Patients' expectations of primary health care from both patients' and physicians' perspectives: a questionnaire study with a qualitative approach.

BACKGROUND: Patients' ideas, concerns, and expectations are three important concepts in consultation techniques. Limited studies on these concepts include responses from both health care providers and care recipients of the same consultation. Highlighting both perspectives provides an increased understanding of the consultation. This study aims to explore the perspectives of patients and health care professionals about patients' expectations of primary health care during consultations with primary care physicians and compare the two sets of perspectives. METHODS: A cross-sectional study. Patients (n = 113) and physicians (n = 67) from five primary health care centers completed a questionnaire after planned consultations. Their responses to open-ended questions about patients' expectations, from patients' and physicians' perspectives were analyzed with qualitative content analyses. RESULTS: The patients expected a personal journey, through the primary health care system where they were the subject of interest. A journey, with ready access to a health care provider followed by a consultation with the physician, medical measures administered, their outcomes discussed, and a plan developed for continued health care. The physicians observed patients' expectations to concern the responsibilities placed on primary health care where patients were the object of interest. Patients' short-term expectations were described in a similar way by both patients and physicians. Patients expressed their long-term expectations as more personal and interpersonal whereas physicians observed them from a more professional and organizational standpoint. CONCLUSIONS: Patients and physicians have different views of what patients expect of primary health care. While patients' short-term expectations were perceived by physicians, their long-term expectations were not. Patients expected more of a personal journey through the primary health care system while physicians observed patients' expectations to concern the responsibilities placed on primary health care. Identifying and meeting patients' expectations is an important part of patient-centered care, and a better understanding of patients' expectations is needed to improve health professionals' consultation skills.

Effectiveness of integrated person-centered interventions for older people's care: Review of Swedish experiences and experts' perspective.

Older adults have multiple medical and social care needs, requiring a shift toward an integrated person-centered model of care. Our objective was to describe and summarize Swedish experiences of integrated person-centered care by reviewing studies published between 2000 and 2023, and to identify the main challenges and scientific gaps through expert discussions. Seventy-three publications were identified by searching MEDLINE and contacting experts. Interventions were categorized using two World Health Organization frameworks: (1) Integrated Care for Older People (ICOPE), and (2) Integrated People-Centered Health Services (IPCHS). The included 73 publications were derived from 31 unique and heterogeneous interventions pertaining mainly to the micro- and meso-levels. Among publications measuring mortality, 15% were effective. Subjective health outcomes showed improvement in 24% of publications, morbidity outcomes in 42%, disability outcomes in 48%, and service utilization outcomes in 58%. Workshop discussions in Stockholm (Sweden), March 2023, were recorded, transcribed, and summarized. Experts emphasized: (1) lack of rigorous evaluation methods, (2) need for participatory designs, (3) scarcity of macro-level interventions, and (4) importance of transitioning from person- to people-centered integrated care. These challenges could explain the unexpected weak beneficial effects of the interventions on health outcomes, whereas service utilization outcomes were more positively impacted. Finally, we derived a list of recommendations, including the need to engage care organizations in interventions from their inception and to leverage researchers' scientific expertise. Although this review provides a comprehensive snapshot of interventions in the context of Sweden, the findings offer transferable perspectives on the real-world challenges encountered in this field.

Medical students' perception of learning from patient encounters in primary health care; a qualitative interview study.

BACKGROUND: Clinical practice gives medical students opportunities to develop clinical skills and to gain insight into their future profession as a physician. Students in the medical programme at Karolinska Institutet in Sweden had clinical practice in primary health care in nine of their 11 semesters. The aim of this study was to explore medical students' perceptions of learning from patient encounters in a primary health care context. METHODS: The study was a qualitative inductive interview study. The 21 participating medical students were from their 3rd, 4th and 5th (final year) year of the study programme. A semi-structured interview guide was used. The data analysis was performed with qualitative content analysis. RESULTS: The overarching theme of the study was: The individual patient encounters are the key to learning in primary health care. The patient encounters presented both useful opportunities and challenges that could contribute to the students' professional development. The following four categories were found: 1. Patient encounters in are instructive, rewarding and challenging. Practising in primary health care provided experience in meeting and communicating with a wide variety of patients. Students described it being challenging to trust in their own clinical competence and feeling a responsibility towards the patients. 2. Encounters with patients in primary health care provide opportunities for gradual professional development. Students had the opportunity of increasing independence based on their level of clinical competence. They experienced a progression in their professional development after each period in primary health care. 3. A committed supervisor plays a significant role in learning. Committed supervisors who set aside time for supervision, offered support, and encouraged the student, played an important role in the student's learning. 4. Learning in primary health care and learning in hospitals complement one another. It could be difficult for the students to sort out exactly where they learnt different things as they perceived that learning in primary health care and in hospitals complemented one another. CONCLUSIONS: The students' encounters with authentic patients in primary health care gave them recurring opportunities to develop communication skills and to be trusted to work on their own under supervision, giving them guidance on their way to becoming future physicians.

