Relationship based care - how general practice developed and why it is undermined within contemporary healthcare systems.

Objective: Investigating the state of generalism in medicine from the outlook of general practice. Line of argument: General practice developed when its pioneers, in continuing relationships, learnt to know their patients through the variety of medical situations. From the 50s, there is an increasing literature on the virtues and challenges of relationship based general practice, and register-based research indicate its benefits. Generalist perspectives and person-centeredness are implemented in specialised care and medical education but need to be complemented by an input from relationship based general practice. The politically defined aim of primary care is not to balance the draw-backs of specialisation, but to provide medicine at the primary care level. In Sweden, and increasingly even in traditional strongholds of general practice, team-based primary care is thought to respond to increasing demands, filtering out non- and minor disease through triage, practicing task distribution, and moving the GP to a secondary level working with the 'really sick', in all a decline in direct contact between patient and GP. Conclusions: When this happens, clinical medicine as a whole becomes drained of the practice of its human dimension. The lack of absolute proof of medical benefits cannot justify a disregard of the value of mutual knowledge and trust in the relationship, but still, in several countries, relationshipbased general practice will be hard to achieve for GPs planning their career. If the political winds should change, a sustaining profession of GPs preserving their relational ethos inside the team model, may be prepared to reform primary care. KEY POINTS Proclaiming both biomedical breadth and the trustful relationship between doctor and patient, as a specialty, general practice embodies medical generalism. A direct input from the patient's personal GP is necessary to make specialised care become more comprehensive and individualised. In reality, the team, practicing triage and task distribution, is increasingly replacing the doctor-patient relationship as working mode in primary care When the disease rather than the doctor-patient relationship, becomes the organising principle of primary care, medicine as a whole will be drained of the practice of its human dimension.

Patient participation in decision-making about cardiovascular preventive drugs - resistance as agency.

OBJECTIVE: The aim of the study was to describe and explore patient agency through resistance in decision-making about cardiovascular preventive drugs in primary care. DESIGN: Six general practitioners from the southeast of Sweden audiorecorded 80 consultations. From these, 28 consultations with proposals from GPs for cardiovascular preventive drug treatments were chosen for theme-oriented discourse analysis. RESULTS: The study shows how patients participate in decision-making about cardiovascular preventive drug treatments through resistance in response to treatment proposals. Passive modes of resistance were withheld responses and minimal unmarked acknowledgements. Active modes were to ask questions, contest the address of an inclusive we, present an identity as a non-drugtaker, disclose non-adherence to drug treatments, and to present counterproposals. The active forms were also found in anticipation to treatment proposals from the GPs. Patients and GPs sometimes displayed mutual renouncement of responsibility for decision-making. The decision-making process appeared to expand both beyond a particular phase in the consultations and beyond the single consultation. CONCLUSIONS: The recognition of active and passive resistance from patients as one way of exerting agency may prove valuable when working for patient participation in clinical practice, education and research about patient-doctor communication about cardiovascular preventive medication. We propose particular attentiveness to patient agency through anticipatory resistance, patients' disclosures of non-adherence and presentations of themselves as non-drugtakers. The expansion of the decision-making process beyond single encounters points to the importance of continuity of care. KEY POINTS Guidelines recommend shared decision-making about cardiovascular preventive treatment. We need an understanding of how this is accomplished in actual consultations.This paper describes how patient agency in decision-making is displayed through different forms of resistance to treatment proposals. •The decision-making process expands beyond particular phases in consultations and beyond single encounters, implying the importance of continuity of care. •Attentiveness to patient participation through resistance in treatment negotiations is warranted in clinical practice, research and education about prescribing communication.

GPs' decision-making--perceiving the patient as a person or a disease.

BACKGROUND: The aim of this study was to analyse the clinical decision making strategies of GPs with regard to the whole range of problems encountered in everyday work. METHODS: A prospective questionnaire study was carried through, where 16 General practitioners in Sweden registered consecutively 378 problems in 366 patients. RESULTS: 68.3% of the problems were registered as somatic, 5.8% as psychosocial and 25.9% as both somatic and psychosocial. When the problem was characterised as somatic the main emphasis was most often on the symptoms only, and when the problem was psychosocial main emphasis was given to the person. Immediate, inductive, decision-making contrary to gradual, analytical, was used for about half of the problems. Immediate decision-making was less often used when problems were registered as both somatic and psychosocial and focus was on both the symptoms and the person. When immediate decision-making was used the GPs were significantly more often certain of their identification of the problem and significantly more satisfied with their consultation. Rules of thumb in consultations registered as somatic with emphasis on symptoms only did not include any reference to the individual patient. In consultations registered as psychosocial with emphasis on the person, rules of thumb often included reference to the patient as a known person. CONCLUSIONS: The decision-making (immediate or gradual) registered by the GPs seemed to have been adjusted on the symptom or on the patient as a person. Our results indicate that the GPs seem to recognise immediately both problems and persons, hence the quintessence of the expert skill of the GP as developed through experience.

