Carl Edvard Rudebeck

Satisfaction is not all – patients' perceptions of outcome of general practice consultations, a qualitative study

BackgroundEvaluation of outcome in general practice can be seen from different viewpoints. In this study we focus on the concepts patients use to describe the outcome of a consultation with a GP.MethodPatients were interviewed within a week after a consultation with a GP. The interviews were made with 20 patients in 5 focus groups and 8 individually. They were analysed with a phenomenographic research approach.ResultsFrom the patients perspective, the outcome of a consultation is about cure or symptom relief, understanding, confirmation, reassurance, change in self-perception and satisfaction.ConclusionGeneral practice consultations are often more important for patients than generally supposed. Understanding is the most basic concept.

The doctor, the patient and the body

Michael Balint has helped us realize that the clinical interaction is, above all, an inter-human interaction. However, the lived experience of the body - the existential anatomy - occupies but a very small space in the consciousness of medicine. Even the ?psychosomatic body? is a theoretical construct favouring observation rather than understanding. The doctor shares the conditions of embodied life with his patients, and, in addition, has the opportunity to refine his sensitivity to the variations of bodily experience in his work with patients. Thus, a bodily empathic basis for clinical interaction is laid on which understanding and diagnosis may reinforce one another in a common endeavour.

How does the thought of cancer arise in a general practice consultation? Interviews with GPs

Abstract Background. Only a few patients on a GPs list develop cancer each year. To find these cases in the jumble of presented problems is a challenge. Objective. To explore how general practitioners (GPs) come to think of cancer in a clinical encounter. Design. Qualitative interviews with Norwegian GPs, who were invited to think back on consultations during which the thought of cancer arose. The 11 GPs recounted and reflected on 70 such stories from their practices. A phenomenographic approach enabled the study of variation in GPs’ ways of experiencing. Results. Awareness of cancer could arise in several contexts of attention: (1) Practising basic knowledge: explicit rules and skills, such as alarm symptoms, epidemiology and clinical know-how; (2) Interpersonal awareness: being alert to changes in patients’ appearance or behaviour and to cues in their choice of words, on a background of basic knowledge and experience; (3) Intuitive knowing: a tacit feeling of alarm which could be difficult to verbalize, but nevertheless was helpful. Intuition built on the earlier mentioned contexts: basic knowledge, experience, and interpersonal awareness; (4) Fear of cancer: the existential context of awareness could affect the thoughts of both doctor and patient. The challenge could be how not to think about cancer all the time and to find ways to live with insecurity without becoming over-precautious. Conclusion: The thought of cancer arose in the relationship between doctor and patient. The quality of their interaction and the doctors accuracy in perceiving and interpreting cues were decisive.

A doctor close at hand: How GPs view their role in cancer care

Abstract Objective. To explore GPs’ own views on their role in cancer care. Design. Qualitative study based on semi-structured interviews. Setting. Norwegian primary care. Methods. The stories of 14 GPs concerning 18 patients were analyzed for core content and abstracted into general ideas, to create a broader sense of the experienced professional role. Results. The GPs claimed to have an important role in cancer care. In our analysis, three main aspects of GPs’ work emerged: first, as a flexible mediator, e.g. between the patient and the clinic, interpreting and translating; second, as an efficient “handyman”, solving practical problems locally; and third, as a personal companion for the patient throughout the illness. Conclusion. The interviewed GPs see their place in cancer care as being close to their patients. In their many tasks we found three main aspects: the mediating, the practical, and the personal.

Concepts underlying outcome measures in studies of consultations in general practice

Objective. To give an overview of the concepts used to describe and evaluate the outcome of general practice consultations. Method. A literature study was undertaken. Among 101 articles relevant to the subject 35 were chosen to illustrate the concepts found. Result. The following concepts were found: disease control, patient compliance, efficacy, symptom relief, enablement, general health, and patient satisfaction. The first three concepts encourage objective measurement while the following four concern the patients subjective assessment. Methods naturally linked to the respective concepts are briefly described. Discussion. The concepts reflect very diverse aspects of general practice. Some of the concepts come from other domains of research, while others have been developed within general practice. Disease is not exclusively in focus. The experience, competence, and life situation of the patient are as well dealt with as they should be in accordance with a patient-centred profession. However, the concepts spring from the researchers’ ideas about what is important to patients. The patients’ priorities were not sought.

