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This paper examines how participants in genetic counseling sessions interactionally manage situations where the results of tests to investigate the causes of identified fetal malformations are inconclusive or missing. The dataset consists of 54 audio-recorded interactions at a unit specialized in moderate- and high-risk pregnancies at a Brazilian public hospital. Conversation analysis was used to examine the data, revealing that the participants deployed interactional actions that exhibited highly negative valence toward diagnostic inconclusiveness, demonstrating that when there is a motivation for a medical examination, insofar as its results will serve as a basis for subsequent decision-making (in this case about future pregnancies), there is a preference for bad diagnostic news over absent or inconclusive diagnostic news. These findings are consistent with prior interactional studies.

Este artigo examina como os participantes em sessões de aconselhamento genético gerenciam interacionalmente resultados de testes genéticos inconclusivos ou ausentes ­ testes para investigar as causas das malformações fetais identificadas. O conjunto de dados consiste em 54 interações gravadas em áudio em uma unidade de gestação de médio e alto risco de um hospital público brasileiro. A abordagem da Análise da Conversa utilizada para examinar os dados revela que os participantes desenvolvem ações interacionais que exibem uma orientação de valência altamente negativa em relação à inconclusividade diagnóstica, demonstrando que quando há motivação para um exame médico, ou seja, usando o resultado do teste diagnóstico como base para tomada de decisão, tal como acontece com futuras gestações, haja uma preferência por más notícias diagnósticas em detrimento de notícias diagnósticas ausentes ou inconclusivas. Tais resultados são consistentes com estudos interacionais anteriores.

Este artículo examina cómo los participantes en las sesiones de asesoramiento genético gestionan de forma interactiva los resultados de pruebas genéticas no concluyentes o faltantes, pruebas para investigar las causas de las malformaciones fetales identificadas. El conjunto de datos consta de 54 interacciones grabadas en audio en una unidad de embarazo de riesgo medio y alto de un hospital público brasileño. El enfoque de Análisis de Conversación utilizado para examinar los datos revela que los participantes desarrollan acciones interaccionales que exhiben una orientación de valencia altamente negativa hacia la falta de conclusión del diagnóstico, lo que demuestra que cuando hay motivación para un examen médico, es decir, utilizar el diagnóstico del resultado de la prueba como base para la toma de decisiones, como ocurre con futuros embarazos, se prefieran las malas noticias diagnósticas a las noticias diagnósticas ausentes o no concluyentes. Estos resultados son consistentes con estudios interaccionales previos.

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Introducción: La comunicación por parte del logofonoaudiólogo con el paciente afásico y su familia garantiza el bienestar biopsicosocial de estos y favorece una adecuada relación médico-paciente. Objetivo: Evaluar una propuesta de estrategia para el fomento del principio de beneficencia entre el logofonoaudiólogo, el paciente afásico y su familia en el Policlínico Universitario Dr. René Vallejo Ortiz, ciudad de Manzanillo, Granma, Cuba. Método: Fue aplicada la técnica de Iadov o criterio de usuario que permitió evaluar la propuesta. Para ello se encuestaron 15 logofonoaudiólogos de la provincia de Granma, Cuba, se escogieron de manera intencional 10, cuyas cualidades cumplían los requisitos exigidos para ser considerados usuarios. Se utilizaron diferentes métodos, técnicas y procedimientos para procesar y analizar los datos recogidos. La escala valorativa Likert facilitó la interpretación cualitativa de los datos recogidos. Resultados: Desde el criterio individual el 60 % de los usuarios consideró la propuesta bastante adecuada; la valoración más baja fue de adecuada (20 %). El cálculo de la valoración grupal, el índice obtenido (0,5 %) le confirió confiabilidad a la propuesta para ser implementada. Conclusiones: Los usuarios consideran que la propuesta de estrategia cumple con los requisitos para la aplicación. No obstante, existen algunos elementos que pudieran dificultar la ejecución de la misma: la incorrecta preparación científico-metodológica de los facilitadores, el uso inadecuado de los métodos y técnicas educativas, así como la negativa de aquellos logofonoaudiólogos que no concienticen la necesidad de alcanzar modos de actuación acorde a los principios y valores profesionales.

Introduction: Communication by the speech-language pathologist with the aphasic patient and his family guarantees their biopsychosocial well-being and promotes an adequate doctor-patient relationship. Objective: To evaluate a proposed strategy to promote the principle of beneficence between the speech-language pathologist, the aphasic patient and their family at the Policlínico Universitario Dr. René Vallejo Ortiz, Manzanillo city, Granma province, Cuba. Method: The Iadov technique or user criteria was applied that allowed the proposal to be evaluated. For this, 15 speech-language pathologists from the province of Granma, were surveyed; 10 were intentionally chosen, whose qualities met the requirements to be considered users. Different methods, techniques and procedures were used to process and analyze the data collected. The Likert rating scale facilitated the qualitative interpretation of the data collected. Results: From individual criteria, 60% of users considered the proposal quite appropriate; the lowest rating was adequate (20%). The calculation of the group assessment, the index obtained (0.5%) conferred reliability to the proposal to be implemented. Conclusions: Users consider that the strategy proposal meets the requirements for the application. However, there are some elements that could make its execution difficult: the incorrect scientific-methodological preparation of the facilitators, the inappropriate use of educational methods and techniques, as well as the refusal of those speech-language pathologists who do not raise awareness of the need to achieve methods. of action in accordance with professional principles and values.

