Die Macht der Atmosphären. Die Beziehung zwischen Arzt und Patient

Kontakti pacijenata s predstavnicima sustava zdravstva obilježeni su određenom atmosferom. Ovdje će biti predstavljena različita izvorišta takvih atmosfera. Arhitektura dviju ustanova za rehabilitaciju pacijenata i pacijentica s povredama mozga i kičmene moždine (Centar za rehabilitaciju u Baselu i Švicarski centar za paraplegičare u Nottwilu) ilustrira nastojanje arhitekata da u djelo provedu projektne ideje korisnika: dok u Baselu prevladava ideja stalnog navođenja na život u kolicima, arhitektura u Nottwilu predočava poletno raspoloženje koje život u kolicima želi osloboditi strahota. I uređenje liječničkih ordinacija oslikava različite namjere da se obilje- ži atmosfera. U drugom dijelu rada razmatra se pitanje kako nastaju atmosfere tijekom susreta kojem na raspolaganju ne stoji potpora estetskim elementima. Kao izvor atmosferskih utjecaja etablira se unutrašnji svijet stručnjaka i pacijenta, a diskutiraju se i trvenja neprihvaćanjem dogme o unutrašnjem svijetu u Novoj fenomenologiji. Kao pretpostavka za nastajanje kompaktnih atmosferskih prostora navodi se stil vođenja razgovora s fokusom na pacijentu i otvoren i radoznao stav, a ovi se onda ilustriraju primjerima.Contacts between patients and health system representatives are marked by a certain atmosphere. In this paper, different sources of this kind of atmospheres will be presented. The architecture of two institutions for the rehabilitation of patients with brain and spinal cord injuries (Centre for rehabilitation in Basel and Swiss Centre for paraplegics in Nottwil) illustrates the architect’s intentions to implement customer ideas. In Basel, the idea of continuous learning about living a life in wheelchair dominates the composition, while the architecture in Nottwil represents an enthusiastic spirit which attempts to free the life in wheelchairs from fear. The internal design of medical offices and dispensaries also reflects different intentions that articulate atmospheres. In the second part of the paper, the question is posed about how atmospheres are created in situations in which there is a lack of aesthetical elements that can support it. As the source of atmospheric influences, we find the inner world of experts and patients, but the discussion will also be about the conflicts that are results of New phenomenology not accepting the dogma of the inner world. Finally, the paper discusses and provides examples for prerequisites for creating compact atmospheric spaces, one of them being a style of leading a dialogue with a special focus on a patient and open-minded and curious attitude.La relation que le patient entretient avec les représentants du système de santé est déterminée par une atmosphère bien spécifique. Ici seront présentées les différentes sources de ces atmosphères. L’architecture de deux institutions (les centres suisses de réadaptation basés à Bâle et à Nottwil) pour la réadaptation des patients et des patientes présentant des lésions cérébrales et des lésions de la moelle épinière illustrent la volonté des architectes de mettre en œuvre les idées des projets des utilisateurs : alors que le centre de Bâle encourage la réinsertion continue en société des patients en fauteuil roulant, l’architecture de Nottwil offre un climat rassurant afin de leur permettre de se défaire de la peur d’une vie en fauteuil roulant. La configuration des cabinets médicaux révèle également les nombreuses intentions de créer une certaine atmosphère. Dans la seconde partie de ce travail sera analysée la question qui touche à la manière dont les atmosphères émergent au sein d’une rencontre qui ne dispose pas de l’appui d’éléments esthétiques. Le monde intérieur qui réunit les spécialistes et les patients est reconnu en tant que l’une des sources d’atmosphères qui exercent une influence, et seront ainsi discutées les tensions issues du refus d’accepter les dogmes du monde intérieur dans la Nouvelle Phénoménologie. La manière de mener des discussions, avec un accent mis sur le patient et sur une attitude qui favorise l’ouverture et la curiosité, constitue la présupposition pour qu’émergent des espaces atmosphériques compacts, discussions qui seront ensuite illustrées par des exemples.Kontakte von Patienten mit Vertretern des Gesundheitssystems sind von einer bestimmten Atmosphäre geprägt. Unterschiedliche Quellen solcher Atmosphären werden vorgestellt. Die Architektur von zwei Rehabilitationseinrichtungen für Patienten und Patientinnen mit Rückenmarks- und Hirnverletzungen (Reha Basel und Schweizer Paraplegiker-Zentrum in Nottwil) verdeutlicht das Bemühen der Architektinnen, die Vorgaben der Bauherrschaft umzusetzen: Während in Basel der Gedanke eines langsamen Heranführens an das Leben im Rollstuhl vorherrscht, vermittelt die Architektur in Nottwil eine Aufbruchsstimmung, die dem Leben im Rollstuhl seine Schrecken nehmen will. Auch die Einrichtung von Praxisräumen widerspiegelt unterschiedliche Absichten, Atmosphäre zu prägen. Im zweiten Teil der Arbeit geht es um die Frage, wie Atmosphären in einer Begegnung entstehen, die nicht auf die Unterstützung ästhetischer Elemente zurückgreifen kann. Als Quelle atmosphärischer Prägungen wird die innere Welt von Fachperson und Patient etabliert, Reibungen mit der Ablehnung des Innenwelt-Dogmas in der Neuen Phänomenologie werden diskutiert. Als Voraussetzung für das Entstehen dichter atmosphärischer Räume wird eine Patienten-zentrierte Gesprächsführung und eine offene und neugierige Haltung benannt und an Beispielen erläutert

