Introducing Point-of-Care PCR technology in general practice: Ambiguities, experiences, and perceptions among health care professionals.

In this paper we present findings from a qualitative ethnographic study investigating the experiences and perceptions of general practitioners and other practice staff when introducing a new point of care diagnostic test technology (point of care polymerase chain reaction (POC PCR)) in general practice in Denmark. The ethnographic study was conducted in five general practice clinics, involving observations in four of the clinics and interviews with general practitioners and practice staff in all five clinics. Following an initial analytic phase in which barriers and facilitators in the implementation process of the Point-of-Care test were identified, we developed theoretically informed themes, drawing upon Hartmut Rosa's social theory of technological acceleration. These themes included ambiguous experiences and perceptions of: (i) diagnostic specification and inflation embedded in diagnostic practices; (ii) empowerment and erosion of professional judgment; (iii) strategies of security and insecurity in communication; (iv) the interdependence between professional autonomy and economic structures associated with organizational power; and (v) subjective and organizational time. We discuss how diagnostic technologies simultaneously contribute to and disrupt treatment safety, efficiency, and medical decision-making. Using Rosa's sociological concepts of alienation and resonance, this article furthermore explores how these ambiguous dynamics are experienced in general practice settings. It also examines the implications of navigating a heterogeneous socio-technical and medical landscape and what it means to be a health professional in a contemporary general practice environment that is increasingly shaped by diagnostic technologies.

Understanding Gut Sensations: Irritable Bowel Syndrome and Diagnostic Fluidity in Danish Clinical Practice.

Irritable bowel syndrome (IBS) is a prevalent health challenge in a Danish welfare context. Drawing on ethnographic fieldwork at two Danish gastroenterology clinics, and inspired by Charles E. Rosenberg's idea of styles of explaining widespread diseases, we outline three styles of understanding and treating gut trouble in daily clinical work: "The microbial gut," "the mindful gut," and "the lifestyled gut." Moreover, we suggest the concept of fluidity to characterize IBS as a diagnostic category that allows clinicians and patients to operate through complex understandings of permeable boundaries between body, mind, and environment to negotiate personalized solutions for embodied gut sensations.

Moving goals. Goal-work in Parkinson's disease rehabilitation.

Chronic diseases often demand considerable work by patients: they must adhere to medical regimes and engage with social and embodied discontinuities. In Denmark, rehabilitees in Parkinson's disease rehabilitation talk about Parkinson's as their new job. In this article, we introduce goal-work as an optical lens to enlarge and explore the micro-social practices that concern a core practice in rehabilitation where professionals and rehabilitees set goals for the future and work toward the goals. To work with goals adds a new task to living with Parkinson's. Rehabilitation research tends to focus on the actual goal-setting meeting. Drawing on data from long-term ethnographic fieldwork on goals and their setting in Parkinson's disease rehabilitation, we show how participants in rehabilitation imagine, set, enact, review or share their rehabilitation goals, and how goals are worked with before and after the goal-setting meeting, across settings. We conceptualize these micro-social practices as goal-work, which we argue is a spatio-temporal process. The concept of goal-work emphasizes the fact that goal-setting is one event in a string of goal-related activities, and it turns our attention to the intersubjective dimensions inherent in goal-work, such as the role of relatives and how acts of imagination and acts of sharing form part of goal-work.

What Are Your Goals? Goal-Setting Logics in Danish Parkinson's Rehabilitation.

Across rehabilitation fields, rehabilitees and professionals meet to set rehabilitation goals. Portrayed as an ordinary, yet foundational practice in rehabilitation, participants often find goal-setting meetings challenging; ideal and real seem to clash. Based on a long-term fieldwork in Danish Parkinson's disease rehabilitation, we explore goal-setting and its rationale to gain insight into why goal-setting qualifies as challenging. We find that challenges relate to disease, organizational matters and an imbalance in institutional knowledge, but also that different logics, of choice, interdependence, and accountability, entangle and affect goal-setting. A competitive aspect between goal-setting logics appears pivotal to understand the challenges in goal-setting.

Cultivating Doctors' Gut Feeling: Experience, Temporality and Politics of Gut Feelings in Family Medicine.

For the past decade, within family medicine there has been a focus on cultivating doctors gut feelings as 'a way of knowing' in cancer diagnostics. In this paper, building on interviews with family doctors in Oxford shire, UK we explore the embodied and temporal dimensions of clinical reasoning and how the cultivation of doctors' gut feelings is related to hierarchies of medical knowledge, professional training, and doctors' fears of litigation. Also, we suggest that the introduction of gut feeling in clinical practice is an attempt to develop a theory of clinical reasoning that fits the biopolitics of our contemporary. The turn towards predictive medicine and the values introduced by accelerated diagnostic regimes, we conclude, introduce a need for situated and embodied modes of reading bodies. We contribute theoretically by framing our analysis within a sensorial anthropology approach.