Make My Day: primary prevention of stroke using engaging everyday activities as a mediator of sustainable health - a randomised controlled trial and process evaluation protocol.

INTRODUCTION: The individual, societal and economic benefits of stroke prevention are high. Even though most risk factors can be reduced by changes to lifestyle habits, maintaining new and healthy activity patterns has been shown to be challenging.The aim of the study is to evaluate the impact of an interdisciplinary team-based, mHealth-supported prevention intervention on persons at risk for stroke. The intervention is mediated by engaging everyday activities that promote health. An additional aim is to describe a process evaluation that serves to increase knowledge about how the programme leads to potential change by studying the implementation process and mechanisms of impact. METHODS AND ANALYSIS: The study will be a randomised controlled trial including 104 persons at risk for stroke. Persons at risk of stroke (n=52) will be randomised to an mHealth-supported stroke prevention programme. Controls will have ordinary primary healthcare (PHC) services. The 10-week programme will be conducted at PHC clinics, combining group meetings and online resources to support self-management of lifestyle change using engaging everyday activities as a mediator. Primary outcomes are stroke risk, lifestyle habits and participation in health-promoting activities. Assessments will be performed at baseline and at follow-up (11 weeks and 12 months). The effects of the programme will be analysed using inferential statistics. Implementation will be analysed using qualitative and quantitative methods. ETHICS AND DISSEMINATION: The study has been approved by the Swedish Ethical Review Authority. Study results will be disseminated in peer-reviewed journals and at regional and international conferences targeting mixed audiences. TRIAL REGISTRATION NUMBER: NCT05279508.

The impact of residency training in family medicine on hospital admissions due to Ambulatory-care Sensitive Conditions in Rio de Janeiro.

Lack of skilled human resources in primary care remains a major concern for policymakers in low- and middle-income countries. There is little evidence supporting the impact of residency training in family medicine in the quality of care, and it perpetuates misconceptions among policymakers that the provision of primary care can be easily done by any physician without special training. This article compares the risk of patients being hospitalized due to Ambulatory care sensitive conditions and the odds of having follow-up visits in primary care after hospital discharge, according to the type of their medical provider: (1) Generalists (reference), (2) Family physicians; and, (3) patients with no consultations prior to the event. Multilevel multivariate binomial regression models estimated the relative risks of a patient being hospitalized in a given month and the relative risks for the occurrence of a follow-up visit in primary care in a retrospective cohort of 636.640 patients between January 2013 and July 2018 in Rio de Janeiro. For all 14 conditions, there was a higher risk of hospitalization when patients had no consultation in primary care prior to the event. Except for Ear, Nose and Throat infections, patients seen by family physicians had a lower risk of being hospitalized, compared to patients seen by Generalists. Follow-up visits were more likely to happen among patients treated by family physicians for almost every condition analyzed. With two years of training in family medicine, Family physicians can reduce the risk of their patients being hospitalized and increase the likelihood of those patients having a follow-up consultation in primary care. Investments in residency training in family medicine should be made to fix the shortage of skilled physicians in primary care, reduce hospitalizations and improve quality and continuity of care.

Multisource feedback in medical students' workplace learning in primary health care.