A theory-based approach to analysing conversation sequences

Aims - To assess the quality of communication generally two procedures are used: one defines categories of utterances and counts their frequency, the other uses global observer ratings. We investigated whether a sequence analysis of utterances yields results which more precisely reflect the process of a conversation. Methods - We re-examined data from a randomised controlled intervention study in which residents' interviews with simulated patients were analysed with the Maastricht History and Advice Checklist (MAAS-R) and the Roter Interaction Analysis System (RIAS). Using the U-file of the RIAS we studied the effect of different types of physician questions (open, closed questions, facilitators, other physician actions) on the length of uninterrupted patients' speech and content of utterances. We investigated also whether reciprocity indices improve after a communication skills training, and whether they correlate with global scores form MAAS-R. Results - Patients respond to a closed question with a mean of 1.78 (± 1.49) utterances as compared to 2.75 (± 2.72) utterances after an open question. The likelihood of a concern was more than lOfold higher after an open question compared to closed questions. Reciprocal sequences make up less than 2 percent of the conversation, Still, they correlate with global items form MAAS-R. The 'empathy index' improves after the training. Declararation of Interest: preparation of the manuscript was supported by a grant from OncoSuiss

Doctors' responses to patients' concerns; an exploration of communication sequences in gynaecology

Aims - Like other medical doctors, gynaecologists have difficulty attending to psychosocial issues and concerns. Communication training has proven to be effective in teaching them to spend more time on discussing these factors. However, whether or not they do this in response to patients' utterances remains unclear. The question is how gynaecologists respond to patients' concerns, whether or not they do this adequately and what the effects of a communication training are on the use of these communication sequences. Methods - Nineteen gynaecologists participated in a study which examined the effects of a three-day residential communication training. Before and after the training the gynaecologists videotaped series of consecutive outpatient visits. The communication during these visits was rated using the Roter Interaction Analysis System. Gynaecologists' responses to patients' concerns were examined at lag one, i.e. immediately following the patient's concern. Results - The most prevalent responses made by the gynaecologists were showing agreement and understanding and giving medical information. Affective responses were observed less. At postmeasurement, the gynaecologists responded neither more adequately nor inadequately to patients' concerns. Conclusions - The gynaecologists did not respond in a very affective way to patients' concerns. However, the patients did not express many concerns. Future studies should focus on more prevalent communication behaviours and incorporate more lags. Declaration of Interest: non