Introdução: A comunicação do fonoaudiólogo com o paciente afásico e sua família garante o seu bem-estar biopsicossocial e promove uma adequada relação médico-paciente. Objetivo: Avaliar uma proposta de estratégia para promover o princípio da beneficência entre o fonoaudiólogo, o paciente afásico e sua familia na Policlínico Universitario Dr. René Vallejo Ortiz, cidade de Manzanillo, Granma, Cuba. Método: Foi aplicada a técnica de Iadov ou critérios de usuário que permitiram avaliar a proposta. Para isso, foram entrevistados 15 fonoaudiólogos da província de Granma, foram escolhidos 10 intencionalmente, cujas qualidades atendiam aos requisitos para serem considerados usuários. Diferentes métodos, técnicas e procedimentos foram utilizados para processar e analisar os dados coletados. A escala de classificação Likert facilitou a interpretação qualitativa dos dados coletados. Resultados: A partir de critérios individuais, 60% dos usuários consideraram a proposta bastante adequada; a classificação mais baixa foi adequada (20%). No cálculo da avaliação do grupo, o índice obtido (0,5%) conferiu confiabilidade à proposta a ser implementada. Conclusões: Os usuários consideram que a proposta de estratégia atende aos requisitos para aplicação. Porém, existem alguns elementos que podem dificultar sua execução: o incorreto preparo científico-metodológico dos facilitadores, o uso inadequado de métodos e técnicas educativas, bem como a recusa dos fonoaudiólogos que não conscientizam sobre o necessidade de alcançar métodos de ação de acordo com princípios e valores profissionais.

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Innovative technologies such as the metaverse and chat GPT-4 (based on artificial intelligence) are present in the daily discourse of society; recently, they have been introduced into medical practice and are bringing about important changes. In the case of the metaverse ("beyond the universe"), various medical schools and departments around the world are beginning to use it as an innovative strategy for teaching subjects such as anatomy, histology, ophthalmology, and simulation in parallel (virtual) worlds for learning and supervision of surgeries, as well as for other applications in medical education and in the doctor-patient relationship. Although it should be regarded as an area of opportunity for the transformation of medicine, it is important to consider the various limitations and risks of the metaverse in medical practice, student training, and physicians' relationship with the health problems they have to deal with in their practice.

Las innovadoras tecnologías del metaverso y el chat GPT4 (basado en inteligencia artificial) están presentes en el discurso cotidiano de la sociedad; recientemente se han introducido en la práctica médica y están provocando importantes cambios. En cuanto al metaverso ("después del universo"), diversas escuelas y facultades de medicina del mundo comienzan a utilizarlo como una estrategia innovadora dirigida a la enseñanza de materias como anatomía, histología, oftalmología y simulación en mundos paralelos (virtuales) para el aprendizaje y supervisión de cirugías, así como para otras aplicaciones en educación médica y en la relación médico-paciente. Si bien debe tomarse en cuenta como un área de oportunidad para la transformación de la medicina, es importante considerar las diversas limitaciones y riesgos del metaverso en la práctica médica, la formación de estudiantes y la relación del médico con los problemas de salud a los que se enfrenta en su práctica.

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Resumen Las innovadoras tecnologías del metaverso y el chat GPT4 (basado en inteligencia artificial) están presentes en el discurso cotidiano de la sociedad; recientemente se han introducido en la práctica médica y están provocando importantes cambios. En cuanto al metaverso ("después del universo"), diversas escuelas y facultades de medicina del mundo comienzan a utilizarlo como una estrategia innovadora dirigida a la enseñanza de materias como anatomía, histología, oftalmología y simulación en mundos paralelos (virtuales) para el aprendizaje y supervisión de cirugías, así como para otras aplicaciones en educación médica y en la relación médico-paciente. Si bien debe tomarse en cuenta como un área de oportunidad para la transformación de la medicina, es importante considerar las diversas limitaciones y riesgos del metaverso en la práctica médica, la formación de estudiantes y la relación del médico con los problemas de salud a los que se enfrenta en su práctica.

Abstract Innovative technologies such as the metaverse and chat GPT-4 (based on artificial intelligence) are present in the daily discourse of society; recently, they have been introduced into medical practice and are bringing about important changes. In the case of the metaverse ("beyond the universe"), various medical schools and departments around the world are beginning to use it as an innovative strategy for teaching subjects such as anatomy, histology, ophthalmology, and simulation in parallel (virtual) worlds for learning and supervision of surgeries, as well as for other applications in medical education and in the doctor-patient relationship. Although it should be regarded as an area of opportunity for the transformation of medicine, it is important to consider the various limitations and risks of the metaverse in medical practice, student training, and physicians' relationship with the health problems they have to deal with in their practice.