BACKGROUND: In medical students' workplace learning, feedback is important for effective learning regarding communication and clinical skills. The provision of multisource feedback (MSF) in clinical practice with focus on the patient's perspective is rarely addressed in the literature. The overall objective was to explore the experience of MSF in medical students' clinical learning in primary healthcare (PHC). METHODS: In the study, patients provided feedback by use of the Patient Feedback in Clinical Practice (PFCP) questionnaire. By use of adapted PFCP questionnaire versions peers and clinical supervisors provided feedback and students performed a self-evaluation. The MSF learning activity was evaluated using surveys (4-point Likert scale/open-ended questions), (students (n = 26), peers (n = 9) and clinical supervisors (n = 7)). Data were analysed using descriptive and qualitative content analysis. RESULTS: Results (mean 4-point Likert scale) from participants evaluation of the MSF learning activity visualises the value of feedback in terms of patient-centred communication (students 3.50, peers 2.44 and clinical supervisors 3.57), guidance for further training (students 3.14, peers 2.89 and clinical supervisors 3.00) and clarification of pedagogical assignment (students 3.14, peers 2.89 and clinical supervisors 3.00). Thematic analysis of participants' free-text answers in the evaluation surveys resulted in three themes: (1) applicability of the MSF, (2) MSF - collaborative learning process and (3) MSF as a facilitator in students' clinical skills development. The participants experienced that the written MSF provided multi-facetted perspectives, which contributed to students' and peers' clinical and communication learning. MSF experience also enhanced clinical supervisors' feedback regarding communication skills, targeting the supervisors' pedagogical assignment. CONCLUSION: Our findings indicate that MSF provided directly after a patient encounter, using the PFCP questionnaire as feedback provider, could be an adequate learning activity for medical students' workplace learning. The MSF, provided through the PFCP questionnaire, was experienced to neutralise and operationalise the provision of concrete feedback, facilitating peers' learning and clinical supervisors' tuition. The results visualise the importance of patients in MSF, as a valuable resource in students' workplace learning. Our study implies that this learning activity could be an applicable tool to facilitate learning and pedagogic development in clinical education in PHC.

Residency training in family medicine and its impact on coordination and continuity of care: an analysis of referrals to secondary care in Rio de Janeiro.

OBJECTIVE: To measure the effect that residency training in family medicine (RTFM) has on continuity and coordination of care. DESIGN: Observational cohort study using electronic health records. SETTING: Rio de Janeiro, Brazil, public primary care system. PARTICIPANTS: 504 940 patients, 633 generalists (physicians without RTFM) and 204 family physicians (FP-doctors with 2 years of RTFM) from one health district between January 2015 and December 2018. INTERVENTION: Two years of RTFM. MAIN OUTCOME MEASURES: Relative risks of patients being referred to secondary care for outpatient consultations and diagnostics tests; and having a follow-up medical consultation in primary care within 3 and 6 months after being referred. RESULTS: We examined 2 414 508 medical consultations and 284 754 referrals to secondary care. FPs were less likely to request ambulatory care services (including surgical specialties), but were more likely to request ophthalmology, physiotherapy, rehabilitationand surgical evaluations for their patients. Patients referred to secondary care by FPs were more likely to have a follow-up visit in primary care for almost every service requested. If all medical consultations were performed by FPs, a 37.6% (95% CI 32.4% to 42.4%) increased demand for rehabilitation services would be noticed. Oppositely, 1532 (95% CI 1458 to 1602) fewer requests for dermatology would happen every year. CONCLUSIONS: RTFM improves coordination and continuity of care by making FPs more competent to retain those health conditions that can be properly managed in primary care and making FPs more competent to detect health conditions that require specific biomedical technologies and skills, increasing the demand for those services. Besides, it increases the chances of patients having follow-up visits in primary care. Policy-makers in low-income and middle-income countries must consider investing in RTFM to make primary care systems more comprehensive, with better coordination and continuity of care.

Migrant physicians' choice of employment and the medical specialty general practice: a mixed-methods study.

OBJECTIVE: In many countries, migrant physicians (MP) tend to fill staff shortages in medical specialties perceived as low status. The aim of this study was to explore aspects that influence MPs', with a medical degree from outside EU/EEA, choice of employment and medical specialty in Sweden, and to explore and understand a potential over-representation in general practice (family medicine), a specialty suffering from staff shortages in Sweden. METHODS: A mixed-methods approach was applied. This included questionnaire data from 101 MPs training and working as medical specialists in Sweden and semi-structured interview data from four MPs specializing in general practice. RESULTS: Regardless of specialty, the most influential aspects when choosing employment were the ability to combine work with family, to develop one´s competence, and to have highly competent colleagues. Women scored higher on some aspects related to private life and the surroundings. More than half (55%) of the respondents specialized in general practice, and more women than men. The MPs in general practice scored higher on the aspect 'ability to have the same patients for a longer period' than MPs specializing in other specialties. No significant difference between MP general practitioner respondents and MPs in other medical specialties was found in relation to the item 'Was the specialty your first choice?'. Aspects identified in the interviews that influenced the choice to specialize in general practice related to job opportunities, positive experiences of primary health care, working conditions, and family conditions. CONCLUSION: Labour market conditions such as high competition, and the time-consuming recertification process, can influence the choice to specialize in general practice as this reduces the time to become a medical specialist. We however did not find any results indicating that MPs' decision to specialize in general practice and to work as general practitioners was any less voluntary than that of MPs who chose other specialties.

