Metaphorically transmitted diseases. How do patients embody medical explanations?

BACKGROUND: The examination was guided by recent theories on metaphors, holding that our conception of the physical world in many ways derives from personal bodily experiences. Such experiences are fundamental to the elaboration of abstract structures of meaning, which, through metaphorical projections, provide a constitutive role in our overall comprehension of the world. It is thus to be assumed that patients will bring their own cluster of metaphors into the consultation room to structure the doctor's explanations. Our study was an attempt to identify some manifestations of this work of structuring and to learn about its consequences for interpersonal communication between patient and doctor. OBJECTIVE: The aim of this study was to examine how, and to what extent patients in a general practice understand pathoanatomical and pathophysiological disturbances as explanations of their illness. METHOD: The empirical basis of the study comprised interviews with a group of patients from a general practice, who were asked to narrate their understanding of medical disturbances. Based on these interviews we identified and classified a number of metaphors they used to describe bodily problems and relations. A deviating mechanical understanding of the body, which we characterize as ethnomechanics, was manifest in all the interviews. This understanding is expanded upon and its significance discussed. Although patients do not feel qualified to understand scientific explanations of their health problems, they do relate to a scientific disease mode of understanding. They do not, however, relate to the fine details and professional implications of this mode. Instead they will associate medical explanations with their pre-established, illness-based system of understanding through imaginative projections. CONCLUSIONS: Doctors need to be aware that patients possess such imaginative and experiential resources to make sense of medical explanations. Attempts to draw patients radically away from these resources may cause confusion and undesired breakdowns in the communication between them and their physician.

[Methaphors and understanding of diseases]. / Metaforer og sygdomsforståelse.

In the recent two decades it has been argued that our language and sense of reality is radically structured by metaphors. Metaphors are not just figurative expressions of existing similarities, but can create such similarities. Certain metaphors (root metaphors) may convey new world views and thus underpin new theoretical formations. The article goes through a series of metaphorical descriptions of illness, and elaborates on the importance of metaphors for medical communication and language-use. The significance of the metaphors for communication between physician and patient is lined out, and it is described how the use and subsequent rendering of metaphors from two different structures of understanding may lead to serious misapprehension.

[Diagnosis and treatment of conjunctivitis]. / Diagnostik og behandling af conjunctivitis.

Conjunctivitis is a frequent reason for consulting a doctor. Most often treatment consists of antibiotics, even though sensitive bacteria are only rarely demonstrated. In our part of the world conjunctivitis is self-limiting, and it may be worth considering the effect of treatment, if any. With this in mind, diagnosis and differential diagnoses are reviewed and with regard to treatment distinctions are made between neonatal conjunctivitis (gonococcus, chlamydia, virus), conjunctivitis in children (symptoms of upper respiratory tract infections), and conjunctivitis in adults and the elderly (dry eyes, epiphora in ectropion).

[Diagnosis and treatment of conjuncitivitis]. / Diagnostik og behandling af conjunctivitis.

Conjunctivitis is a frequent reason for consulting a doctor. Most often treatment consist of antibiotics, even though sensitive bacteria are only rarely demonstrated. In our part of the world conjunctivitis is self-limiting, and it may be worth considering the effect of treatment, if any. With this in mind, diagnosis and differential diagnoses are reviewed, and with regard to treatment distinctions are made between neonatal conjunctivitis (gonococcus, chlamydia, virus), conjunctivitis in children (symptoms of upper respiratory tract infections), and conjunctivitis in adults and the elderly (dry eyes, epiphora in ectropion).

The effect of reimbursement on the use of antibiotics.

