Discovering strengths in patients with medically unexplained symptoms - a focus group study with general practitioners.

BACKGROUND: When patients suffer medically unexplained symptoms, consultations can be difficult and frustrating for both patient and GP. Acknowledging the patient as a co-subject can be particularly important when the symptoms remain unexplained. One way of seeing the patient as a co-subject is by recognizing any among their strong sides. OBJECTIVES: To explore GPs' experiences with discovering strengths in their patients with medically unexplained symptoms and elicit GPs' reflections on how this might be useful. METHODS: Four focus-groups with 17 GPs in Norway. Verbatim transcripts from the interviews were analyzed by systematic text condensation. RESULTS: Recollecting patients' strengths was quiet challenging to the GPs. Gradually they nevertheless shared a range of examples, and many participants had experienced that knowing patients' strong sides could make consultations less demanding, and sometimes enable the GP to provide better help. Identifying strengths in patients with unexplained symptoms required a deliberate effort on the GPs' behalf, and this seemed to be a result of a strong focus on biomedical disease and loss of function. CONCLUSIONS: Acknowledging patients' strong sides can bolster GPs' ability to help patients with medically unexplained symptoms. However, the epistemic disadvantage of generalist expertise makes this hard to achieve. It is difficult for GPs to integrate person-centered perspectives with biomedical knowledge due to the privileged position of the latter. This seems to indicate a need for system-level innovations to increase the status of person-centered clinical work. Key pointsMUS is challenging for both patients and GPs mainly because of the incongruence between symptoms and the dominating biomedical model.GPs' focus on pathology and loss of function can prevent them from discovering patients' strengths.Awareness of patients' strengths can make consultations less demanding for GPs and enable them to provide better help.A conscious effort is needed to discover patients' strengths.

How can task shifting put patient safety at risk? A qualitative study of experiences among general practitioners in Norway.

Objective: To describe experiences among general practitioners (GPs) in Norway regarding horizontal task shifting experiences associated with adverse events that potentially put patient safety at risk.Design and contributors: We conducted a qualitative study with data from a retrospective convenience sample of consecutive, already posted comments in a restricted Facebook group for GPs in Norway. The sample consisted of 43 unique posts from 38 contributors (23 women and 15 men), presenting thick and specific accounts of potentially adverse events in the context of horizontal task shifting. Analysis was conducted with systematic text condensation, a method for thematic cross-case analysis.Results: Contributing GPs reported several types of adverse events associated with horizontal task shifting that could put patient safety at risk. They described how spill-over work dispatched to GPs may generate administrative hassle and hazardous delay of necessary examinations. Overdiagnosis, reduced access and endangered accountability occur when time-consuming procedures and pre-investigation before referral are pushed upon GPs. Resource-draining chores beyond GPs' proficiency is also dispatched without appropriate instruction or equipment. Furthermore, potential malpractice is imposed by hospital colleagues who overrule the GPs' medical judgement.Implications: Patient safety is endangered when horizontal task shifting is initiated and performed without a systematic process involving all stakeholders that considers available resources. A risk and vulnerability analysis, securing competent staff, resources, time and equipment before launching such reforms is necessary to protect patient safety. Infrastructure comprised of local coordination groups may facilitate dialogue between health care service levels and negotiate responsibilities and workload.Key pointsTask shifting between different levels of health care is a relevant and legitimate strategy for planning and policy.GPs in Norway report adverse events related to task shifting from specialist colleagues without proper resource allocation.Patient safety may be put at risk by hazardous delay, overdiagnosis, endangered accountability and potential malpractice.Planning and implementation of task shifting must involve all system levels and relevant stakeholders to ensure patient safety.

Independent medical evaluation for sick-listed workers in Norway: A focus group study of the experience of IME doctors.

