Publications by authors named "Melissa Dominicé Dao"

27 Publications

  • Page 1 of 1

Management of residents in difficulty in a Swiss general internal medicine outpatient clinic: Change is necessary!

PLoS One 2021 20;16(7):e0254336. Epub 2021 Jul 20.

Family Medicine Unit (UIGP), University of Geneva, Geneva, Switzerland.

Aims Of The Study: Residents in difficulty are a major cause for concern in medical education, with a prevalence of 7-15%. They are often detected late in their training and cannot make use of remediation plans. Nowadays, most training hospitals in Switzerland do not have a specific program to identify and manage residents in difficulty. The aim of the study was to explore the challenges perceived by physicians regarding the process of identifying, diagnosing, and supporting residents in difficulty in a structured and programmatic way. We explored perceptions of physicians at different hierarchical levels (residents (R), Chief residents (CR), attending physicians (A), Chief Physician (CP)) in order to better understand these challenges.

Methods: We conducted an exploratory qualitative study between December 2015 and July 2016. We asked volunteers from the Primary Care Division of the Geneva University Hospitals to partake to three focus groups (with CR, A, R) and one interview with the division's CP. We transcribed, coded, and qualitatively analyzed the three focus groups and the interview, using a content thematic approach and Fishbein's conceptual framework.

Results: We identified similarities and differences in the challenges of the management of residents in difficulty on a programmatic way amongst physicians of different hierarchical levels. Our main findings: Supervisors (CR, A, CP) have good identification skills of residents in difficulty, but they did not put in place systematic remediation strategies.Supervisors (CR, A) were concerned about managing residents in difficulty. They were aware of the possible adverse effects on patient care, but "feared to harm" resident's career by documenting a poor institutional assessment.Residents "feared to share" their own difficulties with their supervisors. They thought that it would impact their career negatively.The four physician's hierarchical level reported environmental constraints (lack of funding, time constraint, lack of time and resources…).

Conclusion: Our results add two perspectives to specialized recommendations regarding the implementation of remediation programs for residents in difficulty. The first revolves around the need to identify and fully understand not only the beliefs but also the implicit norms and the feeling of self-efficacy that are shared by teachers and that are likely to motivate them to engage in the management of residents in difficulty. The second emphasizes the importance of analyzing these elements that constitute the context for a change and of identifying, in close contact with the heads of the institutions, which factors may favor or hinder it. This research action process has fostered awareness and discussions at different levels. Since then, various actions and processes have been put in place at the Faculty of Medicine in Geneva.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0254336PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8291751PMC
July 2021

Impact of Confinement in Patients under Long-Term Noninvasive Ventilation during the First Wave of the SARS-CoV-2 Pandemic: A Remarkable Resilience.

Respiration 2021 Jun 15:1-9. Epub 2021 Jun 15.

Division of Pulmonary Diseases, Geneva University Hospitals, Geneva, Switzerland.

Background: During the first wave of the SARS-CoV-2 pandemic in Switzerland, confinement was imposed to limit transmission and protect vulnerable persons. These measures may have had a negative impact on perceived quality of care and symptoms in patients with chronic disorders.

Objectives: To determine whether patients under long-term home noninvasive ventilation (LTHNIV) for chronic respiratory failure (CRF) were negatively affected by the 56-day confinement (March-April 2020).

Methods: A questionnaire-based survey exploring mood disturbances (HAD), symptom scores related to NIV (S3-NIV), and perception of health-care providers during confinement was sent to all patients under LTHNIV followed up by our center. Symptom scores and data obtained by ventilator software were compared between confinement and the 56 days prior to confinement.

Results: Of a total of 100 eligible patients, 66 were included (median age: 66 years [IQR: 53-74]): 35 (53%) with restrictive lung disorders, 20 (30%) with OHS or SRBD, and 11 (17%) with COPD or overlap syndrome. Prevalence of anxiety (n = 7; 11%) and depressive (n = 2; 3%) disorders was remarkably low. Symptom scores were slightly higher during confinement although this difference was not clinically relevant. Technical data regarding ventilation, including compliance, did not change. Patients complained of isolation and lack of social contact. They felt supported by their relatives and caregivers but complained of the lack of regular contact and information by health-care professionals.

Conclusions: Patients under LTHNIV for CRF showed a remarkable resilience during the SARS-CoV-2 confinement period. Comments provided may be helpful for managing similar future health-care crises.
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http://dx.doi.org/10.1159/000516327DOI Listing
June 2021

[Covid-19: how the pandemic revealed gender inequalities].

Rev Med Suisse 2021 May;17(737):881-884

Service d'épidémiologie clinique, HUG, 1211 Genève 14.