How does the thought of cancer arise in a general practice consultation? Interviews with GPs.

BACKGROUND: Only a few patients on a GP's 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 doctor's accuracy in perceiving and interpreting cues were decisive.

"I did not intend to stop. I just could not stand cigarettes any more." A qualitative interview study of smoking cessation among the elderly.

BACKGROUND: Every year, more than 650,000 Europeans die because they smoke. Smoking is considered to be the single most preventable factor influencing health. General practitioners (GP) are encouraged to advise on smoking cessation at all suitable consultations. Unsolicited advice from GPs results in one of 40-60 smokers stopping smoking. Smoking cessation advice has traditionally been given on an individual basis. Our aim was to gain insights that may help general practitioners understand why people smoke, and why smokers stop and then remain quitting and, from this, to find fruitful approaches to the dialogue about stopping smoking. METHODS: Interviews with 18 elderly smokers and ex-smokers about their smoking and decisions to smoke or quit were analysed with qualitative content analysis across narratives. A narrative perspective was applied. RESULTS: Six stages in the smoking story emerged, from the start of smoking, where friends had a huge influence, until maintenance of the possible cessation. The informants were influenced by "all the others" at all stages. Spouses had vital influence in stopping, relapses and continued smoking. The majority of quitters had stopped by themselves without medication, and had kept the tobacco handy for 3-6 months. Often smoking cessation seemed to happen unplanned, though sometimes it was planned. With an increasingly negative social attitude towards smoking, the informants became more aware of the risks of smoking. CONCLUSION: "All the others" is a clue in the smoking story. For smoking cessation, it is essential to be aware of the influence of friends and family members, especially a spouse. People may stop smoking unplanned, even when motivation is not obvious. Information from the community and from doctors on the negative aspects of smoking should continue. Eliciting life-long smoking narratives may open up for a fruitful dialogue, as well as prompting reflection about smoking and adding to the motivation to stop.

Physicians' messages in problematic sickness certification: a narrative analysis of case reports.

BACKGROUND: Many physicians find sickness certification tasks problematic. There is some knowledge about situations that are experienced as problematic, whereas less is understood about how physicians respond to the problems they face. One way to acquire such knowledge is to consider "reflection-in-action", aspects of which are expressed in the physician's interpretation of the patient's story. The aim of this study was to gain knowledge about the meaning content of case reports about problematic sickness certification. Specifically, we looked for possible messages to the colleagues intended to read the reports. METHODS: A narrative approach was used to analyse reports about problematic sickness certification cases that had been written by GPs and occupational health service physicians as part of a sickness insurance course. The analysis included elements from both thematic and structural analysis. Nineteen case reports were used in the actual analysis and 25 in the validation of the results. Main narrative qualities and structural features of the written case reports were explored. RESULTS: Five types of messages were identified in the case reports, here classified as "a call for help", "a call for understanding", "hidden worries", "in my opinion", and "appearing neutral". In the reports, the physicians tried to achieve neutrality in their writing, and the patients' stories tended to be interpreted within a traditional biomedical framework. In some cases there was an open request for help, in others it was not obvious that the physician had any problems. Overall, the messages were about having problems as such, rather than the specific features of the problems. CONCLUSIONS: The case reports clearly demonstrated different ways of writing about problems that arise during sickness certification, from being neutral and not mentioning the problems to being emotionally involved and asking for help. The general character of the messages suggests that they are also relevant for case reports in problematic areas other than sickness certification. If pertinent relationships can be found between reflection-in-practice and the narrative writing about practice, they will provide an approach to further research concerning consultations perceived as problematic and also to medical education.

Leadership in rural medicine: the organization on thin ice?