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Las cuestiones inherentes al final de la vida constituyen un inmenso desafío para los médicos, debido a la falta de educación formal en lo inherente a cuidados paliativos, y a que se entrelazan conceptos médicos, religiosos, legales y bioéticos en su abordaje. El objetivo de este estudio es identificar, desde la perspectiva de los profesionales de la salud, las cuestiones éticas involucradas en el proceso de atención de pacientes incluidos en cuidados paliativos. Para ello se llevó a cabo de una revisión de 10 artículos, en los cuales se observa la carencia de formación bioética y la aplicación inadecuada (o falta) en lo inherente a manejo adecuado de la información y la dificultad en su comunicación, toma de decisiones compartidas, respeto de la autonomía del paciente, verdad médica, limitación de esfuerzos terapéuticos (AU)

End-of-life issues constitute an immense challenge for physicians, due to the lack of formal education regarding palliative care, and the intertwining of medical, religious, legal, and bioethical concepts in their approach. The objective of this study is to identify, from the perspective of health professionals, the ethical issues involved in the care process for patients included in palliative care. For this, a review of 10 articles was carried out, in which the lack of bioethical training and the inadequate application (or lack) is observed in terms of the proper management of information and the difficulty in its communication, decision making shared, respect for patient autonomy, medical truth, limitation of therapeutic efforts (AU)

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La forma como el clínico percibe al paciente y sus conocimientos sobre el consentimiento informado (CI) se reflejan en prácticas de respeto hacia el paciente, con relación a su autonomía y privacidad, desde un marco ético, deontológico y legal. El objetivo fue analizar las percepciones y prácticas de cirujanos en relación con el respeto de la autonomía del paciente durante el proceso de toma del CI en un hospital de la ciudad de Santo Domingo de los Tsáchilas, Ecuador. Metodología Cualitativa. La muestra fue por saturación, aplicando una entrevista semiestructurada. Los datos se analizaron por medio del programa Atlas Ti 8.0®, utilizando rastreo de categorías estructuradas. La mayoría de los médicos asume el consentimiento como un documento legal y obligatorio, por el miedo a procesos sancionatorios. Además, suele delegar su responsabilidad a otros profesionales, desconociendo componentes estructurales y éticos de la toma del consentimiento informado. Concluimos que la falta de conocimiento sobre CI lleva a percepciones y, por ende, a prácticas que vulneran la autonomía y la confidencialidad, además del respeto de recibir la información por parte del clínico que realiza la intervención.

The way in which the clinician perceives the patient and his knowledge about informed consent (IC) are reflected in practices of respect for the patient, in relation to their autonomy and privacy from an ethical, deontological and legal framework. Objective. Analyze the perceptions and practices by surgeons in relation to the respect of the autonomy of the patient during the process of taking the IC in a hospital in the city of de Santo Domingo de los Tsáchilas / Ecuador. Methodology. Cualitattivo. The sample was by saturation applying a semi-structured interview. The data were analyzed using the Atlas Ti 8.0 ® program using structured category tracking. Result. Most doctors take consent as a legal and mandatory document, for fear of sanctioning processes. In addition, they usually delegate their responsibility to other professionals ignoring structural and ethical components of taking informed consent. Conclusion. It is evident that the lack of knowledge about IQ leads to perceptions, and therefore, to practices that violate autonomy and confidentiality, in addition to the respect of receiving information from the clinician who performed the intervention.

A forma como o médico percebe o paciente e seus conhecimentos sobre o consentimento informado (IC) se refletem nas práticas de respeito ao paciente, em relação à sua autonomia e privacidade a partir de um arcabouço ético, deontológico e jurídico. Objetivo. Analise as percepções e práticas dos cirurgiões em relação ao respeito à autonomia do paciente durante o processo de tomada do IC em um hospital na cidade de Santo Domingo de los Tsáchilas/Equador. Metodologia. Qualitativo. A amostra foi por saturação aplicando uma entrevista semiestruturada. Os dados foram analisados utilizandose o programa Atlas Ti 8.0 ® utilizando rastreamento estruturado de categorias. Resultado. A maioria dos médicos toma o consentimento como documento legal e obrigatório, por medo de sancionar processos. Além disso, eles geralmente delegem sua responsabilidade a outros profissionais ignorando componentes estruturais e éticos de obter consentimento informado. Conclusão. É evidente que a falta de conhecimento sobre o QI leva a percepções e, portanto, a práticas que violam autonomia e confidencialidade, além do respeito ao recebimento de informações do médico que realizou a intervenção.

