Per Fugelli

Perceived Vulnerability to Heart Disease in Patients with Familial Hypercholesterolemia: A Qualitative Interview Study

PURPOSE Knowledge about the ways patients perceive their vulnerability to disease is important for communication with patients about risk and preventive health measures. This interview study aimed to explore how patients with a diagnosis of heterozygous familial hypercholesterolemia understand and perceive their vulnerability to coronary heart disease. METHODS We did a qualitative study of 40 patients with familial hypercholesterolemia who were recruited through a lipid clinic in Norway. We elicited participants’ perceptions about their vulnerability to heart disease in semistructured interviews. Data were analyzed by systematic text condensation inspired by Giorgi’s phenomenological method. RESULTS We found that participants negotiated a personal and dynamic sense of vulnerability to coronary heart disease that was grounded in notions of their genetic and inherited risk. Participants developed a sense of their vulnerability in a 2-step process. First, they consulted their family history to assess their genetic and inherited risk, and for many a certain age determined when they could expect to develop symptoms of coronary heart disease. Second, they negotiated a personal sense of vulnerability by comparing themselves with their family members. In these comparisons, they accounted for individual factors, such as sex, cholesterol levels, use of lipid-lowering medications, and lifestyle. Participants’ personal sense of vulnerability to heart disease could shift dynamically as a result of changes in situational factors, such as cardiac events in the family, illness experiences, or becoming a parent. CONCLUSIONS Patients with a diagnosis of familial hypercholesterolemia negotiate a personal and dynamic sense of vulnerability to coronary heart disease that is grounded in their understanding of their genetic and inherited risk. Doctors should elicit patients’ understanding of their family history and their personal vulnerability to individualize clinical management.

Labelling and patient knowledge of dispensed drugs as quality indicators in primary care in Botswana

Objectives: To assess the quality of dispensing and patient knowledge of drugs dispensed in primary care in Botswana. Setting: Thirty randomly assigned primary healthcare facilities in three districts of Botswana. Participants: Patients visiting clinics and health posts. Design: Analysis of data from prospective participative observations of the drug dispensing process and interview of patients about their knowledge of drugs received immediately after dispensing. The quality of drug labelling was assessed by calculating mean labelling scores composed of five dispensing attributes: name of patient, and name, strength, dosage, and volume of the drug (incorrect or no labelling=0, 1 point for each correct labelling attribute; maximum score=5). Mean knowledge scores were obtained immediately after dispensing from patient recall of name and dosage of drug, duration of treatment, and reason for prescription (incorrect recall=0, 1 point for each correct recall attribute; maximum score=4). Results: 2994 consecutive patient consultations were analysed. The mean labelling score was 2.75. Family welfare educators and pharmacy technicians scored highest (3.15 and 2.98, respectively) and untrained staff lowest (2.60). Factors independently associated with the labelling score were analgesics v other drugs, district, health posts v clinics, education of prescriber (nurse best), and years of experience of prescriber (4–11 years best). The mean patient knowledge score was 2.50. The reason for prescription of the drug(s), dosage, duration of treatment, and name of the drug(s) was recalled by 92%, 83%, 44%, and 31% of patients, respectively. The qualification level of the dispenser was the strongest factor independently associated with the knowledge score. Antibiotics had the second lowest score, both for labelling (2.39) and patient knowledge (2.39). Conclusion: Only trained dispensing staff provided satisfactory quality of labelling. Patients had a fair knowledge of the drugs dispensed. The knowledge of drugs dispensed by family welfare educators was less than satisfactory. The labelling score is a useful indicator of the quality of dispensing, and the knowledge score of both the quality of prescribing and of dispensing. These indicators should be added to the WHO list of patient care indicators.

Women at risk of coronary heart disease experience barriers to diagnosis and treatment: A qualitative interview study

Objective. To explore barriers in the health service to diagnosis and treatment experienced by women at increased risk of coronary heart disease (CHD). Design. Qualitative study using semi-structured interviews. Setting. Norway. Subjects. Twenty women diagnosed with heterozygous familial hypercholesterolemia (FH) recruited through a lipid clinic. Results. Women reported three specific barriers related to diagnosis and treatment of CHD. They had to struggle to take a cholesterol test; they experienced that their risk was being downplayed by doctors; and that their symptoms of CHD were misinterpreted when they consulted doctors for evaluation and treatment. Conclusion. Stereotyping CHD as a mans disease may result in barriers to diagnosis and treatment for women. Doctors should ask the patient about the family history of CHD if a concern about heart disease is on the patients agenda.