BACKGROUND: Norwegian politicians have proposed the use of an independent medical evaluation (IME) as a possible solution for reducing long-term sick leave. The use of an IME implies that a new doctor interferes in the relationship between sick-listed workers and their general practitioner (GP). The aim of the current study was to explore experiences of IME doctors from an ongoing randomized controlled trial (the NIME trial evaluating the effect of IME in Norway). METHODS: Two focus group interviews were conducted with eight of the nine IME doctors employed in the NIME trial. The discussions were audio-taped and transcribed. Systematic text condensation was used for analysis. RESULTS: The participants reported that the IME provides important second opinions, which they felt empowered the sick-listed workers and provided new insights into their condition. Beneficial IME working conditions and enhanced insight into different sick leave measures were crucial to this perceived usefulness. Some of the participants expressed disappointment with GPs acting as passive conductors and struggled to provide feedback politely. Some adjustments were proposed as necessary for the IME to be implemented nationwide. CONCLUSIONS: The participants seemed to have gained a different stakeholder identity by sometimes seeing GPs, their peers, as obstacles to return to work and welcomed the use of IME on a regular basis.

Independent medical evaluation for sick-listed patients: a focus group study of GPs´ expectations and experiences.

BACKGROUND: Norwegian general practitioners (GPs) are important stakeholders because they manage 80% of people on long-term sick-leave. Independent medical evaluation (IME) for long-term sick-listed patients is being evaluated in a large randomized controlled trial in one county in Norway in an effort to lower the national sick-leave rate (the NIME trial: Effect Evaluation of IME in Norway). The aim of the current study was to explore GPs' expectations of and experiences with IMEs. METHODS: We conducted three focus group interviews with a convenience sample of 14 GPs who had had 2-9 (mean 5) of their long-term sick-listed patients summoned to an IME. We asked them to recollect and describe their concrete expectations of and experiences with patients assigned to an IME. Systematic text condensation, a method for thematic cross-case analysis, was applied for analysis. RESULTS: To care for and to reassure their assigned sick-listed patients, the participants had spent time and applied different strategies before their patients had attended an IME. The participants welcomed a second opinion from an experienced GP colleague as a way of obtaining constructive advice for further sick-leave measures and/or medical advice. However, they mainly described the IME reports in negative terms, as these were either too categorical or provided unusable advice for further follow-up of their sick-listed patients. The participants did not agree with the proposed routine use of IMEs but instead suggested that GPs should be able to select particularly challenging sick-listed patients for an IME, which should be performed by a peer. CONCLUSION: Our participants showed positive attitudes towards second opinions but found the regular IMEs to be unsuitable. The participants did however welcome IMEs if they themselves could select particularly challenging patients for a mandatory second opinion by a peer but emphasized that IME-doctors should not be able to overrule a GP's sick-leave recommendation. These findings, together with other evaluations, will serve as a basis for the Norwegian government's decision on whether or not to implement IMEs for long-term sick-listed patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT02524392 . Registered 23 June, 2015.

Small-scale implementation with pragmatic process evaluation: a model developed in primary health care.

BACKGROUND: Research often fails to impose substantial shifts in clinical practice. Evidence-based health care requires implementation of documented interventions, with implementation research as a science-informed strategy to identify core experiences from the process and share preconditions for achievement. Evidence developed in hospital contexts is often neither relevant nor feasible for primary care. Different evidence types may constitute a point of departure, stretching and testing the transferability of the intervention by piloting it in primary care. Comprehensive descriptions of aims, context and procedures can be a more useful outcome than traditional effect studies. MAIN TEXT: We present a model for small-scale implementation of relevant research evidence, monitored by pragmatic evaluation. The model, which is applicable in primary care, is supported by Weiner's theory about organizational readiness for change and consists of four steps: 1) recognize the problem - identify a workable intervention, 2) assess the context - prepare for inception, 3) pilot the intervention on site, and 4) upscale and accomplish the intervention. The process is evaluated by exploring selected relevant aspects of experiences and outcomes from the first to the last step. Process evaluation is a logical precondition for outcome evaluation - attempting to assess either the efficacy or the effectiveness of a "black box" intervention makes no sense. We argue why evidence beyond effect studies and evaluation beyond randomized controlled trials may be adequate for science-informed evaluation of a small-scale implementation project such as is often conducted by primary health care practitioners. The model is illustrated by an ongoing project, in which a strategy for upgrading the management of depression in nursing homes in Norway is currently being implemented. CONCLUSIONS: A flexible and manageable approach is suggested, in which the inevitable unpredictability of clinical practice is incorporated. Finding the appropriate middle ground between rigour and flexibility, some compromises must be made. Our model recognizes the skills of practical knowing as something other than traditional medical research, while maintaining academic values such as systematic and transparent reflection, using adequate tools. Considering the purpose and context of our model, we argue that these priorities, emphasizing relevance and feasibility, are strengths, not limitations.