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Resumen Introducción: Una buena relación médico-paciente es crucial para la práctica médica. Un elemento fundamen tal de la misma es la empatía del médico tratante, y esta puede ser cuantificada mediante una escala validada llamada Escala de Empatía de Jefferson. Métodos: En este estudio buscamos correlacionar los valores de empatía de los médicos del servicio con los resultados de las encuestas de satisfacción del pa ciente ambulatorio, medido mediante una herramienta llamada HCAPS. Resultados: Encontramos que los pacientes percibían un mayor trato respetuoso y que se les explicaba mejor sus opciones de tratamiento por parte de los médicos con mayores niveles de empatía. No hubo diferencias en los niveles de empatía de los médicos según su edad, sexo, o tiempo desde la obtención del título de especialista. Discusión: Los resultados validan a la empatía como una habilidad clave dentro de la relación médico-paciente.

Abstract Introduction: A good doctor-patient relationship is crucial to medical practice. A fundamental element of it is the empathy of the treating physician, and it can be quantified by means of a validated scale called the Jefferson Empathy Scale. Methods: In this study we sought to correlate the empathy values of our physicians with the results of outpatient satisfaction surveys, measured using a tool called HCAPS. Results: We found that patients perceived greater respectful treatment and had their treatment options better explained to them by physicians with higher lev els of empathy. There were no differences in physicians' empathy levels according to their age, gender, or time since qualifying as a specialist. Discussion: These results validate empathy as a key skill in the doctor-patient relationship.

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Introducción: El artículo reflexiona sobre la naturaleza multidimensional y compleja de la ética y su relación con las ciencias médicas. Objetivo: Reflexionar sobre la atención a pacientes en estadio terminal desde el punto de vista de la ética médica para una atención médica integral en el primer nivel de atención. Métodos: estudio cualitativo; se emplearon análisis documental, sistematización, análisis y síntesis de publicaciones sobre la temática estudiada como métodos teóricos, para ello se valoran los criterios de autores y resultados que se expresan en artículos publicados. Se realizaron búsquedas, tanto en bases de datos estudiadas como en las plataformas de productos del Nacional Council for Biotechnology Information de la Nacional Library of Medicine of United States of America; y de Elsevier, esta última productora de Embase y Scopus, a través del motor de búsqueda Google Académico, en español e inglés, y sin límite de tiempo. Se emplearon los términos: ética médica, deontología médica, relación médico-paciente, paciente terminal y cuidados paliativos. Se excluyeron aquellos artículos que no habían sido revisados por pares o no mostraban el texto completo. Se revisó la información suministrada por cada fuente y se sintetizó. Conclusiones: En Cuba, la bioética avanza en la medida que lo permite la estrategia de Atención Primaria de Salud, con un Programa del Médico y Enfermera de la Familia resiliente y de valores humanos demostrados nacional e internacionalmente. Como reto se plantea estimular el debate entre saberes para generar cambios a favor de los pacientes, las familias, las comunidades y la sociedad(AU)

Introduction: The article reflects on the multidimensional and complex nature of ethics and its relationship to the medical sciences. Objective: To reflect on the care of terminally ill patients from the point of view of medical ethics for comprehensive medical care at the primary level of care. Methods: A qualitative study was carried out using documentary analysis, systematization, analysis and synthesis of publications on the subject studied as theoretical methods. For this purpose, the criteria of authors and results expressed in published articles were evaluated. Searches were carried out in Spanish and English through Google Scholar, and without time limit, both in the databases studied and in the product platforms of the National Council for Biotechnology Information of the National Library of Medicine of the United States of America and Elsevier. The terms: medical ethics, medical deontolog, physician-patient relationship, terminal patient and palliative care were used. Articles that were not peer-reviewed and those that did not show the full text were excluded. The information provided by each source was reviewed and synthesized. Conclusions: In Cuba, bioethics advances to the extent allowed by the Primary Health Care strategy, with a resilient Family Physician and Nurse Practitioner Program and human values demonstrated nationally and internationally. The challenge is to stimulate the debate between knowledge to generate changes in favor of patients, families, communities and society(AU)

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INTRODUCTION: A good doctor-patient relationship is crucial to medical practice. A fundamental element of it is the empathy of the treating physician, and it can be quantified by means of a validated scale called the Jefferson Empathy Scale. METHODS: In this study we sought to correlate the empathy values of our physicians with the results of outpatient satisfaction surveys, measured using a tool called HCAPS. RESULTS: We found that patients perceived greater respectful treatment and had their treatment options better explained to them by physicians with higher levels of empathy. There were no differences in physicians' empathy levels according to their age, gender, or time since qualifying as a specialist. DISCUSSION: These results validate empathy as a key skill in the doctor-patient relationship.

Introducción: Una buena relación médico-paciente es crucial para la práctica médica. Un elemento fundamental de la misma es la empatía del médico tratante, y esta puede ser cuantificada mediante una escala validada llamada Escala de Empatía de Jefferson. Métodos: En este estudio buscamos correlacionar los valores de empatía de los médicos del servicio con los resultados de las encuestas de satisfacción del paciente ambulatorio, medido mediante una herramienta llamada HCAPS. Resultados: Encontramos que los pacientes percibían un mayor trato respetuoso y que se les explicaba mejor sus opciones de tratamiento por parte de los médicos con mayores niveles de empatía. No hubo diferencias en los niveles de empatía de los médicos según su edad, sexo, o tiempo desde la obtención del título de especialista. Discusión: Los resultados validan a la empatía como una habilidad clave dentro de la relación médico-paciente.