Building the case for the use of gut feelings in cancer referrals: perspectives of patients referred to a non-specific symptoms pathway.

BACKGROUND: Gut feelings may be useful when dealing with uncertainty, which is ubiquitous in primary care. Both patients and GPs experience this uncertainty but patients' views on gut feelings in the consultation have not been explored. AIM: To explore patients' perceptions of gut feelings in decision making, and to compare these perceptions with those of GPs. DESIGN AND SETTING: Qualitative interviews with 21 patients in Oxfordshire, UK. METHOD: Patients whose referral to a cancer pathway was based on their GP's gut feeling were invited to participate. Semi-structured interviews were conducted from November 2019 to January 2020, face to face or over the telephone. Data were analysed with a thematic analysis and mind-mapping approach. RESULTS: Some patients described experiencing gut feelings about their own health but often their willingness to share this with their GP was dependent on an established doctor-patient relationship. Patients expressed similar perspectives on the use of gut feelings in consultations to those reported by GPs. Patients saw GPs' gut feelings as grounded in their experience and generalist expertise, and part of a process of evidence gathering. Patients suggested that GPs were justified in using gut feelings because of their role in arranging access to investigations, the difficult 'grey area' of presentations, and the time- and resource-limited nature of primary care. When GPs communicated that they had a gut feeling, some saw this as an indication that they were being taken seriously. CONCLUSION: Patients accepted that GPs use gut feelings to guide decision making. Future research on this topic should include more diverse samples and address the areas of concern shared by patients and GPs.

Tinkering with Time versus Being under the Spell of Time.

Drawing upon ethnographic fieldwork in a Danish pediatric oncology ward we explore how children - as cancer patients - respond to the time constraints of cancer treatment that may save their lives but simultaneously hold them under a spell of time. Children respond through practices of what we have called "tinkering with time," which enable them to seize control not of life, but of time. We suggest that tinkering be understood as time work through which children mold their experience of the constraints of time. We regard this as an expression of existential agency that simultaneously sustains children's sense of autonomy.

GPs' use of gut feelings when assessing cancer risk: a qualitative study in UK primary care.

BACKGROUND: The use of gut feelings to guide clinical decision making in primary care has been frequently described but is not considered a legitimate reason for cancer referral. AIM: To explore the role that gut feeling plays in clinical decision making in primary care. DESIGN AND SETTING: Qualitative interview study with 19 GPs in Oxfordshire, UK. METHOD: GPs who had referred patients to a cancer pathway based on a gut feeling as a referral criterion were invited to participate. Interviews were conducted between November 2019 and January 2020, and transcripts were analysed using the one sheet of paper method. RESULTS: Gut feeling was seen as an essential part of decision making that facilitated appropriate and timely care. GPs distanced their gut feelings from descriptions that could be seen as unscientific, describing successful use as reliant on experience and clinical knowledge. This was especially true for patients who fell within a 'grey area' where clinical guidelines did not match the GP's assessment of cancer risk, either because the guidance inadequately represented or did not include the patient's presentation. GPs sought to legitimise their gut feelings by gathering objective clinical evidence, careful examination of referral procedures, and consultation with colleagues. CONCLUSION: GPs described their gut feelings as important to decision making in primary care and a necessary addition to clinical guidance. The steps taken to legitimise their gut feelings matched that expected in good clinical practice.

Disengaging with the cancerous body.

In recent years, the organisation of healthcare in many welfare states is gradually moving towards an individualised and responsibility-driven self-care and use of healthcare services. Departing in this restructuring of care, this article explores how bodies are experienced and how care is sough, by socially disadvantaged cancer patients. Based on repeated ethnographic interviews with 10 socially deprived cancer patients in Denmark, the article illustrates that socially disadvantaged cancer patients often experience their bodies and move between feeling fine and feeling sick in a disjunctive manner engulfed by the practicality of getting through the day. From a critical phenomenological perspective, we argue that this way of being in the world appears counterfactual to welfare expectations of proactive attention to the body, and contemporary moves towards increased individual responsibility for preventing serious disease and monitoring the body.

Reconfiguring diagnostic work in Danish general practice; regulation, triage and the secretaries as diagnostician.