The SARS-CoV-2 pandemic has revealed inequalities between men and women and has deepened some existing disparities. While in Switzerland, more women than men have been infected, men have been at greater risk of developing complications and dying. A weaker immune response and more co-morbidities help to explain this poorer prognosis. Socially and economically, women have become more precarious as a result of less stable employment and greater involvement in domestic work. Domestic violence has increased and women's access to sexual and reproductive health services has become more difficult. Finally, women have been under-represented as research authors but also among experts in task forces and media.
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May 2021

How Do Patients Want Us to Use the Computer During Medical Encounters?-A Discrete Choice Experiment Study.

J Gen Intern Med 2021 Jul 26;36(7):1875-1882. Epub 2021 Apr 26.

Unit of Development and Research in Medical Education (UDREM), University of Geneva, Geneva, Switzerland.

Background: Primary care physicians (PCPs) now widely use electronic health records (EHRs) during medical encounters. Experts in clinical communication issued recommendations for a patient-centered use of EHRs. However, they have never been validated by patients themselves.

Objective: To explore patients' preferences regarding physicians' EHR-related behaviors.

Design: Discrete choice experiment study.

Patients: French-speaking patients waiting for a medical consultation at two outpatient clinics in Geneva, Switzerland.

Main Measures: We invited patients to watch videos displaying 2 or 3 variations of four specific EHR-related behaviors and asked them to indicate which one they preferred. EHR-related behaviors were (1) typing: continuous/intermittent/handwriting in biomedical or psychosocial focused consultations; (2) maintaining contact while typing: visual/verbal/both; (3) signposting the use of EHR: with/without; (4) position of physicians' hands and bust: on the keyboard and towards the patient/away from the keyboard and towards the patient/on the keyboard and towards the screen.

Key Results: Three hundred thirty-six patients participated (response rate 61.4%). They preferred intermittent typing versus handwriting or continuous typing for biomedical issues (32.7%; 95% CI: 26.0-40.2% vs 31.6%; 95% CI: 24.9-39.0% or 14.9%; 95% CI: 10.2-21.1%) and psychosocial issues (38.7%; 95% CI: 31.6-46.3% vs 24.4% 95% CI: 18.4-31.5% or 17.9%; 95% CI; 12.7-24.4%). They favored visual and verbal contact (38.9%; 95% CI: 31.9-46.3%) over verbal (30.3%; 95% CI: 23.9-37.5%) or visual contact only (11.4%; 95% CI: 7.5-17.1%) while the doctor was typing. A majority preferred signposting the use of EHR versus no signposting (58.9%; 95% CI: 53.5-64.0% vs 34.8%; 95% CI: 29.9-40.1%). Finally, half of the patients (49.7%; 95% CI: 42.0-57.4%) favored the position with the physician's bust towards the patient and hands away from the keyboard.

Conclusions: Our study shows that patients' preferences regarding EHR-related behaviors are in line with most experts' recommendations. Such recommendations should be more consistently integrated into under- and postgraduate communication skills training.
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http://dx.doi.org/10.1007/s11606-021-06753-1DOI Listing
July 2021

Online Synchronous Clinical Communication Training During the Covid-19 Pandemic.

Adv Med Educ Pract 2020 24;11:1029-1036. Epub 2020 Dec 24.

Unit of Development and Research in Medical Education, Geneva Faculty of Medicine and Institute of Primary Care, Geneva University Hospitals, Geneva, Switzerland.

Purpose: As the COVID-19 pandemic outbreak occurred, most structured clinical communication training were transformed from in-person to remote seminars. The aim of our study was to evaluate the usefulness and feasibility of online synchronous clinical communication training from both students' and tutors' perspectives.

Patients And Methods: We conducted a cross-sectional study. Geneva Faculty of Medicine' 3rd year medical students and tutors involved in clinical communication were asked to respond to an online survey.

Results: Eighty-five of 149 students and 15/16 tutors responded. Students highly valued both online seminars and reported little technical difficulty. They felt that tutors were well prepared and actively involved them in experiential learning. Tutors globally reported little technical difficulty and felt rather well prepared to do so online. Although both students and tutors preferred the in-person format, half of them could still consider using an online format in the future outside the pandemic but mentioned it required specific rules.

Conclusion: Our results suggest that clinical communication can be taught and practiced online and that tutors can quickly adapt to such changes.
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http://dx.doi.org/10.2147/AMEP.S286552DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7769081PMC
December 2020

[Ethical questions regarding the medical care of adults with disabilities].

Rev Med Suisse 2020 Sep;16(708):1790-1795

Service de médecine de premier recours, HUG, 1211 Genève.

Medical care of adults with disabilities, especially those with intellectual disabilities, can be ethically difficult. Several questions arise frequently. Can we administer a life-saving treatment that could impact negatively the patient's quality of life when the patient isn't able to give consent? During this Covid-19 period, can the use of chemical or physical restraints be considered as mistreatment, whereas the aim is to protect others? These are situations where the ethical question holds a central role. Although each clinical situation is unique, this article highlights, through four clinical cases, the ethical principles that should guide physicians in their decision-making process.
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September 2020

[Cross glances on the videoconsultation].