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Approximately one out of ten COVID-19 cases in Ecuador was a physician. It has been reported that this situation has led to a serious detriment of physicians' health and well-being. This study aimed to (i) identify predictors of emotional exhaustion, somatization, and work alienation in Ecuadorian physicians working with COVID-19 patients and (ii) explore the pandemic impact on doctor-patient relationships and on empathy. In 79 Ecuadorian physicians (45 women) who worked with COVID-19 patients, two separate multiple regression models explained the following: 73% of the variability of emotional exhaustion was based on somatization, work alienation, working sector, and passing through a symptomatic infection (p < 0.001), and 56% of the variability of somatization was based on gender and emotional exhaustion (p < 0.001), respectively. Furthermore, intention to leave the profession was more frequent among physicians with greater work alienation (p = 0.003). On the contrary, more empathic physicians never considered leaving their profession during the COVID-19 pandemic (p = 0.03). In physicians' verbatim, cognitive empathy appeared associated to a positive change in doctor-patient relationships. On the contrary, having an overwhelming emotional empathy appeared associated to a negative change in doctor-patient relationships. These findings characterize differences in how physicians cope while working in the frontline of the pandemic.

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Resumo No Brasil, a violência obstétrica vem sendo pesquisada desde os anos 1980. Na década de 90, no entanto, o fenômeno passou a receber maior destaque. A forma de violência analisada neste trabalho refere-se a uma violência velada, chamada de "violência perfeita". Este ensaio reflete sobre a ocorrência da violência perfeita na obstetrícia, especialmente no que concerne às sutilezas do discurso médico, que pode travestir essa agressão numa forma de cuidado. A violência perfeita pode soar como preocupação da parte do médico com a saúde da gestante, que pode se submeter às recomendações médicas de forma passiva, por acreditar que deve ser o melhor para ela ou para o bebê. Ao praticar a violência perfeita, o obstetra pode interferir no desfecho do parto. A "epidemia" de cesarianas no Brasil tem sido justificada pelos médicos como preferência da mulher, mas pesquisas refutam essa hipótese e provocam a reflexão: quem está de fato escolhendo a modalidade de parto? O presente ensaio nos mostra que observar as sutilezas do discurso médico pode ajudar a responder essa pergunta.

Abstract In Brazil obstetric violence has been researched since the 1980s. However, in the nineties the phenomenon started to have a more prominent position. The form of violence analysed in this study refers to a covert violence, called "perfect violence". This essay reflects about the occurrence of perfect violence in obstetrics, especially regarding the subtleties of medical discourse, which can disguise this aggression as a form of care. This type of violence may sound as if it was a concern with the patient's health on behalf of the doctor, but it can make the patient submit herself to the medical recommendations in a passive manner, believing it is the best for her and her baby. In this way, violence is disguised as good practice, allegedly aiming at what is best for the patient. In practicing perfect violence, the doctor can interfere in the delivery outcome. The caesarean "epidemic" in Brazil has been justified by doctors as the woman's preference, but research undermines this hypothesis and raises the reflection: who is in fact choosing the type of childbirth? This essay shows us that observing the subtleties of medical discourse can help answering this question.

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BACKGROUND: Inflammatory bowel diseases (IBDs) are chronic diseases that demand continuous interaction between patients and healthcare providers. Quality of care (QoC) is a factor that contributes to a patient's adherence to treatment and its success. AIM: To evaluate QoC in patients from a single IBD reference center. METHODS: This cross-sectional study included 133 patients from a single Brazilian IBD public health center. QoC was evaluated through the QoC Through the Eyes of Patients with IBD (QUOTE-IBD) questionnaire (based on patient perspectives), which measures eight dimensions of care. We compared QoC among patients with Crohn's disease and ulcerative colitis and analyzed the clinical and psychological factors associated with QoC satisfaction. Clinical evaluations assessed disease characteristics, quality of life, anxiety, and depression levels. RESULTS: Sixty-nine patients with Crohn's disease and 64 with ulcerative colitis were interviewed. The mean age was 37.26 years ± 13.05 years, and 63.91% of the patients were women. The mean duration of the disease was 8.44 years ± 7.59 years, where most patients were in remission (70.31% of patients with ulcerative colitis and 62.32% with Crohn's disease). The total QoC score of the sample was 8.61 years ± 1.31 points, indicating that the QoC provided by the center was unsatisfactory. According to univariate logistic regression, patients with Crohn's disease had higher satisfaction rates than those with ulcerative colitis [odds ratio (OR): 2.746; 95% confidence interval (CI): 1.360-5.541; P = 0.0048] and patients on infliximab (OR: 2.175; 95%CI: 1.037-4.562; P = 0.0398). CONCLUSION: Patients from the IBD public center reported good doctor-patient relationships, but had problems related to the healthcare structure. Evaluation of healthcare centers is of paramount to improve QoC for the patients involved.

