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L'annonce d'une mauvaise nouvelle en cancérologie constitue un exercice anxiogène pour les médecins. La théorie de la régulation émotionnelle laisse à penser que les médecins vont avoir recours à des stratégies afin de réguler leurs émotions au moment de l'annonce. Nous nous sommes interrogés sur l'impact des stratégies de régulation émotionnelle des médecins confrontés à l'annonce d'une mauvaise nouvelle, sur l'ajustement psychologique de leurs patients. Pour y répondre, quatre études ont été menées. La première visait à analyser l'anxiété des médecins et deux stratégies de régulation émotionnelles ( la réévaluation cognitive et la suppression expressive), à l'annonce d'une mauvaise nouvelle. Dans la seconde étude, les résultats de l'analyse quantitative d'entretiens menés auprès de médecins nous ont permis d'élargir l'éventail des émotions (négatives et positives) et des stratégies de régulation émotionnelle des médecins à l'annonce d'une mauvaise nouvelle. Dans la troisième étude, l'analyse IPA du discours des médecins a fait émerger deux éléments clés de compréhension de l'expérience subjective des médecins face à l'annonce : le sens que les médecins donnent à l'annonce et à leur rôle, et le lien établi avec leurs patients. La dernière étude s'est focalisée sur l'analyse des liens entre l'anxiété, les stratégies de régulation émotionnelle et les compétences relationnelles des médecins au moment de l'annonce, et l'ajustement psychologique de leurs patients quinze jours après l'annonce. Les résultats de ces quatre études apportent de nouveaux éléments de réflexion concernant les formations à l'annonce de mauvaises nouvelles proposées aux médecins. / Breaking bad news in oncology is a difficult task for physicians, generating anxiety. The theory of emotion regulation suggests that physicians are using emotion regulation strategies to influence their emotions when breaking bad news to patients. The literature has led us to question the impact of the emotion regulation strategies of physicians facing giving bad news in oncology, on their patient's psychological adjustment. To address this topic, four studies were carried out. The first one enables us to analyse physicians' anxiety and two emotions regulation strategies (expressive suppression and cognitive reappraisal) at three different stages of the announcement : just before, just after and a week later. In the second study, the results of qualitative analysis from semi-structured interviews with physicians allow us to expand the range of emotions (negative and positive) and physicians' emotion regulation strategies when announcing a bad news. In the third study, the interpretative phenomenological analysis of the physicians' interviews enables us to understand two key elements of the subjective experience of physicians facing the announcement : the importance that physicians give to the announcement and their role, and the relationship established with their patients. Tha last study focusses on the analysis of the link between anxiety, emotion regulation strategies and the physicians' interpersonal skills when breaking bad news in oncology, and the patient's psychological adjustment fifteen days after the announcement. The results of these four studies allow to provide new lines of approach regarding the training in breaking bad news currently available for physicians.

Objetivo: avaliar o grau de empatia dos estudantes de medicina e suas mudanças durante o curso médico de uma Faculdade na cidade de São Paulo, Brasil. Método: Estudo descritivo, comparativo e transversal. Amostra não aleatória de 296 alunos. O estudo foi conduzido de Setembro até Dezembro de 2013. A avaliação da empatia foi realizada usando a escala de empatia médica de Jefferson (JSPE) na versão para estudantes de medicina, e a escala multidimensional de reatividade interpessoal de Davis (EMRI) na versão validade e adaptada no Brasil. Ambas escalas foram aplicadas simultaneamente a cada aluno. A JSPE contém 20 itens que são respondidos de acordo com a variante de escala de Likert de sete pontos (Concordo = 7 / Discordo = 1) .Esta escala avalia atributos cognitivos da empatia. A EMRI contém 21 itens que são respondidos de acordo com a escala de Likert de cinco pontos ( Descreve-me muito bem = 5 / Não me descreve muito bem = 1). Esta escala avalia tanto componentes cognitivos quanto afetivos da empatia. Os alunos foram divididos em três grupos de acordo com o ano da graduação: o grupo básico (1º e 2º ano), grupo clínico (3º e 4º ano ) e o grupo do internato (5 º e 6 º ano), e foram comparados os escores de empatia entre os três grupos. Resultados: Ao aplicar JSPE não houve uma diferença significativa quando comparado o escore entre os 3 grupos. Por outro lado ao aplicar a EMRI foi identificado um escore de empatia significativamente menor no grupo do internato quando avaliado o componente afetivo (p < 0,01). Tanto na JSPE quanto na EMRI, as mulheres obtiveram os melhores escores de empatia (p < 0,01) quando comparada aos homens. Os alunos que pretendiam seguir especialidade clínica obtiveram escore de empatia maior quando comparada com especialidade cirúrgica utilizando tanto a JSPE (p=0,05) quanto a EMRI (p < 0,01). Conclusões: O nível de empatia pode mudar e, neste caso, a dimensão afetiva é a mais afetada durante o curso médico. A identificação desta erosão afetiva mostra a necessidade de elaborar estratégias educacionais efetivas que possam contribuir para uma boa formação do futuro profissional médico / Purpose: This study was designed to examine changes in medical students\' empathy during medical school in São Paulo, Brazil. Method: Descriptive, comparative and cross-sectional study. Not randomized sample of 296 students. The study was conducted from September to December 2013. The empathy evaluation was performed using the Jefferson Scale of Physician Empathy (JSPE), version for medical students, and the Davis\'s multidimensional Interpersonal Reactivity Index (EMRI), both of then being applied simultaneously to each student. The JSPE contains 20 items that are answered according to the scale of Likert variant of seven points (7= completely in agreement / 1= completely in disagreement). It is important to emphasize that this scale assesses cognitive attributes of empathy. The EMRI contains 21 items that are answered according to the scale of Likert variant of five ponts (5= describe me very well /1= not describe me very well). This scale assesses cognitive and affective attributes of empathy. The students were divided into three groups, according to the year of professional career: the Basic Group (1st and 2 nd year), the Clinical Group (3rd and 4th year) and the Clerkship group (5th and 6th year). The score of empathy between the three groups was compared. Results: The JSPE scores were similar among the students from the Basic, Clinical and Clerkship groups (p=0.53). On the other hand, the affective dimension of EMRI revealed a significantly lower score in the Clerkship Group (p < 0.01). Women obtained better scores for empathy compared to men, in both scales (p < 0,01). Students who intended to follow clinical careers had higher empathy scores when compared to those who intended to follow surgical careers so when applied to JSPE (p = 0.05) as the EMRI (p < 0.01). Conclusions: The level of empathy can change and in this case, the affective dimension is most affected during medical school. The identification of affective erosion support the need to develop effective educational strategies that contribute to a good training medical professional future

Introdução - O uso da internet entre médicos e pacientes é prática cada vez mais freqüente na Medicina. Sua introdução, entretanto, incorre em implicações éticas, legais e econômicas além de influenciar a relação médico-paciente e o processo de trabalho médico. Objetivos - Identificar o uso da internet por médicos ginecologistas e obstetras da cidade de São Paulo na prática médica, sua influencia na relação médico-paciente e suas possíveis implicações éticas, legais e econômicas. Métodos - Foram enviados 1.120 questionários para médicos ginecologistas e obstetras da cidade de São Paulo, dos quais retornaram 152, o correspondente a 13,6% da amostra ou 6,1% do total dos médicos cadastrados na SOGESP. A análise quantitativa do comportamento do médico quanto ao uso da internet foi realizada por meio de proporções, médias e cálculos de desviospadrão conforme os dados obtidos através do questionário. A comparação entre o grupo de médicos que utiliza a internet na prática médica e o grupo que não a utiliza, sua distribuição segundo local e tipo de atendimento, recursos da internet utilizados, formação ou titulação acadêmica, idade e tempo de formado foi feita através do teste de associação do qui-quadrado. Através da técnica de Cluster Analysis, foram determinados 4 grupos segundo o perfil dos profissionais relacionado ao uso desta ferramenta. Conclusões - Os ginecologistas obstetras pesquisados utilizam a internet na prática médica para própria atualização através do acesso a base de dados, para obter informações sobre saúde e doença, para comunicação com pacientes ou para oferecer serviços às mesmas com diferentes assiduidades. Entretanto, este uso é ainda parcial, talvez relacionado ao receio de interferências negativas na relação com o paciente, além de preocupações quanto à implicações legais, éticas e principalmente econômicas que a introdução desta ferramenta possa causar no desenvolvimento da profissão. / Introduction - The use of internet by patients and physicians has increased and has been increasingly integrated into clinical practice. Moreover, the internet is changing the traditional doctor-pacient relationship and adds new ethical, legal and economic concepts to its practice. Objective To identify the use of internet by gynecologists and obstetricians who work in São Paulo city, its influence on the physician-patient relationship and the ethical, legal and economic aspects of