Rev Med Suisse 2020 Sep;16(706):1709-1713

Service de médecine de premier recours, Département de médecine de premier recours et urgences, HUG, 1211 Genève 14.

The covid-19 outbreak prompted many health care providers to use video consultation for the first time. While it is particularly useful in times of pandemic, a number of patients wish to continue using video consultation as it allows easy access to their physician. However, many physicians may be uncomfortable communicating with new technologies and without performing a traditional physical examination. Training in communication and virtual physical examination in telemedicine appears to be necessary, making it possible to make videoconsultation sustainable into daily practice while guaranteeing quality of care.
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September 2020

Training junior faculty to become clinical teachers: The value of personalized coaching.

Med Teach 2020 06 4;42(6):663-672. Epub 2020 Mar 4.

Department of community medicine and primary care, Geneva University Hospitals, Geneva, Switzerland.

Junior clinical faculty require institutional support in the acquisition of feedback and clinical supervision skills of trainees. We tested the effectiveness of a personalized coaching versus guided self-reflection format of a faculty development program at improving faculty skills and self-efficacy. Participants were evaluated both before and after the program using a four-station Objective Structured Teaching Exercise (OSTE). A gain-score analysis, one-way ANOVA, and paired -tests were used to evaluate both groups. The impact on the learning environment was measured by resident ratings of the Maastricht Clinical Teaching Questionnaire. One hundred and twenty-seven participants completed the study over a three-year period. Both groups had significant improvements in self-efficacy. Participants in the coaching group demonstrated superior performance in encouraging learner self-reflection, teaching effectiveness, verifying learner understanding, exploring feelings/needs, and defining learning objectives. Over a 5-year period, the overall institutional learning climate significantly improved concerning faculty role-modeling, coaching, articulation, and explorations skills. Offering a contextualized faculty-development program using OSTEs that provides multiple opportunities for feedback and is focused on creating a community of practice is an effective method to facilitate the transfer of skills to the clinical environment, supports teacher identity development, and favorably impacts the learning climate.
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http://dx.doi.org/10.1080/0142159X.2020.1732316DOI Listing
June 2020

Jeûne du Ramadan et maladie chronique : mobilité dans l’accompagnement du patient.

Rev Med Suisse 2019 Jan;15(636):259-261

Service de médecine de premier recours, Département de médecine communautaire, de premier recours et des urgences, HUG, 1211 Genève 14.

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January 2019

[Knowing how to deliver healthcare is now as important as having medical knowledge].

Rev Med Suisse 2019 Jan;15(634):134-140

Service de médecine de premiers recours, HUG, 1211 Genève 14.

Traditionally, the doctor has focused his efforts on mastering medical knowledge. Given the challenges facing him, the medical institutions and the society, it becomes clear that his concern must also be about how this medical knowledge hits the patients and the general population. Knowing how to deliver our care is now as important as having the medical knowledge ! In this article, we present new models of healthcare delivery that we implemented or plan to implement in Geneva, Switzerland.
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January 2019

What factors influence the use of electronic health records during the first 10 minutes of the clinical encounter?

Int J Gen Med 2018 9;11:393-398. Epub 2018 Oct 9.

Department of Community Medicine, Primary Care and Emergencies, Geneva University Hospitals, Geneva, Switzerland.

Purpose: The use of electronic health records (EHRs) by physicians during the consultation is common and can be problematic. Factors influencing the use of EHRs during clinical encounters include physician and patient characteristics, consultation type as well as spatial organization of the room and type of EHR template. Their relative importance is however not well known. This study aimed to explore to what extent several physician, patient and consultation factors were associated with EHR use during the first 10 minutes of primary care consultations.

Methods: We examined EHR use of 17 residents in 142 videotaped consultations at the Primary Care Division of the Geneva University Hospitals, Switzerland. We conducted univariable and multivariable analyses with patient, physician and consultation variables to predict EHR use: sex and age of the patient; physician's sex, age, postgraduate experience and EHR-use self-perception; and language, type of consultation (new/follow-up) and content of the consultation using the Roter interaction analysis system (RIAS), the main variable being the percentage of utterances in relation to EHR use during the first 10 minutes.

Results: Male physicians (residents) and those with less clinical experience and conducting a new consultation or addressing biomedical content were positively correlated with EHR use (+5.3% for male physicians, =0.101; +0.6% per year of experience, =0.021; +6.0% for new consultation, =0.097; +0.4% per 1% of biomedical content increase; =0.018).

Conclusion: Only a small number of physician, patient and consultation factors appear to have an impact on the use of EHR during primary care consultations, and this impact remains modest. Given the influence of EHR use on physician-patient relationship, further research should explore what other factors are implicated in EHR use and whether they can be changed or improved.
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http://dx.doi.org/10.2147/IJGM.S178672DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6183548PMC
October 2018

The relevance of clinical ethnography: reflections on 10 years of a cultural consultation service.

