Per Hjortdahl

Patients Who Use E-Mediated Communication With Their Doctor: New Constructions of Trust in the Patient-Doctor Relationship

The introduction of information and communication technology (ICT) into the patient-doctor relationship represents a significant change in modern health care. Communication via computers—e-mediated communication—is affecting the context of patient-doctor interaction, touching core elements of the relationship. Based on data from a qualitative study conducted among Norwegian patients who had used ICT to communicate with their doctors, the authors argue that patients’ use of ICT and the element of trust in the patient-doctor relationship influence each other. Furthermore, they contend that patients’ constructions of trust in this relationship can be understood in light of basic mechanisms in modern society. The study sheds light on some potential concerns and benefits as communication technology increasingly is integrated into the patient-doctor relationship.

Designing mobile dietary management support technologies for people with diabetes

We performed two cycles of laboratory-based usability testing of three food registration prototypes for people with diabetes. The design concepts were a commercial web application, various smartphones and a mobile phone photo blogging approach. Six adults with Type 1 diabetes and three adults with Type 2 diabetes participated in the usability tests. The results provided five distinct implications for devices for the future dietary management support of people with diabetes. Study participants valued many of the features offered by the three systems that were tested, although the usability tests also revealed several opportunities to enhance their design. Our findings suggest that further development is justified of mobile dietary and nutritional support for individuals living with diabetes. Applications that support healthy eating habits should be integrated with applications for managing blood glucose data and physical activity data, and potentially medication data as well.

Improving doctors' prescribing behaviour through reflection on guidelines and prescription feedback: a randomised controlled study.

Background—It is difficult to put research findings into clinical practice by either guidelines or prescription feedback. Aim—To study the effect on the quality of prescribing by a combined intervention of providing individual feedback and deriving quality criteria using guideline recommendations in peer review groups. Methods—199 general practitioners in 32 groups were randomised to participate in peer review meetings related to either asthma or urinary tract infections. The dispensing by the participating doctors of antiasthmatic drugs and antibiotics during the year before the intervention period provided the basis for prescription feedback. The intervention feedback was designed to describe the treatment given in relation to recommendations in the national guidelines. In each group the doctors agreed on quality criteria for their own treatment of the corresponding diseases based on these recommendations. Comparison of their prescription feedback with their own quality criteria gave each doctor the proportion of acceptable and unacceptable treatments. Main outcome measure—Difference in the prescribing behaviour between the year before and the year after the intervention. Results—Before intervention the mean proportions of acceptably treated asthma patients in the asthma group and urinary tract infection (control) group were 28% and 27%, respectively. The mean proportion of acceptably treated patients in the asthma group was increased by 6% relative to the control group; this difference was statistically significant. The mean proportions of acceptable treatments of urinary tract infection before intervention in the urinary tract infection group and asthma (control) group were 12% for both groups which increased by 13% in the urinary tract infection group relative to the control group. Relative to the mean pre-intervention values this represented an improvement in treatment of 21% in the asthma group and 108% in the urinary tract infection group. Conclusions—Deriving quality criteria of prescribing by discussing guideline recommendations gave the doctors a basis for judging their treatment of individual patients as acceptable or unacceptable. Presented with feedback on their own prescribing, they learned what they did right and wrong. This provided a foundation for improvement and the process thus instigated resulted in the doctors providing better quality patient care.

Mandates of Trust in the Doctor–Patient Relationship

We examine the conditions for trust relationships between patients and physicians. A trust relationship is not normally negotiated explicitly, but we wanted to discuss it with both patients and physicians. We therefore relied on a combination of interviews and observations. Sixteen patients and 8 family physicians in Norway participated in the study. We found that trust relationships were negotiated implicitly. Physicians were authorized by patients to exercise their judgment as medical doctors to varying degrees. We called this phenomenon the patient’s mandate of trust to the physician. A mandate of trust limited to specific complaints was adequate for many medical procedures, but more open mandates of trust seemed necessary to ensure effective and humane treatment for patients with more complex and diffuse illnesses. More open mandates of trust were given if the physician showed an early interest in the patient, was sensitive, gave time, built alliances, or bracketed normal behavior.