its introduction into medical practice. Methods - A postal questionnaire was sent to 1.120 gynecologists and obstetricians of São Paulo city, 152 of which were returned, which represents a return rate of 13.6% and 6.1% of all the professionals of SOGESP. The quantitative analysis of the doctors` behavior related to the use of the internet has been made by calculation of averages, proportions and standard deviations. The comparison between these doctors who have introduced internet into their practice and those who haven`t, its distribution by professional activity and office location, internet tools utilized and personal characteristics have been undertaken using the chi-squared test. Four different groups have been determined by Cluster Analysis depending on the way this technology is used. Conclusions The gynecologists and obstetricians investigated in this research project use internet in their medical practice, for the updating of data collection, to obtain new information about health care, for communication with patients or offer their medical services by the Web. Although its use has been improved doctors are afraid of possible negative consequences regarding the physician-patient relationship and legal, economic and ethical consequences that this use may bring to clinical practice.

Introdução - O uso da internet entre médicos e pacientes é prática cada vez mais freqüente na Medicina. Sua introdução, entretanto, incorre em implicações éticas, legais e econômicas além de influenciar a relação médico-paciente e o processo de trabalho médico. Objetivos - Identificar o uso da internet por médicos ginecologistas e obstetras da cidade de São Paulo na prática médica, sua influencia na relação médico-paciente e suas possíveis implicações éticas, legais e econômicas. Métodos - Foram enviados 1.120 questionários para médicos ginecologistas e obstetras da cidade de São Paulo, dos quais retornaram 152, o correspondente a 13,6% da amostra ou 6,1% do total dos médicos cadastrados na SOGESP. A análise quantitativa do comportamento do médico quanto ao uso da internet foi realizada por meio de proporções, médias e cálculos de desviospadrão conforme os dados obtidos através do questionário. A comparação entre o grupo de médicos que utiliza a internet na prática médica e o grupo que não a utiliza, sua distribuição segundo local e tipo de atendimento, recursos da internet utilizados, formação ou titulação acadêmica, idade e tempo de formado foi feita através do teste de associação do qui-quadrado. Através da técnica de Cluster Analysis, foram determinados 4 grupos segundo o perfil dos profissionais relacionado ao uso desta ferramenta. Conclusões - Os ginecologistas obstetras pesquisados utilizam a internet na prática médica para própria atualização através do acesso a base de dados, para obter informações sobre saúde e doença, para comunicação com pacientes ou para oferecer serviços às mesmas com diferentes assiduidades. Entretanto, este uso é ainda parcial, talvez relacionado ao receio de interferências negativas na relação com o paciente, além de preocupações quanto à implicações legais, éticas e principalmente econômicas que a introdução desta ferramenta possa causar no desenvolvimento da profissão. / Introduction - The use of internet by patients and physicians has increased and has been increasingly integrated into clinical practice. Moreover, the internet is changing the traditional doctor-pacient relationship and adds new ethical, legal and economic concepts to its practice. Objective To identify the use of internet by gynecologists and obstetricians who work in São Paulo city, its influence on the physician-patient relationship and the ethical, legal and economic aspects of its introduction into medical practice. Methods - A postal questionnaire was sent to 1.120 gynecologists and obstetricians of São Paulo city, 152 of which were returned, which represents a return rate of 13.6% and 6.1% of all the professionals of SOGESP. The quantitative analysis of the doctors` behavior related to the use of the internet has been made by calculation of averages, proportions and standard deviations. The comparison between these doctors who have introduced internet into their practice and those who haven`t, its distribution by professional activity and office location, internet tools utilized and personal characteristics have been undertaken using the chi-squared test. Four different groups have been determined by Cluster Analysis depending on the way this technology is used. Conclusions The gynecologists and obstetricians investigated in this research project use internet in their medical practice, for the updating of data collection, to obtain new information about health care, for communication with patients or offer their medical services by the Web. Although its use has been improved doctors are afraid of possible negative consequences regarding the physician-patient relationship and legal, economic and ethical consequences that this use may bring to clinical practice.