BMC Health Serv Res 2018 01 11;18(1):19. Epub 2018 Jan 11.

Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, 4 rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland.

Background: Training health professionals in culturally sensitive medical interviewing has been widely promoted as a strategy for improving intercultural communication and for helping clinicians to consider patients' social and cultural contexts and improve patient outcomes. Clinical ethnography encourages clinicians to explore the patient's explanatory model of illness, recourse to traditional and alternative healing practices, healthcare expectations and social context, and to use this information to negotiate a mutually acceptable treatment plan. However, while clinical ethnographic interviewing skills can be successfully taught and learned, the "real-world" context of medical practice may impose barriers to such patient-centered interviewing. Creating opportunities for role modeling and critical reflection may help overcome some of these barriers, and contribute to improved intercultural communication in healthcare. We report and reflect on a retrospective analysis of 10 years experience with a "cultural consultation service" (CCS) whose aim is to provide direct support to clinicians who encounter intercultural difficulties and to model the usefulness of clinical ethnographic interviewing for patient care.

Methods: We analyzed 236 cultural consultation requests in order to identify key patient, provider and consultation characteristics, as well as the cross cultural communication challenges that motivate health care professionals to request a cultural consultation. In addition, we interviewed 51 clinicians about their experience and satisfaction with the CCS.

Results: Requests for cultural consultations tended to involve patient care situations with complex social, cultural and medical issues. All patients had a migration background, two-thirds spoke French less than fluently. In over half the cases, patients had a high degree of social vulnerability, compromising illness management. Effective communication was hindered by language barriers and undetected or underestimated patient/provider differences in health-related knowledge and beliefs. Clinicians were highly satisfied with the CCS, and appreciated both the opportunity to observe how clinical ethnographic interviewing is done and the increased knowledge they gained of their patients' context and perspective.

Conclusions: A cultural consultation service such as ours can contribute to institutional cultural competence by drawing attention to the challenges of caring for diverse patient populations, identifying the training needs of clinicians and gaps in resource provision, and providing hands-on experience with clinical ethnographic interviewing.
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http://dx.doi.org/10.1186/s12913-017-2823-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5765648PMC
January 2018

Learning to use electronic health records: can we stay patient-centered? A pre-post intervention study with family medicine residents.

BMC Fam Pract 2017 May 26;18(1):69. Epub 2017 May 26.

Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, rue Gabrielle Perret-Gentil, CH-1211, Geneva, Switzerland.

Background: The Electronic Health Record (EHR) is now widely used in clinical encounters. Because its use can negatively impact the physician-patient relationship, several recommendations on the "patient-centered" use of the EHR have been published. However, the impact of training to improve EHR use during clinical encounters is not well known. The aim of this study was to assess the impact of training on residents' EHR-related communication skills and explore whether they varied according to the content of the consultation.

Methods: We conducted a pre-post intervention study at the Primary Care Division of the Geneva University Hospitals, Switzerland. Residents were invited to attend a 3-month training course that included 2 large group sessions and 2-4 individualized coaching sessions based on videotaped encounters. Outcomes were: 1) residents' perceptions regarding the use of EHR, measured through a self-administered questionnaire and 2) objective use of the EHR during the first 10 min of patient encounters. Changes in practice were measured pre and post intervention using the Roter interaction analysis system (RIAS) and EHR specific items.

Results: Seventeen out of 27 residents took part in the study. Participants used EHR in about 30% of consultations. After training, they were less likely to consider EHR to be a barrier to the physician-patient relationship, and felt more comfortable using the EHR. After training, participants increased the use of signposting when using the EHR (pre: 0.77, SD 1.69; post: 1.80, SD3.35; p 0.035) and decreased EHR use when psychosocial issues appeared (pre: 24.5% and post: 9.76%, p < 0.001).

Conclusions: This study suggests that training can improve residents' EHR-related communication skills, especially in situations where patients bring up sensitive psychosocial issues. Future research should focus on patients' perceptions of the relevance and usefulness of such skills.
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http://dx.doi.org/10.1186/s12875-017-0640-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5446676PMC
May 2017

Vulnerability in the clinic: case study of a transcultural consultation.

J Med Ethics 2018 03 24;44(3):167-170. Epub 2016 Jun 24.

Discrimination and inequalities in healthcare can be experienced by many patients due to many characteristics ranging from the obviously visible to the more subtly noticeable, such as race and ethnicity, legal status, social class, linguistic fluency, health literacy, age, gender and weight. Discrimination can take a number of forms including overt racist statement, stereotyping or explicit and implicit attitudes and biases. This paper presents the case study of a complex transcultural clinical encounter between the mother of a young infant in a highly vulnerable social situation and a hospital healthcare team. In this clinical setting, both parties experienced difficulties, generating explicit and implicit negative attitudes that heightened into reciprocal mistrust, conflict and distress. The different factors influencing their conscious and unconscious biases will be analysed and discussed to offer understanding of the complicated nature of human interactions when faced with vulnerability in clinical practice. This case vignette also illustrates how, even in institutions with long-standing experience and many internal resources to address diversity and vulnerability, cultural competence remains a constant challenge.
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http://dx.doi.org/10.1136/medethics-2015-103337DOI Listing
March 2018

[Medical consult before taking a plane: assessment and advice by the primary care physician].

