Annika Brorsson

Physical activity on prescription (PAP) from the general practitioner’s perspective – a qualitative study

BackgroundPhysical activity on prescription (PAP) is a successful intervention for increasing physical activity among patients with a sedentary lifestyle. The method seems to be sparsely used by general practitioners (GPs) and there is limited information about GPs’ attitudes to counselling using PAP as a tool. The aim of the study was to explore and understand the meaning of prescribing physical activity from the general practitioner’s perspective.MethodsThree focus group interviews were conducted with a purposive sample of 15 Swedish GPs in the south of Sweden. Participants were invited to talk about their experience of using PAP. The interviews were transcribed verbatim, analysed using qualitative content analysis.ResultsThe analysis resulted in four categories: The tradition makes it hard to change attitude, Shared responsibility is necessary, PAP has low status and is regarded with distrust and Lack of procedures and clear guidelines. Traditionally GPs talk with patients about the importance of an increased level of physical activity but they do not prescribe physical activity as a treatment. Physician’s education focuses on the use of pharmaceuticals. The responsibility for patients’ physical activity level is shared with other health professionals, the patient and society. The GPs express reservations about prescribing physical activity. A heavy workload is a source of frustration. PAP is regarded with distrust and considered to be a task of less value and status. Using a prescription to emphasize an increased level is considered to be redundant and the GPs think it should be administered by someone else in the health care system. Scepticism about the result of the method was also expressed.ConclusionsThere is uncertainty about using PAP as a treatment since physicians lack education in non-pharmaceutical methods. The GPs do not regard the written referral as a prioritized task and rather refer to other professionals in the health care system to prescribe PAP. GPs pointed out a need to create routines and arrangements for the method to gain credibility and become everyday practice among GPs.

Frail elderly patients' experiences of information on medication. A qualitative study.

BackgroundOlder patients generally have only poor knowledge about their medicines. Knowledge is important for good adherence and for participating in decisions about treatment. Patients are entitled to be informed on an individual and adequate level. The aim of the study was to explore frail elderly patients’ experiences of receiving information about their medications and their views on how the information should best be given.MethodsThe study was qualitative in design and was carried out in 2011. Twelve frail elderly (aged 68–88) participants taking cardiovascular medications participated in semi-structured interviews covering issues related to receiving information about prescribed medicines. The interviews were recorded, transcribed and subjected to content analysis, in which the text was analysed in five steps, inspired by Graneheim and Lundman.ResultsThe results revealed that the experiences which the elderly participants had regarding the receiving of medical information fell into two main categories: “Comfortable with information” or “Insecure with information”. The elderly felt comfortable when they trusted their physician or their medication, when they received enough information from the prescriber or when they knew how to find out sufficient information by themselves. They felt insecure if they were anxious, if the availability of medical care was poor or if they did not receive enough information.ConclusionsFactors that frequently caused insecurity about information and anxiety were too short consultations, lack of availability of someone to answer questions or of the opportunity to contact the physician if adverse effects are suspected. These factors could easily be dealt with and there must be improvements in the clinics if the patients´ feelings of security are to be increased.

Fears of disease and disability in elderly primary health care patients

Some diseases are more frightening than others to patients and every culture or society has its own most dreaded disease(s). In some previous studies it has been shown that the fears of the patients sometimes have their roots in events in family history. In this qualitative study fourteen men and women aged 66-83 years, all of whom were primary care patients were interviewed with regard to their fears in connection with their present symptoms as well as in general. The results showed that diseases believed to entail disability, bodily changes and/or loss of control over body or environment, were the most feared. These diseases are also likely to stigmatise or shame the bearer, i.e., to change the identity for the worse. This is in line with other studies, where control and autonomy is demonstrated to be essential for elderly peoples self-esteem.

It is meaningful; I feel that I can make a difference -A qualitative study about GPs' experiences of work at nursing homes in Sweden.