Health care systems as well as bodies of medical knowledge are dynamic and change as the result of political and social transformations. In recent decades, health care systems have been subjected to a whole assemblage of regulatory practices. The local changes undertaken in Denmark that are being explored here are indicative of a long-term shift that has occurred in many welfare states intended to make public services in the Global North more efficient and transparent. Departing in prolonged field work in Danish general practice and the anthropological literature on audit culture, this paper suggests that the introduction of regulatory practices has enhanced the need for triage as a key organising principle. The term triage literally means separating out and refers to the process of sorting and placing patients in time and space. The paper suggests that an increasing introduction of triage feeds into a reconfiguration of diagnostic work, where the clinical setting is gradually becoming more intertwined with the governing domains of policy, and the work of the secretary is gradually becoming more intertwined with that of the doctor. Finally, the paper argues that an increasing regulation of general practice poses an ethically charged challenge to existing welfare politics of responsibility between the state and the public, as it makes it increasingly difficult to negotiate access to care.

The cancer may come back: experiencing and managing worries of relapse in a North Norwegian village after treatment.

Little is known about how people living in the aftermath of cancer treatment experience and manage worries about possible signs of cancer relapse, not as an individual enterprise but as socially embedded management. One-year ethnographic fieldwork was conducted in a coastal village of under 3000 inhabitants in northern Norway. Ten villagers who had undergone cancer treatment from six months to five years earlier were the main informants. During fieldwork, the first author conducted qualitative, semi-structured monthly interviews with them, and participated in their everyday activities and relationships, including families, friends and co-villagers. In this article, we contemplate human emotions as arising in contexts of transactions, capable of creating social realities. By including this perspective, we highlight how people who recover from cancer construct and experience worry about possible relapse in relation to close family members, friends and co-villagers in the socially closely-knit and relatively isolated village. These emotional experiences emerge through relationships with others have communicative characteristics and take place in interaction with the social environment of their village. While informants attempt to protect family members by avoiding sharing worries with them, they express the need to share their worries within friendships. However, they experience both comfort and challenges in managing their worries in relation to acquaintances in the village. Overall, the study enhances understanding of the social embeddedness of emotions in everyday life, by revealing how worries of relapse of cancer configure and relate to various social contexts.

It is important that the process goes quickly, isn't it?" A qualitative multi-country study of colorectal or lung cancer patients' narratives of the timeliness of diagnosis and quality of care.

PURPOSE: The emphasis on early diagnosis to improve cancer survival has been a key factor in the development of cancer pathways across Europe. The aim of this analysis was to explore how the emphasis on early diagnosis and timely treatment is reflected in patient's accounts of care, from the first suspicion of colorectal or lung cancer to their treatment in Denmark, England and Sweden. METHOD: We recruited 155 patients in Denmark, England and Sweden who were within six months of being diagnosed with lung or colorectal cancer. Data were collected via semi-structured narrative interviews and analysed using a thematic approach. RESULTS: Participants' accounts of quality of care were closely related to how quickly (or not) diagnosis, treatment and/or healthcare processes went. Kinetic metaphors as a description of care (such as treadmill) could be interpreted positively as participants were willing to forgo some degree of control and accept disruption to their lives to ensure more timely care. Drawing on wider cultural expectations of the benefits of diagnosing and treating cancer quickly, some participants were concerned that the waiting times between interventions might allow time for the cancer to grow. CONCLUSIONS: Initiatives emphasising the timeliness of diagnosis and treatment are reflected in the ways some patients experience their care. However, these accounts were open to further contextualisation about what speed of healthcare processes meant for evaluating the quality of their care. Healthcare professionals could therefore be an important patient resource in providing reassurance and support about the timeliness of diagnosis or treatment.

Patients' initial steps to cancer diagnosis in Denmark, England and Sweden: what can a qualitative, cross-country comparison of narrative interviews tell us about potentially modifiable factors?

OBJECTIVES: To illuminate patterns observed in International Cancer Benchmarking Programme studies by extending understanding of the various influences on presentation and referral with cancer symptoms. DESIGN: Cross-country comparison of Denmark, England and Sweden with qualitative analysis of in-depth interview accounts of the prediagnostic process in lung or bowel cancer. PARTICIPANTS: 155 women and men, aged between 35 and 86 years old, diagnosed with lung or bowel cancer in 6 months before interview. SETTING: Participants recruited through primary and secondary care, social media and word of mouth. Interviews collected by social scientists or nurse researchers during 2015, mainly in participants' homes. RESULTS: Participants reported difficulties in interpreting diffuse bodily sensations and symptoms and deciding when to consult. There were examples of swift referrals by primary care professionals in all three countries. In all countries, participants described difficulty deciding if and when to consult, highlighting concerns about access to general practitioner appointments and overstretched primary care services, although this appears less prominent in the Swedish data. It was not unusual for there to be more than one consultation before referral and we noted two distinct patterns of repeated consultation: (1) situations where the participant left the primary care consultation with a plan of action about what should happen next; (2) participants were unclear about under which conditions to return to the doctors. This second pattern sometimes extended over many weeks during which patients described uncertainty, and sometimes frustration, about if and when they should return and whether there were any other feasible investigations. The latter pattern appeared more evident in the interviews in England and Denmark than Sweden. CONCLUSION: We suggest that if clear action plans, as part of safety netting, were routinely used in primary care consultations then uncertainty, false reassurance and the inefficiency and distress of multiple consultations could be reduced.

