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ObjectivesTo explore allophone immigrant women’s knowledge and perceptions of epidural analgesia for labour pain, in order to identify their information needs prior to the procedure.DesignWe conducted focus groups interviews with allophone women from five different linguistic immigrant communities, with the aid of professional interpreters. Thematic analysis of focus group transcripts was carried out by all authors.SettingWomen were recruited at two non-profit associations offering French language and cultural integration training to non-French speaking immigrant women in Geneva.ParticipantsForty women from 10 countries who spoke either Albanian, Arabic, Farsi/Dari, Tamil or Tigrigna took part in the five focus groups. Four participants were nulliparous, but all others had previous experience of labour and delivery, often in European countries. A single focus group was conducted for each of the five language groups.ResultsWe identified five main themes: (1) Women’s partial knowledge of epidural analgesia procedures; (2) Strong fears of short-term and long-term negative consequences of epidural analgesia during childbirth; (3) Reliance on multiple sources of information regarding epidural analgesia for childbirth; (4) Presentation of salient narratives of labour pain to justify their attitudes toward epidural analgesia; and (5) Complex community positioning of pro-epidural women.ConclusionsWomen in our study had partial knowledge of epidural analgesia for labour pain and held perceptions of a high risk-to-benefits ratio for this procedure. Diverse and sometimes conflicting information about epidural analgesia can interfere with women’s decisions regarding this treatment option for labour pain. Our study suggests that women need comprehensive but also tailored information in their own language to support their decision-making regarding epidural labour analgesia.

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. 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. 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 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.

BackgroundPrimary 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.ObjectiveTo explore patients’ preferences regarding physicians’ EHR-related behaviors.DesignDiscrete choice experiment study.PatientsFrench-speaking patients waiting for a medical consultation at two outpatient clinics in Geneva, Switzerland.Main MeasuresWe 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 ResultsThree 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.ConclusionsOur 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.

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.

While the use of telemedicine (TLM) increased worldwide during the early phases of the COVID-19 pandemic, little is known about the use and acceptance of TLM post the COVID-19 pandemic. This study aims to evaluate patients' and physicians' self-reported use, preferences, and acceptability of different types of TLM after the initial phases of the COVID-19 pandemic. We conducted a cross-sectional survey among patients and physicians in Geneva, Switzerland, between September 2021 and January 2022. Patients in waiting rooms of both private and public medical centers and emergency services were invited to answer a web-based questionnaire. Physicians working in private and public settings were invited by email to answer a similar questionnaire. The questionnaires assessed participants' sociodemographics and digital literacy; self-reported use of TLM; as well as preferences and acceptability of TLM for different clinical situations. A total of 567 patients (309/567, 55% women) and 448 physicians (230/448, 51% women and 225/448, 50% in private practice) responded to the questionnaire. Patients (263/567, 46.5%) and physicians (247/448, 55.2%) generally preferred the phone over other TLM formats and considered it to be acceptable for most medical situations. Email (417/567, 73.6% and 308/448, 68.8%) was acceptable for communicating exam results, and medical certificates (327/567, 67.7% and 297/448, 66.2%) and video (302/567, 53.2% and 288/448, 64.3%) was considered acceptable for psychological support by patients and physicians, respectively. Older age was associated with lower acceptability of video for both patients and physicians (odds ratio [OR] 0.03, 95% CI 0.00-0.33 and OR 0.23, 95% CI 0.08-0.66) while previous use of video was positively associated with video acceptability (OR 3.16, 95% CI 1.84-5.43 and OR 3.34, 95% CI 2.91-5.54). Psychiatrists and hospital physicians were more likely to consider video to be acceptable (OR 10.79, 95% CI 3.96-29.30 and OR 3.97, 95% CI 2.23-7.60). Despite the development of video, the acceptability of video remains lower than that of the phone for most health issues or patient requests. There is a need to better define for which patients and in which medical situations video can become safe and efficient.

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.

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.

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.

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.

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. 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. 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. 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.