OBJECTIVE: To examine the effect of a reduction on the reimbursement of drugs on the use of antibiotics by general practitioners in Denmark. DESIGN: A prospective study using a questionnaire comparing the results with a similar study 3 years before, a period with normal reimbursement. PARTICIPANTS: 553 general practitioners prescribed antibiotics for 5765 patients. MAIN OUTCOME MEASURE: Number of treated patients and choice of antibiotics. RESULTS: 7607 patients were treated in 1987 compared with 5765 in 1990, the relative number of patients treated for sinusitis, other upper respiratory tract infections, acute bronchitis, pneumonia and upper gynaecological infections was significantly less in 1990 than in 1987. Other infections, particularly those that are often diagnosed by culture or microscopy by the general practitioners themselves, increased significantly. They included tonsillitis and urinary tract infections. CONCLUSION: Reimbursement can be a very powerful tool controlling the use of antibiotics by general practitioners.

[General practitioners are carrying a heavy load of work, but they are satisfied with their choice of profession]. / Praktiserende laeger er belastede af arbejdsvilkår, men tilfredse med erhvervsvalget.

Seven hundred and seventy-six general practitioners (GPs) sampled randomly from the list of GPs in Denmark were asked about job satisfaction and professional attitudes by questionnaire. The majority (four-fifth) felt that they would decide to become GPs if they were to choose again. On the other hand, two-thirds complained about a workload which had negative effects on their family life. Low job satisfaction was associated with a preference for public employment instead of the current system of private practice. Dissatisfied GPs tended to believe that patients have too great expectations and present problems that they ought to solve themselves. They, also, felt that daily work didn't leave time for preventive medicine and they felt anxiety because of the risk of overlooking serious diseases.

Changes in prescription of antibiotics in general practice in relation to different strategies for drug information.

The worldwide use of antibiotics is increasing with increasing costs and resistant bacteria as a consequence. The Danish use of antibiotics is one of the lowest in DDD/1,000 inhabitants/year; however, the use of ampicillin and co-trimoxazole has been found to be too high. An information campaign in the beginning of 1987, using written material, stressed the importance of reducing the ampicillin and co-trimoxazole and increasing the penicillin usage in Denmark. This campaign was followed up by 10 lectures given by the same person in two (I and II) of the five counties of Zealand, Denmark. In county I, the lectures were given in meetings arranged by the local department of clinical microbiology. In county II, the lectures were given at meetings sponsored by a pharmaceutical company. The prescribing habits were generally changed significantly. In county I, the changes were significantly higher compared with counties only receiving written material. In county II, the prescribing habits did not change further compared with the counties only receiving written material. It is concluded that face-to-face information can improve the efficacy of written information, but sponsorship by pharmaceutical companies may weaken this efficacy.

The role of thyroid tests in handling of patients in general practice. A phenomenologic study.

During a period of 2 months thyroid function tests, performed on out-patients referred to the laboratory from general practitioners, were studied. The relative informative value of the tests was estimated in relation to the reasons given for requesting the tests. In 86% of the samples from patients with no history of earlier thyroid disease the conventional thyroid tests were found within the reference intervals. 3% showed a definite abnormal pattern of values. In 11% the results were in some way abnormal. In the group of patients with earlier history of thyroid disease 50% of the tests were abnormal. The relative merits of adding a sensitive TSH assay test were analyzed, and it was estimated whether using the sensitive TSH as a first-line discrimination test would add or subtract information compared to the conventional thyroid function tests. It was concluded that in the situation where the general practitioner wants laboratory information of thyroid parameters on patients in order to make decisions on the further handling of the patient, the sensitive TSH test is of limited value as a first-line discrimination test and should be supplemented by other tests.

An information campaign--an important measure in controlling the use of antibiotics.

Denmark is one of the countries using the smallest quantity of antibiotics in proportion to its population. Nevertheless, the use of ampicillin and co-trimoxazole has been found to be undesirably high. An information campaign was carried out to reduce the ampicillin and co-trimoxazole usage and to increase the penicillin usage as a consequence. To evaluate the efficacy of the campaign 602 general practitioners participated in the study, and the antibiotic treatment of 7607 patients, treated in week 13 in 1987, was recorded. These prescriptions were compared with the prescriptions recorded in two previous but identical investigations in 1979 and in 1983. The prescribing habits had changed significantly after the information campaign, resulting in national savings of two million Danish kroner/million inhabitants/year. Information could be an important measure in controlling the worldwide use of antibiotics.

