in which these competencies take shape, and it is from this perspective that these competencies are examined here. OBJECTIVES: The aim of this narrative review of empirical studies and the multisciplinary literature is to provide primary care physicians with some tips for a good management of the medical consultation. These tips outline the competencies needed in general practice, rethought within the paradigm of complexity of care. RESULTS: The concepts, practices and values on which the 12 tips are based are: a) an attitude of attention to the complexity of care in which the patient's subjectivity can only be understood through an encounter with one's own subjectivity; b) the peculiar method of clinical reasoning in general practice, which includes the early generation of diagnostic hypotheses to be verified using simple and inexpensive tests, such as history taking and physical examination; these tests should have a high negative predictive value to rule out more serious conditions; c) the contextualisation of the working diagnosis (opposed to a definitive diagnosis) as a tool for dealing with complexity; d) the analysis of the evolution of scenarios as a tool for planning and choosing courses of action; e) the assessment of uncertainty in addition to that of measurable risk; f) the involvement of the patient and the use of the test of time as tools for managing uncertainty; g) the centrality of sharing the decision with the patient.

[The methodological and relational core competencies of General practice/Family medicine in Primary Care.] / Le competenze distintive metodologiche e relazionali del medico di medicina generale nelle cure primarie.

In this article, we examine three out of the seven distinctive values of General practice/family medicine (Gpfm), as proposed by World Organization of Family Doctors (Wonca) and recently translated into Italian: patient-centered care, continuity of care, and evidence-based care. We believe that these values can contribute to the ongoing debate on the reorganization of the primary care model and the reform of the core curriculum of Italian Gpfm. These three values are the basis of the distinctive methodological and relational competencies of Gpfm. In this contribution, we analyze them through the lens of epistemology of complexity, aiming to highlight the unique aspects of this method and relationship, thus identifying the necessary competencies for Gpfm. The thought and method of care - the first and third values - are analyzed considering that the framework in which Gpfm operates leads to significant modifications of the clinical method. While it certainly encompasses elements of the traditional clinical method, they are executed at different paces and with different objectives, employing distinct strategies. For instance, the epidemiological context with a high prevalence of symptomatic distress but low prevalence of "true" disease needs the early generation of diagnostic hypotheses. These hypotheses are then tested using verbal and physical examinations as exclusion tests with high predictive power. The aim is to arrive at diagnoses that are not exhaustive, yet operational and contextualized. Furthermore, the uncertainty inherent in Gpfm requires the utilization of contextual knowledge related to the patient's environment, negotiation with the patient about the tolerable threshold of decisional uncertainty, their involvement - which increases with greater uncertainty - and the use of the test of time within an organizational and relational protective network. Complex thinking enables reflection on the second value - the relationship - by assigning the physician's subjectivity a place as precious as that of the patient, which is already historically established. Thus, both the physician and patient, as subjects, exist on the same ontological plane but differ methodologically due to their distinct roles. Adopting an epistemology of complexity in Gpfm allows each variable of the system - subjects, context, method, clinical aspects - to regain significance. This approach favours a genuine science in service of humanity.

The Up-Side of the COVID-19 Pandemic: Are Core Belief Violation and Meaning Making Associated with Post-Traumatic Growth?

The negative impact of the COVID-19 pandemic on mental health has been extensively documented, while its possible positive impact on the individual, defined as Post-Traumatic Growth (PTG), has been much less investigated. The present study examines the association between PTG and socio-demographic aspects, pre-pandemic psychological adjustment, stressors directly linked to COVID-19 and four psychological factors theoretically implicated in the change processes (core belief violation, meaning-making, vulnerability and mortality perception). During the second wave of the pandemic 680 medical patients completed an online survey on direct and indirect COVID-19 stressors, health and demographic information, post-traumatic growth, core belief violation, meaning-making capacity, feelings of vulnerability and perceptions of personal mortality. Violation of core beliefs, feelings of vulnerability and mortality, and pre-pandemic mental illness positively correlated with post-traumatic growth. Moreover, the diagnosis of COVID-19, stronger violation of core beliefs, greater meaning-making ability, and lower pre-existing mental illness predicted greater PTG. Finally, a moderating effect of meaning-making ability was found. The clinical implications were discussed.

Analysis of General Practitioners' Attitudes and Beliefs about Psychological Intervention and the Medicine-Psychology Relationship in Primary Care: Toward a New Comprehensive Approach to Primary Health Care.

The biopsychosocial paradigm is a model of care that has been proposed in order to improve the effectiveness of health care by promoting collaboration between different professions and disciplines. However, its application still faces several issues. A quantitative-qualitative survey was conducted on a sample of general practitioners (GPs) from Milan, Italy, to investigate their attitudes and beliefs regarding the role of the psychologist, the approach adopted to manage psychological diseases, and their experiences of collaboration with psychologists. The results show a partial view of the psychologist's profession that limits the potential of integration between medicine and psychology in primary care. GPs recognized that many patients (66%) would often benefit from psychological intervention, but only in a few cases (9%) were these patients regularly referred to a psychologist. Furthermore, the referral represents an almost exclusive form of collaboration present in the opinions of GPs. Only 8% of GPs would consider the joint and integrated work of the psychologist and doctor useful within the primary health care setting. This vision of the role of psychologists among GPs represents a constraint in implementing a comprehensive primary health care approach, as advocated by the World Health Organization.

Linguistic Markers of the Emotion Elaboration Surrounding the Confinement Period in the Italian Epicenter of COVID-19 Outbreak.

The expressive writing method has rarely been proposed in contexts of large-scale upheavals that affect large populations. In this study this method was applied as an intervention and tool of investigation during the confinement period in the Lombardy region, the Italian Epicenter of COVID-19 outbreak. Sixty-four participants took part in an online expressive writing project, and a total of 167 writings were collected together with some self-report evaluations on emotions and physical sensations. A linguistic analysis through two different sets of computerized linguistic measures was conducted on the collected writings in order to study the linguistic markers of emotion regulation and elaboration. Results indicated that online expressive writing has helped respondents to get more in touch with the intense emotions that were experienced following the upheavals they witnessed. Writing even only once or twice helped, particularly those respondents who had at least one COVID-19 patient among close friends or relatives. Their writings showed an intense emotional involvement together with the ability to reflect and reorganize the personal meaning of the events and emotions experienced. This study shows that expressive writing can be used in the context of a psychological emergency, both as a powerful instrument to investigate and detect the complex psychodynamic processes underpinning the distress, and as a useful intervention to reduce the negative impact of traumatic events.