Coronary artery disease and depression

Coronary artery disease (CAD) as well as depression are both highly prevalent diseases. Both cause a significant decrease in quality of life for the patient and impose a significant economic burden on society. There are several factors that seem to link depression with the development of CAD and with a worse outcome in patients with established CAD: worse adherence to prescribed medication and life style modifications in depressive patients, as well as higher rates in abnormal platelet function, endothelial dysfunction and lowered heart rate variability. The evidence is growing that depression per se is an independent risk factor for cardiac events in a patient population without known CAD and also in patients with established diagnosis of CAD, particularly after myocardial infarction. Treatment of depression has been shown to improve patients' quality of life. However, it did not improve cardiovascular prognosis in depressed patients even though there is open discussion about the trend to better outcome in treated patients. Large scale clinical trials are needed to answer this question. Selective serotonin reuptake inhibitors seem to be preferable to tricyclic antidepressants for treatment of depressive patients with comorbid CAD because of their good tolerability and absence of significant cardiovascular side effects. Hypericum perforatum (St. John's wort), an increasingly used herbal antidepressant drug should be used with caution due to severe and possibly dangerous interaction with cardioactive drug

Students’ satisfaction with general practitioners’ feedback to their reflective writing: a randomized controlled trial

Background: Reflective Writing (RW) is increasingly being implemented in medical education. Feedback to students’ reflective writing (RW) is essential, but resources for individualized feedback often lack. We aimed to determine whether general practitioners (GPs) teaching students clinical skills could also provide feedback to RW and whether an instruction letter specific to RW feedback increases students’ satisfaction.Methods: GPs were randomized to the two study arms using block randomization. GPs in both groups received an instruction letter on giving students feedback on clinical skills. Additionally, intervention group GPs received specific instructions on providing feedback to students’ RW. Students completed satisfaction questionnaires on feedback received on clinical skills and RW. T-tests were employed for all statistical analysis to compare groups.Results: Eighty-three out of 134 physicians participated: 38 were randomized to the control, 45 to the intervention group. Students were very satisfied with the feedback on RW and clinical skills regardless of tutors’ group allocation. A specific instruction letter had no additional effect on students’ satisfaction.Conclusion: Based on student satisfaction, GPs who give students feedback on clinical skills are also well suited to provide feedback on RW. This approach can facilitate the introduction of mandatory RW into the regular medical curriculum

Does information structuring improve recall of discharge information? A cluster randomized clinical trial

The impact of the quality of discharge communication between physicians and their patients is critical on patients' health outcomes. Nevertheless, low recall of information given to patients at discharge from emergency departments (EDs) is a well-documented problem. Therefore, we investigated the outcomes and related benefits of two different communication strategies: Physicians were instructed to either use empathy (E) or information structuring (S) skills hypothesizing superior recall by patients in the S group.; For the direct comparison of two communication strategies at discharge, physicians were cluster-randomized to an E or a S skills training. Feasibility was measured by training completion rates. Outcomes were measured in patients immediately after discharge, after 7, and 30 days. Primary outcome was patients' immediate recall of discharge information. Secondary outcomes were feasibility of training implementation, patients' adherence to recommendations and satisfaction, as well as the patient-physician relationship.; Of 117 eligible physicians, 80 (68.4%) completed the training. Out of 256 patients randomized to one of the two training groups (E: 146 and S: 119) 196 completed the post-discharge assessment. Patients' immediate recall of discharge information was superior in patients in the S-group vs. E-group. Patients in the S-group adhered to more recommendations within 30 days (p = .002), and were more likely to recommend the physician to family and friends (p = .021). No differences were found on other assessed outcome domains.; Immediate recall and subsequent adherence to recommendations were higher in the S group. Feasibility was shown by a 69.6% completion rate of trainings. Thus, trainings of discharge information structuring are feasible and improve patients' recall, and may therefore improve quality of care in the ED

A longitudinal, Bologna-compatible model curriculum "communicationand social competencies" : results of an interdisciplinary workshop of German-speaking medical schools

