Sexual assault and harassment of doctors, by doctors: a qualitative study.

CONTEXT: Although sexual harassment frequently occurs in medical education and medical workplaces, doctors who have been sexually harassed or assaulted by other doctors remain a largely invisible population. This study aimed to identify, using personal accounts, the impact on doctors of sexual harassment and assault by doctors in the workplace. METHODS: This narrative study used in-depth interviews, legal reports and victim impact statements, tracing trajectories from the event's pre-history to its aftermath and impact on professional practice. Participants were six Australian women doctors who had been subjected to one or more non-consensual sexual acts through coercion or intimidation by another doctor in their working environments, within hospital training programmes. RESULTS: All women identified long-term personal and professional impacts of their experience. Three women had never reported the abuse. The meaning and impact of sexual abuse for the doctors followed a trajectory with discrete phases: prelude, assault, limbo, exposure and aftermath. Discounting the event and its impacts, and returning to the workplace were characterised as 'being professional'. Those who sought legal restitution said it damaged their personal well-being and their standing among fellow doctors. DISCUSSION: Understanding the phases of experience of abuse enables the development of effective interventions for different phases. Interventions to minimise the risk of occurrence of sexual abuse must be distinguished from interventions to increase reporting rates, and interventions to mitigate harm and impact on victims' futures. Idealised notions of professionalism can act as obstacles to doctors responding to sexual abuse.

Early career GPs, mental health training and clinical complexity: a cross-sectional analysis.

Patients with mental health conditions commonly present in General Practice. Mental health curricula are broad. We do not know that trainees are exposed to the learning they require. This study aimed to establish the prevalence, characteristics and associations of GP trainees' management of mental health problems. This paper presents a cross-sectional analysis of the Registrar Clinical Encounters in Training (ReCEnT) study, an ongoing multisite cohort study of Australian GP trainees (registrars) documenting their clinical experiences over 60 consecutive consultations. Univariate and multivariable logistic regression analyses were conducted with outcome of the problem/diagnosis being a mental health condition. 1659 trainees provided data on 218,325 consultations and 340,453 problems/diagnoses. Mental health conditions were associated with patients being male, of Aboriginal or Torres Strait Islander or English-speaking background. Trainee characteristics were being more senior and having trained in Australia. Practice characteristics included being in low socioeconomic areas. Trainees sought less help for mental health concerns than they did for other problems. While early-career GPs see a broad range of mental health conditions, they may benefit from training to manage patients from cross-cultural contexts. They may also need support to generate appropriate learning goals and seek assistance if they are to continue to deepen competence.

Managing medically unexplained illness in general practice.

BACKGROUND: Patients with medically unexplained symptoms commonly present to general practice and experience significant disability. Many have a history of trauma, which complicates the therapeutic relationship between doctor and patient. Because diagnosis is an expected outcome of a medical interaction, doctors and patients can feel frustrated and lost without one. OBJECTIVE: This article provides practical management strategies that general practitioners (GPs) can use when patients present with medically unexplained symptoms. DISCUSSION: Three types of common presentations are discussed. Enigmatic illnesses occur when the doctor and patient believe that a bio-medical disease is likely, but a diagnosis is not forthcoming. Contested illnesses occur when a patient is committed to a diagnosis the doctor does not accept. Chaotic illnesses occur when symptoms are over-determined; there are many possible diagnoses, but none fully explain the complex web of distress the patient experiences. Common strategies for managing medically unexplained symptoms are discussed, and specific approaches to each presentation are outlined.

Managing the consultation with patients with medically unexplained symptoms: a grounded theory study of supervisors and registrars in general practice.

BACKGROUND: Patients with medically unexplained symptoms (MUS) commonly present in general practice. They often experience significant disability and have difficulty accessing appropriate care. Many feel frustrated and helpless. Doctors also describe feeling frustrated and helpless when managing these patients. These shared negative feelings can have a detrimental effect on the therapeutic relationship and on clinical outcomes. The aim of this study was to explore how novice and experienced GPs manage patients with MUS and how these skills are taught and learned in GP training. METHODS: A constructivist grounded theory study with 24 general practice registrars and supervisors in GP training practices across Australia. RESULTS: Registrars lacked a framework for managing patients with MUS. Some described negative feelings towards patients that were uncomfortable and confronting. Registrars also were uncertain about their clinical role: where their professional responsibilities began and ended. Supervisors utilised a range of strategies to address the practical, interpersonal and therapeutic challenges associated with the care of these patients. CONCLUSIONS: Negative feelings and a lack of diagnostic language and frameworks may prevent registrars from managing these patients effectively. Some of these negative feelings, such as frustration, shame and helplessness, are shared between doctors and patients. Registrars need assistance to identify and manage these difficult feelings so that consultations are more effective. The care of these patients also raises issues of professional identity, roles and responsibilities. Supervisors can assist their registrars by proactively sharing models of the consultation, strategies for managing their own feelings and frustrations, and ways of understanding and managing the therapeutic relationship in this difficult area of practice.

