Where the joy comes from: a qualitative exploration of deep GP-patient relationships.

BACKGROUND: Relationship-based, whole person care is foundational to quality general practice. Previous research has identified several characteristics of deep General Practitioner (GP)-patient relationships and their association with improved patient concordance, satisfaction and perceived health outcomes. Psychological attachment theory has been used to understand therapeutic relationships, but has only been explored to a limited extent in the general practice context. Additionally, evolving changes in sociocultural and commercial practice contexts may threaten relationship-based care. In view of this, we aimed to explore the nature and experience of deep GP-patient relationships, as identified by patients, from GP and patient perspectives. METHODS: Semi-structured interview design. An initial survey assessed patients' perceived depth of their relationship with their GP, using the Health Care Provider Attachment Figure Survey and Patient-Doctor Depth of Relationship Scale. Patients who reported a deep relationship, and their GPs, were purposively selected for individual interviews exploring their experience of these relationships. A post-interview survey assessed interviewees' attachment styles, using the Modified and Brief Experiences in Close Relationships Scale. Patient interviewees also rated the patient-centredness of their GP's clinic using the Person-Centred Primary Care Measure. Transcripts were analysed using thematic analysis. RESULTS: Thirteen patients and five GPs were interviewed. Four themes characterised deep relationships: the 'professional'; human connection; trust; and 'above and beyond'. Patient, GP and practice team all contributed to their cultivation. CONCLUSIONS: We present a revised conceptual framework of deep GP-patient relationships. Deep relationships come to the fore in times of patient trouble. Like attachment relationships, they provide a sense of safety, caring and support for patients experiencing vulnerability. They can stretch GP boundaries and capacity for self-care, but also provide joy and vocational satisfaction. Patients may not always desire or need deep relationships with their GP. However, findings highlight the importance of enabling and cultivating these for times of patient hardship, and challenges of doing so within current healthcare climates.

Survivorship Navigation for Young Women With Early-Stage Breast Cancer.

BACKGROUND: Young women treated for breast cancer experience unique concerns in follow-up. We developed a program to direct young breast cancer survivors to a dedicated survivorship visit and evaluated their experience. MATERIALS AND METHODS: Early-stage breast cancer patients diagnosed under age 45 within 1 year of completing breast surgery, chemotherapy and/or radiation therapy were systematically referred for a survivorship visit. Patients completed a one-time, post-visit survey about their experience. RESULTS: Sixty-nine out of 89 (78%) eligible patients attended a survivorship visit, and 40 of those 69 (58%) completed the post-visit survey. Most respondents learned about the survivorship clinic after completing treatment (30/40; 75%) and reported the survivorship visit occurred at an appropriate time in their follow-up care (26/40; 65%). Of the 34 respondents who reported receiving a treatment summary and survivorship care plan, 30 indicated it would be helpful when visiting their primary care provider (88.2%). Participants reported gaining valuable knowledge about cancer treatment (28/38; 73.7%), side effects (32/39; 82.1%), and cancer surveillance (30/40; 75%), and discussed emotional health (32/40; 80%), exercise (38/40; 95%), and ongoing cancer surveillance (32/37; 86.5%). Several reported intentions to make changes to their follow-up oncology care (8/20; 40%), exercise routines (16/30; 53.3%), and emotional health care (15/22; 68.2%). DISCUSSION: Survivorship visit navigation is feasible for young breast cancer patients. These visits can influence knowledge gained and intended future health plans and behaviors. Systematic approaches to survivorship care may improve the physical and mental health of cancer survivors. Future health care delivery research focused on survivorship is warranted.

Holding the complex whole: Generalist philosophy, priorities and practice that facilitate whole-person care.

BACKGROUND: Generalist work is often complex, especially in the face of undifferentiated, uncertain, uncomfortable or unremitting presentations. This complexity can be exacerbated by difficult social circumstances and health system constraints, as well as by dissonance between patient and clinician conceptions of ideal care. OBJECTIVE: This article offers philosophical and practical encouragement to help general practitioners (GPs) 'be with' patients, care for their own needs and value their complex work. DISCUSSION: Caring for the whole person is challenging. When done well, this complex care may look simple. Alongside biomedical knowledge, generalists require sophisticated relational sensitivity and capacity to notice and attend to context, culture, meaning and subjective inner experience, including the person's strengths and deepest fears. Generalist philosophy, priorities and clinical skills are named in this paper as part of the ongoing effort to help GPs value, hone and protect the often-misunderstood complexity of their work.

Whole person assessment for family medicine: a systematic review.