OBJECTIVE. To explore the personal experiences of and conceptions regarding leading rural primary care in Northern Norway. DESIGN. Qualitative content analysis of focus-group interviews. SETTING. Lead primary care physicians in the three northernmost counties. Subjects. Four groups with 22 out of 88 municipal lead physicians in the region. RESULTS. Three main categories were developed and bound together by an implicit theme. Demands and challenges included the wide leadership span of clinical services and public health, placed in a merged line/board position. Constraints of human resources and time and the ever changing organizational context added to the experience of strain. Personal qualifications indicates the lack of leadership motivation and training, which was partly compensated for by a leader role developed through clinical undergraduate training and then through the responsibilities and experiences of clinical work. In Exercising the leadership, the participants described a vision of a coaching and coordinating leadership and, in practice, a display of communication skills, decision-making ability, result focusing, and ad hoc solutions. Leadership was made easier by the features of the small, rural organization, such as overview, close contact with cooperating partners, and a supportive environment. There was incongruence between demands and described qualifications, and between desired and executed leadership, but nevertheless the organization was running. Leadership demonstrated a "working inadequacy". CONCLUSION. Under resource constraints, leadership based on clinical skills favours management by exception which, in the long run, appears to make the leadership less effective. Leadership training which takes into account the prominent features of rural and decentralized primary care is strongly needed.

Usability of computerised physician order entry in primary care: assessing ePrescribing with a new evaluation model.

BACKGROUND: The incorrect use of medications may result from improper prescribing. The poor interface and design of computerised physician order entry (CPOE) systems may contribute. To improve the quality of electronic drug prescription, ePrescribing, there is a need for an evaluation model that is able to assess the quality of the CPOE, focusing on usability. OBJECTIVE: To develop and apply a model to evaluate the usability of different CPOEs used for ePrescribing in electronic health records (EHRs) in primary care. METHOD: An evaluation model for CPOEs was designed by assembling existing quality criteria for ePrescribing, supplemented with new criteria. The evaluation model was used to assess CPOEs from seven EHRs in primary care. RESULTS: The evaluation model included five categories comprising 73 single criteria. The model was found to be easy to use, and facilitated the assessment process. Evaluation of the EHRs revealed differences and similarities between the systems. None of the CPOEs was perfect in that all of them had distinct shortcomings. The most prominent deficiencies were a non-intuitive interface and incorrect dosage function. CONCLUSION: The model developed might be used not only to evaluate usability in ePrescribing, but also as a basis for studying the usability of other CPOEs. To reduce the risk of drugs being prescribed with incorrect dosages, the most urgent improvement is the development of a more consistent and intuitive interface for the EHRs and an improvement in the dosage function.

Dealing with being prescribed cardiovascular preventive medication: a narrative analysis of qualitative interviews with patients with recent acute coronary heart disease in Sweden.

OBJECTIVE: To explore how patients with experience of acute coronary heart disease make sense of, and deal with, the fact of being prescribed cardiovascular preventive medication. DESIGN: Qualitative interview study. SETTING: Swedish primary care. PARTICIPANTS: Twenty-one participants with experience of being prescribed cardiovascular preventive medication, recruited from a randomised controlled study of problem-based learning for self-care for coronary heart disease. METHODS: The participants were interviewed individually 6-12 months after their hospitalisation for acute coronary disease. A narrative analysis was conducted of their accounts of being prescribed cardiovascular preventive medication. RESULTS: Four themes shape the patients' experiences: 'A matter of living' concerns an awareness of the will to live linked to being prescribed cardiovascular preventive medication regarded in the light of the recent hospitalisation. In 'Reconciliation of conflicting self-images', patients dealt with being prescribed preventive medication through work to restore an identity of someone responsible in spite of viewing the taking of medication as questionable. The status of feeling healthy, while being someone in need of medication, also constituted conflicting self-images. Following this, taking medication was framed as necessary, not as an active choice. 'Being in the hands of expertise' is about the seeking of an answer from a reliable prescriber to the question: 'Is this medication really necessary for me?' Existential labour was done to establish that the practice of taking cardiovascular preventive medication was an inevitable necessity, rather than an active choice. 'Taking medicines no longer a big deal' could be the resulting experience of this process. CONCLUSIONS: Unmet existential needs when being prescribed cardiovascular preventive medication seem to be a component of the burden of treatment. A continuous and trustful relationship with the prescribing doctor may facilitate the reconciliation of conflicting self-images, and support patients in their efforts to incorporate their medicines taking into daily life.

A doctor close at hand: How GPs view their role in cancer care.

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.