BackgroundSwedish nursing homes (NH) have limited capacity. As a result elderly people living in NH represent the part of the elderly population in most need of care. In Sweden a General Practitioner (GP) is usually responsible for the medical care of all subjects living in a NH. The residents in NH seldom have adequate pharmacological treatment according to diagnosis and often have polypharmacy and/or inappropriate medical treatment regarding concerns of declining renal function. What prevents optimal care for the elderly is multifaceted, but there is limited research on how GPs experience their work with the elderly in NH in Sweden. This study aims to illuminate the GPs’ work with the elderly in NH to provide input on how the care can be improved, as well as to identify potential obstacles for good quality of care.MethodsThis qualitative study is based on individual semi-structured interviews with 12 GPs and a follow-up focus group discussion with six of the interviewed GPs.The interviews were analysed with systematic text condensation, with the process leading to identify categories and themes. Thereafter, the themes were discussed among six of the participating GPs in a focus group interview.ResultsTwo main themes were identified: concern for the patient and sustainable working conditions. The principal focus for the GPs was to contribute to the best possible quality of life for the patients. The GPs described discordance between the demand from staff for medications and the patients’ actual need of care. GPs found their work with NH enjoyable. Even though the patients at the NH often suffered from multiple illnesses, which could lead to difficult decisions being made, the doctors felt confident in their role by having a holistic view of the patient in tandem with reliable support from the nurse at the NH.ConclusionWorking with NH patients was considered important and meaningful, with the GPs striving for the patient’s well-being with special consideration to the continuum of ageing. A continuous and well-functioning relationship between the GP and the nurse was crucial for the patients´ well-being.

Management of patients with sore throats in relation to guidelines: An interview study in Sweden

Abstract Objective. To explore how a group of Swedish general practitioners (GPs) manage patients with a sore throat in relation to current guidelines as expressed in interviews. Design. Qualitative content analysis was used to analyse semi-structured interviews. Setting. Swedish primary care. Subjects. A strategic sample of 25 GPs. Main outcome measures. Perceived management of sore throat patients. Results. It was found that nine of the interviewed GPs were adherent to current guidelines for sore throat and 16 were non-adherent. The two groups differed in terms of guideline knowledge, which was shared within the team for adherent GPs while idiosyncratic knowledge dominated for the non-adherent GPs. Adherent GPs had no or low concerns for bacterial infections and differential diagnosis whilst non-adherent GPs believed that in patients with a sore throat any bacterial infection should be identified and treated with antibiotics. Patient history and examination was mainly targeted by adherent GPs whilst for non-adherent GPs it was often redundant. Non-adherent GPs reported problems getting patients to abstain from antibiotics, whilst no such problems were reported in adherent GPs. Conclusion. This interview study of sore throat management in a strategically sampled group of Swedish GPs showed that while two-thirds were non-adherent and had a liberal attitude to antibiotics one-third were guideline adherent with a restricted view on antibiotics. Non-adherent GPs revealed significant knowledge gaps. Adherent GPs had discussed guidelines within the primary care team while non-adherent GPs had not. Guideline implementation thus seemed to be promoted by knowledge shared in team discussions.

I'm Dr Jekyll and Mr Hyde: are GPs' antibiotic prescribing patterns contextually dependent? A qualitative focus group study.

Abstract Objective. To explore factors and circumstances contributing to prudent antibiotic prescribing for respiratory tract infections in primary care. Design. Two focus groups representing rural and urban areas. A semi-structured interview guide with open-ended questions and an editing analysis style was used. They were examined to identify meaning units that were sorted into categories in an iterative process throughout the analysis. Setting. Primary health care in two counties in southern Sweden. Subjects. Two groups including seven and six general practitioners (GPs) respectively, men and women of different ages with different professional experiences. Main outcome measures. Exploration of categories, determination of themes, construction of models. Results. The decision to prescribe antibiotics takes place in the encounter between GP and patient, initially characterized by harmony or fight and the subsequent process by collaboration or negotiation, resulting in agreement, compromise, or disagreement. Several factors influence the meeting and contribute to enhancing the conditions for rational prescribing. These conditions are connected to the GP, the relationship, and the setting; organization as well as professional culture. The findings indicate synergies between the factors, and that one factor can sometimes compensate for lack of another. Continuity and mutual trust can make a brief consultation successful, but lack of continuity can eliminate the effects of knowledge and professional skills. Conclusions. The findings emphasize the importance of the encounter between the GP and the patient for prudent antibiotic prescribing. Furthermore, the importance of an appropriate organization of primary care, which promotes continuity and encourages professional autonomy, is demonstrated.

Serious, frightening and interesting conditions: differences in values and attitudes between first-year and final-year medical students.