Three success factors for continual improvement in healthcare: an analysis of the reports of improvement team members

Introduction The objectives of the Breakthrough Series Collaborative are to close the gap between what we know and what we do, and to contribute to continuous quality improvement (CQI) of healthcare through collaborative learning. The improvement efforts are guided by a systematic approach, combining professional and improvement knowledge. Objectives To explore what the improvement teams have learnt from participating in the collaborative and from dealing with promoting and inhibiting factors encountered. Method Qualitative interviews with 19 team members were conducted in four focus groups, using the Critical Incident Technique. A critical incident is one that makes significant contributions, either positively or negatively, to an activity. Results The elements of a culture of improvement are revealed by the critical incidents, and reflect the eight domains of knowledge, as a product of collaborative learning. The improvement knowledge and skills of individuals are important elements, but not enough to achieve sustainable changes. 90% of the material reflects the need for a system of CQI to solve the problems that organisations experience in trying to make lasting improvements. Conclusion A pattern of three success factors for CQI emerges: (1) continuous and reliable information, including measurement, about best and current practice; (2) engagement of everybody in all phases of the improvement work: the patient and family, the leadership, the professional environment and the staff; and (3) an infrastructure based on improvement knowledge, with multidisciplinary teams, available coaching, learning systems and sustainability systems.

Chlamydia and gonorrhoea in pregnant Batswana women: time to discard the syndromic approach?

BackgroundChlamydia and gonorrhoea are major causes of morbidity among women in developing countries. Both infections have been associated with pregnancy-related complications, and case detection and treatment in pregnancy is essential. In countries without laboratory support, the diagnosis and treatment of cervical infections is based on the syndromic approach. In this study we measured the prevalence of chlamydia and gonorrhoea among antenatal care attendees in Botswana. We evaluated the syndromic approach for the detection of cervical infections in pregnancy, and determined if risk scores could improve the diagnostic accuracy.MethodsIn a cross-sectional study, 703 antenatal care attendees in Botswana were interviewed and examined, and specimens were collected for the identification of C trachomatis, N gonorrhoeae and other reproductive tract infections. Risk scores to identify attendees with cervical infections were computed based on identified risk factors, and their sensitivities, specificities, likelihood ratios and predictive values were calculated.ResultsThe prevalence of chlamydia was 8%, and gonorrhoea was found in 3% of the attendees. Symptoms and signs of vaginal discharge did not predict cervical infection, and a syndromic approach failed to identify infected women. Age (youth) risk factor most strongly associated with cervical infection. A risk score with only sociodemographic factors had likelihood ratios equivalent to risk scores which incorporated clinical signs and microscopy results. However, all the evaluated risk scores were of limited value in the diagnosis of chlamydia and gonorrhoea. A cut-off set at an acceptable sensitivity to avoid infected antenatal care attendees who remained untreated would inevitably lead to considerable over-treatment.ConclusionAlthough in extensive use, the syndromic approach is unsuitable for diagnosing cervical infections in antenatal care attendees in Botswana. None of the evaluated risk scores can replace this management. Without diagnostic tests, there are no adequate management strategies for C trachomatis and N gonorrhoeae in pregnant women in Botswana, a situation which is likely to apply to other countries in sub-Saharan Africa. Screening for cervical infections in pregnant women is an essential public health measure, and rapid tests will hopefully be available in developing countries within a few years.

Trichomoniasis and bacterial vaginosis in pregnancy: inadequately managed with the syndromic approach

OBJECTIVEnTo measure the prevalence of Trichomonas vaginalis (TV) infection and bacterial vaginosis (BV) among pregnant women in Botswana, and to evaluate the syndromic approach and alternative management strategies for these conditions in pregnancy.nnnMETHODSnIn a cross-sectional study, 703 antenatal care attendees were interviewed and examined, and specimens were collected to identify TV, BV, Candida species, Chlamydia trachomatis and Neisseria gonorrhoeae. Information on reproductive tract infections earlier in pregnancy was obtained from a structured interview and the antenatal record.nnnFINDINGSnTV was found in 19% and BV in 38% of the attendees. Three-fourths of women with TV or BV were asymptomatic. Syndromic management according to the vaginal discharge algorithm would lead to substantial under-diagnosis and over-treatment of TV and BV. Signs of vaginal discharge were more predictive of the presence of these conditions than were symptoms. Among the 546 attendees on a repeat antenatal visit, 142 (26%) had been diagnosed with vaginal discharge earlier in their pregnancy--14 of them twice. In 143 cases, an attendee was diagnosed with vaginal discharge in the second or third trimester; however, metronidazole had been prescribed only 17 times (12%).nnnCONCLUSIONnDiagnosis and treatment of TV and BV among pregnant women in sub-Saharan Africa presents major challenges. Half the pregnant women in this study were diagnosed with TV or BV, but these conditions were not detected and treated during antenatal care with syndromic management. Also, health workers did not adhere to treatment guidelines. These results indicate that management guidelines for TV and BV in antenatal care should be revised.

