En el umbral de la muerte: clínica de lo irrepresentable / Au seuil de la mort: clinique de l’irreprésentable / On the threshold of death: the clinic of the unrepresentable

Teóricamente este trabajo se enmarca en el pensamiento de numerosos psicoanalistas, desde Freud, Klein, Winnicott, Milner, León y Rebeca Grinberg, entre otros, hasta las conceptualizaciones actuales de Roussillon sobre el papel de los procesos de simbolización en la constitución psíquica. Se ilustra una experiencia analítica conmovedora con una niña de cuatro años desahuciada antes de su nacimiento. El material clínico permite seguir muy de cerca cómo la pequeña Milagros se va iniciando en la capacidad de representación, especialmente de las huellas sin simbolizar que subyacen a su trastorno de alimentación severo, percibido como un «acto mensajero» de experiencias dolorosas sufridas durante los primeros años de su vida. Se presentan viñetas de sesiones a través de las cuales es posible tomar contacto con demandas transferenciales de necesidades psíquicas muy tempranas, así como también con la intensa vivencia contratransferencial que suscita la niña ya desde su primer encuentro. Algunos de los temas tratados tienen relación con el acceso a experiencias traumáticas no simbolizadas, el lugar de su inscripción en el psicosoma, su imposibilidad de acceso en forma de recuerdos y su abordaje mediante la técnica específica del psicoanálisis infantil. (AU)

Conceptually this paper is framed within the thinking of numerous psychoanalysts, from Freud, Klein, Winnicott, Milner and León and Rebeca Grinberg, among others, to the current conceptualizations of Roussillon on the role of the processes of symbolization in psychic constitution. A moving analytic experience with a four-year-old girl who was made homeless before her birth is illustrated. This clinical material provides a detailed analysis of how little Milagros gradually achieves the beginnings of the capacity for representation, especially of the unsymbolized traces underlying her severe eating disorder, perceived as a “message-bearing act” for painful experiences suffered during her early years of life. Vignettes from the sessions are presented, through which the analyst was able to make contact with transference demands of the patient’s very early psychic needs, but also with the intense countertransference experience elicited by the young girl from their very first encounter. Several of the themes explored are related to access to unsymbolized traumatic experiences, their site of inscription in the psycho-soma, the inability to access them as memories and how they are treated via the specific technique of child psychoanalysis. (AU)

Théoriquement ce travail se situe dans la pensée de nombreux psychanalystes depuis Freud, Klein, Winnicott, Milner et León et Rebeca Grinberg, entre autres, jusqu’aux conceptualisations actuelles de Roussillon sur le rôle des processus de symbolisation dans la constitution psychique. On illustre une expérience analytique touchante avec une petite fille de quatre ans, condamnée avant sa naissance. Le matériel clinique permet de suivre de très près comment la petite Milagros s’initie à la capacité de représentation, spécialement des traces sans symboliser qui sous-tendent à son trouble alimentaire sévère, perçu comme un «acte messager» d’expériences douloureuses endurées pendant les premières années de sa vie. Des vignettes de séances sont présentées, à travers lesquelles il est possible de prendre contact avec des demandes transférentielles de besoins psychiques très précoces, ainsi qu’avec l’intense expérience contre-transférentielle que suscita la fillette dès la première rencontre. Certains sujets traités sont en rapport avec l’accès à des expériences traumatiques non symbolisées, le lieu de leur inscription dans le psyché-soma, leur impossibilité d’accès en forme de souvenirs et leur abordage à travers la technique spécifique de la psychanalyse infantile. (AU)

Integrating Physician Services in the Home: evaluation of an innovative program.