Effect of Fish Oil on Blood Pressure and Blood Lipids in Men with Mild to Moderate Hypertension

Forty men with mild to moderate hypertension were given one of two dietary supplements for 6 weeks: 20 capsules of fish oil (MaxEPA) or placebo (olive and corn oil). The MaxEPA supplement provided about 7 g omega-3-fatty acids pr day, whereas the placebo contained about 7 g omega-6-fatty acids and only 0.2 g omega-3-fatty acids. A clinical insignificant reduction in blood pressure was noted in both groups. In the fish oil group, the serum triglyceride levels fell by 30%. A decrease in the ratio total cholesterol/high density lipoprotein (HDL-) cholesterol was noted in both groups, most pronounced in the placebo group. No significant effect on total serum cholesterol level was observed during this study.

How do patients at risk portray candidates for coronary heart disease? A qualitative interview study

Objective. To explore how patients at risk of coronary heart disease (CHD) portray candidates for CHD. Design. Qualitative interview study. Setting. Norway. Subjects. A total of 20 men and 20 women diagnosed with heterozygous familial hypercholesterolemia (FH) recruited through a lipid clinic. Main outcome measures. Participants’ beliefs concerning persons who are considered candidates for CHD. Results. Some participants believed that CHD could happen to anyone, while the majority conveyed detailed notions of persons they considered to be likely victims of CHD. Participants often portrayed the coronary candidate as someone who was different from themselves. Among those who mentioned gender, all presented the candidate as a man. Some women said that they had to reconcile themselves to being at risk of CHD, since they at first had conceived CHD as a mans disease. While some participants considered their notions to be valid for assessing peoples risk of CHD, others questioned how valid their notions were. Conclusion. Doctors should recognize that distancing is a way patients cope with risk and that such a strategy may have psychological and moral reasons. When communicating about risk, doctors should take into account that patients’ notions of risk may differ from medical notions of risk.

Medicine and the arts in the undergraduate medical curriculum at the University of Oslo Faculty of Medicine, Oslo, Norway.

The authors describe a course titled Medicine and the Arts, established in 1996, that is part of the first semester of the undergraduate medical curriculum at the University of Oslo Faculty of Medicine. The course comprises four two-hour seminars on literature, visual arts, architecture, and music. The core objectives of the course are to demonstrate how art can be a source of personal and professional development, and also how art represents a source of insight into patients’ experiences and the social, cultural, and historical context of medical practice. The course emphasizes that art is ambiguous and many layered and that its interpretation requires sensitivity, engagement, imagination, and reflection. Fostering these skills is a major aim of the course because these skills are also essential for clinical competence and professional development. The course’s seminars are integrated into the curriculum but are not compulsory. Although the topics covered by the course have not been explicitly addressed in the formal examination of students, there has been some discussion about doing so, which would be a signal that those topics are as important as others in the curriculum.

Work disability and health-affecting psychosocial problems among patients in general practice.

Psychosocial problems are often ignored among patients in general practice. By identifying high risk groups this situation could possibly be altered. This study aimed to explore if patients in general practice perceiving themselves as work-disabled by at least 50% more often have health-affecting psychosocial problems than those not work-disabled. In a geographically defined population, 1,058 consecutive adult patients consulting 89 general practitioners were approached during one regular working day in March 1995. They completed a questionnaire at home, returning it directly to the department of general practice. Male patients considered themselves work-disabled more often than female patients. All psychosocial problems except having a demanding care-giving task were more common among the work-disabled. The doctors should bear in mind that work-disabled patients more often than other patients have concomitant healthaffecting psychosocial problems. Granting long-term sick leaves or a disability pension may not be the only management needed.

The Duration of Acute Respiratory Tract Infections in Children

In a rural district in Western Norway with 400 children under 16 years, we recorded all children with acute respiratory infections who attended their general practitioner during a period of four months. 90 cases were recorded, giving an incidence of 5.6% per month. Half of the patients contacted the doctor within four days from the initial symptom, every sixth waited more than two weeks. Their symptoms were monitored by the parents. Low fever, nasal discharge and cough were the most long-standing symptoms. After three weeks less than 50% of the patients were completely recovered. The children under one year of age recovered more quickly than the rest. No serious complications or sequelae were recorded.

The Patient Europe — calling for the general practitioner

Opening lecture, European Conference of General Practice and Family Medicine, Strasbourg, October 1995.

Death and planetary health

Colleagues, friends— I will now present to you: “The contribution of death to planetary health.” This may seem a strange thing to do. Here is my excuse. I have lived with the patient Per for 6 years now, with new cancers coming to the lungs and being carved out every year. Current condition? Myriads of metastases in both lungs. Dancing with death is not pleasant, but it is a discovery channel. I have used this pre-mortem time to explore the potential of death—for life. Here is my prescription.