'We got the whole story all at once': physiotherapists' use of key questions when meeting patients with long-standing pain.

Long-standing musculoskeletal pain has many dimensions. Physiotherapy lacks a tested method of dialogue with which physiotherapists and patients can together explore pain in all its complexity. The present aim was to find out how physiotherapists experienced the influence of systematically prepared key questioning on their relation to, and understanding of, patients with long-standing pain. A group of six physiotherapists with long experience of pain rehabilitation used such questions in their encounters with their patients. Two periods of work with the questions were followed by discussions in which the physiotherapists shared their experience in a joint focus group. Verbatim transcripts of the discussions constitute the data of the study. A phenomenographic method was used for the analysis. The responses to the key questions gave the physiotherapists an insight into the patient as a person. The questions started a process of change in the patient, and changed the physiotherapist's relation to her or him. The patient expressed feelings and experience, and this also seemed to encourage a change in chosen coping strategies. This new content of the interaction challenged the physiotherapist's role, thus raising questions about her professional mandate.

To make a difference--how GPs conceive consultation outcomes. A phenomenographic study.

BACKGROUND: Outcomes from GPs' consultations have been measured mainly with disease specific measures and with patient questionnaires about health, satisfaction, enablement and quality. The aim of this study was to explore GPs' conceptions of consultation outcomes. METHODS: Interviews with 17 GPs in groups and individually about consultation outcomes from recently performed consultations were analysed with a phenomenographic research approach. RESULTS: The GPs conceived outcomes in four ways: patient outcomes, GPs' self-evaluation, relationship building and change of surgery routines. CONCLUSION: Patient outcomes, as conceived by the GPs, were generally congruent with those that had been taken up in outcome studies. Relationship building and change of surgery routines were outcomes in preparation for consultations to come. GPs made self-assessments related to internalized norms, grounded on a perceived collegial professional consensus. Considerations of such different aspects of outcomes can inspire professional development.

Characteristics of sick-listing cases that physicians consider problematic--analyses of written case reports.

OBJECTIVE: The aim was to discern common characteristics in the sick-listing cases that physicians in general practice and occupational health services find problematic. DESIGN: Descriptive categorization within a narrative theoretical framework. SETTING: Sickness-insurance course for physicians in general practice and occupational health services. SUBJECTS: A total of 195 case reports written by 195 physicians. Main outcome measures. Categories of features regarding medical, work, and social situation as well as medical interventions. RESULTS: Beside age and sex, the following information was often provided: family situation, stressful life events, occupation, problem at work, considerations concerning diagnoses, medical investigations, treatments, and vocational rehabilitation measures. Two-thirds of the patients had been sickness absent for more than a year. The most common type of case reports concerned women, employed in non-qualified nursing occupations, and sick listed due to mental disorders. The most common measures taken by the physicians were referrals to psychotherapy and/or physiotherapy, and prescribing antidepressants (SSRI). Facts about alcohol habits were rarely provided in the cases. CONCLUSIONS: Some of the circumstances, such as prolonged sick-listing, are likely to be more or less inevitable in problematic sick-listing cases. Other circumstances, such as stress-full life events, more closely reflect what the reporting physicians find problematic. The categories identified can be regarded as markers of problematic sick-listing cases in general practice and occupational health service.

Hormone Use is Associated with Lymphovascular Invasion in Breast Cancer.

BACKGROUND: Risk of developing breast cancer increases with short breastfeeding and the use of hormones. The prognosis of breast cancer is better if the tumours are hormone receptor positive. Since breast feeding affects estrogen and progesterone receptors, we wanted to investigate how such reproductive factors as breastfeeding and the use of hormones interact with known prognostic markers and specific tumour characteristics in women with breast cancer. MATERIALS AND METHODS: A total of 250 women treated for breast cancer from a larger cohort completed a questionnaire on breastfeeding, number and age at births and use of hormones. A logistic regression analysis was made to search for connections between known prognostic markers on the one hand (type of cancer, grade, tumor size, estrogen receptor and progesterone receptor, lymphovascular invasion and DNA-ploidy) and reproductive data, breastfeeding, and hormone use on the other. RESULTS AND CONCLUSIONS: Hormone use, but not breastfeeding, was significantly associated, also on multivariate analysis, with the prognostic variable lymphovascular invasion, connected to a worse prognosis. No other hormone use or breast feeding correlations with prognostic variables were found.

Breastfeeding Associated with Reduced Mortality in Women with Breast Cancer.