Using mainly quantitative methods of evaluation, as well as patient comment assessment, this study evaluated whether changing the current informed consent process for labor epidural analgesia to a longer, more informational process resulted in a more satisfied patient. Satisfaction with the labor epidural informed consent process was evaluated using a questionnaire that was mailed and also available online. Half of the patient population was given a written labor epidural risk/benefit document at their 36-week obstetric check up. All patients received the standard informed consent. Survey responses were evaluated based on three independent variables dealing with the modality, timing, amount of informed consent information and one dependent variable, whether the patient's expectations of the epidural were met, which is equated with satisfaction. Patients in this study clearly indicated that they want detailed risk/benefit information on epidural analgesia earlier in their pregnancy. A meaningfully larger percentage of patients who received the written risk/benefit document were satisfied with the epidural process as compared to those who did not receive the document.

Atualmente, os profissionais da saúde não vêm sendo preparados para lidar com as dificuldades inerentes à morte e o morrer, no entanto, observa-se que, dentre eles, é o médico que vivencia mais negativamente essa realidade, em detrimento das intervenções psicossociais. A literatura aponta que, crenças e práticas religiosas são importantes na vida de muitos pacientes que procuram assistência, entretanto, muitos médicos e demais profissionais da equipe ainda estão incertos sobre a melhor maneira para abordar questões espirituais e religiosas. Esta pesquisa teve a intenção de compreender a vivência de religiosidade de médicos oncologistas no cuidado com o paciente oncológico. Optou-se pela modalidade de pesquisa qualitativa, na perspectiva da Fenomenologia Ontológica- Hermenêutica de Martin Heidegger, para a compreensão das situações vivenciadas. Foram realizadas entrevistas com oito médicos oncologistas, após a assinatura do consentimento livre e informado. As entrevistas foram gravadas e transcritas na íntegra, seguida de uma leitura ampla. Posteriormente, verificadas as convergências e divergências dos relatos, emergiram as categorias de análise. A análise interpretativa desvelou que os médicos têm uma abertura para a compreensão da dimensão religiosa do paciente, no entanto, a fazem com muita dificuldade e ambigüidade quanto às condutas a serem tomadas. Mostram-se sensíveis a uma nova postura médica que precisa de bases seguras para se solidificar, porém encontra-se em momento inicial, na construção de um novo paradigma, que transita entre o cuidar autêntico e o inautêntico. Revelaram a compreensão da importância de Deus, como facilitador ao enfrentamento da facticidade introduzida pelo adoecer e, paralelamente, relataram que, também buscam e confortam-se em sua relação com a espiritualidade e o transcendente. Diante do desamparo sentido pela angústia, na proximidade da fronteira vida-morte, emergem os modos de existir destes cuidadores, na medida em que deparam-se com a finitude humana. Alguns continuam agregados aos rituais religiosos, como missas, velórios e práticas de rezas como forma de elaboração do luto que vivenciam cotidianamente, assim, conservam a dimensão pública do evento morte. Outros mostram-se em uma postura mais contemplativa diante de um Deus interno, cultivando a religiosidade em seu mundo próprio, sem freqüentarem rituais. Acolheram a necessidade do paciente ser-com-o-divino, nos diversos momentos, ao longo do tratamento. Embora, alguns médicos não se sintam confortáveis, ponderando o valor científico das práticas, não há oposição. Tendo em vista que o cuidado permeia toda e qualquer ação humana, segundo a ontologia de Heidegger, podemos vislumbrar, a partir dos resultados desta pesquisa, filosofias educacionais que envolvam os modos de ser-com e suas implicações para o cuidado e o existir autêntico na relação do médico com a religiosidade. (CAPES). / Nowadays, the health professionals have not been prepared to deal with the difficulties inherent to death and dying, however, it is noticeable that, among them, it is the physician who experiences more negatively this reality, for he is the focus of the patients and their relatives. Literature points out that beliefs and religious practices are important the lives of many patients who look for assistance, however, many doctors and other professionals of the staff are still wrong about the best way