Margareta Troein

A hidden curriculum: mapping cultural competency in a medical programme

Background  Cultural competency can be understood as those learned skills which help us understand cultural differences and ease communication between people who have different ways of understanding health, sickness and the body. Recently, medical schools have begun to recognise a need for cultural competency training. However, few reports have been published that articulate and evaluate cultural competency in medical curricula.

Guidelines and reported practice for the treatment of hypertension and hypercholesterolaemia

Troein M, Gardell B, Selander S, Råstam L (Department of Community Medicine, Lund University, Malmö, and Stockholm Institute of Education, Stockholm, Sweden). Guidelines and reported practice for the treatment of hypertension and hypercholesterolaemia. J Intern Med 1997; 242: 173–8.

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.

Workplace health resources based on sense of coherence theory

Purpose – In workplace health promotion, enhancing resources are less explored than risk factors. The aim of this paper is to explore the usability of the sense of coherence (SOC) theory to identif ...

Influence of self-registration on audit participants and their non-participating colleagues A retrospective study of medical records concerning prescription patterns

Objective To compare participants and non-participants early in the process of an audit on treatment of respiratory tract infections (RTIs) and to analyse any effect of the actual self-registration on the prescription of antibiotics in both groups. Design All 80 general practitioners (GPs) at 14 health centres were invited to audit their use of antibiotics and 45 agreed to participate. There were both participants and non-participants at all centres. Data were collected retrospectively from the electronic patient records of all visits for RTI during five periods including the self-registration period. Comparisons were made over time within and between the groups. Setting Primary health care in Blekinge county, Southern Sweden. Subjects 80 GPs: 45 participants and 35 non-participants. Main outcome measure Proportion of patients with RTI who received antibiotics. Results At the start, the difference in prescription frequency between participants and non-participants was six percentage points (RR=0.92; 95% CI=0.87–0.97), and at the end seven percentage points (0.88; 0.81–0.95). The proportion of RTIs treated with antibiotics fell for both groups, (0.86; 0.80–0.92 and 0.90; 0.83–0.97, respectively). Conclusions GPs who chose to take part in the audit had a different prescription pattern from the non-participants right from the start. Both groups reduced their prescription of antibiotics during the study period. Either the registration had no effect on the participants or it had an effect on both the participants and the non-participants.

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.

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.

The meaning of quality work from the general practitioner's perspective: an interview study

BackgroundThe quality of health care and its costs have been a subject of considerable attention and lively discussion. Various methods have been introduced to measure, assess, and improve the quality of health care. Many professionals in health care have criticized quality work and its methods as being unsuitable for health care. The aim of the study was to obtain a deeper understanding of the meaning of quality work from the general practitioners perspective.MethodsFourteen general practitioners, seven women and seven men, were interviewed with the aid of a semi-structured interview guide about their experience of quality work. The interviews were tape-recorded and transcribed verbatim. Data collection and analysis were guided by a phenomenological approach intended to capture the essence of the statements.ResultsTwo fundamentally different ways to view quality work emerged from the statements: A pronounced top-down perspective with elements of control, and an intra-profession or bottom-up perspective. From the top-down perspective, quality work was described as something that infringes professional freedom. From the bottom-up perspective the statements described quality work as a self-evident duty and as a professional attitude to the medical vocation, guided by the principles of medical ethics. Follow-up with a bottom-up approach is best done in internal processes, with the profession itself designing structures and methods based on its own needs.ConclusionsThe study indicates that general practitioners view internal follow-up as a professional obligation but external control as an imposition. This opposition entails a difficulty in achieving systematism in follow-up and quality work in health care. If the statutory standards for systematic quality work are to gain a real foothold, they must be packaged in such a way that general practitioners feel that both perspectives can be reconciled.

General practitioners' conceptions of depressive disorders in relation to regional sales levels of antidepressive drugs. A study based on a postal survey and ecological data.

Objectives To examine how local sales levels of antidepressive agents (ADs) correlated with GPs’ conceptions of depressive disorders and of factors that may influence their work with depressed patients. Design A postal questionnaire survey to GPs requesting their conceptions of depression and their opinions of additional factors that may influence their work with depressed patients. GPs’ conceptions and opinions were compared with local sales rates of ADs. Settings Three selected groups of Swedish municipalities: those with the highest, the average, and the lowest sales rates of ADs. Subjects All 535 GPs who worked in the selected municipalities. Main outcome measures Spearman rank correlations for responses to the questionnaire with the sales levels of ADs. Results High sales levels correlated positively with a high evaluation of ADs’ effectiveness in depression and panic disorders and were inversely correlated with the degree of appreciation of psychotherapy-based treatments. High sales levels were also associated with a high evaluation of GPs’ own clinical and private experience, with a positive appreciation of the work with depressed patients and with a high level of participation in the pharmaceutical companies’ activities. The demonstrated statistical correlations were not particularly strong and included less than half of the items. Conclusions This ecological study confirms a number of statistical associations between sales levels of ADs and GPs’ prevailing conceptions of factors related to depression. However, their explanatory value of the geographical sale variation appears limited. To further clarify this variation, studies employing information on individual GPs’ conceptions and prescribing are required.

GP's Adherence to Guidelines for Cardiovascular Disease among Elderly: A Quality Development Study.

Background. Evidence-based guidelines should in most cases be followed also in the treatment of elderly. Older people are often suboptimally treated with the recommended drugs. Objectives. To describe how well general practitioners adhere to current guidelines in the treatment of elderly with cardiovascular disease and evaluate local education as a tool for improvement. Method. Data was collected from the medical records of patients aged ≥65, who visited a primary health care center in Sweden 2006 and had one or more of the following diagnoses: hypertension, ischemic heart disease, heart failure, chronic atrial fibrillation, or prior stroke. Local education was organized and included feed-back to the patients doctor and discussion about regional guidelines. Repeated measurements were performed in 2008. Results and Conclusion. The adherence to guidelines was low. Approximately one-third of the patients with hypertension reached target blood pressure, stroke patients more often. More patients with heart failure were treated with angiotensin converting enzyme inhibitor than in other European countries, but still only 60%. Half of the patients with chronic atrial fibrillation were treated with Warfarin, although more than two-thirds had a CHADS2 score indicating the need. Educational efforts appeared to increase the adherence and hence should be encouraged.