Knut Holtedahl

When patients have cancer, they stop seeing me--the role of the general practitioner in early follow-up of patients with cancer--a qualitative study.

BackgroundThe role of the general practitioner (GP) in cancer follow-up is poorly defined. We wanted to describe and analyse the role of the GP during initial follow-up of patients with recently treated cancer, from the perspective of patients, their relatives and their GPs.MethodsOne focus group interview with six GPs from the city of Bodø and individual interviews with 17 GPs from the city of Tromsø in North Norway. Text analysis of the transcribed interviews and of free text comments in two questionnaires from 91 patients with cancer diagnosed between October 1999 and September 2000 and their relatives from Tromsø.ResultsThe role of the GP in follow-up of patients with recently treated cancer is discussed under five main headings: patient involvement, treating the cancer and treating the patient, time and accessibility, limits to competence, and the GP and the hospital should work together.ConclusionThe GP has a place in the follow-up of many patients with cancer, also in the initial phase after treatment. Patients trust their GP to provide competent care, especially when they have more complex health care needs on top of their cancer. GPs agree to take a more prominent role for cancer patients, provided there is good access to specialist advice. Plans for follow-up of individual patients could in many cases improve care and cooperation. Such plans could be made preferably before discharge from in-patient care by a team consisting of the patient, a carer, a hospital specialist and a general practitioner. Patients and GPs call on hospital doctors to initiate such collaboration.

Prevalence, 1-year incidence and factors associated with urinary incontinence: a population based study of women 50–74 years of age in primary care

OBJECTIVES To study prevalence, incidence, remissions and factors associated with urinary incontinence in women 50-74 years of age. METHODS Cross-sectional study of prevalence and associated factors and a 1-year prospective study of incidence and remissions. A random sample of 698 women were invited for a gynecological examination in general practice in three municipalities in Northern Norway in 1994-1995. Five hundred and seven (73%) met for the first consultation, 489 of them for the second one. Questionnaires were answered by women and doctors during consultations at inclusion and 1 year later. Prevalence was estimated at three levels of evidence. RESULTS Any leakage was reported by 47% and regularly by 31%. For 19%, leakage was objectively demonstrated and claimed to be a social or hygienic problem. Incontinence was associated with high body weight, with poor ability to contract pelvic floor muscles and with previous gynecological operations excluding hysterectomy. Three women (0.6%) developed regular incontinence during the year of investigation. There was no convincing case of spontaneous remission. CONCLUSION Urinary incontinence is very frequent in women aged 50-74 years and about one in five are potential patients needing treatment. Urinary incontinence is an enduring condition with little tendency for remission without treatment.

A population based, randomized, controlled trial of conservative treatment for urinary incontinence in women

Background. Urinary incontinence remains a hidden and inadequately treated problem in a high proportion of women.Methods. Ninety women 50–74 years of age were recruited to a population-based, randomized, controlled clinical trial of conservative treatment for urinary incontinence, with delayed treatment for the control group. The study was performed in general practice in three north-Norwegian municipalities, in cooperation with two local departments of gynecology. Three patients were found protocol deviant and analysis was based on 87 patients.Intervention. Local estrogen, physiotherapy and electrostimulation combined with close follow-up.Main outcome measures. 1. Change in severity of incontinence from start of treatment (index range 0–8). 2. Change in impact from start of treatment (index range 0–4). 3. Quantitative measures in relation to micturition. 4. Criteria based classification into cured, improved, unchanged, worse.Results. Treatment reduced severity (index change 1.8 in the intervention group v...

Usefulness of Urodynamic Examination in Female Urinary Incontinence: Lessons from a Population-Based, Randomized, Controlled Study of Conservative Treatment

Objective: To test the usefulness of urodynamic examination in female urinary incontinence. Material and Methods: As part of a population-based, randomized, controlled treatment study in general practice, the control group was offered urodynamic examination before and after delayed treatment starting 6 months after inclusion in the study, i.e. after the first outcome evaluation comparing the initially treated group with the control group. The intervention group was offered urodynamic examination only after the final outcome evaluation at 12 months. Eighty-seven women, aged 50-74, from three Norwegian municipalities participated. Results: There was no difference in treatment outcome whether the patients had urodynamic examination or not. Eleven patients (26% of 42 control patients) had their diagnosis revised after urodynamic examination, ten of them with a subsequent change in treatment. The outcome for this group was no different than for the other patients. As a subgroup, the 11 patients had more severe leakage (p = 0.048) and more previous gynecological operations (p = 0.038) than the other control group patients. Conclusions: Our study supports the idea that in general practice, or in rather unselected patients, women with urinary incontinence may be classified and treated without urodynamic examination. If there is little or no improvement during the first few months referral should be considered, and this should be done sooner for patients with severe incontinence or prior gynecological operations than for other patients.