Blame, shame and hopelessness: medically unexplained symptoms and the 'heartsink' experience.

BACKGROUND: 'Heartsink' patients present a moral dilemma. We recognise their suffering, but at the same time struggle with the feelings they trigger in us. Patients also experience negative feelings. Without a diagnosis they lack a narrative or vocabulary to make sense of their own suffering. OBJECTIVE: This article explores some of the challenges faced and strategies utilised when managing patients with medically unexplained symptoms. DISCUSSION: Doctors and patients often experience frustration and helplessness in consultations around medically unexplained symptoms. Without a diagnosis, patients lack social legitimacy as 'sick' people with 'real' illnesses. They often describe feeling blamed for their own distress. Because of this, they can experience deep feelings of worthlessness and shame. Patients with a history of abuse can be particularly vulnerable. Management includes validating their suffering, helping them construct appropriate explanations for their distress and providing empathic interpersonal care, while minimising the risk of iatrogenic harm.

Reframing chaos--a qualitative study of GPs managing patients with medically unexplained symptoms.

BACKGROUND: Diagnosis brings order, predictability and validation to suffering. Patients with medically unexplained symptoms experience vulnerability and cultural invalidation. Doctors also struggle to manage these patients. OBJECTIVE: To explore the strategies general practitioners use to manage patients with mixed emotional and physical symptoms and no diagnosis. METHODS: Thematic analysis utilising semi-structured interviews of 24 Australian GPs. RESULTS: Validation of the patient as a person involved building a helpful therapeutic alliance. Commitment to the patient, which the GPs described as 'ownership', involved advocacy and support. Holding uncertainty involved managing the need for a disease name. This included harm minimisation, including uncertainty management. Shift to coping involved the challenges of managing ongoing symptoms that had no name, no cure and no predictable outcome. DISCUSSION: Managing patients with medically unexplained symptoms involves professional and personal challenges. However, many of the GPs in this study found managing these patients rewarding in the long term.

A is for aphorism - 'Wherever the art of medicine is loved there is also a love of humanity'.

He was an amazing diagnostician. He could listen to the history and then with this long, pointy, bony finger he'd say, "So, what do you think was significant in that bit of the history? What did you feel there as you examined the abdomen? Did you look at this here? Have you seen these?" But he was a very warm person too - just so caring.

Being a botanist and a gardener: using diagnostic frameworks in general practice patients with medically unexplained symptoms.

Patients with multiple medically unexplained symptoms commonly seek treatment in primary care. Many of these patients seem to have a psychological 'core' to their illness that affects the way they experience, conceptualise and communicate their distress. There is considerable debate around diagnosis for this group of patients. Existing diagnoses include somatoform disorders in psychiatry and functional disorders in the medical specialties. Some clinicians use the term 'heartsink' patients, which reflects the interpersonal frustration inherent in some therapeutic relationships. A good diagnosis should be clinically useful, helping clinicians and patients understand and manage illness. Diagnosis should also provide a reliable classification for research and evidence-based treatment. The allegory of the botanist and the gardener has been used to describe diagnosis. For the botanist, a good diagnosis produces a taxonomy that is rigorous and reliable. For the gardener, it informs the way a garden is described and understood in a specific context. Clinicians need both: a 'botanical' type of classification to bring rigour to research and therapy, and clinical 'gardening', which allows for multiple perspectives and diagnostic frameworks. Clinical reasoning is a form of research with therapeutic intent. Botany and gardening represent a mixed-methods approach that can enrich diagnosis. The challenge is to integrate multiple perspectives in clinically helpful ways that help us retain both richness and rigour.

Dialectics, power dynamics, and undercurrents of meaning: using psychotherapeutic strategies in primary care with trans and gender-diverse clients.

Trans and gender-diverse individuals experience poor mental health, and face significant barriers when trying to access appropriate mental health care. Most seek treatment from mainstream primary care services, who have an ethical duty to provide care to all. Primary care practitioners can ameliorate traumatic harms by identifying helpful strategies and avoiding inappropriate or harmful strategies. However, there is limited robust, culturally sensitive evidence informing clinicians about the appropriateness and efficacy of psychological interventions for trans and gender-diverse clients. This forum article argues that the epistemological and ontological frameworks underlying psychotherapies can impact the therapeutic relationship, and are therefore important factors to consider in primary care practice with trans and gender-diverse clients. Our paper synthesises selected psychotherapies into four clusters. Each cluster is accompanied by discussion of the potential or demonstrated benefits and limitations of the underlying framework, in the context of primary care with trans and gender-diverse clients. We also explore power dynamics in therapeutic relationships with trans and gender-diverse clients, and the challenges these factors pose to developing a shared understanding of the client's needs and preferences. The article concludes with some practical considerations for managing these issues in primary care.

Mapping young people's journeys through mental health services: A prospective longitudinal qualitative study protocol.

