April 2011

In this issue :

The notion of pleasure : a positive way to raise the issue of obesity with young people  
|   Changing habits : a real challenge !   |   Stress and distress among physicians : PAMQ meets with externs 
|   Identifying patients who are victims of violence : missed training opportunities?  | 


The notion of pleasure : a positive way to raise the issue of obesity with young people


No one can deny it: The prevalence of obesity in children in Québec is growing. How will tomorrow's physicians deal with this worrisome issue? The faculty of medicine at Université de Montréal offers fourth-year students a teaching activity on this topic during the community medicine clerkship.


Using clinical vignettes of children of various ages, Dr. Elisabeth Rousseau, paediatrician at Ste-Justine hospital, gives students practical advice on how to approach parents to help them prevent their child from gaining excessive weight: make parents aware that they could stimulate their child’s interest in a variety of foods by offering colourful meals that arouse curiosity, remain neutral about the action of eating, and prohibit eating in front of the television. She also discusses with students different ways of supporting children who present signs of obesity and how to avoid obsessing about the scales.

An intervention by the physician often helps parents become aware of the role they play in choosing quality food for their child. Parents can also realize that their child is very capable of registering when he or she is full, a signal expressed naturally from a very young age. Therefore, it is useless to force children to finish a meal if they show they feel satisfied.

Beyond using a care approach based on interdisciplinarity as well as on the obvious benefits of eating a balanced diet and engaging in regular physical activity, it is essential to discuss the notion of pleasure with the parents of a child with a high nutritional risk index. A 2010 pilot study conducted in six countries using
Épode, an integrated community program that focuses on the enjoyment of eating well and on having fun being active, resulted in a reduction of overweight and stabilization of weight among children.

A physician who listens and is patient and flexible can assess from the start how difficult change can be for these families.  The physician can help them overcome the obstacles that different lifestyle habits raise by reminding them to go slowly and to set realistic, achievable goals, and especially by telling them it is never too late to act.

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Changing habits : a real chalenge !


You want to be more active, eat better, sleep more... One thing’s for sure: Everyone's been there. But how do you start? That's the challenge presented to students in the community medicine clerkship at Université de Montréal.  Students are given pedometers at the beginning of the clerkship, which helps raise their awareness; they are asked to think about their current lifestyles and to identify changes they would like to make.

By accepting to play along, students set targets for the duration of the clerkship and write their impressions in a journal. What emerges is that most students report dealing with a number of obstacles that prevent them from initiating change (e.g. full schedule, stressful exam periods, fatigue). Other students insist on the fact that "there's always a good excuse" not to take action and that the major obstacles are a lack of organization, motivation and support from friends and family.

To reach their goals, students think of ways to combine business with pleasure: for example, cut up vegetables or exercise while watching their favourite TV show, bicycle or walk while listening to music, or go on a diet with their partner or spouse to avoid temptations. Anything goes when it comes to initiating change as long as the idea of fun is central.

Students who successfully meet the challenge are clear: They feel they can concentrate better and are in a better mood, less stressed, in better shape and happier. At the end of the clerkship, they are proud of their success and have better self-esteem. But they also realize that "it is easier to lose a good habit than to develop one". This new awareness allows students to put themselves in the patient's shoes and understand the difficulties inherent to initiating and maintaining a new lifestyle habit.

One student writes: "As physicians, we have to come at it from the point of view of a person who has the same difficulties as patients rather than just give them the recommendations of a specialist." Finding concrete, adapted solutions, proceeding step by step, setting reasonable objectives, choosing the right time and a pleasurable activity, asking loved ones to participate: this is how these future doctors want to approach their patients. But first and foremost, a physician must show he or she is able to understand and talk with patients to ensure they don't perceive changing habits as painful but rather as an investment in their health, even "if it’s hard and requires persistence." 


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Stress and distress among physicians : PAMQ meets with externs


Dr Claude Rajotte - PAMQ
Photo : Louise Lefort

Distress affects not only physicians in practice but also residents and medical students. According to a study conducted by the Fédération des étudiants en médecine du Québec, 40% of medical students experience anxiety, 19% depression, and 8% suicidal ideation.

In Québec, an independent organization,
Programme d’aide aux médecins du Québec (PAMQ), offers confidential assistance and referral services for physicians struggling with these types of problems. To introduce this resource to medical students at Université de Montréal, physicians who are members of PAMQ meet with students during the community medicine clerkship.  

During the last meeting, externs are asked to identify sources of stress that could be associated with various stages of their training and to recognize burnout and overextension. They are also made aware of the fact that personal and professional circumstances can trigger distress (such as separation from a spouse or a complaint), that distress is not necessarily an isolated phenomenon, and that it does not equal weakness or mean they are "not as good" as other physicians.

PAMQ's main messages to students are that stress is an inherent part of their training and practice, that different people experience it differently, and that distress should not be underestimated. To counter distress, we must learn to take care of ourselves, be attentive to others to identify it, and help colleagues who suffer from it. It is also important to know how to ask and receive help.

During medical training it is important to acknowledge the presence of distress among physicians and to demystify it; this can go a long way towards breaking taboos and towards taking action to prevent it. 


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Identifying patients who are victims of violence : missed training opportunities?


Violence, negligence and abuse can take various forms (physical, psychological, verbal, economic or sexual) and occurs among all age groups. Some factors—particularly pregnancy, loss of autonomy, vulnerable situations and social isolation,—can increase vulnerability to violence. For victims, the fact of experiencing violence can be at the root of physical or psychological problems, or can aggravate such problems. 

Available statistics do not clearly reflect the scope of this issue since victims are often reluctant to denounce the perpetrators. Among health professionals, physicians may be in the best position to raise the issue of violence in relation to their patients' health problems, and to direct victims to the resources most able to help them.

To document the importance given to prevention during medical training, the Lucie and André Chagnon Chair in Preventive Medical Education conducted a study of 2010 medical graduates from two universities in Québec (Laval and Montréal).

Of all the clerkships, paediatrics stands out as the one where students gained the most awareness of the importance of identifying patients who are victims of violence; over half of the students perceived that most of their supervisors were concerned about this issue. Figures were lower in other specializations: geriatrics (44%), psychiatry (33%), family medicine (32%), obstetrics and gynaecology (26%), internal medicine (4%) and surgery (1%). Even more striking, 1 out of 5 respondents reported not perceiving that supervisors in all clerkships felt it was important to identify patients who might be victims of violence.

Given the particular educational contexts and the patients who received care, clerkships do not all provide the same training opportunities when it comes to violence. However, the data raise questions for supervisors of various clerkships regarding their respective contributions to educating future physicians about this issue. 


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