Let's ask the patient - composition and validation of a questionnaire for patients' feedback to medical students.

BACKGROUND: Adequate communication and maintaining a patient-centered approach throughout patient encounters are important skills for medical students to develop. Feedback is often provided by clinical teachers. Patients are seldom asked to provide feedback to students that systematically addresses knowledge and skills regarding communication and patient-centeredness during an encounter. One way for patients to provide feedback to students is through a questionnaire; there is, however, a lack of such validated feedback questionnaires. This study aimed to compose and validate a feedback questionnaire for patients' feedback to medical students regarding students' ability to communicate and apply patient-centeredness in clinical practice. METHOD: This study comprises (a) composition of the questionnaire and (b) validation of the questionnaire. The composition included (1) literature review, (2) selection and composition of items and construction of an item pool, (3) test of items' content, and (4) test of the applicability of the questionnaire. The items originated from the Calgary-Cambridge Guide (Kurtz S, Silverman J, Benson J and Draper J, Acad Med 78:802-809, 2003), the 'Swedish National Patient Survey' (National Patient Survey, Primary Health Care, 2020), patient evaluation form by Braend et al. (Tidsskr Nor Laegeforen 126:2122-5, 2006), and additional developed items. The items were further developed after feedback from 65 patients, 22 students, eight clinical supervisors, and six clinical teachers. The validation process included 246 patients who provided feedback to 80 students. Qualitative content analysis and psychometric methods were used and exploratory factor analysis assessed internal validity. Cronbach's alpha was used to test the reliability of the items. RESULTS: The process resulted in the 19-item 'Patient Feedback in Clinical Practice' (PFCP) questionnaire. Construct validity revealed two dimensions: consultational approach and transfer of information. Internal consistency was high. Thematic analysis resulted in three themes: ability to capture the personal agenda of the consultation, alignment with the consultation, and constructs and characteristics. Students reported that the PFCP questionnaire provided useful feedback that could facilitate their learning in clinical practice. CONCLUSIONS: The results of this study indicate that the questionnaire is a valid, reliable, and internally consistent instrument for patients' feedback to medical students. The participants found the questionnaire to be useful for the provision of feedback in clinical practice. However, further studies are required regarding the PFCP questionnaire applicability as a feedback tool in workplace learning.

Validation and initial results of surveys exploring perspectives on risks and solutions for diagnostic and medication errors in primary care in Sweden.

OBJECTIVE: To (1) validate and (2) display initial results of surveys to health care professionals and patients on the importance and mitigation of specified risks for diagnostic and medication errors. DESIGN: For validation, psychometric properties were analysed by assessment of construct validity and internal consistency by factor analysis. Non-parametric analyses were used concerning areas of risk, and top ranking of solutions were reported descriptively. SETTING: Primary health care in Sweden. PARTICIPANTS: Health care professionals (HCPs); including physicians, nurses and practice managers, as well as patients who had experienced diagnostic or medication errors. MAIN OUTCOME MEASURES: Psychometric properties of the surveys. Median ratings for risks and top rankings of solutions for professionals and patients. RESULTS: There were 939 respondents to the HCP survey. Construct validity resulted in a model with four dimensions: Patient-provider level; Support systems for every day clinical work; Shared information and cooperation between different caregivers; Risks in the environment. Internal consistency was acceptable with Cronbach's α values above 0.7. Confirmatory factor analysis generally showed an acceptable fit. Initial results from the professionals showed the importance of continuity of care, a nationwide on-line medical platform and cooperation in transfer of care. The patient survey could not be validated because of low response rate. CONCLUSION: The HCP survey showed some contradicting results regarding model fit and may be tentatively acceptable but validity needs further study. HCP survey answers indicated that relational continuity of care and a nationwide on-line medical platform are highly valued. Current awareness Health care professionals and patients are rather untapped sources of knowledge regarding patient safety in primary health care Main statements Validation is performed on a new survey capturing rating of risks and solutions. The validation of the health care professional survey is tentatively acceptable. Survey answers indicate that health care professionals' and patients' perspectives are complementary.