Characteristics of sick-listing cases that physicians consider problematic – analyses of written case reports

Abstract Objective. The aim was to discern common characteristics in the sick-listing cases that physicians in general practice and occupational health services find problematic. Design. Descriptive categorization within a narrative theoretical framework. Setting. Sickness-insurance course for physicians in general practice and occupational health services. Subjects. A total of 195 case reports written by 195 physicians. Main outcome measures. Categories of features regarding medical, work, and social situation as well as medical interventions. Results. Beside age and sex, the following information was often provided: family situation, stressful life events, occupation, problem at work, considerations concerning diagnoses, medical investigations, treatments, and vocational rehabilitation measures. Two-thirds of the patients had been sickness absent for more than a year. The most common type of case reports concerned women, employed in non-qualified nursing occupations, and sick listed due to mental disorders. The most common measures taken by the physicians were referrals to psychotherapy and/or physiotherapy, and prescribing antidepressants (SSRI). Facts about alcohol habits were rarely provided in the cases. Conclusions. Some of the circumstances, such as prolonged sick-listing, are likely to be more or less inevitable in problematic sick-listing cases. Other circumstances, such as stress-full life events, more closely reflect what the reporting physicians find problematic. The categories identified can be regarded as markers of problematic sick-listing cases in general practice and occupational health service.

Working behaviour of competent general practitioners: personal styles and deliberate strategies.

Objective. To study how competent GPs perform their work within the consultation and in relation to the team and practice organization. Design. Ethnographic study with thick description. A participant observation of the GP was followed by a personal interview. A substantial description was elaborated that was analysed qualitatively. Setting. Primary care surgeries in Sweden. Subjects. A number of competent GPs. Results. Two main categories emerged, deliberated strategy and personal style. These categories set up the individual pattern of working behaviour for each GP. A behaviour that is a deliberate strategy for one GP for the other belongs to his or her personal style. Common denominators in the overall working behaviour were attention to the patient as a person, practising patient-centred medicine, saving the consultations from disturbances, rejecting taking over responsibilities from the patients, and safeguarding own autonomy. Conclusion. The transition of deliberate, favourable strategies into ones personal style is an important aspect of professional development. A well-developed personal style is necessary to obtain the spontaneous interchange between attentive listening and detachment characteristic of patient-centeredness.

Assessing Body Awareness in Healthy Subjects ? The First Steps Towards the Construction of the BAS-Health

The aim of this study was to find out if it is possible to differentiate a group of healthy subjects, in this case general practitioners, in terms of body awareness. The Body Awareness Scale, which had previously been used and validated for psychiatric patients, was employed. The scale had to be adjusted to serve the purpose of the study. Our paper describes the changes made and the rea sons for making them. When assessed by the adjusted scale, the doctors showed substantial differences, which indicates that the scale might be a useful tool. There was also a high degree of inter-rater reliability between our two assessors. Lastly, some of the scale items were more discriminative than others and, therefore, it may be possible that only a limited number are required when assessing body awareness in healthy subjects. Further studies are needed to find out whether the scale would be useful in other contexts. The possible uses of body awareness assessments in physiotherapy and in the clinical work of doctors are discussed.

Breastfeeding and prognostic markers in breast cancer

BACKGROUND Several studies suggest that total breastfeeding time reduces breast cancer risk. The underlying mechanisms are unclear. Whether breastfeeding also affects the prognosis is not yet investigated. A number of tumour characteristics, i.e. histological type of cancer, grade, tumour size, Nottingham prognostic index, vascular invasion and DNA-ploidy, have been demonstrated to be of prognostic value. METHODS We have searched for a possible link between these prognostic markers and breastfeeding time, age at first child and number of children. 250 women treated for breast cancer have answered a questionnaire. RESULTS No significant interactions were found possibly with one exception, LVI vs. age at first child. We found, significant correlations between lobular cancer, and thereby also DNA-ploidy, and age at first childbirth. CONCLUSIONS We have found that lobular cancer (and thereby also diploid tumours) are connected, independently, to age at first childbirth and possibly also to number of children but no other correlations between reproductive data, breastfeeding included, and prognostic markers used in this study were found.

GPs´ decision-making - perceiving the patient as a person or a disease

BackgroundThe aim of this study was to analyse the clinical decision making strategies of GPs with regard to the whole range of problems encountered in everyday work.MethodsA prospective questionnaire study was carried through, where 16 General practitioners in Sweden registered consecutively 378 problems in 366 patients.Results68.3% of the problems were registered as somatic, 5.8% as psychosocial and 25.9% as both somatic and psychosocial. When the problem was characterised as somatic the main emphasis was most often on the symptoms only, and when the problem was psychosocial main emphasis was given to the person. Immediate, inductive, decision-making contrary to gradual, analytical, was used for about half of the problems. Immediate decision-making was less often used when problems were registered as both somatic and psychosocial and focus was on both the symptoms and the person. When immediate decision-making was used the GPs were significantly more often certain of their identification of the problem and significantly more satisfied with their consultation. Rules of thumb in consultations registered as somatic with emphasis on symptoms only did not include any reference to the individual patient. In consultations registered as psychosocial with emphasis on the person, rules of thumb often included reference to the patient as a known person.ConclusionsThe decision-making (immediate or gradual) registered by the GPs seemed to have been adjusted on the symptom or on the patient as a person. Our results indicate that the GPs seem to recognise immediately both problems and persons, hence the quintessence of the expert skill of the GP as developed through experience.