OBJECTIVE: To evaluate a new program, Integrating Physician Services in the Home (IPSITH), to integrate family practice and home care for acutely ill patients. DESIGN: Causal model, mixed-method, multi-measures design including comparison of IPSITH and non-IPSITH patients. Data were collected through chart reviews and through surveys of IPSITH and non-IPSITH patients, caregivers, family physicians, and community nurses. SETTING: London, Ont, and surrounding communities, where home care is coordinated through the Community Care Access Centre. PARTICIPANTS: A total of 82 patients receiving the new IPSITH program of care (including 29 family physicians and 1 nurse practitioner), 82 non-randomized matched patients receiving usual care (and their physicians), community nurses, and caregivers. MAIN OUTCOME MEASURES: Emergency department (ED) visits and satisfaction with care. Analysis included a process evaluation of the IPSITH program and an outcomes evaluation comparing IPSITH and non-IPSITH patients. RESULTS: Patients and family physicians were very satisfied with the addition of a nurse practitioner to the IPSITH team. Controlling for symptom severity, a significantly smaller proportion of IPSITH patients had ED visits (3.7% versus 20.7%; P = .002), and IPSITH patients and their caregivers, family physicians, and community nurses had significantly higher levels of satisfaction (P < .05). There was no difference in caregiver burden between groups. CONCLUSION: Family physicians can be integrated into acute home care when appropriately supported by a team including a nurse practitioner. This integrated team was associated with better patient and system outcomes. The gains for the health system are reduced strain on hospital EDs and more satisfied patients.

Characteristics and practice patterns of international medical graduates: how different are they from those of Canadian-trained physicians?

OBJECTIVE: To investigate the personal characteristics and practice patterns of international medical graduates (IMGs) practising in southwestern Ontario and to compare them with the personal characteristics and practice patterns of Canadian-trained family physicians practising in the same region. DESIGN: Cross-sectional analysis of data gathered from a census of family physicians. SETTING: Southwestern Ontario. PARTICIPANTS: A total of 685 family physicians. MAIN OUTCOME MEASURES: Characteristics and practice patterns of IMG physicians and Canadian-trained physicians. RESULTS: Among all family physicians practising in southwestern Ontario, 15.3% were IMGs. The IMGs were more likely than Canadian-trained medical graduates to be older and to have been in practice longer, and less likely to have completed a family medicine residency or to have been involved in undergraduate or postgraduate teaching. The IMGs were more likely to have practised longer in their current locations and to be in solo practice and accepting new patients, but were less likely to be providing maternity and newborn care. They were also more likely than Canadian-trained medical graduates were to be serving in small towns and rural and isolated communities. CONCLUSION: The personal and practice characteristics of IMG physicians vary somewhat from those of their Canadian-trained colleagues. Policy efforts aimed at increasing and integrating IMG family physicians into the work force need to recognize these differences. Further research is needed before our results can be generalized to physicians practising beyond southwestern Ontario.

Improving communication between doctors and breast cancer patients.

PURPOSE: We wanted to assess the effectiveness of intensive education for physicians compared with a traditional session on communicating with breast cancer patients. METHODS: A randomized controlled trial was conducted in practices in London, Hamilton, and Toronto, Canada, with 17 family physicians, 16 surgeons, and 18 oncologists, and with 102 patients of the surgeons and oncologists. Doctors were randomized to 1 of 2 continuing education approaches: a traditional 2-hour version (control group), or a new 6-hour intensive version including exploring the patients' perspectives and reviewing videotapes and receiving feedback (intervention group). Communication behavior of the physicians was measured objectively both before and after the intervention. As well, 4 postintervention patient outcomes were measured, by design only for surgeons and oncologists: patient-centerdness of the visit, satisfaction, psychological distress, and feeling better. RESULTS: No significant differences were found on the communication score of the intervention vs the control physicians when controlling for preintervention communication scores. Intervention family physicians, however, had significantly higher communication subscores than control family physicians. Also, patients of the intervention surgeons and oncologists were significantly more satisfied (scores of 82.06 vs 77.78, P = .03) and felt better (88.2% vs 70.6%, P=.02) than patients of the control surgeons and oncologists when controlling for covariates and adjusting for clustering within doctor. CONCLUSIONS: The continuing medical education intervention was effective in terms of some but not all physician and patient outcomes.