Use of online knowledge base in primary health care and correlation to health care quality: an observational study.

BACKGROUND: Evidence-based information available at the point of care improves patient care outcomes. Online knowledge bases can increase the application of evidence-based medicine and influence patient outcome data which may be captured in quality registries. The aim of this study was to explore the effect of use of an online knowledge base on patient experiences and health care quality. METHODS: The study was conducted as a retrospective, observational study of 24 primary health care centers in Sweden exploring their use of an online knowledge base. Frequency of use was compared to patient outcomes in two national quality registries. A socio-economic Care Need Index was applied to assess whether the burden of care influenced the results from those quality registries. Non-parametric statistical methods and linear regression were used. RESULTS: Frequency of knowledge base use showed two groups: frequent and non-frequent users, with a significant use difference between the groups (p < 0.001). Outcome data showed significant higher values for all seven National Primary Care Patient Survey dimensions in the frequent compared to the non-frequent knowledge base users (p < 0.001), whereas 10 out of 11 parameters in the National Diabetes Register showed no differences between the groups (p > 0.05). Adjusting for Care Need Index had almost no effect on the outcomes for the groups. CONCLUSIONS: Frequent users of a national online knowledge base received higher ratings on patient experiences, but figures on health care quality in diabetes showed near to no correlation. The findings indicate that some effects may be attributed to the use of knowledge bases and requires a controlled evaluation.

"Standing on common ground" - a qualitative study of self-management support for patients with multimorbidity in primary health care.

BACKGROUND: Multimorbidity, the co-existence of two or more chronic conditions in an individual, is present in most patients over 65 years. Primary health care (PHC) is uniquely positioned to provide the holistic and continual care recommended for this group of patients, including support for self-management. The aim of this study was to explore professionals', patients', and family caregivers' perspectives on how PHC professionals should support self-management in patients with multimorbidity. This study also includes experiences of using telemedicine to support self-management. METHODS: A mixed qualitative method was used to explore regular self-management support and telemedicine as a tool to support self-management. A total of 42 participants (20 physicians, 3 registered nurses, 12 patients, and 7 family caregivers) were interviewed using focus group interviews (PHC professionals), pair interviews (patients and family caregivers), and individual interviews (registered nurses, patients, and family caregivers). The study was performed in urban areas in central Sweden and rural areas in southern Sweden between April 2018 and October 2019. Data were analyzed using content analysis. RESULTS: The main theme that emerged was "Standing on common ground enables individualized support." To achieve such support, professionals needed to understand their own views on who bears the primary responsibility for patients' self-management, as well as patients' self-management abilities, needs, and perspectives. Personal continuity and trustful relationships facilitated this understanding. The findings also indicated that professionals should be accessible for patients with multimorbidity, function as knowledge translators (help patients understand their symptoms and how the symptoms correlated with diseases), and coordinate between levels of care. Telemedicine supported continual monitoring and facilitated patient access to PHC professionals. CONCLUSION: Through personal continuity and patient-centered consultations, professionals could collaborate with patients to individualize self-management support. For some patients, this means that PHC professionals are in control and monitor symptoms. For others, PHC professionals play a less controlling role, empowering patients' self-management. Development and improvement of eHealth tools for patients with multimorbidity should focus on improving the ability to set mutual goals, strengthening patients' inner motivation, and including multiple caregivers to enhance information-sharing and care coordination.

Patient and provider perspectives on reducing risk of harm in primary health care: a qualitative questionnaire study in Sweden.

Objective: To explore how patients, that had experienced harm in primary care, and how primary providers and practice managers understood reasons for harm and possibilities to reduce risk of harm.Design: Inductive qualitative analysis of structured questionnaires with free text answers.Setting: Primary health care in Sweden.Patients/subjects: Patients (n = 22) who had experienced preventable harm in primary health care, and primary care providers and practice managers, including 15 physicians, 20 nurses and 24 practice managers.Main outcome measures: Categories and overarching themes from the qualitative analysis.Results: The three categories identified as important for safety were continuity of care, communication and competence. With flaws in these, risks were thought to be greater and if these were strengthened the risks could be reduced. The overarching theme for the patient was the experience of being neglected, like not having been properly examined. The overarching theme for primary care providers and practice managers was lack of continuity of care.Conclusion: Primary care providers, practice managers and patients understood the risks and how to reduce the risks of patient safety problems as related to three main categories: continuity of care, communication and competence. Future work towards a safer primary health care could therefore benefit from focusing on these areas.Key pointsCurrent awareness: • Patients and primary care providers are rather untapped sources of knowledge regarding patient safety in primary health care.Main statements: • Patients understood the risk of harm as stemming from that they were not properly examined. • Primary care providers understood the risk of harm to a great extent as stemming from poor continuity of care. • Patients, primary care providers and practice managers believed continuity, communication and competence play an important role in reducing risks.