Predictors of job satisfaction among doctors, nurses and auxiliaries in Norwegian hospitals: relevance for micro unit culture

ObjectiveTo explore what domains of work are important for job satisfaction among doctors, nurses and auxiliaries and to discuss differences between professional groups in the perspective of micro team culture.DesignCross-sectional survey data from hospital staff working clinically at inpatient hospital wards in Norway in 2000.MeasuresLinear regression models predicting job satisfaction for the three professions were compared. First, five domains of hospital work were examined for general job satisfaction. Based on the result of the first regression, five items concerning local leadership were explored in a second regression.ResultsA total of 1814 doctors, nurses and auxiliaries working at 11 Norwegian hospitals responded (overall response rate: 65%). The only domain of work that significantly predicted high job satisfaction important for all groups was positive evaluation of local leadership. Both steps of analyses suggested that professional development is most important for doctors. For registered nurses, experiencing support and feedback from the nearest superior was the main explanatory variable for job satisfaction. Job satisfaction of auxiliaries was equally predicted by professional development and local leadership. The results are discussed and interpreted as reflections of cultural values, loyalties and motivation.ConclusionThe professional values of medicine, the organizational and holistic skills of nurses and the practical experience of auxiliaries should all be valued in the building of interdependent micro teams.

Medical students’ cognitive and affective attitudes towards learning and using communication skills – a nationwide cross-sectional study

Aims: We wanted to explore cognitive and affective attitudes towards communication skills among students in Norwegian medical schools. Method: 1833 (60% response rate) medical students at the four medical schools in Norway filled in questionnaires by the end of term in May 2003. The Communication Skills Attitudes Scale (CSAS) was used for assessing affective and cognitive attitudes separately. Results and conclusions: Medical students have positive attitudes towards learning and using communication skills. Cognitive and affective attitudes displayed different patterns. Being female and having worked in the health services before admission to the medical school predicted more positive scores both towards cognitive and affective attitudes. Having worked as a junior doctor during medical school predicted more positive cognitive attitudes. Cognitive attitudes towards communication skills did not vary significantly between year groups in any of the medical schools. Scores reflecting affective attitudes gradually fell for each year in all schools, but rose again in the final year in two of them. Implications for curriculum design are discussed.

Which is the best method to trace group A streptococci in sore throat patients: culture or GAS antigen test?

Objective – To compare an antigen detection test (GAS antigen test) with the results from combinations of two various bacteriological test media in general practice patients with sore throat. Furthermore to assess the diagnostic properties of the chosen GAS antigen test and to compare semi-quantitative results of this test with the bacterial load found in the throat culture. Setting – Two Norwegian general practices in Stokke and Kongsberg communities. Subjects – 306 patients with sore throat lasting less than 7 days; 244 were adults, 62 were children under 10 years old, mean age 23.9 years (SD 15.0), 40% were men. Main outcome measures – Results from GAS antigen test, and distribution of bacteriological findings in throat cultures, compared with the results of our GAS antigen test; semi-quantitative results of the GAS antigen test compared with the bacterial load by culture. Results – In the primary culture 110 patients harboured group A streptococci (GAS) infection, while the second culture identified another 17, giving a total of 127 patients. Some 33 patients harboured large-colony groups C and G. The GAS antigen test used had a sensitivity of 97% and specificity of 95% regarding GAS when compared with the two cultures. We found a significant correlation between the bacterial loads by culture and the semi-quantitative results of the GAS antigen test. Conclusions – By using a second, different set of bacteriological media, we identified an additional 17 patients with GAS infections. This raises the question of validity of frequently used reference standards in studies related to streptococcal infections. Compared with the combined results of the two throat cultures, the GAS antigen test used showed high sensitivity and specificity. Semi-quantitative evaluations of the rapid immunological test may also be of clinical value.