Sick-listed workers' expectations about and experiences with independent medical evaluation: a qualitative interview study from Norway.

PURPOSE: To reduce the country's sick leave rate, Norwegian politicians have suggested independent medical evaluations (IMEs) for sick-listed workers. IME was tested in a large, randomized controlled trial in one Norwegian county (Evaluation of IME in Norway, or 'the NIME trial'). The current study´s aim was to explore sick-listed workers' expectations about and experiences with participating in an IME. MATERIAL AND METHODS: Nine individual semi-structured telephone interviews were conducted. Our convenience sample included six women and three men, aged 35-59 years, who had diverse medical reasons for being on sick leave. Systematic text condensation was used for analysis. RESULTS: The participants questioned both the IME purpose and timing, but felt a moral obligation to participate. Inadequate information provided by their general practitioner (GP) to the IME doctor was considered burdensome by several participants. However, most participants appreciated the IME as a positive discussion, even if they did not feel it had any impact on their follow-up or return-to-work process. CONCLUSIONS: According to the sick-listed workers the IMEs were administered too late and disturbed already initiated treatment processes and return to work efforts. Still, the consultation with the IME doctor was rated as a positive encounter, contrary to their expectations. Our results diverge from findings in other countries where experiences with IME consultations have been reported as predominantly negative. These findings, along with additional, upcoming evaluations, will serve as a basis for the Norwegian government's decision about whether to implement IMEs on a regular basis. Key points  Independent medical evaluations for sick-listed workers has been tested out in a large Norwegian RCT and will be evaluated through qualitative interviews with participating stakeholders and by assessing the effects on RTW and costs/benefits. In this study, we explored sick-listed workers' expectations about and experiences with participating in an IME. • Participants questioned both the IME purpose and timing, but felt a moral obligation to participate. • Inadequate information provided by their general practitioner (GP) to the IME doctor was considered burdensome by several participants • Sick-listed workers appreciated the IME as a positive discussion, even if they did not feel it had any impact on their follow-up or return-to-work process.

Helpful strategies for GPs seeing patients with medically unexplained physical symptoms: a focus group study.

BACKGROUND: Patients with long-lasting and disabling medically unexplained physical symptoms (MUPS) are common in general practice. GPs have previously described the challenges regarding management and treatment of patients with MUPS. AIM: To explore GPs' experiences of the strategies perceived as helpful when seeing patients with MUPS. DESIGN AND SETTING: Three focus group interviews with a purposive sample of 24 experienced GPs were held in southern Norway. METHOD: Discussions were audiotaped and transcribed. Systematic text condensation was used for analysis. RESULTS: Several strategies were considered helpful during consultations with patients with MUPS. A comprehensive outline of the patient's medical past and present could serve as the foundation of the dialogue. Reviewing the patient's records and sharing relevant information with them or conducting a thorough clinical examination could offer 'golden moments' of trust and common understanding. A very concrete exchange of symptoms and diagnosis interpretation sometimes created a space for explanations and action, and confrontations could even strengthen the alliance between the GP and the patient. Bypassing conventional answers and transcending tensions by negotiating innovative explanations could help patients resolve symptoms and establish innovative understanding. CONCLUSION: GPs use tangible, down-to-earth strategies in consultations with patients with MUPS. Important strategies were: thorough investigation of the patient's symptoms and story; sharing of interpretations; and negotiation of different explanations. Sharing helpful strategies with colleagues in a field in which frustration and dissatisfaction are not uncommon can encourage GPs to develop sustainable responsibility and innovative solutions.

