Bente Prytz Mjølstad

Applying clinical guidelines in general practice: A qualitative study of potential complications

BackgroundClinical guidelines for single diseases often pose problems in general practice work with multimorbid patients. However, little research focuses on how general practice is affected by the demand to follow multiple guidelines. This study explored Norwegian general practitioners’ (GPs’) experiences with and reflections upon the consequences for general practice of applying multiple guidelines.MethodsQualitative focus group study carried out in Mid-Norway. The study involved a purposeful sample of 25 Norwegian GPs from four pre-existing groups. Interviews were audio-recorded, transcribed and analyzed using systematic text condensation, i.e. applying a phenomenological approach.ResultsThe GPs’ responses clustered around two major topics: 1) Complications for the GPs of applying multiple guidelines; and, 2) Complications for their patients when GPs apply multiple guidelines. For the GPs, applying multiple guidelines created a highly problematic situation as they felt obliged to implement guidelines that were not suited to their patients: too often, the map and the terrain did not match. They also experienced greater insecurity regarding their own practice which, they admitted, resulted in an increased tendency to practice ‘defensive medicine’. For their patients, the GPs experienced that applying multiple guidelines increased the risk of polypharmacy, excessive non-pharmacological recommendations, a tendency toward medicalization and, for some, a reduction in quality of life.ConclusionsThe GPs experienced negative consequences when obliged to apply a variety of single disease guidelines to multimorbid patients, including increased risk of polypharmacy and overtreatment. We believe patient-centered care and the GPs’ courage to non-comply when necessary may aid in reducing these risks. Health care authorities and guideline developers need to be aware of the potential negative effects of applying a single disease focus in general practice, where multimorbidity is highly prevalent.

Standardization meets stories: Contrasting perspectives on the needs of frail individuals at a rehabilitation unit

Background Repeated encounters over time enable general practitioners (GPs) to accumulate biomedical and biographical knowledge about their patients. A growing body of evidence documenting the medical relevance of lifetime experiences indicates that health personnel ought to appraise this type of knowledge and consider how to incorporate it into their treatment of patients. In order to explore the interdisciplinary communication of such knowledge within Norwegian health care, we conducted a research project at the interface between general practice and a nursing home. Methods In the present study, nine Norwegian GPs were each interviewed about one of their patients who had recently been admitted to a nursing home for short-term rehabilitation. A successive interview conducted with each of these patients aimed at both validating the GPs information and exploring the patients life story. The GPs treatment opinions and the patients biographical information and treatment preferences were condensed into a biographical record presented to the nursing home staff. The transcripts of the interviews and the institutional treatment measures were compared and analysed, applying a phenomenological–hermeneutical framework. In the present article, we compare and discuss: (1) the GPs’ specific recommendations for their patients; (2) the patients’ own wishes and perceived needs; and (3) if and how this information was integrated into the institutions interventions and priorities. Results Each GP made rehabilitation recommendations, which included statements regarding both the patients personality and life circumstances. The nursing home staff individualized their selection of therapeutic interventions based on defined standardized treatment approaches, without personalizing them. Conclusion We found that the institutional voice of medicine consistently tends to override the voice of the patients lifeworld. Thus, despite the institutions best intentions, their efforts to provide appropriate rehabilitation seem to have been jeopardized to some extent.