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INTRODUCTION: Our objective was to assess whether physicians who care for people with type 2 diabetes address andrological symptoms such as erectile sexual dysfunction, decreased libido, and symptoms and/or signs of hypogonadism. METHODS: An anonymous survey was carried out with 171 doctors, 113 were females (66.1%), the mean age was 46 ± 10 years (females: 45 ± 10 and males: 49 ± 10, p = 0.006). RESULTS: There were no differences in responses according to gender. Regarding the presence of erectile sexual dysfunction and/or decreased libido, 44.4% (n = 76) and 55.6% (n = 95) did not ask about them, respectively. In patients with symptoms of hypogonadism, 50.9% (n = 87) did not request a testosterone measurement. Regarding the improvement of the metabolic profile of type 2 diabetes mellitus and sexual symptoms after replacement with testosterone, 65.8% of the respondents answered that both conditions could improve after treatment. In the presence of symptoms compatible with hypogonadism, 74.7% of those surveyed stated that the measurement of testosterone should be performed. A total of 108 (63.2%) showed interest in being trained on topics related to type 2 diabetes and disorders of the sexual sphere. CONCLUSION: A large percentage of physicians who take care of men with type 2 diabetes do not inquire about andrological disorders. It is necessary to raise awareness and train doctors to detect, treat and/or refer these frequent health problems, not only to improve the quality of life of patients but also to effectively respond and prevent a major health problem.

Introducción: Los trastornos andrológicos son frecuentes en varones con diabetes tipo 2. El objetivo fue evaluar si los médicos que atienden a personas con diabetes tipo 2 abordan problemas andrológicos como disfunción sexual eréctil, disminución de libido y síntomas de hipogonadismo. Métodos: Se llevó a cabo una encuesta anónima a 171 médicos, de ellos 113 fueron mujeres (66.1%) con una edad media de 46 ± 10 años (mujeres: 45 ± 10 y varones: 49 ± 10, p = 0.006). Resultados: No hubo diferencias en las respuestas según el género. El 44.4% (n = 76) y el 55.6% (n = 95) no preguntan sobre la presencia de disfunción sexual eréctil y/o disminución de libido, respectivamente. El 50.9% (n = 87) no solicitó medición de testosterona en pacientes con síntomas de hipogonadismo. El 65.8% de los participantes respondió que el reemplazo con testosterona puede mejorar el perfil metabólico de la diabetes mellitus tipo 2 y los síntomas sexuales. El 74.7% de los encuestados afirmó que la medición de testosterona debería realizarse ante la presencia de síntomas compatibles con hipogonadismo. El 63.2% (n = 108) mostró interés en formación sobre temas relacionados a diabetes tipo 2 y trastornos de la esfera sexual. Conclusión: Un gran porcentaje de médicos que asisten a varones con diabetes tipo 2 no indaga sobre trastornos andrológicos. Es necesario concientizar y entrenar a los médicos, para detectar, tratar y/o derivar estos problemas de salud tan frecuentes, no solo para mejorar la calidad de vida de los pacientes sino para responder y prevenir efectivamente a un problema mayor de salud.

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O trabalho teve como objetivo apresentar estratégias e dificuldades que influenciam o processo de Comunicação de Notícias Difíceis por médicos em um hospital universitário. Trata-se de um estudo descritivo-exploratório, de orientação qualitativa, sobre as estratégias e dificuldades encontradas por residentes (R1, R2 ou R3) e staffs, dos quatro programas da área médica: Ginecologia e Obstetrícia (GO), Pediatria, Cirurgia Geral (CG) e Clínica Médica (CM). A partir de uma entrevista semiestruturada para a análise dos dados foi utilizado o método do Discurso do Sujeito Coletivo (DSC), que mostrou como é importante utilizar protocolos para subsidiar a melhor abordagem com o paciente. Além da formação profissional, para realizar a comunicação de notícias difíceis, foi citado o protocolo SPIKES, seus pontos estratégicos e como ele pode auxiliar o profissional a realizar a melhor conduta. No que tange às dificuldades, a falta de preparo foi um dos destaques, bem como a ausência de um local adequado para a comunicação e os aspectos emocionais envolvidos, tanto por parte dos pacientes quanto dos profissionais de saúde. (AU)

The aim of this study was to present the strategies and difficulties that influence the process of communicating difficult news by doctors in a university hospital. This is a descriptive-exploratory study with a qualitative orientation on the strategies and difficulties encountered by residents (R1, R2 or R3) and staff from the four medical programs: Obstetrics and Gynecology (O&G), Pediatrics, General Surgery (GS) and Internal Medicine (IM). Based on a semi-structured interview, the Collective Subject Discourse (CSD) method was used for data analysis, which showed the importance of using protocols to support the best approach to the patient. In addition to professional training for communicating difficult news, the SPIKES protocol and its strategic points were mentioned, as well as how it can help professionals to conduct themselves effectively. The lack of preparation was one of the main difficulties reported, as well as the absence of an appropriate location for communication and the emotional aspects involved for both patients and health professionals. (AU)