[Primary health services in China]. / Primaer sundhedstjeneste i Kina.

PIP: The authors visited China in 1988 as part of a delegation of Danish physicians invited by Chinese medical authorities to visit Chinese colleagues and study China's health care system. The group visited installations in Laichou, a region with approximately 860,000 inhabitants on the Yellow Sea. The roughly 1000 villages have 33 hospitals with a total of 975 beds, a maternity center and 1034 rural health stations. The inhabitants have an average of 7-8 contracts with the health station/year -- nearly double the rate of Danes, even counting telephone contacts. Physical complaints are the most frequent, not surprising in an area where heavy physical field work is performed usually without the help of machines. Health station workers are employed by the village committee which pays 70% of the costs. Patients pay 30%. They can handle hygienic problems and health problems common in their area, for example, certain infections as well as premarital health checkups to ascertain that the prospective parents are healthy and do not suffer from genetic diseases. The center also offers contraceptives. When a woman becomes pregnant, she is offered regular health care examinations at the center or at the local health station, some of which offer amniotic testing. Births usually take place at the center.^ieng

Differences in referral rates from general practice.

There are many unexplained differences in the rates at which general practitioners make referrals to other medical specialists. This study investigated 17,586 referrals from 141 general practitioners to specialists in seven specialties in Ringkjøbing county in Denmark. As an expression of the referral rate, a referral index was estimated for every general practitioner. The referral index was the number of referrals to the specialist per 1000 patients per year, including children, standardized for age and sex to the average population in Ringkjøbing county. The following six variables were evaluated in relation to the referral index: specialists in the local area, doctors per practice, consultations per general practitioner per year, patients registered, consultations per 1000 patients per year standardized for age and sex, and supplementary procedures per consultation. Stepwise multiple regression analysis was used. The study showed that the referral index rose both with a better access to specialist and with an increasing number of consultations per practitioner per year. The referral index fell with increased numbers of patients registered. No correlation was found between the referral index and number of supplementary procedures per consultation, number of doctors per practice and number of consultations per 1000 patients per year.

Use of antibiotics in general practice in Denmark in 1987.

The worldwide usage of antibiotics is increasing making detailed information on prescribing patterns and intervention methods necessary. This investigation focused on the general practitioner's (GP's) usage of antibiotics in Denmark. Information on 7,607 patients treated by 602 GP's during 1 week in March 1987 were collected. The most commonly treated infectious diseases were upper respiratory tract infections (40%) and lower respiratory tract infections (17%). Penicillin was by far the most frequently prescribed antibiotic (44%), followed by antibiotics used locally (17%) and ampicillins (14%). Compared with previous investigations, this result indicated a relative increase in prescription of penicillin during recent years. The mean number of daily dosages was 2-3 and the duration of treatment 6-7 days, with ampicillin generally given 1 day longer than penicillin. The differences between prescribed daily dosages (PDD) found and defined daily dosages (DDD) ranged from + 40% to - 50%, making estimations of numbers of treated patients from total usage of antibiotics in DDD/1,000 inhabitants/day impossible.

Variation in use of penicillin for treatment of sinusitis in general practice.

The present study describes the use of phenoxymethylpenicillin and broad-spectrum penicillin for the treatment of sinusitis in general practice, in relation to some variables related to the prescribing doctors: region (county), practice form (single-handed or partnership), and the doctors' seniority (year of graduation). Log-linear analysis was used to make it possible to evaluate the influence of single factors. There was considerable variation between the counties included in the study. Practitioners in partnership practices used phenoxymethylpenicillin more frequently and broad-spectrum penicillin less frequently in the treatment of patients with sinusitis, compared with their colleagues in single-handed practices. Younger practitioners chose broad-spectrum penicillin more frequently and phenoxymethylpenicillin less frequently than their older colleagues. The individual practitioner was rather stable in his choice of drug for the treatment of consecutive patients with the same diagnosis.