Patients' ideas, concerns, expectations and satisfaction in primary health care - a questionnaire study of patients and health care professionals' perspectives.

Objective: Explore the perceptions of patients and health care professionals about patients' ideas, concerns, expectations (ICE), and satisfaction in consultations with general practitioners (GPs), district nurses (DNs) and physiotherapists (PTs).Design: Cross-sectional questionnaire study of participants in planned consultations.Setting: Five primary health care centers and two rehabilitation centers in Stockholm, Sweden.Subjects: Pairs of patients and GPs (n = 156), patients and DNs (n = 73), and patients and PTs (n = 69).Main outcome measures: Multiple-choice questions about patients' ICE and satisfaction.Results: Approximately 75% of patients and GPs reported that patients' thoughts and explanations about their symptoms emerged during the consultation. For patient-DN pairs, the figure was 60%, and for patient-PT pairs, 80%. A majority of patients reported not having concerns and anxiety about the investigation/treatment, whereas health care professionals thought patients were more concerned. One-third of patients consulting GPs and PTs expected to receive a reason/explanation for their symptoms. Figures were lower for the DNs. About 70% of patients were satisfied with the consultation.Conclusions: Most patients expressed their ideas, a minority had concerns, and a minority expected an explanation of their illness. Patients and health care professionals rated patient satisfaction high, but health care professionals tended to believe patients were less satisfied than patients reported they were.Key pointsPatient surveys show that important aspects of patient-centeredness remain weak in Swedish primary health care; for example, shared decision-making.In this study of planned consultations, few patients expected to receive an explanation of their symptoms, but most were satisfied with the consultation.Health care professionals thought patients' experiences were more negative than they were.This discrepancy was observed in responses to questions about patients' concerns, expectations and satisfaction.

Migrant physicians' entrance and advancement in the Swedish medical labour market: a cross-sectional study.

BACKGROUND: Worldwide, physicians are migrating to new countries and want to practise their profession. However, they may experience difficulties doing so. To optimise and accelerate their entrance into and advancement within the Swedish healthcare system, there is an urgent need to explore how they are currently doing so, as their competences should be put to use without any unnecessary delay. The aim of the study was to explore how migrant physicians with a medical degree from outside EU/EEA enter and advance within the medical labour market in Sweden and to identify perceived barriers and facilitating aspects in the process. The empirical findings are discussed in light of Bourdieu's concept symbolic capital as adapted in the Swedish medical field. METHODS: A cross-sectional study with a self-administrated questionnaire was disseminated. A sample of 498 migrant physicians were identified. Descriptive statistical analysis and qualitative thematic analysis were used to analyse the data. RESULTS: The response rate was 57% (n = 283). Respondents mainly found their first positions via spontaneous job applications, during internships, while participating in an educational intervention or via personal contacts. Perceived barriers to entering and advancing within the medical field in Sweden were mainly related to having a medical degree from and/or originating from another country, which could in turn represent discrimination and/or having one's competence undervalued as a result. Facilitating aspects included having or developing contacts in Swedish healthcare and gaining proficiency or fluency in the Swedish language. CONCLUSIONS: When MPs find their first positions, the contacts they have developed appear to play a role, and when advancing in their positions, the active development of a variety of contacts seems to be beneficial. MPs experience a variety of barriers to entering and advancing within the field that could be related to discrimination. Many MPs perceived having their competences undervalued due to their origin or to being educated abroad. Based on the respondents' experiences, our interpretation is that MPs as a group are hierarchically positioned lower in the Swedish medical field than physicians trained in the country. Facilitating aspects included educational interventions, having contacts and developing language skills. For optimal entry into the labour market, it is vitally important for MPs to learn the new language and obtain a job or internship in the field as soon as possible.

Diagnostic errors reported in primary healthcare and emergency departments: A retrospective and descriptive cohort study of 4830 reported cases of preventable harm in Sweden.