"Medically unexplained" symptoms and symptom disorders in primary care: prognosis-based recognition and classification.

BACKGROUND: Many patients consult their GP because they experience bodily symptoms. In a substantial proportion of cases, the clinical picture does not meet the existing diagnostic criteria for diseases or disorders. This may be because symptoms are recent and evolving or because symptoms are persistent but, either by their character or the negative results of clinical investigation cannot be attributed to disease: so-called "medically unexplained symptoms" (MUS). MUS are inconsistently recognised, diagnosed and managed in primary care. The specialist classification systems for MUS pose several problems in a primary care setting. The systems generally require great certainty about presence or absence of physical disease, they tend to be mind-body dualistic, and they view symptoms from a narrow specialty determined perspective. We need a new classification of MUS in primary care; a classification that better supports clinical decision-making, creates clearer communication and provides scientific underpinning of research to ensure effective interventions. DISCUSSION: We propose a classification of symptoms that places greater emphasis on prognostic factors. Prognosis-based classification aims to categorise the patient's risk of ongoing symptoms, complications, increased healthcare use or disability because of the symptoms. Current evidence suggests several factors which may be used: symptom characteristics such as: number, multi-system pattern, frequency, severity. Other factors are: concurrent mental disorders, psychological features and demographic data. We discuss how these characteristics may be used to classify symptoms into three groups: self-limiting symptoms, recurrent and persistent symptoms, and symptom disorders. The middle group is especially relevant in primary care; as these patients generally have reduced quality of life but often go unrecognised and are at risk of iatrogenic harm. The presented characteristics do not contain immediately obvious cut-points, and the assessment of prognosis depends on a combination of several factors. CONCLUSION: Three criteria (multiple symptoms, multiple systems, multiple times) may support the classification into good, intermediate and poor prognosis when dealing with symptoms in primary care. The proposed new classification specifically targets the patient population in primary care and may provide a rational framework for decision-making in clinical practice and for epidemiologic and clinical research of symptoms.

Patients with persistent medically unexplained physical symptoms: a descriptive study from Norwegian general practice.

BACKGROUND: Further research on effective interventions for patients with peristent Medically Unexplained Physical Symptoms (MUPS) in general practice is needed. Prevalence estimates of such patients are conflicting, and other descriptive knowledge is needed for development and evaluation of effective future interventions. In this study, we aimed to estimate the consultation prevalence of patients with persistent MUPS in general practice, including patients' characteristics and symptom pattern, employment status and use of social benefits, and the general practitioners' (GPs) management strategy. METHOD: During a four-week period the participating Norwegian GPs (n=84) registered all consultations with patients who met a strict definition of MUPS (>3 months duration and function loss), using a questionnaire with simple tick-off questions. Analyses were performed with descriptive statistics for all variables and split analysis on gender and age. RESULTS: The GPs registered 526 patients among their total of 17 688 consultations, giving a consultation prevalence of persistent MUPS of 3%. The mean age of patients was 46 years, and 399 (76%) were women. The most frequent group of symptoms was musculoskeletal problems, followed by asthenia/fatigue. There was no significant gender difference in symptom pattern. Almost half of the patients were currently working (45%), significantly more men. The major GP management strategy was supportive counseling. CONCLUSION: A consultation prevalence rate of 3% implies that patients with persistent MUPS are common in general practice. Our study disclosed heterogeneity among the patients such as differences in employment status, which emphasizes the importance of personalized focus rather than unsubstantiated stereotyping of "MUPS patients" as a group.

Sickness absence, marginality, and medically unexplained physical symptoms: a focus-group study of patients' experiences.

