Ordinary defensive medicine: in the shadows of general practitioners' postures toward (over-)medicalisation.

This paper draws on qualitative research using focus groups involving 38 general practitioners (GPs). It explores their attitudes and feelings about (over-)medicalisation. Our main findings were that GPs had a complex representation of (over-)medicalisation, composed of many professional, social, technological, economic and relational issues. This representation led GPs to feel uncomfortable. They felt pressure from all sides, which led them to question their social roles and responsibilities. We identified four main GP-driven proposals to deal with (over-)medicalisation: (1) focusing on the communication in doctor-patient relationships; (2) grounding practices in evidence-based medicine; (3) relying on clinical skills, experience and intuition; and (4) promoting training, leadership bodies and social movements. Drawing on these proposals, we identify and discuss five paradigms that underpin GPs' attitudes toward (over-)medicalisation: underlying social factors, preventing medicalisation, managing uncertainties, sharing medical decision-making and thinking about care as a rationale. We suggest that these paradigms constitute a defensive posture against GPs' uncomfortable feelings. All five defensive paradigms were identified in our focus groups, echoing contemporary political debates on public health. This non-exhaustive framework forms the outline of what we call ordinary defensive medicine. GPs' uncomfortable feelings are the origin of their defensive solutions and the manifestation of their vulnerability. This professional vulnerability can be shared with the patient's vulnerability. In our view, this creates an opportunity to rediscover patient-doctor relationships and examine patients' and doctors' vulnerabilities together."There are many cases in which-though the signs of a confusion of tongues between the patient and his doctor are painfully present-there is apparently no open controversy. Some of these cases demonstrate the working of two other, often interlinked, factors. One is the patient's increasing anxiety and despair, resulting in more and more fervently clamouring demands for help. Often the doctor's response is guilt feelings and despair that his most conscientious, most carefully devised examinations do not seem to throw real light on the patient's "illness", that his most erudite, most modern, most circumspect therapy does not bring real relief." (Balint M. The Doctor, His Patient and the Illness. New York: International Universities; 2005. [1957].)"Theories about care put an unprecedented emphasis on vulnerability-taking up that challenge to transform what really counts in today's hospitals implies letting colleagues inside previously closely guarded professional boundaries" (2, our translation).

Amalia Revisited-A Reanalysis of Amalia's Dreams with the Method Structural Dream Analysis.

Since Freud's "The interpretation of Dreams", working with dreams has continued to play a major role in psychoanalysis, though different perspectives have developed about the function and meaning of dreams. This controversy is discussed on the background of findings in empirical as well as clinical dream research. In this paper, the research method Structural Dream Analysis is introduced which investigates the changes in structure of dreams over the course of psychotherapy. The method is applied to the specimen case Amalia X, which is considered to be the best investigated case in the history of psychotherapy research. Based on the results from this case and from other studies, the implications for psychoanalytic dream theories, namely those of Jung and Freud, are discussed.

[Shock and Coma after Ingestion of Morels]. / Morchelvergiftung mit Schock und Koma.

Shock and Coma after Ingestion of Morels Abstract. We present the case report of a previously healthy, 42-year-old woman who suffered from a hypovolemic shock, hypoglycemic coma, NSTEMI and temporary dependency on dialysis following the ingestion of morels. Alas there is little public knowledge about the toxicity of morels and the importance of their appropriate preparation so that intoxications can be prevented.

Lost in translation? A qualitative study of representations and management of chronic depression in general practice.

BACKGROUND: GPs are on the front line for the identification and management of chronic depression but not much is known of their representations and management of chronic depression. OBJECTIVES: To analyze GPs' representations of chronic depression and to explore how they manage it. METHODS: Three focus groups were conducted with 22 French-speaking general practitioners in Switzerland. The focus groups were transcribed and coded with MaxQDA. A detailed content analysis was carried out and the results were synthesized into a conceptual map. RESULTS: GPs form representations of chronic depression at the intersection of expert and lay knowledge. When talking about patients suffering from chronic depression, GPs mention middle-aged women with complex psychosocial situations and somatic complaints. GPs' management of chronic depression relies on the relationship with their patients, but also on taking care of them as a whole: psyche, body and social context. GPs often feel helpless and lonely when confronted with a patient with chronic depression. They insist on the importance of collaboration and supervision. As regards chronic depression management, GPs remain alone with patients suffering from complex biopsychosocial situations. In other situations, GPs seek the help of a psychiatrist, sometimes quickly, sometimes after a long approach. In each situation, GPs have to develop skills for translating patients' complaints. CONCLUSION: GPs endorse a role of interpreter, making the physical presentation of their patient complaints move towards a psychological appreciation. Our results call for a renewed interest in GPs' role as interpreters and the means to achieve it.

Swiss general internal medicine board examination: quantitative effects of publicly available and unavailable questions on question difficulty and test performance.

