Jean-Pierre Lebeau

Residency places trainees in a liminal position between student and doctor that generates learning opportunities and identity tensions. While liminality is often seen as a transitional phase, this study explored how its persistence creates a paradoxical experience at the intersection of the professional and academic expectations that may influence the residents' well-being and identity development. This qualitative study used a constructivist grounded theory approach. Residents were recruited by snowball sampling to ensure maximum variation in participant characteristics. Eleven semi-structured interviews were carried out between May 2022 and January 2023. Data were analysed by open and axial coding with thematic triangulation, then interpreted through the lens of paradox theory. Residents described four interwoven trajectories characterizing how they navigated the paradox: adapting to it, enduring it, becoming a professional, and developing their professional identity over time. Some experienced liminality as disorienting and unsupported, whereas others perceived it as a space for professional growth. Successful adaptation was linked to emotional regulation, reflexivity and recognition of their dual role by supervisors and institutions. The student-doctor paradox is not a temporary discomfort, but a structural and enduring tension. Medical educators should explicitly acknowledge this paradox and support residents through reflective spaces, supervisor development programs, and recognition of their evolving professional identity.

Background: There are various Medical Subject Headings (MeSH) terms used to index general practice research, without consistency.Aim: To understand how general practice-related research is indexed in the main general practice journals between 2011 and 2021, and to analyse the factors that influenced the choice of the general practice-related MeSH.Design and setting: This was a quantitative bibliometric study conducted on MEDLINE.Method: MeSH were selected according to the international definition of General Practice/Family Medicine: ‘General Practice’, ‘Primary Health Care’, ‘Family Practice’, ‘General Practitioners’, ‘Physicians, Primary Care’, and ‘Physicians, Family’. Their use was studied from 2011 to 2021 on MEDLINE, reviewing the 20 general practice journals with the highest impact factors. A descriptive and analytical approach was used; the association of the country, journal, and year with the choice of general practice-related MeSH terms was analysed.Results: A total of 8514 of 150 286 articles (5.7%) were using one of the general practice-related MeSH terms. The most used were ‘Primary Health Care’ (4648/9984, 46.6%) and ‘General Practice’ (2841/9984, 28.5%). A total of 80.0% (6172/7723) of the articles were related to the UK or US and 71.0% (6055/8514) of the articles came from four journals (BJGP,BMJ,Journal of General Internal Medicine, andAnnals of Family Medicine). Two main country clusters emerged from the use of general practice-related MeSH: a British cluster mainly using ‘General Practice’ and an American cluster using ‘Primary Health Care’. The journals also mainly differed in their used of these two MeSH terms.Conclusion: Important variations in the indexation of general practice research were found. Researchers should consider combining ‘Primary Health Care’ and ‘General Practice’ in their PubMed searches to access all the general practice research, regardless of their country of origin.

Interindividual differences in personality traits, especially impulsivity traits, are robust risk factors for addictive disorders. However, their impact on addictive disorders during the COVID-19 lockdown remains unknown. This study assessed patients being followed for addictive disorders before the lockdown. We aimed to determine whether impulsivity traits (i.e., negative- and positive urgency) were associated with addictive disorders severity during the lockdowns. We also explored the patients’ subjective experiences, focusing on high versus low impulsivity. The quantitative study assessed 44 outpatients consulting for addictive disorders, for impulsivity, emotion regulation, anxiety/depression, and their addictive disorder characteristics, using self-administered questionnaires. In the qualitative study, six patients from the quantitative study were assessed using guided interviews. We observed that higher negative and positive urgencies were associated with addictive disorder severity. The subjective experiences of patients during the lockdowns differed according to their emotion-related impulsivity: high versus low. Low impulsive patients used online technologies more effectively to maintain follow-up, with more positive reappraisal. In contrast, highly impulsive patients reverted more frequently to self-medication with substances and/or behaviors, more social isolation, and found coping with negative emotions more challenging. Overall, the patient’s ability to cope with stressful events, like the COVID-19 lockdown, depended on their emotion-related impulsivity.

The 20% observed mortality within 5 years among survivors of myocardial infarction may be explained in part by non-adherence to the recommended treatment over the long term. To investigate post-myocardial infarction patients’ adherence to the therapeutic, lifestyle and risk factor control recommendations of the French health authority over 6 years. A cohort of survivors of myocardial infarction established in Tours in 2009 was followed over 6 years. The general practitioner of the patients included in the first 1-year follow-up study was contacted to collect data on treatments, cardiovascular risk factors and lifestyle between January and June 2015. Data were described and compared with the recommendations and predictors of achieving all the recommended targets were determined. A total of 97 patients (52%) among the 185 patients who underwent a coronary angioplasty for MI were included at baseline. Treatment was adapted by the general practitioner on the advice on the cardiologist for 75% (73/97) patients, by both of them for 12% (12/97) and by the general practitioner alone for 7% (7/97) patients. Among the 97 initial patients, 62 were included in the final analysis at 6 years. Fatal events rate was 5% (5/97) at 1 year and 12% (11/91) at 6 years. Non-fatal events rate was 44% (43/97) at 6 months, 19% (17/91) at 1 year and 29% (18/62) at 6 years. Six years after the myocardial infarction, 6 (10%) patients achieved the recommended targets in terms of prescriptions of treatment, risk factors and lifestyle targets. Exposure to a cardiac rehabilitation program after a myocardial infarction was associated with long-term achievement of optimal therapeutic objectives (OR = 7.31 [95% CI 1.74; 44.88], p<0.002). Our data show suboptimal long-term adherence to secondary prevention treatment in this high-risk population of survivors of myocardial infarction, which seems to be improved in patients exposed to a cardiac rehabilitation program.