OBJECTIVE: To study whether breastfeeding affects survival from breast cancer. BACKGROUND: There are few studies on the relationship between breastfeeding, reproductive health, and breast cancer survival. This study is a follow-up of an earlier study showing no convincing associations between breastfeeding and breast cancer prognostic parameters. METHODS: From a cohort of 629 women with primary breast cancer having undergone surgery between 1988 and 1992, 341 were traced and consequently studied 20 years later regarding breastfeeding and reproductive variables, as well as for prognostic parameters such as the Nottingham histological grade, tumor size, lymph node status, and vascular invasion (VI). Multivariate Cox regression analyses were used. RESULTS: Increased breast cancer mortality was associated with the Nottingham prognostic index (hazard rate ratio (HR) 4.47; 95% confidence interval (CI) 2.04-9.79), VI (HR 3.44; CI 2.03-5.82), fewer pregnancies (three categories; >2, 1-2, 0) (HR per category 2.04; CI 1.34-3.11), and breastfeeding ≤6 months (HR 2.74; CI 1.41-5.35). The HRs for overall mortality were, as expected, lower for the Nottingham prognostic index (HR 1.28; CI 0.89-1.85) and VI (HR 2.09; CI 1.38-3.17), and they were slightly lower for the number of pregnancies (HR 1.61; CI 1.48-4.59), but notably similar for breastfeeding (HR 3.01;CI 1.92-4.73). CONCLUSION: A total breastfeeding history >6 months and pregnancy are associated with both greater overall and breast cancer-specific survival for women diagnosed with breast cancer, having lived long enough for other causes of death to contribute substantially to mortality.

Satisfaction is not all--patients' perceptions of outcome of general practice consultations, a qualitative study.

BACKGROUND: Evaluation of outcome in general practice can be seen from different viewpoints. In this study we focus on the concepts patients use to describe the outcome of a consultation with a GP. METHOD: Patients were interviewed within a week after a consultation with a GP. The interviews were made with 20 patients in 5 focus groups and 8 individually. They were analysed with a phenomenographic research approach. RESULTS: From the patient's perspective, the outcome of a consultation is about cure or symptom relief, understanding, confirmation, reassurance, change in self-perception and satisfaction. CONCLUSION: General practice consultations are often more important for patients than generally supposed. Understanding is the most basic concept.

["Not the doctor's pigeon"--a common dilemma in sick-listing consultations]. / "Inte doktorns bord"--ett vanligt dilemma i sjukskrivningskonsultationer.

The role played by doctors in the high sick-listing figures is a subject of vigorous discussion. The point of departure for the course "The generalpractitioner and the medical certificate" is that the doctor can combine concern for the patient with objective assessment. With the course participants' own sick-listing cases as material, it has been possible to categorize the difficulties. One such category is "Not the doctor's pigeon", when the doctor sees that the patients' problems concerning sick-listing would be better handled by, for example, the employer, the employment office, the social insurance office, or the patient himself. The categories found can be regarded as a practical support for the doctor in considering and discovering alternative actions.

Touch and relate: body experience among staff in habilitation services.

In habilitation centres staff meet children with different impairments, children who need extensive support and training while growing up. A prevailing biomedical view of the body in habilitation services is gradually becoming supplemented by a perspective on the body as constantly involved in experiencing and communicating, the latter involving also the bodies of the therapists. Investigating body experience in habilitation staff in their encounters with the children may provide concepts that make it easier to reflect on what is going on in the interaction. When shared among larger number of peers and supported by further research in the field, reflected body experience may become a substantial aspect of professional self-knowledge. Our aim with this study was to contribute to the understanding of what it means to be a body for other bodies in the specific relational context of child habilitation, and more specifically to investigate what role the therapists' body experience may play for professional awareness and practice. In the study, five physiotherapists and three special-education teachers spoke of physical and emotional closeness (the body as affection) but also of a provoking closeness (the body as provoked) with the children and of how their own body experience made them more attentive to the children's experience (the body as reference). Situations that included bodily limitations (the body as restriction) were described, as were situations where the body came into focus through the gazes of others or one's own (the body as observed). The body was described as a flexible tool (the body as tool), and hands were given an exclusive position as a body part that was constantly communicating. Three shifts of intentionality that form a comprehensive structure for this body experience were discerned. When professional reflection is evoked it may further body awareness, deepen reflection in practice and strengthen intercorporeality.