Mental ill health is a major health risk for young people. There is unmet need for mental health assessment and treatment across Australia despite significant investment in government-funded plans to cover mental health and youth-oriented services. Understandings of mental health care for young people are impeded by a lack of longitudinal research. Without this research, it is difficult to understand how services do or do not support the recovery of young people over time. This project will analyse the healthcare journeys of young people aged 16-25 years experiencing their first episode of mental ill health for which they have sought GP support, over 12 months in the Australian Capital Territory. The study team will recruit up to 25 diverse young people and their general practitioners (GPs), and conduct four qualitative semi-structured interviews over 12 months with each participant. GP interviews will explore their role in the mental health care and care coordination for the young person. Interviews with young people will explore experiences and perceptions of navigating the health system, and the supports and resources they engaged with during the 12-month period. In between interviews, young people will be asked to keep a record of their mental health care experiences, through their choice of media. Participant-produced materials will also form the basis for interviews, providing stimuli to discuss the lived experience of care. Through analysing the narratives of both young people and their GPs, the study will establish how young people understand value in mental health care delivery. The study will use longitudinal qualitative mapping of healthcare journeys to identify key barriers and enablers to establishing effective, person-centred health care for young people with mental ill health.

On botany and gardening - diagnosis and uncertainty in the GP consultation.

BACKGROUND: Diagnosis is not only about disease classification, it also incorporates other ways of knowing. This includes understanding the patient's unique experience of illness, their psychosocial context and any history of trauma. OBJECTIVE: This article examines how different perspectives on diagnosis can be utilised in the consultation to improve clinical outcomes for patients with chronic and complex illness. DISCUSSION: The goal of any clinician is not simply to apply a reliable classification system, but to use scientific knowledge and clinical skill to heal specific patients in their specific contexts. In patients with complex and chronic illness, this involves three types of diagnosis: the medical diagnosis, the psychosocial formulation and the psychiatric diagnosis. These different aspects of diagnosis intersect and interact and involve different ways of thinking about the patient and their illness. Having the flexibility to consider these diverse points of view has the potential to improve our understanding of the patient and their illness and to facilitate healing. Sadler illustrates this diversity of perspectives by using the metaphor of the botanist and the gardener. For the botanist, classification produces a taxonomy that is rigorous and reliable. For the gardener, classification informs the way a garden is developed and nurtured. Both perspectives are important to achieve a good clinical outcome.

Illness uncertainty and risk management for people with cancer.

BACKGROUND: Patients with cancer live with considerable uncertainty. This uncertainty can be related to the process of diagnosis, treatment, remission or palliative care, and therefore it can be experienced repeatedly or continuously throughout a patient's life. For patients with low literacy or low numeracy, it can be difficult to access, understand and interpret risk, so shared decision making may be difficult. OBJECTIVE: The aim of this article is to address the challenges of managing anxiety and uncertainty for patients with cancer in the general practice setting. DISCUSSION: The diagnosis of cancer is a life-changing event, and it can herald a long journey of anxiety, uncertainty and change. General practitioners (GPs) can assist patients to navigate complex health systems and find a sense of autonomy and agency in an otherwise marginalising life experience. For patients with low literacy and numeracy, GPs have a critical role in enabling shared decision making and ensuring consent is fully informed.

Recognising and responding to domestic and family violence in general practice.

BACKGROUND: Domestic and family violence (DFV) is often difficult to recognise despite its high prevalence in the community. General practitioners require specialised skills to elicit a history of DFV, remain aware of the complex patterns of DFV, respond to potential risk and maintain engagement as part of a team involved in ongoing care. OBJECTIVE: The aim of this article is to outline the principles of recognising, responding, referring, recording and reflecting on care for those who may be experiencing DFV. DISCUSSION: GPs have unique opportunities to identify, assess and respond to DFV because of the trusting therapeutic relationships they develop with patients. Managing DFV requires a safe place to disclose, skilled risk assessment, careful documentation, safety planning and ongoing therapeutic processes that soothe, validate, empower and connect to wider social supports. Trauma-informed general practice is a key element of integrated systems responses to DFV in our community.

Explaining the unexplainable - crafting explanatory frameworks for medically unexplained symptoms.

BACKGROUND: Patients with multiple medically unexplained symptoms are common in general practice. Comorbid depression, anxiety, substance abuse and significant psychosocial stressors are common. It can be challenging to find a balance between excluding and treating organic causes and overinvestigating and overtreating. OBJECTIVE: This article provides the general practitioner with a suggested framework for explaining multiple medically unexplained symptoms to patients. DISCUSSION: An adequate explanation of the problem is important. General practitioners can use a number of explanatory models, including reassurance, somatisation and narrative techniques. Sometimes a solution to a specific problem is available and may involve referral to other health professionals. In many cases the more important management strategy may be to provide supportive care by being with the sufferer and acknowledging the suffering, without succumbing to the urge to fix the problem. General practitioners have a unique role in supporting patients who cope with symptoms, but without a clear medical diagnosis.