El objetivo de este trabajo fue presentar estrategias y dificultades que influyen en el proceso de Comunicación de Noticias Difíciles por parte de médicos en un hospital universitario. Se trata de un estudio descriptivo-exploratorio, con orientación cualitativa, sobre las estrategias y dificultades encontradas por los residentes (R1, R2 o R3) y personal, de los cuatro programas del área médica: Ginecología y Obstetricia (GO), Pediatría, General Cirugía (CG) y Medicina Interna (CM). A partir de una entrevista semiestructurada para el análisis de los datos, se utilizó el método del Discurso del Sujeto Colectivo (CSD), que mostró cuán importante es el uso de protocolos para apoyar el mejor abordaje del paciente. Además de la formación profesional, para comunicar noticias difíciles, se mencionó el protocolo SPIKES, sus puntos estratégicos y cómo puede ayudar a los profesionales a llevar a cabo la mejor conducta. En cuanto a las dificultades, la falta de preparación fue uno de los destaques, así como la ausencia de un lugar adecuado para la comunicación y los aspectos emocionales involucrados, tanto por parte de los pacientes como de los profe-sionales de la salud. (AU)

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O presente ar tigo, pautado no método hipotético-dedutivo, tratou do seguro de responsabilidade civil médica no Brasil diante do aumento das ações judiciais relacionadas à saúde. A partir de uma pesquisa com abordagem qualitativa e utilização de procedimentos bibliográficos e documentais, objetivou-se descobrir se a contratação de seguros profissionais teria um possível efeito preventivo de proteção ao médico e ao paciente contra danos durante a assistência. Para tanto, apresentaram-se noções introdutórias sobre esse tipo de seguro e os principais desafios contemporâneos relacionados a sua utilização para, finalmente, se avaliarem as prováveis consequências dele frente às ações indenizatórias. Verificou-se que a contratação do seguro de responsabilidade civil médica ainda não alcançou números expressivos no país, e que a inexistência de imposição legislativa e a ausência de incentivo pelo conselho profissional competente podem ser fatores que contribuem para esse cenário. Com desafios pré-existentes semelhantes, a experiência nos Estados Unidos demonstrou efeito contrário à prevenção, com o crescimento de ações indenizatórias e o surgimento de uma nova crise. Por fim, os resultados apontaram para a solidificação da segurança do paciente em detrimento das adversidades decorrentes da adesão ao seguro.

The present article, based on the hypotheticaldeductive method, dealt with medical liability insurance in Brazil in view of the increase in health-related lawsuits. From a research with a qualitative approach and the use of bibliographic and documental procedures, the objective was to discover whether the contracting of professional insurance would have a possible preventive effect of protecting the doctor and the patient against damages during care. To do so, introductory notions about this type of insurance and the main contemporary challenges related to its use were presented, and finally, the probable consequences of this type of insurance Against indemnity claims were evaluated. It was verified that the contracting of medical liability insurance has not yet reached expressive numbers in the country, and that the inexistence of legislative imposition and the absence of incentive by the competent professional council may be factors that contribute to this scenario. With similar pre-existing challenges, the experience in the United States has demonstrated the opposite effect to prevention, with the growth of indemnity suits and the emergence of a new crisis. Finally, the results pointed to the solidification of patient safety at the expense of the adversities arising from insurance adherence.

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Resumen Introducción: Los trastornos andrológicos son frecuentes en varones con diabetes tipo 2. El objetivo fue evaluar si los médicos que atienden a personas con diabetes tipo 2 abordan problemas andro lógicos como disfunción sexual eréctil, disminución de libido y síntomas de hipogonadismo. Métodos: Se llevó a cabo una encuesta anónima a 171 médicos, de ellos 113 fueron mujeres (66.1%) con una edad media de 46 ± 10 años (mujeres: 45 ± 10 y varones: 49 ± 10, p = 0.006). Resultados: No hubo diferencias en las res puestas según el género. El 44.4% (n = 76) y el 55.6% (n = 95) no preguntan sobre la presencia de disfunción sexual eréctil y/o disminución de libido, respectivamente. El 50.9% (n = 87) no solicitó medición de testosterona en pacientes con síntomas de hipogonadismo. El 65.8% de los participantes respondió que el reemplazo con testosterona puede mejorar el perfil metabólico de la diabetes mellitus tipo 2 y los síntomas sexuales. El 74.7% de los encuestados afirmó que la medición de testosterona debería realizarse ante la presencia de síntomas compatibles con hipogonadismo. El 63.2% (n = 108) mostró interés en formación sobre temas relacionados a diabetes tipo 2 y trastornos de la esfera sexual. Conclusión: Un gran porcentaje de médicos que asisten a varones con diabetes tipo 2 no indaga sobre trastornos andrológicos. Es necesario concientizar y entrenar a los médicos, para detectar, tratar y/o derivar estos problemas de salud tan frecuentes, no solo para mejorar la calidad de vida de los pacientes sino para responder y prevenir efectivamente a un problema mayor de salud.