OBJECTIVES: To identify and evaluate clinical approaches to whole person assessment (WPA) that are translatable to family medicine regarding feasibility, quality and alignment with theoretical models of whole person care (WPC). DESIGN: Systematic literature review. DATA SOURCES: MEDLINE, CINAHL, PsycINFO and ATLA Religion databases were searched through 9 March 2020, with additional handsearches. ELIGIBILITY CRITERIA: English language clinical assessments of multiple domains; which involve patient-clinician interaction and are translatable to general practice (GP); from the fields of medicine, allied health, nursing, mental health and pastoral care. Tools designed for single diseases or symptoms, for outcome rather than clinical assessment or with outdated classification systems were excluded. DATA EXTRACTION AND SYNTHESIS: We appraised the quality of included papers using Johanna Briggs' Institute Checklists and Terwee's criteria for validation studies. Clinical assessments' alignment with theoretical WPC, feasibility for adaptation to GP and quality were examined. We analysed extracted data using framework synthesis. RESULTS: Searches retrieved 7535 non-duplicate items. Fifty-nine were included after screening, describing 42 WPA methods and representing multiple disciplines, purposes and formats. All included assessments aligned partially with models of WPC, but most did not adequately encompass all aspects of WPC. Robustness varied significantly and was often inadequately described. We judged none of the identified assessments to be ideal as a multipurpose WPA in GP. Some could be used for specific purposes, such as elicitation of patient perspectives or complexity assessment. CONCLUSIONS: While no WPAs were found that were sufficient for broad implementation in GP, some approaches may be suitable with adaptation and evaluation. Strengths of existing approaches could inform WPA development in future. PROSPERO REGISTRATION NUMBER: CRD42020164417.

Community perspectives on delivering trauma-aware and culturally safe perinatal care for Aboriginal and Torres Strait Islander parents.

BACKGROUND: Since colonisation, Aboriginal and Torres Strait Islander peoples have experienced violence, loss of land, ongoing discrimination and increased exposure to traumatic events. These include adverse childhood experiences which can lead to complex trauma, and are associated with increased incidence of high-risk pregnancies, birth complications and emergence of post-traumatic symptoms during the perinatal period, potentially impacting parenting and leading to intergenerational trauma. The perinatal period offers unique opportunities for processing experiences of trauma and healing yet can also be a time when parents experience complex trauma-related distress. Therefore, it is essential that trauma-aware culturally safe perinatal care is accessible to Aboriginal and Torres Strait Islander parents. AIM: This study aimed to understand community perspectives of what 'trauma-aware culturally safe perinatal care' would look like for Aboriginal and Torres Strait Islander parents. METHODS: Data were collected during a workshop held with predominantly Aboriginal and Torres Strait Islander key stakeholders to co-design strategies to foster trauma-aware culturally safe perinatal care. Data were thematically analysed. FINDINGS: Four overarching themes represent proposed goals for trauma-aware culturally safe care: Authentic partnerships that are nurtured and invested in to provide the foundations of care; a skilled workforce educated in trauma awareness; empowering and compassionate care for building trust; and safe and accessible environments to facilitate parent engagement. CONCLUSIONS: Provision of trauma-aware culturally safe care achieving these goals is likely to enable parents experiencing complex trauma to access appropriate support and care to foster healing in the critical perinatal period.

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.

'I thought I was about to die': Management of non-fatal strangulation in general practice.

BACKGROUND: Awareness of the significance of non­fatal strangulation is increasing in health and justice settings. While approximately half of patients strangled will sustain no immediate physical injury, strangulation has potential significant sequelae such as carotid dissection, hypoxic brain injury and laryngeal injury. Non-fatal strangulation by an intimate partner increases homicide risk by 7.48 times. General practitioners have a key role in identification, education and appropriate treatment.  OBJECTIVE: The aim of this article is to provide an understanding of strangulation and its associated risks, to inform decision making regarding assessment, investigation and appropriate patient referral and safety netting.  DISCUSSION: Informing patients of the increased risk of future homicide if strangled by an intimate partner may prevent death. Awareness of the red flag signs and symptoms, from subtle bruises or petechiae to significant oedema, focal neurological deficits and cognitive impairment, aids decision making regarding referrals and imaging as well as informing documentation for legal purposes.

'Things we are expected to just do and deal with': Using the medical humanities to encourage reflection on vulnerability and nurture clinical skills, collegiality, compassion, and self-care.