Rev Med Suisse 2014 Sep;10(443):1753-4, 1756-61

Many of our patients travel by air. During the flight, they are exposed to specific physical conditions: decrease of the PaO2, increase of body gas volume and decrease in humidity. Depending on their illness, their tolerance to these conditions may vary. The primary care physician's role is to adequately counsel patients in order to ensure their security during and after the flight, as well as to prescribe additional therapies, when needed. Patients with a hypoxemic medical condition or patients that were recently operated deserve particular attention. Complications of common ear, nose and throat diseases should not be underestimated. Preventive recommendations for thromboembolic disease need to be addressed, while drug prophylaxis is not systematically recommended any more for patients with major thromboembolic risk factors.
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September 2014

A "migrant friendly hospital" initiative in Geneva, Switzerland: evaluation of the effects on staff knowledge and practices.

PLoS One 2014 8;9(9):e106758. Epub 2014 Sep 8.

Programme Santé Migrants, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.

Background: International migration poses important challenges to European health care systems. The development of "migrant friendly hospitals" has been identified as a priority in both Europe and Switzerland.

Methods: A multi-pronged initiative was developed at Geneva University Hospitals (HUG) to improve staff knowledge and use of existing "migrant friendly" resources. A self-administered questionnaire was sent pre and post-intervention to random samples of 4 major professional groups with direct patient contact at the HUG. The questionnaire assessed staff knowledge, attitudes and reported practices regarding the care of migrant patients.

Results: Overall response rate was 51% (N = 1460) in 2010 but only 19% (N = 761) in 2013 owing to an institutionally imposed change in survey method. Despite these difficulties, and after adjusting for sample differences, we found that respondents in 2013 were significantly more likely to have received training in how to organize an appointment with an interpreter, how to work with an interpreter and about health and social services available for migrant patients. Respondents were also significantly more likely to have used several Migrant Friendly structures at the HUG. Use of, preference for and perceived skill at working with professional interpreters all improved, and respondents were both more likely to be encouraged by their supervisors to use professional interpreters, and less likely to be encouraged to look for alternative solutions for communicating with non francophone patients. Finally, 2013 respondents encountered fewer difficulties caring for migrant patients, although lack of time and language barriers continued to be the most important sources of difficulty.

Conclusion: Our results suggest that an institution-wide information campaign may contribute to increased awareness and use of migrant friendly resources by clinical staff. Hospital commitment and financing, along with inter-departmental participation in all activities were important in creating and maintaining project visibility, and in contributing to a migrant friendly institutional culture.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0106758PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4157774PMC
May 2015

Interpreter-mediated diabetes consultations: a qualitative analysis of physician communication practices.

BMC Fam Pract 2013 Oct 24;14:163. Epub 2013 Oct 24.

Department of Community Medicine, Primary Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland.

Background: Patient-provider communication, in particular physicians' ability to listen to their patients, and support them in making difficult lifestyle changes, is an essential component of effective diabetes care. Clinical communication around diabetes can be especially challenging when language barriers are present, and may contribute to poor diabetes management and outcomes. Clinicians need to be aware of and address potential communication difficulties associated with interpreter-mediated consultations. The purpose of our study was to explore how physicians communicate in interpreter-mediated consultations with diabetic patients, and how their communication behaviors may impact diabetes communication and care.

Method: We analyzed transcripts from 8 audio recorded, outpatient consultations at the Basel University Hospital general medicine outpatient clinic involving Turkish-speaking patients, German-speaking physicians, and Turkish-German interpreters (both community interpreters and family members).

Results: Clinicians used closed questions when asking about symptoms and glucose control. When providing information and explanation, they spoke in long and complex speech turns. They often directed their speech to interpreters or became sidetracked by family members' questions or requests for information. Patients' participation in the consultation was minimal, and limited to brief answers to clinicians' questions.

Conclusions: Clinicians need to be aware of common pitfalls that diminish patient-centeredness during interpreter-mediated consultations, and learn strategies to avoid them. Attention to established guidelines on triadic communication is recommended, as is hands-on training with interpreters.
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http://dx.doi.org/10.1186/1471-2296-14-163DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4016471PMC
October 2013

Text-messaging to reduce missed appointment in a youth clinic: a randomised controlled trial.

J Epidemiol Community Health 2013 Oct 12;67(10):888-91. Epub 2013 Jun 12.