Abstract Introduction: Our objective was to assess whether physicians who care for people with type 2 dia betes address andrological symptoms such as erectile sexual dysfunction, decreased libido, and symptoms and/ or signs of hypogonadism. Methods: An anonymous survey was carried out with 171 doctors, 113 were females (66.1%), the mean age was 46 ± 10 years (females: 45 ± 10 and males: 49 ± 10, p = 0.006). Results: There were no differences in responses according to gender. Regarding the presence of erectile sexual dysfunction and/or decreased libido, 44.4% (n = 76) and 55.6% (n = 95) did not ask about them, respectively. In patients with symptoms of hypogonadism, 50.9% (n = 87) did not request a testosterone measurement. Regarding the improvement of the metabolic profile of type 2 diabetes mellitus and sexual symptoms after replacement with testosterone, 65.8% of the respondents answered that both conditions could improve after treatment. In the presence of symptoms compatible with hypogonadism, 74.7% of those surveyed stated that the measurement of testosterone should be performed. A total of 108 (63.2%) showed interest in being trained on topics related to type 2 diabetes and disorders of the sexual sphere. Conclusion: A large percentage of physicians who take care of men with type 2 diabetes do not inquire about andrological disorders. It is necessary to raise awareness and train doctors to detect, treat and/or refer these frequent health problems, not only to improve the quality of life of patients but also to effectively respond and prevent a major health problem.

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Despite relational continuity (RC) with the doctor being key to care quality for chronic patients, particularly in fragmented healthcare systems, like many in Latin America (LA), little is known about RC and its attributes, particularly regarding specialists. Aim: We aim to analyse chronic patients' perceptions of RC with primary (PC) and secondary (SC) care doctors, and record changes between 2015 and 2017 in the public healthcare networks of six LA countries. An analysis of two cross-sectional studies applying the CCAENA questionnaire to chronic patients (N = 4881) was conducted in Argentina, Brazil, Chile, Colombia, Mexico, and Uruguay. The dependent variables of RC with PC and SC doctors were: consistency, trust, effective communication, and synthetic indexes based on RC attributes. Descriptive and multivariate analyses were performed. Although the RC index was high in 2015, especially in PC in all countries, and at both levels in Argentina and Uruguay, low perceived consistency of PC and SC doctors in Colombia and Chile and of SC doctors in Mexico revealed important areas for improvement. In 2017 the RC index of SC doctors increased in Chile and Mexico, while SC doctors' consistency in Colombia decreased. This study reveals important gaps in achieving RC with doctors, particularly in SC, which requires further structural and organisational reforms.

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Romper com o modelo biomédico é necessário, e o ponto inicial pode vir com a compreensão da narrativa do usuário ou da usuária. Este estudo buscou avaliar a compreensão de estudantes de medicina das narrativas de adoecimento, utilizando a entrevista McGillIllness Narrative Interview (MINI). Trata-se de estudo exploratório, descritivo e qualitativo, realizado durante cinco semanas com 11 estudantes do quinto ano de uma universidade privada, no internato de Medicina de Família e Comunidade, que prestavam atendimento a 29 pessoas usuárias de unidades de saúde. Por meio de encontros individuais on-line, foram levantadas questões sobre essa experiência. Os relatos foram inseridos em núcleos argumentais, o que possibilitou o estabelecimento de relações com o referencial teórico da Medicina Narrativa, da Antropologia Médica e da Clínica Ampliada. Para os alunos e alunas houve uma nova experiência de entrevista clínica, uma valorização da narrativa e o desejo de incorporar uma abordagem mais ampliada à sua prática, embora não contemplem incorporar o MINI na sua forma integral, atribuindo a isso dificuldades na rotina médica. Acreditamos que o MINI pode colaborar com a aquisição de competências interpretativa e narrativa em estudantes, embora o ensino esteja ainda, emparte, vinculado ao modelo biomédico.

It is essential to break with the biomedical model. The starting point for that can come from the understanding of patients' narratives. This study sought to evaluate medical students' comprehension of illness narratives using the McGill Illness Narrative Interview (MINI). This is an exploratory, descriptive, and qualitative study, carried out with 11 fifth-year students at a private university in the internship of Family and Community Medicine, for five weeks, involving the care of 29 patients in health units. Through individual online meetings, questions were raised about the experience.The reports were inserted into categories, which allowed us to establish relationships among the theoretical referential elements of Narrative Medicine, Medical Anthropology, and Expanded Clinic. It was a new experience of clinical interviews for the students, with a new appreciation of narratives and a desire to incorporate a more extended approach to their practice, although they do not contemplate incorporating the MINI in its full form due to difficulties in the physician's routine. We believe that MINI can collaborate with the acquisition of interpretative and narrative competence in students, although teaching is still partly linked to the biomedical model.

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