Frequency of ‘warning signs of cancer’ in Norwegian general practice, with prospective recording of subsequent cancer

BACKGROUND Early diagnosis of cancer is an important challenge in general practice. Symptoms are the most common starting points. OBJECTIVE To assess the association between symptoms presented and subsequent cancer. DESIGN A cohort study of all patients seen consecutively by GPs. Prospective recording of cancer diagnosis, new cancer or new recurrence. SETTING Two hundred and eighty-three general practice surgeries and 10 working days. METHOD During patient consultations, GPs registered seven focal symptoms and three general symptoms, commonly considered as warning signs of cancer (WSC). Follow-up 6-11 months later with registration of any subsequent diagnosis of cancer was done. RESULTS Of 51 073 patients, 6321 (12.4%) had recordings of 7704 WSC. During a median follow-up period of 8 months, 263 patients were diagnosed with cancer and 59 of them with recurrence of a previously diagnosed cancer. Of the cancer patients, 106 (40%) had presented one or more WSC during a preceding consultation. Examined symptoms had likelihood ratios for cancer from 1.5 to 8.2 and positive predictive values (PPVs) from 0.8% to 3.8%. Limited to older age groups, PPVs were a little higher. General symptoms were rarely associated with cancer unless a focal symptom had been recorded as well. Multiple symptoms increased the probability of cancer. CONCLUSION 12.4% of GP patients presented with WSC. A general symptom may have cancer diagnostic value, but usually, only when it occurs along with a focal symptom. PPV of any single symptom is low, and decisions about referral require additional information.

Do cancer patients benefit from short-term contact with a general practitioner following cancer treatment? A randomised, controlled study.

Goals of workTo investigate whether increased contact with the patient’s general practitioner (GP) soon after cancer treatment can increase patient quality of life (QoL) and satisfaction with follow-up.Patients and methodsA randomised controlled study with 91 patients from one Norwegian municipality. The intervention group got a 30-min invited consultation with the patient’s GP and an invitation to further GP follow-up. Quality of life and patient satisfaction with diagnosis, treatment and overall care were measured with validated instruments.Main resultsRelatives’ satisfaction with care increased over 6 months in the intervention group (P=0.018), but otherwise, there was no difference between the intervention and control groups concerning QoL, satisfaction with care or number of consultations. Patient satisfaction with care showed a tendency to increase when treatment intent was curative. Some functional QoL measures and satisfaction tended to increase during the first 6 months after treatment. Free text comments suggested that some patients appreciated the contact with their GP.ConclusionSome cancer patients benefit from follow-up by their GP. The way to perform this kind of follow-up in primary care, and who these cancer patients are, should be further studied. Short follow-up time and an urban setting may have contributed to the lack of group differences in our study, but patients treated for cancer may have limited need for follow-up as long as they feel well and the situation remains stable.

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.

TONOMETRY IN THE GENERAL PRACTICE SETTING. I: TONO-PEN COMPARED TO GOLDMANN APPLANATION TONOMETRY

Abstract Intraocular pressure was measured in 132 consecutive patients over the age of 20 in a general pratice with two general practitioners (GP). Tono‐Pen tonometry was compared to Goldmann applanation tonometry in a masked, randomized design. Also, agreement between Tono‐Pen measurements by the GPs and the ophthalmologist was estimated. Both mean difference between Tono‐Pen and Goldmann applanation measurements and mean differences between Tono‐Pen readings made by GPs and ophthalmologist were less than 1 mmHg. Ninety‐five percent limits of agreement between the two methods were approximately ‐4.5 mmHg and 5.5 mmHg, and between observers approximately ‐4 mmHg and 5 mmHg. The Tono‐Pen was agreeable both to patients and physicians. The GPs made as accurate measurements as the ophthalmologist. The wide limits of agreement are clinically much more important than the small differences between means. Random variation was much greater than systematic variation. Wide limits of agreement will apply to all known methods of clinical tonometry.

Insulin treatment for poorly regulated diabetic patients in general practice: Better regulation and symptom relief?

OBJECTIVE To study the relationship between symptoms, metabolic control and insulin treatment in diabetes mellitus. DESIGN A cross-sectional questionnaire study of diabetic patients, and a 1-year follow-up study of poorly regulated patients prescribed insulin. Regulation criteria were predefined and the patients acted as their own controls. SETTING Five primary care practices in Nordland county, Norway. PATIENTS 111 patients in the cross-sectional study, with 18 of them participating in the follow-up study. MAIN OUTCOME MEASURES Symptom scores and sum scores, based on five general symptoms--dizziness, depression, fatigue, thirst and dry mouth--and on two urinary symptoms--urinary frequency and urination during the night. RESULTS Poorly regulated diabetic patients had a higher sum score for general symptoms than better regulated patients (6.1 vs. 4.2, p = 0.078 with Wilcoxon two-sample rank sum test). With parametric analysis, the difference was significant, and remained so when adjusted for age and sex. Females reported more symptoms than males. Symptom relief with insulin was not statistically significant; however, there was a slight but consistent tendency towards less symptoms with better regulation. There was no correlation with HbA1 values at any time during the follow-up study. Only one patient wanted to stop taking insulin after 1 year. CONCLUSION Better metabolic control and better general well-being seem to be achieved in many cases when poorly regulated patients with type 2 diabetes mellitus begin insulin treatment. The general practitioner should be cautious in promising relief of specific symptoms.