BACKGROUND: Formerly, a substantial number of the 120 multiple-choice questions of the Swiss Society of General Internal Medicine (SSGIM) board examination were derived from publicly available MKSAP questions (Medical Knowledge Self-Assessment Program®). The possibility to memorise publicly available questions may unduly influence the candidates' examination performance. Therefore, the examination board raised concerns that the examination did not meet the objective of evaluating the application of knowledge. The society decided to develop new, "Helvetic" questions to improve the examination. The aim of the present study was to quantitatively assess the degree of difficulty of the Helvetic questions (HQ) compared with publicly available and unavailable MKSAP questions and to investigate whether the degree of difficulty of MKSAP questions changed over time as their status changed from publicly available to unavailable. METHODS: The November 2019 examination consisted of 40 Helvetic questions, 40 publicly available questions from MKSAP edition 17 (MKSAP-17) and 40 questions from MKSAP-15/16, which were no longer publicly available at the time of the examination. An one factorial univariate analysis of variance (ANOVA) examined question difficulty (lower values mean higher difficulty) between these three question sets. A repeated ANOVA compared the difficulty of MKSAP-15/16 questions in the November 2019 examination with the difficulty of the exact same questions from former examinations, when these questions belonged to the publicly available MKSAP edition. The publicly available MKSAP-17 and the publicly unavailable Helvetic questions served as control. RESULTS: The analysis of the November 2019 exam showed a significant difference in average item difficulty between Helvetic and MKSAP-17 questions (71% vs 86%, p <0.001) and between MKSAP-15/16 and MKSAP-17 questions (70% vs 86%, p <0.001). There was no significant difference in item difficulty between Helvetic and MKSAP-15/16 questions (71% vs 70%, p = 0.993). The repeated measures ANOVA on question use and the three question categories showed a significant interaction (p <0.001, partial eta-squared = 0.422). The change in the availability of MKSAP-15/16 questions had a strong effect on difficulty. Questions became on average 21.9% more difficult when they were no longer publicly available. In contrast, the difficulty of the MKSAP-17 and Helvetic questions did not change significantly across administrations. DISCUSSION: This study provides the quantitative evidence that the public availability of questions has a decisive influence on question difficulty and thus on SSGIM board examination performance. Reducing the number of publicly available questions in the examination by introducing confidential, high-quality Helvetic questions contributes to the validity of the board examination by addressing higher order cognitive skills and making rote-learning strategies less effective.

Representations of personalised medicine in family medicine: a qualitative analysis.

BACKGROUND: The promise of personalised medicine (PM) to transform healthcare has sparked great enthusiasm in the last years. Yet, its lack of consensus around the nature and scope of the concept has ended in terminological confusion amongst the users in primary care. We aimed to investigate the perceptions of doctors and their patients in response to this evolving concept. This present article focuses on the general understanding of personalised medicine, underlining the confusion over the concept. METHODS: Semi-structured comprehensive interviews were conducted with 10 general practitioners (GPs) and 10 of their patients. The purposive sampling took into account the doctor's age, sex, and place of practice (rural/urban); each doctor recruited one patient of the same age and sex. Each interview began with the same open-ended question about the participant's knowledge of the topic, after which a working definition was provided to continue the discussion. Using the grounded theory method, the analysis consisted of open coding, axial coding and selective coding. RESULTS: From our present analysis focusing on the general understanding of PM, three main themes representing the concept emerged. The first two representations being "centred on the person as a whole" and "focused on alternative and complementary methods", in which the therapeutic relationship was stated as key. The third theme "medicine open to innovation" involved the few participants who had a good understanding of the concept and could associate personalised medicine with genomics. For those who value therapeutic relationship, the risks of accepting innovation could result in "fast-food" medicine and interpersonal barriers. DISCUSSION: PM is predominantly unfamiliar in family medicine. It is misinterpreted as a holistic or integrative type of medicine. This semantic confusion probably lies in the choice of the label "personalised" or from the lack of a uniform definition for the term.

[Personalized medicine and chronic disease prevention: Needs, attitudes and expectations regarding in general practice]. / Médecine personnalisée et prévention des maladies chroniques - Besoins, perceptions et attentes des patients et des médecins généralistes.

The ambition of personalized medicine now also concerns the prevention of chronic diseases, based on genetic risk profiles. The objective of this project was to describe the perception and attitudes of patients and general practitioners (GP) on this issue, in order to consider the consequences on the health system. The study included two axes, patients (questionnaire survey) and GPs (consensus study using the Delphi method), preceded by a qualitative exploratory phase. The study showed that genetic screening for disease risk factors was not a priority, either for patients or for GPs. On the other hand, the role of the GP in the use of these tests will probably be predominant. This implies the need for training and availability of up-to-date information.

L'ambition de la médecine personnalisée (MP) concerne désormais aussi la prévention des maladies chroniques en se basant sur les profils génétiques de risque. L'objectif de ce projet était de connaître la perception et les attentes des patients et des médecins généralistes (MG) sur cette question, pour envisager les conséquences sur le système de santé. L'étude comprenait deux axes, patients (enquête par questionnaire) et MG (étude de consensus par méthode Delphi), précédés d'une phase exploratoire qualitative. Elle a montré que le dépistage génétique des facteurs de risque aux maladies ne constituait pas une priorité, ni pour les patients, ni pour les MG. En revanche, la place du MG autour de l'utilisation de ces tests sera probablement prépondérante. Cela implique la nécessité de formations et la disponibilité d'informations à jour.

Médecine personnalisée et prévention des maladies chroniques : l'attitude des médecins généralistes.

OBJECTIVES: In a context of future generalization of access to genetic risk profiles, general practitioners (GP) will have a major role to play. The objective of this study was to understand their attitude towards this approach and the potential consequences on their practice. METHODS: In 2018, the University Center of General Medicine and Public Health of Lausanne, the Department of Primary Care Medicine of the University Hospitals of Geneva, and the Institute of Social Sciences of the University of Lausanne set up a study with patients and general practitioners concerning the access to genetic risk profiles. The GPs attitude, the subject of this study, was explored using the two-round Delphi consensus method. 120 interns and senior clinicians responded to 24 statements. RESULTS: A consensus was reached for 80% of the statements. The GP’s significant role in terms of access to genetic profiles became evident, even if their position seems conditioned by their position as front-line health workers, and doubts remain as to the impact of this process in guiding their practice. The need for training was widely emphasized as well as the possibility multidisciplinary support and management. There was also a consensus for the need of a legislative framework for these practices. CONCLUSION: This study has underlined the importance of anticipating the needs in developing an advanced and evolving training and information program for GPs in the domain of genomic medicine in light of the prevention activities that could result.