PURPOSE: Medically unexplained physical symptoms (MUPS) form a major cause of sickness absence. The purpose of this study was to explore factors which may influence further marginalization among patients with MUPS on long-term sickness absence. METHODS: Two focus-group discussions were conducted with a purposive sample of 12 participants, six men and six women, aged 24-59 years. Their average duration of sickness absence was 10.5 months. Participants were invited to share stories about experiences from the process leading to the ongoing sickness absence, with a focus on the causes being medically unexplained. Systematic text condensation was applied for analysis. Inspired by theories of marginalization and coping, the authors searched for knowledge of how patients' positive resources can be mobilized to counteract processes of marginality. RESULTS: Analysis revealed how invisible symptoms and lack of objective findings were perceived as an additional burden to the sickness absence itself. Factors that could counteract further marginalization were a supportive social network, positive coping strategies such as keeping to the daily schedule and physical activity, and positive attention and confidence from professionals. CONCLUSIONS: Confidence from both personal and professional contacts is crucial. GPs have an important and appreciated role in this aspect.

Phenomena associated with sick leave among primary care patients with Medically Unexplained Physical Symptoms: a systematic review.

OBJECTIVE: To explore and synthesize the literature on phenomena associated with sick leave among patients with Medically Unexplained Physical Symptoms (MUPS). DESIGN: A systematic review of the literature was undertaken in three phases: (1) a search of the following databases: Medline, Embase, Psych Info, Cochrane Collaboration Library, Digital Dissertations, DiVA, SweMed +, NORART, and ISI Web of Science, (2) selection of studies based on pre-specified inclusion criteria was undertaken, extracting study design and results, (3) quality assessment was undertaken independently by two reviewers. Due to heterogeneity in study designs, populations, interventions, and outcome measures, a mixed research synthesis approach was used. Results were assessed in a pragmatic and descriptive way; textual and numerical data were extracted from the included studies, and classified into patient- and doctor-related factors. RESULTS: Sixteen studies were included. With regard to patients, an association was found between sick leave and psychiatric comorbidity as well as total symptom burden. With regard to doctors, knowledge of the patient, sympathy, and trust appeared to increase the probability of the patient being sick-listed. None of the interventions in the educational programmes aiming to improve doctors' management of MUPS patients succeeded in lowering sick leave. IMPLICATIONS: Despite MUPS being a leading cause of sickness absence, the review identified only a small number of studies concerning phenomena associated with sick leave. The authors did not identify any studies regarding the impact of the working conditions on sick leave among MUPS patients. This is an important area for further studies.

Salt restriction among hypertensive patients: modest blood pressure effect and no adverse effects.

OBJECTIVE: Previous studies, mainly evaluating short-term very low salt diets, suggest that salt restriction may influence glucose and insulin metabolism, catecholamines, renin, aldosterone, and lipid levels adversely. The authors wanted to explore whether sodium restriction for eight weeks influenced insulin secretion unfavourably, and evaluate the efficacy and safety of such treatment also in terms of other parameters important in the management of hypertensive patients. DESIGN: A double-blind randomized controlled parallel group designed trial. All participants received dietary advice aimed at a moderate salt-restricted diet. Half of the participants received salt capsules, the others received identical placebo capsules. SETTING: General practice. SUBJECTS: Forty-six hypertensive patients inadequately controlled by drug treatment. MAIN OUTCOME MEASURES: Fasting serum insulin C-peptide and glucose and levels of these measures after oral glucose, blood pressure, serum aldosterone and lipids, peripheral resistance, and skin conductance. RESULTS: Salt restriction did not influence glucose and insulin metabolism, aldosterone, or lipid levels adversely. We observed better blood pressure regulation in the low salt group than in the high salt group, with a systolic and diastolic blood pressure difference of 5/5 mmHg after eight weeks. The difference was only statistically significant for diastolic blood pressure, p 0.02. CONCLUSION: This study revealed a modest diastolic blood pressure reducing effect of moderate sodium restriction. This reduction was obtained without any apparent unfavourable side effects such as increased insulin secretion, impaired glucose tolerance or dyslipidaemia.