of approaching spiritual and religious issues. This research had the aim of comprehending the experience of religiosity of oncologist physicians in the caring of the oncologic patient. We opted for the qualitative research, through the perspective of Martin Heideggers Ontological-Hermeneutic Phenomenology, to understand the situations experienced. We interviewed eight oncologist physicians, after the signature of the informed and free consent. The interviews were recorded and transcribed entirely, followed by a broad reading. After the convergences and divergences of the reports were verified, the categories of analysis emerged. The interpretative analysis unveiled that the physicians have an opening for the comprehension of the patients religious dimension, however, they do it with much difficulty and ambiguity in relation to the actions to be taken. It is a new medical posture that needs safe foundations to solidify, but it is in an initial moment, in the construction of a new paradigm that oscillates between the authentic and non-authentic treating. The Physicians revealed the importance of God as a facilitator to the coping with the adversity of sickening and alongside they reported that they also search for and comfort themselves with their relation with spirituality and the transcendental. In the situation of helplessness caused by anguish, in the proximity to death, these care takers existing forms emerge: some continue attached to religious rituals, such as masses, funerals and praying practices as a way of elaborating the grief that they experience daily, so as to keep the public dimension of the death event. Others show themselves in a more contemplative posture before an inner God, cultivating the religiosity in their own world, without attending rituals. The physicians incorporated the patients necessity of being-with-the-divine, in the various moments along the treatment. Although some physicians do not feel comfortable, considering the scientific value of the practices, there is no opposition. Seen that the care permeates all and every human action, according to Heideggers ontology, we can discern educational philosophies that involve the results of this research and the being-with ways and their implications for the caring and the authentic existing in the relationships between physicians and religiosity (CAPES).

The general practitioner has a central position in the health care system, but demands have increased and there are signs of exhaustion in the corps. Patient-centredness is beneficial for the patients and probably for the outcome of health care. In Balint groups general practitioners study and gain further understanding of the physician-patient relationship by means of the participants’ own experiences. This thesis aims at studying experienced effects of Balint groups on the working life of general practitioners. General practitioners with and without Balint group experience are compared by means of a questionnaire, using statistical methods. General practitioners with Balint group experience are interviewed. Both these studies show positive experiences of Balint group participation in the physicians’ working life in terms of feeling of control and satisfaction, and on relations to patients, particularly patients with complex problems. A new instrument for measuring physicians’ degree of patient-centredness is presented. It can be used in groups of physicians to evaluate training programmes or by the individual physician to detect decline in patient-centredness as an early sign of burnout. Balint groups are viewed critically in interviews with Balint group leaders, focussed on difficulties and dropouts from the groups. Balint groups are found to fit into modern theories of small groups as complex systems, submitted to group dynamics that are sometimes malicious. Professionally conducted Balint groups seem to be a gentle, efficient method to train physicians, but with limits. Participation of a member demands a stable psychological condition and an open mind, and obligatory Balint groups are questioned. The thesis concludes that Balint groups are generally beneficial for general practitioners’ working life as a means to enable the physicians endure, even thrive in their job. The method facilitates development of new understanding of the physician-patient relationship with possible positive effects for the patient as well.

Thesis (Ph. D.)--University of Virginia, 2007. / Includes bibliographical references. Also available online through Digital Dissertations.

Thesis (M.S.)--University of Michigan, 1992.