Context and objective  During medical education and training, the values and attitudes of medical students are shaped both by knowledge and by role models. In this study, the aim was to compare the views of first‐ and final‐year students concerning patients with different medical conditions.

Uncertainty in clinical practice - an interview study with Swedish GPs on patients with sore throat.

BackgroundUncertainty is inevitable in clinical practice in primary care and tolerance for uncertainty and concern for bad outcomes has been shown to vary between physicians. Uncertainty is a factor for inappropriate antibiotic prescribing. Evidence-based guidelines as well as near-patient tests are suggested tools to decrease uncertainty in the management of patients with respiratory tract infections. The aim of this paper was to describe strategies for coping with uncertainty in patients with pharyngotonsillitis in relation to guidelines.MethodsAn interview study was conducted among a strategic sample of 25 general practitioners (GPs).ResultsAll GPs mentioned potential dangerous differential diagnoses and complications. Four strategies for coping with uncertainty were identified, one of which was compliant with guidelines, “Adherence to guidelines”, and three were idiosyncratic: “Clinical picture and C-reactive protein (CRP)”, “Expanded control”, and “Unstructured”. The residual uncertainty differed for the different strategies: in the strategy “Adherence to guidelines” and “Clinical picture and CRP” uncertainty was avoided, based either on adherence to guidelines or on the clinical picture and near-patient CRP; in the strategy “Expanded control” uncertainty was balanced based on expanded control; and in the strategy “Unstructured” uncertainty prevailed in spite of redundant examination and anamnesis.ConclusionThe majority of the GPs avoided uncertainty and deemed they had no problems. Their strategies either adhered to guidelines or comprised excessive use of tests. Thus use of guidelines as well as use of more near-patient tests seemed associated to reduced uncertainty, although the later strategy at the expense of compliance to guidelines. A few GPs did not manage to cope with uncertainty or had to put in excessive work to control uncertainty.

Near-patient tests and the clinical gaze in decision-making of Swedish GPs not following current guidelines for sore throat - a qualitative interview study

BackgroundExcessive antibiotics use increases the risk of resistance. Previous studies have shown that the Centor score combined with Rapid Antigen Detection Test (RADT) for Group A Streptococci can reduce unnecessary antibiotic prescribing in patients with sore throat. According to the former Swedish guidelines RADT was recommended with 2–4 Centor criteria present and antibiotics were recommended if the test was positive. C- reactive protein (CRP) was not recommended for sore throats. Inappropriate use of RADT and CRP has been reported in several studies.MethodsFrom a larger project 16 general practitioners (GPs) who stated management of sore throats not according to the guidelines were identified. Half-hour long semi-structured interviews were conducted. The topics were the management of sore throats and the use of near-patient tests. Qualitative content analysis was used.ResultsThe use of the near-patient test interplayed with the clinical assessment and the perception that all infections caused by bacteria should be treated with antibiotics. The GPs expressed a belief that the clinical picture was sufficient for diagnosis in typical cases. RADT was not believed to be relevant since it detects only one bacterium, while CRP was considered as a reliable numerical measure of bacterial infection.ConclusionsInappropriate use of near-patient test can partly be understood as remnants of outdated knowledge. When new guidelines are introduced the differences between them and the former need to be discussed more explicitly.

We lived and breathed medicine - then life catches up: Medical students' reflections

BackgroundReflective writing enhances personal and professional development. It is essential for the teachers to be familiar with the students’ perceptions to improve the students’ learning. Our aim was to deepen the understanding of the medical students’ perceptions of the studies and the coming profession.MethodsOur theoretical perspective is constructivist, based upon the relativist view that individuals construct realities to understand and navigate the world. Constructivist methodologies are hermeneutic, with the focus on understanding rather than explaining. Thirty-five written reflections were collected in the first and fifth semesters at Lund University Medical School, Sweden. We used a thematic analysis, close to editing style analysis, inspired by K Malterud, who has modified Giorgi’s phenomenological method.ResultsFor first-semester students the focus is on studies and methods to structure them. The fifth semester is permeated by strategies for achieving a sense of ‘good enough’, qualities of a good doctor and applicability. Clinical placement as a motivating element is important for both semesters.ConclusionsA sense of ‘good enough’ is crucial for students to get by. Reflective writing can illuminate the strategies for achieving this. Clinical placement is vital for motivation.