El impacto de la violencia social sobre la estructuración psíquica: desde la experiencia intrauterina hacia la vinculación madre-hijo / The impact of the social violence on the psychic structuring: from the intrauterine experience towards the entailment mother-son

Basándose en el supuesto que el paciente re-crea aspectos de su funcionamiento mental en la relación transferencia/contratransferencia, y que es en ese espacio potencial donde se puede acceder creativamente a una comprensión y elaboración de los conflictos; es que la autora da cuenta detallada de un proceso terapéutico donde ese espacio se pierde por momentos, produciéndose suspensiones de las transacciones transferenciales, y de cómo se trabajó para construirlo con límites más nítidos y con mayor continuidad en la mente. Lo anterior se explicita a través de las visicitudes propias de un proceso analítico con un niño de siete años de edad, que presenta un trastorno de personalidad limítrofe con estados donde predomina un funcionamiento psicótico y defensas autistas. Se muestra como evoluciona hacia un funcionamiento mental acorde a los logros esperables del proceso de separación-individuación (M. Mahler). A través de material clínico se ilustra como la experiencia traumática (de guerra) de la madre durante el embarazo del paciente, y por ende la experiencia intrauterina estresante del paciente, influyó en la configuración de su estructuración psíquica. Donde ciertos comportamientos como el encapsulamiento autista, son comprendidos como un fenómeno patológico defensivo de su vida fetal. Se señala además, que esta actividad defensiva cumple un sentido de refugio psíquico contra experiencias de aniquilamiento. En base a este caso clínico y a diversas investigaciones en el ámbito de las neurociencias que dan cuenta de registros de experiencias en el feto durante la vida intrauterina, es que en este trabajo se plantea la necesidad de considerar como un continuo la experiencia intrauterina y la temprana infancia. Se finaliza con una discusión teórica relativa al impacto que puede tener en el feto y en el vínculo madre-hijo un contexto de realidad social de gran violencia. Se explica el entrecruzamiento entre violencia social, experiencia intrauterina, función de reverie y transmisión inconsciente transgeneracional.

Universal influenza immunization. Were Ontario family physicians prepared?

OBJECTIVE: To explore family physicians' experiences during the first year of Ontario's universal influenza immunization program. DESIGN: Qualitative study using in-depth interviews. SETTING: Thames Valley region of southwestern Ontario. PARTICIPANTS: A maximum variation sample of nine family physicians selected by snowball sampling after initial consultation with a local family physician advisory committee. METHOD: Interviews were audiotaped and transcribed verbatim. Analysis was sequential, using a combination of editing, immersion, and crystallization. Interview transcripts were read by individual members of the team who met to compare findings at several stages during data collection. MAIN FINDINGS: The program affected family physicians because immunization strategies designed for immunizing high-risk patients needed to be modified to deal with greater numbers of patients. While generally supportive of the program, physicians found it difficult to implement. Responses reflected ongoing conflict between individual and public health priorities, particularly regarding children and pregnant women. CONCLUSION: The program could have been more effective if the culture and climate of Ontario family practice had been considered during its development and implementation.

Evolving the delivery of acute care services in the home.

To serve escalating acute care caseloads, physicians affiliated with one Canadian home care program have piloted a project to integrate physician services into the home (IPSITH). This paper presents the 18-month qualitative evaluation. Phenomenological methodology and in-depth interviewing were used to construct a holistic interpretation of the implementation from the experiences of all involved: patients, family caregivers, physicians, case managers, community nurses and the project's nurse practitioner. Findings revealed the central role of the nurse practitioner, who served as a clinical expert, care coordinator and case manager. Several unsolved issues were identified: the extent to which home care is a viable alternative to hospitalization, the feasibility of physician involvement, redundancies with hospital emergency services, and the limitations of system resources for funding such services. The researchers conclude that full-scale long-term integration of physician services in the home may require macro-level decisions about system design, resource allocation, and professional regulations.