Objectives To elaborate and validate operational definitions for appropriate inaction and for inappropriate inertia in the management of patients with hypertension in primary care. Design A two-step approach was used to reach a definition consensus. First, nominal groups provided practice-based information on the two concepts. Second, a Delphi procedure was used to modify and validate the two definitions created from the nominal groups results. Participants 14 French practicing general practitioners participated in each of the two nominal groups, held in two different areas in France. For the Delphi procedure, 30 academics, international experts in the field, were contacted; 20 agreed to participate and 19 completed the procedure. Results Inappropriate inertia was defined as: to not initiate or intensify an antihypertensive treatment for a patient who is not at the blood pressure goals defined for this patient in the guidelines when all following conditions are fulfilled: (1) elevated blood pressure has been confirmed by self-measurement or ambulatory blood pressure monitoring, (2) there is no legitimate doubt on the reliability of the measurements, (3) there is no observance issue regarding pharmacological treatment, (4) there is no specific iatrogenic risk (which alters the risk-benefit balance of treatment for this patient), in particular orthostatic hypotension in the elderly, (5) there is no other medical priority more important and more urgent, and (6) access to treatment is not difficult. Appropriate inaction was defined as the exact mirror, that is, when at least one of the above conditions is not met. Conclusion Definitions of appropriate inaction and inappropriate inertia in the management of patients with hypertension have been established from empirical practice-based data and validated by an international panel of academics as useful for practice and research.

Objective To construct a typology of general practitioners’ (GPs) responses regarding their justification of therapeutic inertia in cardiovascular primary prevention for high-risk patients with hypertension. Design Empirically grounded construction of typology. Types were defined by attributes derived from the qualitative analysis of GPs’ reported reasons for inaction. Participants 256 GPs randomised in the intervention group of a cluster randomised controlled trial. Setting GPs members of 23 French Regional Colleges of Teachers in General Practice, included in the EffectS of a multifaceted intervention on CArdiovascular risk factors in high-risk hyPErtensive patients (ESCAPE) trial. Data collection and analysis The database consisted of 2638 written responses given by the GPs to an open-ended question asking for the reasons why drug treatment was not changed as suggested by the national guidelines. All answers were coded using constant comparison analysis. A matrix analysis of codes per GP allowed the construction of a response typology, where types were defined by codes as attributes. Initial coding and definition of types were performed independently by two teams. Results Initial coding resulted in a list of 69 codes in the final codebook, representing 4764 coded references in the question responses. A typology including seven types was constructed. 100 GPs were allocated to one and only one of these types, while 25 GPs did not provide enough data to allow classification. Types (numbers of GPs allocated) were: ‘optimists’ (28), ‘negotiators’ (20), ‘checkers’ (15), ‘contextualisers’ (13), ‘cautious’ (11), ‘rounders’ (8) and ‘scientists’ (5). For the 36 GPs that provided 50 or more coded references, analysis of the code evolution over time and across patients showed a consistent belonging to the initial type for any given GP. Conclusion This typology could provide GPs with some insight into their general ways of considering changes in the treatment/management of cardiovascular risk factors and guide design of specific physician-centred interventions to reduce inappropriate inaction. Trial registration number NCT00348855.

ObjectiveThe aim of the ESCAPE AMPA 2 trial was to describe the evolution of end-digit preference (EDP) practices in primary care after 2 years of trial.MethodsA descriptive analysis of the EDP in the intervention group (IG) and in the electronic control group (ECG) of the ESCAPE trial and a comparative analysis of EDP changes in blood pressure (BP) measures of both groups were carried out between baseline and 2 years. In the ESCAPE trial, physicians in the IG were new users of electronic devices provided in the trial to measure their patients' BP and physicians in the ECG were former users of electronic devices. Hierarchical mixed-effects models were used for statistical analysis in a pragmatic cluster randomized-controlled trial.ResultsAfter 2 years, the proportion of BP measures ending with a 0 or a 5 was significantly higher in the ECG than in the IG (50.4 vs. 33.4%, P<0.0001). There was no significant change in EDP tendency between baseline and the end of the trial in the ECG (65.6-56.7%, P=0.39) and in the IG (29.6-38.2%, P=0.07), with a between-groups P value of 0.11. Over 2 years, there was no significant change in systematic EDP in the ECG (18.8-20.0%, P=0.29) and in the IG (4.8-10.6%, P=0.01), with a between-groups P value of 0.17.ConclusionEDP is not eliminated by electronic devices and tends to increase with time for new users.

Colorectal cancer (CRC) mass screening has been implemented in France since 2008. Participation rates remain too low. The objective of this study was to test if the implementation of a training course focused on communication skills among general practitioners (GP) would increase the delivery of gaiac faecal occult blood test and CRC screening participation among the target population of each participating GP. A cluster randomised controlled trial was conducted with GP's practice as a cluster unit. GPs from practices in the control group were asked to continue their usual care. GPs of the intervention group received a 4‐h educational training, built with previous qualitative data on CRC screening focusing on doctor–patient communication with a follow‐up of 7 months for both groups. The primary outcome measure was the patients' participation rate in the target population for each GP. Seventeen GPs (16 practices) in intervention group and 28 GPs (19 practices) in control group participated. The patients' participation rate in the intervention group were 36.7% vs. 24.5% in the control group (P = 0.03). Doctor–patient communication should be developed and appear to be one of the possible targets of improvement patients adherence and participation rate in the target population for CRC mass screening.