Department of Child and Adolescent, Adolescent & Young Adult Program, Geneva University Hospitals and Geneva University, , Geneva, Switzerland.

Background: To assess the effectiveness of text-messages in reducing the proportion of non-attendance in a youth clinic of a University Hospital.

Methods: Patients who registered for an appointment and provided a mobile phone number were randomly selected to receive or not a text-message reminder before the planned appointment. A 10% reduction in the proportion of missed appointments was considered clinically and economically useful and the study was powered accordingly.

Results: The proportion of missed appointments was 16.4% (95% CI 13.1% to 19.8%) in the text-message group (N 462) and 20.0% (95% CI 16.6% to 23.4%) in the control group (N 529), showing no significant effect of the intervention (p=0.346).

Conclusions: In our primary care youth clinic, text-message reminders are not effective in reducing the proportion of missed appointments. This may in part be due to the fact that most patients are referred by a professional or by their parents and do not initiate appointments themselves.
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http://dx.doi.org/10.1136/jech-2013-202510DOI Listing
October 2013

Quality in practice: integrating routine collection of patient language data into hospital practice.

Int J Qual Health Care 2013 Sep 21;25(4):437-42. Epub 2013 May 21.

Division of Primary Care Medicine, Department of Community Medicine, Primary Care and Emergency Medicine, University Hospitals of Geneva, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland.

Quality Problem: Timely identification of patients' language needs can facilitate the provision of language-appropriate services and contribute to quality of care, clinical outcomes and patient satisfaction.

Initial Assessment: At the University Hospitals of Geneva, Switzerland, timely organization of interpreter services was hindered by the lack of systematic patient language data collection.

Choice Of Solution: We explored the feasibility and acceptability of a procedure for collecting patient language data at the first point of contact, prior to its hospital-wide implementation.

Implementation: During a one-week period, receptionists and triage nurses in eight clinical services tested a new procedure for collecting patient language data. Patients were asked to identify their primary language and other languages they would be comfortable speaking with their doctor. Staff noted patients' answers on a paper form and provided informal feedback on their experience with the procedure.

Evaluation: Registration staff encountered few difficulties collecting patient language data and thought that the two questions could easily be incorporated into existing administrative routines. Following the pilot test, two language fields with scroll-down language menus were added to the electronic patient file, and the subsequent filling-in of these fields has been rapid and hospital wide.

Lessons Learned: Our experience suggests that routine collection of patient language data at first point of contact is both feasible and acceptable and that involving staff in a pilot project may facilitate hospital-wide implementation. Future efforts should focus on exploring the sensitivity and specificity of the proposed questions, as well as the impact of data collection on interpreter use.
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http://dx.doi.org/10.1093/intqhc/mzt035DOI Listing
September 2013

Text-messaging versus telephone reminders to reduce missed appointments in an academic primary care clinic: a randomized controlled trial.

BMC Health Serv Res 2013 Apr 4;13:125. Epub 2013 Apr 4.

Division of primary care medicine, Department of community medicine, primary care and emergency medicine, Geneva University Hospitals, 4 rue Gabrielle Perret-Gentil, Geneva 14, 1211, Switzerland.

Background: Telephone or text-message reminders have been shown to significantly reduce the rate of missed appointments in different medical settings. Since text-messaging is less resource-demanding, we tested the hypothesis that text-message reminders would be as effective as telephone reminders in an academic primary care clinic.

Methods: A randomized controlled non-inferiority trial was conducted in the academic primary care division of the Geneva University Hospitals between November 2010 and April 2011. Patients registered for an appointment at the clinic, and for whom a cell phone number was available, were randomly selected to receive a text-message or a telephone call reminder 24 hours before the planned appointment. Patients were included each time they had an appointment. The main outcome was the rate of unexplained missed appointments. Appointments were not missed if they were cancelled or re-scheduled before or independently from the intervention. We defined non-inferiority as a difference below 2% in the rate of missed appointments and powered the study accordingly. A satisfaction survey was conducted among a random sample of 900 patients (response rate 41%).

Results: 6450 patients were included, 3285 in the text-message group and 3165 in the telephone group. The rate of missed appointments was similar in the text-message group (11.7%, 95% CI: 10.6-12.8) and in the telephone group (10.2%, 95% CI: 9.2-11.3 p = 0.07). However, only text message reminders were cost-effective. No patient reported any disturbance by any type of reminder in the satisfaction survey. Three quarters of surveyed patients recommended its regular implementation in the clinic.

Conclusions: Text-message reminders are equivalent to telephone reminders in reducing the proportion of missed appointments in an academic primary care clinic and are more cost-effective. Both types of reminders are well accepted by patients.
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http://dx.doi.org/10.1186/1472-6963-13-125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3623700PMC
April 2013

[Prescription of physical therapy by the physician].

Rev Med Suisse 2011 Sep;7(310):1852-4, 1856-7

Haute ecole de santé, Filière physiothérapie, Carouge.