The Vulnerability in Medicine (ViM) program was developed to provide protected time and psychologically safe spaces for third-year medical students to consider challenges in the doctor-patient relationship and the clinical workplace. A suite of discussion-prompts presented in a small-group learning environment provides a springboard for students to reflect on their development as clinicians, understand the personhood of their patients, explore the therapeutic relationship, and consider emotional responses and personal, cultural, and social assumptions that impact on care. The program supports students to recognise vulnerability in themselves, the patient, their tutors, and the wider clinical team, as they face the challenge of aligning the clinician they want to become with ideals of professionalism and the imperfect clinical workplace. This 6­week program focuses on the vulnerability of patients, students, and doctors in a weekly tutorial interposed with clinical placements primarily in geriatric, rehabilitation, or palliative medicine. The tutorials draw from the medical humanities and use experiential, reflective, and narrative learning techniques. They are facilitated by generalist clinicians who model their own vulnerability, humanity, and reflective practice by sharing tutorial tasks equally with students. Students report feeling supported, and appreciate the opportunity to discuss ethical, psychosocial, and emotional aspects of medicine whilst reflecting on what medical practice means to them. Tutors experience a deeper appreciation of student journeys and their own vocations as clinicians and teachers. The sharing of vulnerability exposes the humanity of patients, students, and clinicians, and sustains our whole-person approach to the care of patients, students, and ourselves.

The Craft of Generalism clinical skills and attitudes for whole person care.

RATIONALE, AIMS AND OBJECTIVES: Generalists manage a broad range of biomedical and biographical knowledge as part of each clinical encounter, often in multiple encounters over time. The sophistication of this broad integrative work is often misunderstood by those schooled in reductionist or constructivist approaches to evidence. There is a need to describe the practical and philosophically robust ways that understanding about the whole person is formed. In this paper we describe first principles of generalist approaches to knowledge formation in clinical practice. We name the Craft of Generalism. METHODS: The newly described methodology of Transdisciplinary Generalism is examined by skilled generalist clinicians and translated into skills and attitudes useful for everyday generalist person-centred practice and research. RESULTS: The Craft of Generalism defines the required scope, process, priorities, and knowledge management skills of all generalists seeking to care for the whole person. These principles are Whole Person Scope, Relational Process, Healing Orientation, and Integrative Wisdom. These skills and attitudes are required for whole person care. If any element of these first principles is left out, the resultant knowledge is incomplete and philosophically incoherent. CONCLUSIONS: Naming the Craft of Generalism defines the generalist gaze and protects generalism from the colonization of a narrowed medical gaze that excludes all but reductionist evidence or constructivist experience. Defining the Craft of Generalism enables clear teaching of the sophisticated skills and attitudes of the generalist clinician. These philosophically robust principles encourage and defend the use of generalist approaches to knowledge in settings across the community - including health policy, education, and research.

Heard, known, and safe in general practice? An interview study with patients with severe and persistent mental illness.

BACKGROUND: Although GPs provide care to many patients with severe and persistent mental illness, the role and skillset of the GP in this space are contested. Patients are less satisfied with GP care of mental health than physical health issues. AIM: To explore patient expectations and experiences of GP roles in their mental health, and identify opportunities for improving mental health care in general practice. DESIGN & SETTING: Patient participants were recruited from community mental health clinics in Brisbane, Australia. METHOD: Individual semi-structured interviews were conducted with a convenience sample of patients. Interviews were audio-recorded and transcribed professionally. The authors conducted an inductive thematic analysis, attending to participant vulnerability and reflexivity. RESULTS: Sixteen interviews were conducted by one author (RW), with an average duration of 29 minutes. Three overarching themes were identified: being heard, being known, and being safe. Participants greatly valued 'good GPs' who were able to detect early signs of relapse, and with whom they came to feel heard, known, and safe over time. Experiences of perfunctory, hurried care and avoidance of mental health issues were also reported. Many participants were uncertain whether GP training in mental health was sufficient to keep them safe. Patients may suspect GPs who predominantly engage with their physical health to have negative attitudes to mental illness. CONCLUSION: Some GPs play central roles in patients' mental health care. Barriers for others need further exploration, and may include time, confidence, and/or expertise. Findings challenge GPs to engage more actively and effectively with these patients in their general practice consultations.

Long-term antidepressant use in general practice: a qualitative study of GPs' views on discontinuation.