Zielsetzung: Ziel des Projekts ist es, ein longitudinales Modell-Curriculum "Kommunikative und soziale Kompetenzen" für die medizinische Ausbildung zur Diskussion zu stellen. Vorgehen und Ergebnisse: Auf einem 2-tägigen Workshop wurde interfakultär und interdisziplinär auf der Grundlage des "Basler Consensus Statements: Kommunikative und soziale Kompetenzen im Medizinstudium" ein Curriculum entwickelt, das deutschsprachigen Fakultäten bei der Planung und Implementierung als Vorlage dienen kann. Das Modell lässt sich als Gesamt-Curriculum oder in Teilmodulen implementieren. Es kann auch bei der Umstellung auf Bachelor- und Masterstudiengänge genutzt werden. Das longitudinale Modell-Curriculum weist neben 131 definierten Ausbildungszielen geeignete didaktische Konzepte und Prüfungsformate auf und gibt Vorschläge, zu welchem Zeitpunkt die verschiedenen Fächer die entsprechenden Lernziele vermitteln können. Fazit: Mit diesem longitudinalen "Modell-Curriculum Kommunikative und Soziale Kompetenzen" liegt für den deutschen Sprachraum erstmalig ein curriculares Instrument vor, das breite Anwendung an einer Vielzahl deutscher, österreichischer und schweizerischer Fakultäten finden und eine Umsetzung des Bologna-Prozesses auch fakultätsübergreifend vereinfachen kann. Schlüsselwörter: Modell-Curriculum, kommunikative/soziale Kompetenzen, Basler Consensus Statement, medizinische Ausbildung, Didaktik, Prüfung, Bologna-ProzessAim: The aim of the project is to present and discuss a longitudinal model curriculum "Communication and social competencies" for undergraduate medical education. Procedure and results: In a two-day workshop, a multidisciplinary, cross-faculty group of medical educators developed a curriculum model based on the "Basel Consensus Statement". It can now be used by German-speaking medical schools as a blueprint for curriculum planning and implementation processes. The modular structure enables it to be implemented either in whole or in part. The model can also be used to facilitate the conversion of medical education into Bachelor and Master degree programmes. The longitudinal model curriculum features 131 educational objectives and makes suggestions for didactic concepts and assessment tools. For various disciplines, it also recommends at what point in time specific topics should be taught. Conclusion: The longitudinal model curriculum "Communication and social competencies", based on the educational objectives of the "Basel Consensus Statement", is a new curricular instrument that can be used by German, Austrian and Swiss medical schools. It can help to simplify the realisation of the Bologna process, also across different faculties. Keywords: model curriculum, communication/social competencies, Basel Consensus Statement, undergraduate medical education, didactic, assessment, Bologna proces

Open and hidden agendas of "asymptomatic" patients who request check-up exams

BACKGROUND: Current guidelines for a check-up recommend routine screening not triggered by specific symptoms for some known risk factors and diseases in the general population. Patients' perceptions and expectations regarding a check-up exam may differ from these principles. However, quantitative and qualitative data about the discrepancy between patient- and provider expectations for this type of clinic consultation is lacking. METHODS: For a year, we prospectively enrolled 66 patients who explicitly requested a "check-up" at our medical outpatient division. All patients actively denied upon prompting having any symptoms or specific health concerns at the time they made their appointment. All consultations were videotaped and analysed for information about spontaneously mentioned symptoms and reasons for the clinic consultation ("open agendas") and for cues to hidden patient agendas using the Roter interaction analysis system (RIAS). RESULTS: All patients initially declared to be asymptomatic but this was ultimately the case in only 7 out of 66 patients. The remaining 59 patients spontaneously mentioned a mean of 4.2 ± 3.3 symptoms during their first consultation. In 23 patients a total of 31 hidden agendas were revealed. The primary categories for hidden agendas were health concerns, psychosocial concerns and the patient's concept of disease. CONCLUSIONS: The majority of patients requesting a general check-up tend to be motivated by specific symptoms and health concerns and are not "asymptomatic" patients who primarily come for preventive issues. Furthermore, physicians must be alert for possible hidden agendas, as one in three patients have one or more hidden reasons for requesting a check-up

Personalisierte Medizin: Grundlagen für die interprofessionelle Aus-, Weiter- und Fortbildung von Gesundheitsfachleuten

Hinweise zur Ausarbeitung dieser Publikation: Die SAMW hat im Auftrag der Akademien der Wissenschaften Schweiz die thematische Plattform «Chancen und Risiken der Personalisierten Gesundheit» etabliert. In diesem Rahmen hat der SAMW-Vorstand eine Arbeitsgruppe beauftragt, das Thema der Aus-, Weiter- und Fortbildung von Gesundheitsfachleuten im Bereich «Personalisierte Medizin» zu bearbeiten