The physical therapist is an essential actor of the medical management of patients with osteo-articular problems. After an initial evaluation, based on the information provided by the prescribing physician, he provides a "physiotherapeutic diagnosis" in terms of deficiency. He then proposes a number of passive and active techniques and may teach the patient exercises to practice at home. This article outlines prescription information for the physician, describes the main techniques used by the physical therapist and makes prescription recommendations for common osteo-articular problems.
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September 2011

[General internal medicine: important articles about ambulatory care published in 2010].

Rev Med Suisse 2011 Feb;7(280):285-8

Département de Médecine Communautaire, de Premier Recours et des Urgences, HUG, Genève.

This review of articles published in 2010 covers the new role of dabigatran in atrial fibrillation, the lack of efficacy on pain of chondroïtine/ glucosamine in knee arthrosis, the risk of thrombosis with antipsychotics, the increase cardiovascular risk in case of migraine with aura and the insufficient prescription of adjuvant chemotherapy in elderly with colon cancer. Authors also highlight public health topics such as the association of poor oral hygiene and increased cardiovascular risk, the positive effect of opioid substitution therapy by primary care practitioners on mortality, the high frequency of prenatal violence on pregnant women and the negative impact of financial constraint on the risk of hospitalization.
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February 2011

Reduction of missed appointments at an urban primary care clinic: a randomised controlled study.

BMC Fam Pract 2010 Oct 25;11:79. Epub 2010 Oct 25.

Division of Primary Care, Department of Community Medicine and Primary Care, Geneva University Hospitals, Geneva, Switzerland.

Background: Missed appointments are known to interfere with appropriate care and to misspend medical and administrative resources. The aim of this study was to test the effectiveness of a sequential intervention reminding patients of their upcoming appointment and to identify the profile of patients missing their appointments.

Methods: We conducted a randomised controlled study in an urban primary care clinic at the Geneva University Hospitals serving a majority of vulnerable patients. All patients booked in a primary care or HIV clinic at the Geneva University Hospitals were sent a reminder 48 hrs prior to their appointment according to the following sequential intervention: 1. Phone call (fixed or mobile) reminder; 2. If no phone response: a Short Message Service (SMS) reminder; 3. If no available mobile phone number: a postal reminder. The rate of missed appointment, the cost of the intervention, and the profile of patients missing their appointment were recorded.

Results: 2123 patients were included: 1052 in the intervention group, 1071 in the control group. Only 61.7% patients had a mobile phone recorded at the clinic. The sequential intervention significantly reduced the rate of missed appointments: 11.4% (n = 122) in the control group and 7.8% (n = 82) in the intervention group (p < 0.005), and allowed to reallocate 28% of cancelled appointments. It also proved to be cost effective in providing a total net benefit of 1846. - EUR/3 months. A satisfaction survey conducted with 241 patients showed that 93% of them were not bothered by the reminders and 78% considered them to be useful. By multivariate analysis, the following characteristics were significant predictors of missed appointments: younger age (OR per additional decade 0.82; CI 0.71-0.94), male gender (OR 1.72; CI 1.18-2.50), follow-up appointment >1 year (OR 2.2; CI: 1.15-4.2), substance abuse (2.09, CI 1.21-3.61), and being an asylum seeker (OR 2.73: CI 1.22-6.09).

Conclusion: A practical reminder system can significantly increase patient attendance at medical outpatient clinics. An intervention focused on specific patient characteristics could further increase the effectiveness of appointment reminders.
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http://dx.doi.org/10.1186/1471-2296-11-79DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2984453PMC
October 2010

Use of a computer-based simulated consultation tool to assess whether doctors explore sociocultural factors during patient evaluation.

J Eval Clin Pract 2009 Dec;15(6):1190-5

Academic Primary Care Physicians, Geneva University Hospitals, Genève, Switzerland.

Rationale, Aims And Objectives: The delivery of patient-centred care to diverse populations requires that doctors identify sociocultural factors that may affect care. We adapted a computer-based simulated consultation tool and tested its utility for assessing whether doctors explore sociocultural factors during a patient evaluation, and whether they include such information in their case conclusions and follow-up recommendations.

Methods: We developed two detailed patient 'stories' that involved sociocultural issues that doctors needed to identify and consider for adequate clinical management. They were incorporated into an existing 'Virtual Internet Patient Simulation' (VIPS) program designed to test clinical reasoning skills. Doctors and medical students (n = 618) were invited to access the program via Internet. For each consultation, participants were assigned a sociocultural score, corresponding to the number of sociocultural domains explored. Scores were then compared with subjective ratings of participants' performance by expert doctors.