BACKGROUND: There is considerable concern about increasing antidepressant use, with Australians among the highest users in the world. Evidence suggests this is driven by patients on long-term use, rather than new prescriptions. Most antidepressant prescriptions are generated in general practice, and it is likely that attempts to discontinue are either not occurring or are proving unsuccessful. AIM: To explore GPs' insights about long-term antidepressant prescribing and discontinuation. DESIGN AND SETTING: A qualitative interview study with Australian GPs. METHOD: Semi-structured interviews explored GPs' discontinuation experiences, decision-making, perceived risks and benefits, and support for patients. Data were analysed using reflexive thematic analysis. RESULTS: Three overarching themes were identified from interviews with 22 GPs. The first, 'not a simple deprescribing decision', spoke to the complex decision-making GPs undertake in determining whether a patient is ready to discontinue. The second, 'a journey taken together', captured a set of steps GPs take together with their patients to initiate and set-up adequate support before, during, and after discontinuation. The third, 'supporting change in GPs' prescribing practices', described what GPs would like to see change to better support them and their patients to discontinue antidepressants. CONCLUSION: GPs see discontinuation of long-term antidepressant use as more than a simple deprescribing decision. It begins with considering a patient's social and relational context, and is a journey involving careful preparation, tailored care, and regular review. These insights suggest interventions to redress long-term use will need to take these considerations into account and be placed in a wider discussion about the use of antidepressants.

Transdisciplinary Generalism: Naming the epistemology and philosophy of the generalist.

BACKGROUND: Transdisciplinary research and generalist practice both face the task of integrating and discerning the value of knowledge across disciplinary and sectoral knowledge cultures. Transdisciplinarity and generalism also both offer philosophical and practical insights into the epistemology, ontology, axiology, and logic of seeing the 'whole'. Although generalism is a skill that can be used in many settings from industry to education, the focus of this paper is the literature of the primary care setting (i.e., general practice or family medicine). Generalist philosophy and practice in the family medicine setting highly values whole person care that uses integrative and interpretive wisdom to include both biomedical and biographical forms of knowledge. Generalist researchers are often caught between reductionist (positivist) biomedical measures and social science (post-positivist) constructivist theories of knowing. Neither of these approaches, even when juxtaposed in mixed-methods research, approximate the complexity of the generalist clinical encounter. A theoretically robust research methodology is needed that acknowledges the complexity of interpreting these ways of knowing in research and clinical practice. METHODS: A conceptual review of literature to define the alignment between (a) the philosophy and practice of generalism in primary care and (b) both the practical (Zurich) and philosophical or methodological (Nicolescuian) schools of transdisciplinarity. RESULTS: The alignment between generalism and transdisciplinarity included their broad scope, relational process, complex knowledge management, humble attitude to knowing, and real-world outcome focus. CONCLUSION: The concurrence between these approaches to knowing is offered here as Transdisciplinary Generalism - a coherent epistemology for both primary care researchers and generalist clinicians to understand, enact, and research their own sophisticated craft of managing diverse forms of knowledge.

The effects of social group interventions for depression: Systematic review.

BACKGROUND: There is a growing prevalence of prolonged antidepressant use globally. Social group interventions may be an effective way to manage mild to moderate depression, especially with patients seeking to discontinue antidepressant use. This systematic review evaluates studies that used social group interventions to manage depression. METHODS: Studies published up to June 2019 in nine bibliographic databases were identified using search terms related to depression, social interventions, and social participation. Formal therapies for depression (cognitive behaviour therapy, music therapy) were excluded as they have been reviewed elsewhere. RESULTS: 24 studies met inclusion criteria; 14 RCTs, 6 non-randomised controlled trials and 4 pre-post evaluations. In total, 28 social group programs were evaluated, 10 arts-based groups, 13 exercise groups and 5 others. Programs ranged in 'dose' from 5 to 150 hours (M = 31 hours) across 4 to 75 weeks (M = 15 weeks) and produced effect sizes on depression in the small to very large range (Hedge's g = .18 to 3.19, M = 1.14). A regression analysis revealed no participant variables, study variables or intervention variables were related to effect size on depression. LIMITATIONS: Risks of bias were found, primarily in the non-randomised studies, which means the findings must be regarded as preliminary until replicated. CONCLUSION: These findings indicate that social group interventions are an effective way to manage mild to moderate depression symptoms in a variety of populations. This approach may also help to prevent relapse among patients tapering off antidepressant medication.

Breast cancer patients' experiences of adherence and persistence to oral endocrine therapy: A qualitative evidence synthesis.