Background: Diagnostic errors are a major patient safety concern in primary healthcare and emergency care. These settings involve a high degree of uncertainty regarding patients' diagnoses and appear to be those most prone to diagnostic errors. Diagnostic errors comprise missed, delayed, or incorrect diagnoses preventing the patient from receiving correct and timely treatment. Data regarding which diagnoses are affected in these settings are scarce. Objectives: To understand the distribution of diagnoses among reported diagnostic errors in primary health and emergency care as a step towards creating countermeasures for safer care. Methods: A retrospective and descriptive cohort study investigating reported diagnostic errors. A nationwide cohort was collected from two databases. The study was performed in Sweden from 1 January 2011 until 31 December 2016. The setting was primary healthcare and emergency departments. Results: In total, 4830 cases of preventable harm were identified. Of these, 2208 (46%) were due to diagnostic errors. Diagnoses affected in primary care were cancer (37% and 23%, respectively, in the two databases; mostly colon and skin), fractures (mostly hand), heart disease (mostly myocardial infarction), and rupture of tendons (mostly Achilles). Of the diagnostic errors in the emergency department, fractures constituted 24% (mostly hand and wrist, 29%). Rupture/injury of muscle/tendon constituted 19% (mostly finger tendons, rotator cuff tendons, and Achilles tendon). Conclusion: Our findings show that the most frequently missed diagnoses among reported harm were cancers in primary care and fractures in the emergency departments.

Quality of Research Practice - An interdisciplinary face validity evaluation of a quality model.

There are few acknowledged multidisciplinary quality standards for research practice and evaluation. This study evaluates the face validity of a recently developed comprehensive quality model that includes 32 defined concepts based on four main areas (credible, contributory, communicable, and conforming) describing indicators of research practice quality. Responses from 42 senior researchers working within 18 different departments at three major universities showed that the research quality model was-overall-valid. The vast majority believed all concepts in the model to be important, and did not indicate the need for further development. However, some of the sub-concepts were indicated as being slightly less important. Further, there were significant differences concerning 'communicable' between disciplines and academic levels, and for 'conforming' between genders. Our study indicates that the research quality model proposes the opportunity to move to a more systematic and multidisciplinary approach to research quality improvement, which has implications for how scientific knowledge is obtained.

Investigating psychometric properties and dimensional structure of an educational environment measure (DREEM) using Mokken scale analysis - a pragmatic approach.

BACKGROUND: Questionnaires and surveys are used throughout medical education. Nevertheless, measuring psychological attributes such as perceptions of a phenomenon among individuals may be difficult. The aim of this paper is to introduce the basic principles of Mokken scale analysis (MSA) as a method for the analysis of questionnaire data and to empirically apply MSA to a real-data example. METHODS: MSA provides a set of statistical tools for exploring the relationship between items and latent traits. MSA is a scaling method of item selection algorithms used to partition an array of items into scales. It employs various methods to probe the assumptions of two nonparametric item response theory models: the monotone homogeneity model and the double monotonicity model. The background and theoretical framework underlying MSA are outlined in the paper. MSA for polytomous items was applied to a real-life data example of 222 undergraduate students who had completed a 50-item self-administered inventory measuring the educational environment, the Dundee Ready Educational Measure (DREEM). RESULTS: A pragmatic and parsimonious approach to exploring questionnaires and surveys from an item response theory (IRT) perspective is outlined. The use of MSA to explore the psychometric properties of the Swedish version of the DREEM failed to yield strong support for the scalability and dimensional structure of the instrument. CONCLUSIONS: MSA, a class of simple nonparametric IRT models - for which estimates can be easily obtained and whose fit to data is relatively easily investigated - was introduced, presented, and tested. Our real-data example suggests that the psychometric properties of DREEM are not adequately supported. Thus, the empirical application depicted a potential and feasible approach whereby MSA could be used as a valuable method for exploring the behavior of scaled items in response to varying levels of a latent trait in medical education research.

Impact of group treatment for insomnia on daytime symptomatology: Analyses from a randomized controlled trial in primary care.