Results: 118 respondents completed at least one virtual consultation (19%), 92 conducted both. The mean number of sociocultural dimensions explored by doctors (i.e. sociocultural score) was 3.9 (standard deviation 2.6) for case 1, and 5.2 (standard deviation 2.3) for case 2. The two sociocultural scores were moderately correlated (Spearman r = 0.65, P < 0.001). Sociocultural scores correlated positively with experts' subjective ratings of participants' performance (Spearman r = 0.84 for case 1 and 0.78 for case 2, both P < 0.001).

Conclusions: The adapted computer-based simulated consultation tool provided a feasible means to assess doctors' exploration of sociocultural issues during a clinical evaluation. Further validation of this method should be conducted by comparing VIPS results with other skills assessment methods such as objective structured clinical examination or direct observation of clinical performance.
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http://dx.doi.org/10.1111/j.1365-2753.2009.01302.xDOI Listing
December 2009

Health perceptions of African HIV-infected patients and their physicians.

Patient Educ Couns 2010 Aug 30;80(2):185-90. Epub 2009 Nov 30.

Geneva University Hospitals, Community Medicine and Primary Care Department, Geneva, Switzerland.

Objective: We explored how patients from Sub Saharan Africa (SSA) infected with HIV and living in Switzerland, and their treating physicians perceived their health, whether these perceptions correlated with biological markers, and what organisational changes participants considered likely to improve quality of care.

Methods: A prospective standardized questionnaire was submitted to HIV-infected patients from SSA and their physicians. Results were correlated with biological data.

Results: While physicians deduced improved health status from laboratory results, these did not provide an adequate surrogate marker of good health for patients. Patients experienced important social and economical difficulties with adverse consequences on their mental health. They requested social assistance, whereas physicians sought improved cultural competency.

Conclusion: Patients and physicians did not agree in their evaluation of patients' health status. Patients did not perceive their health through biological markers, but linked their mental health with their socioeconomic context. Physicians underestimated patients' biological health and their evaluation of global health.

Practice Implications: Exploring difficulties perceived by physicians with specific patients lead to identification of structural weaknesses, resulting in suggestions to improve physicians' medical training and patients' care. This illustrates the importance of accessing patients' perspective and not relying solely on physicians' perception of the problem.
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http://dx.doi.org/10.1016/j.pec.2009.10.023DOI Listing
August 2010

GPs' strategies in intercultural clinical encounters.

Fam Pract 2007 Apr 5;24(2):145-51. Epub 2007 Feb 5.

Department of Family Medicine, McGill University and St Mary's Hospital, Montreal, Quebec, Canada.

Background: In North America and Europe, patients and physicians are increasingly likely to come from non-Western cultural backgrounds. The expectations of these patients may not match those of physicians.

Objective: To identify strategies used by GPs with patients from cultures other than their own.

Methods: We conducted a qualitative inductive study based on 25 semi-structured interviews with family physicians practising in Montreal, Canada. We elicited physicians' strategies when dealing with patients from a cultural background different from their own. We began by asking physicians to describe an encounter they found difficult and one they found easy.

Results: Physicians reported three types of strategies: (i) insistence on patient adaptation to local beliefs and behaviours; (ii) physician adaptation to what he or she assumed patients wanted; and (iii) negotiation of a mutually acceptable plan. Individual physicians did not adopt the same strategy in all situations. Their choice of strategy depended on the topic. When dealing with issues they felt deeply about, such as the autonomy of women, many physicians insisted on patient adaptation. Physicians used a patient-centred model of care, but had no framework to elicit information about patients' culture.

Conclusions: A patient-centred model of care enables physicians to consult effectively despite a wide range of cultural differences between themselves and their patients. However, their lack of a conceptual framework for addressing cultural difference prevents systematic data collection and consideration of challenges to respect for individual autonomy. Physician training should include the provision of an explicit conceptual framework for approaching patients from a different culture.
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http://dx.doi.org/10.1093/fampra/cmm004DOI Listing
April 2007

Explaining medically unexplained symptoms.

Can J Psychiatry 2004 Oct;49(10):663-72

Division of Social and Transcultural Psychiatry, McGill University, Montreal, Quebec.

Patients with medically unexplained symptoms comprise from 15% to 30% of all primary care consultations. Physicians often assume that psychological factors account for these symptoms, but current theories of psychogenic causation, somatization, and somatic amplification cannot fully account for common unexplained symptoms. Psychophysiological and sociophysiological models provide plausible medical explanations for most common somatic symptoms. Psychological explanations are often not communicated effectively, do not address patient concerns, and may lead patients to reject treatment or referral because of potential stigma. Across cultures, many systems of medicine provide sociosomatic explanations linking problems in family and community with bodily distress. Most patients, therefore, have culturally based explanations available for their symptoms. When the bodily nature and cultural meaning of their suffering is validated, most patients will acknowledge that stress, social conditions, and emotions have an effect on their physical condition. This provides an entree to applying the symptom-focused strategies of behavioural medicine to address the psychosocial factors that contribute to chronicity and disability.
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http://dx.doi.org/10.1177/070674370404901003DOI Listing
October 2004
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