PURPOSE: Adjuvant endocrine therapy (AET) significantly reduces the risk of breast cancer recurrence and mortality in women with hormone receptor (HR+) breast cancer. Despite the documented survival benefits with AET, non-adherence and non-persistence remains a significant problem. This systematic review of qualitative research aimed to synthesise breast cancer patients' experiences of adherence and persistence to oral endocrine therapy. METHODS: The ENTREQ guidelines were followed. A systematic search strategy was performed across eleven electronic databases (Embase, Cinahl, Pubmed, Psychinfo, Proquest, Lenus, Scopus, Web of Science, Rian.ie, EThOS e-theses online, DART Europe). Thomas and Harden's three-stage approach to thematic analysis was undertaken on the findings of all included studies. Confidence in the findings were reviewed using GRADE-CERQual. RESULTS: Twenty-four qualitative studies were included in the synthesis. Three analytic themes were identified (We don't have an option; the side effects are worse than the disease; help us with information and support). Adherence was often driven by women feeling they had no option and a fear of cancer recurrence. Persistence was helped with support and information. Non-adherence and non-persistence were associated with debilitating side effects, inadequate information and lack of support. CONCLUSIONS: Adherence and persistence to AET was often suboptimal among breast cancer patients. Women commonly felt isolated and neglected as a result of insufficient information and support from healthcare professionals. If women are to persist with AET, primary care providers should be aware of the facilitators and barriers to adherence, and they should be knowledgeable in symptom management strategies.

Beyond symptoms: defining primary care mental health clinical assessment priorities, content and process.

The assessment of undifferentiated psychological distress is a daily aspect of primary care practice. Primary care practitioners' underlying values influence the priorities, process and content of assessment. Currently there is a lack of definition of these values in primary care clinical mental health assessment. This paper presents the case for adopting the philosophical values and principles of holistic transdisciplinary generalism to influence practice worldwide. Furthermore, it raises awareness of current constraints on practice, including an overreliance on the psychiatric paradigm of care and resulting criteria-based diagnoses. Finally, the paper seeks to promote discussion among primary care practitioners and researchers globally about how to define primary care clinical mental health assessment priorities, process and content.

The effectiveness of a group cognitive-behavioural breathlessness intervention on health status, mood and hospital admissions in elderly patients with chronic obstructive pulmonary disease.

Non-pharmacological breathlessness interventions in lung cancer have proven beneficial. Breathlessness is also a major symptom in chronic obstructive pulmonary disease (COPD). This study measured the effectiveness of a non-exercise-based four-week cognitive-behavioural breathlessness intervention, delivered in a group setting for elderly patients with severe COPD. The results of the one-year feasibility study are presented. Patients with COPD were asked to complete the St. George's Respiratory Questionnaire and Hospital Anxiety and Depression Scale six weeks before the intervention, at the start and end of the intervention and at six weeks follow-up. The multidisciplinary intervention used a cognitive-behavioural format to address understanding of COPD and medication, anxiety, panic and depression, activity pacing, relaxation, breathing retraining and goal-setting. Retrospective data on accident & emergency (A&E) attendances and length of hospital stay was collected six months before and six months after the intervention and the data compared to a matched waiting list control group. The results showed significant improvements in depression and health status. There was a non-significant improvement in anxiety. There was a significant reduction in A&E attendance and a non-significant reduction in length of hospital stay in the intervention group, compared to comparative increases in the control group, highlighting the cost-effectiveness of the intervention.

Screening for psychological distress in patients with lung cancer: results of a clinical audit evaluating the use of the patient Distress Thermometer.

PURPOSE: Patients with lung cancer frequently suffer psychological distress and guidelines in the United Kingdom recommend screening of all cancer patients for this problem. The audit investigated use of the Distress Thermometer in terms of staff adherence to locally developed guidelines, patient willingness to use the tool, its impact on referral rates to clinical psychology services and concordance between the tool and the clinical assessment. METHOD: Use of the Distress Thermometer was audited over a 3-month period in one lung cancer outpatient clinic. Referrals to clinical psychology services in response to clearly delineated referral indicators were assessed. Patient-reported outcomes were compared with practitioner assessment of need during clinical consultations to see whether the tool was measuring distress effectively. RESULTS: Thirty three of 34 patients used the Distress Thermometer during the audit period. Ten reported distress levels above 4 in the emotional or family problems domains. On ten occasions, the clinical interview identified problems not elicited by the Distress Thermometer. Guidelines were adhered to by staff, and patients were offered information about local support services and referral to clinical psychology services where indicated. Whilst all patients were happy to receive written information about further sources of support, none wanted to be referred to psychological services at that time. CONCLUSIONS: The Distress Thermometer is acceptable to patients with lung cancer in outpatient settings but it did not increase referrals for psychological support. Staff found it to be a useful tool in opening up communication about patient issues although it should not replace a comprehensive clinical interview.