BACKGROUND: People typically seek primary health care for daytime symptoms and impairments they experience in association with their insomnia. However, few studies address the question of whether insomnia treatment can improve such symptomatology. OBJECTIVES: To investigate whether a nurse-led group treatment program, based on the techniques of cognitive behavioral therapy for insomnia (CBT-I), improved daytime symptomatology in primary care patients with insomnia. OUTCOMES: Fatigue (Fatigue Severity Scale [FSS]; main outcome), mood (General Health Questionnaire and Montgomery-Asberg Depression Rating Scale), health-related quality of life (Short-Form Health Survey), general daytime functioning, specific daytime symptoms (individual items from the Insomnia Severity Index and Uppsala Sleep Inventory), and dysfunctional beliefs (Dysfunctional Beliefs and Attitudes about Sleep). DESIGN: A randomized controlled trial including baseline and post-treatment assessment and a 1-year post-treatment follow-up of the intervention group. SETTINGS: Seven primary health care centers (Stockholm, Sweden). PARTICIPANTS: One hundred and sixty-five primary care patients who meet the criteria for insomnia disorder (mean age 54 years, SD 16). Most were women (73%). EXCLUSION CRITERIA: severe untreated illness, bipolar disorder, current stressful life event, night shift work, and untreated sleep disorder other than insomnia. METHODS: Data came from a randomized controlled trial of a 10-week nurse-led group treatment for insomnia based on CBT-I (n = 90). The control condition was treatment as usual (n = 75). In accordance with intention-to-treat principles, analyses included data on patients who completed baseline assessments (intervention n = 82, and control group n = 71; post-treatment dropout rate 20%). Fifty-four patients were included in the 1-year follow-up. RESULTS: Fatigue severity improved significantly more (p < 0.001) in the intervention than in the control group (intervention, total FSS score 37.2 [SD 11.9] to 31.0 [SD 13.4] vs. control 35.9 [SD 12.1] to 35.7 [SD 12.8]). This was true also for measurements on mood (psychological distress and depressive symptoms), health-related quality of life (mental functioning), general daytime functioning, specific daytime symptoms (worry about sleep, sleepiness, bodily tiredness, and difficulty concentrating) and dysfunctional beliefs. All improvements were maintained one year after group treatment. CONCLUSIONS: Many aspects of the daytime symptomatology of insomnia were improved via nurse-led group treatment based on CBT-I in primary health care.

Effect of traditional yoga, mindfulness-based cognitive therapy, and cognitive behavioral therapy, on health related quality of life: a randomized controlled trial on patients on sick leave because of burnout.

BACKGROUND: To explore if health related quality of life(HRQoL) increased after traditional yoga(TY), mindfulness based cognitive therapy(MBCT), or cognitive behavioral therapy(CBT), in patients on sick leave because of burnout. METHODS: Randomized controlled trial, blinded, in ninety-four primary health care patients, block randomized to TY, MBCT or CBT (active control) between September 2007 and November 2009. Patients were living in the Stockholm metropolitan area, Sweden, were aged 18-65 years and were on 50%-100% sick leave. A group treatment for 20 weeks, three hours per week, with homework four hours per week. HRQoL was measured by the SWED-QUAL questionnaire, comprising 67 items grouped into 13 subscales, each with a separate index, and scores from 0 (worse) to 100 (best). SWED-QUAL covers aspects of physical and emotional well-being, cognitive function, sleep, general health and social and sexual functioning. Statistics: Wilcoxon's rank sum and Wilcoxon's sign rank tests, Bonett-Price for medians and confidence intervals, and Cohen's D. RESULTS: Twenty-six patients in the TY (21 women), and 27 patients in both the MBCT (24 women) and in the CBT (25 women), were analyzed. Ten subscales in TY and seven subscales in MBCT and CBT showed improvements, p < 0.05, in several of the main domains affected in burnout, e.g. emotional well-being, physical well-being, cognitive function and sleep. The median improvement ranged from 0 to 27 points in TY, from 4 to 25 points in CBT and from 0 to 25 points in MBCT. The effect size was mainly medium or large. Comparison of treatments showed no statistical differences, but better effect (small) of both TY and MBCT compared to CBT. When comparing the effect of TY and MBCT, both showed a better effect (small) in two subscales each. CONCLUSIONS: A 20 week group treatment with TY, CBT or MBCT had equal effects on HRQoL, and particularly on main domains affected in burnout. This indicates that TY, MBCT and CBT can be used as both treatment and prevention, to improve HRQoL in patients on sick leave because of burnout, reducing the risk of future morbidity. TRIAL REGISTRATION: July 22, 2012, retrospectively registered. ClinicalTrails.gov NCT01168661 . FUNDING: Stockholm County Council, grant 2003-5.