Activation of professional and personal network relations when experiencing a symptom: a population-based cross-sectional study.

OBJECTIVE: To describe patterns of disclosure of symptoms experienced among people in the general population to persons in their personal and/or professional network. DESIGN: A population-based cross-sectional study. Data were collected from a web-based survey. SETTING: The general population in Denmark. PARTICIPANTS: 100 000 individuals randomly selected, representative of the adult Danish population aged ≥20 years were invited. Approximately 5% were not eligible for inclusion. 49 706 (men=23 240; women=26 466) of 95 253 eligible individuals completed the questionnaire; yielding a response rate of 52.2%. Individuals completing all questions regarding social network relations form the study base (n=44 313). PRIMARY AND SECONDARY OUTCOME MEASURES: Activation of personal and/or professional relations when experiencing a symptom. RESULTS: The 44 313 individuals reported in total 260 079 symptom experiences within the last 4 weeks. No professional network relation was used in two-thirds of all reported symptoms. The general practitioner (GP) was the most frequently reported professional relation activated (22.5%). People reporting to have available personal relations were slightly less inclined to contact the GP (21.9%) when experiencing a symptom compared with people with no reported personal relations (26.8%). The most commonly activated personal relations were spouse/partner (56.4%) and friend (19.6%). More than a quarter of all reported symptom experiences was not shared with anyone, personal nor professional. The symptom experiences with the lowest frequency of network activation were symptoms such as black stool, constipation, change in stool texture and frequent urination. CONCLUSION: This study emphasises variation in the activation of network relations when experiencing a symptom. Symptoms were shared with both personal and professional relations, but different patterns of disclosures were discovered. For symptoms derived from the urogenital or colorectal region, the use of both personal and professional relations was relatively small, which might indicate reticence to involve other people when experiencing symptoms of that nature.

Resisting "Reason": A Comparative Anthropological Study of Social Differences and Resistance toward Health Promotion and Illness Prevention in Denmark.

Social differences in health and illness are well documented in Denmark. However, little is known about how health practices are manifested in the everyday lives of different social classes. We propose acts of resistance and formation of health subjectivities as helpful concepts to develop our understanding of how dominant health discourses are appropriated by different social classes and transformed into different practices promoting health and preventing illness. Based on fieldwork in two different social classes, we discuss how these practices both overtly and subtly challenge the normative power of the health promotion discourse. These diverse and ambiguous forms of everyday resistance illustrate how and when situated concerns move social actors to subjectively appropriate health promotion messages. Overall, the different forms of resistance elucidate how the standardized awareness and education campaigns may perpetuate the very inequalities they try to diminish.

Situating Social Differences in Health and Illness Practices.

This article suggests that in order to understand the social differences evident in disease prevalence and outcomes, it is necessary to understand what it means to live with multiple social, physical, and psychological challenges. Drawing on research in cancer diagnosis, we discuss practices of health, illness, and care-seeking. We suggest that the focus on lifestyle and behavioral change that dominates contemporary public health interventions should be complemented with a Weberian circumstantial approach. Acknowledging the situatedness of health and illness practices may enable us to help our patients gain access to, and benefit from, the health-care system.

Class, Social Suffering, and Health Consumerism.

In recent years an extensive social gradient in cancer outcome has attracted much attention, with late diagnosis proposed as one important reason for this. Whereas earlier research has investigated health care seeking among cancer patients, these social differences may be better understood by looking at health care seeking practices among people who are not diagnosed with cancer. Drawing on long-term ethnographic fieldwork among two different social classes in Denmark, our aim in this article is to explore the relevance of class to health care seeking practices and illness concerns. In the higher middle class, we predominantly encountered health care seeking resembling notions of health consumerism, practices sanctioned and encouraged by the health care system. However, among people in the lower working class, health care seeking was often shaped by the inseparability of physical, political, and social dimensions of discomfort, making these practices difficult for the health care system to accommodate.

Self-reported symptoms and healthcare seeking in the general population--exploring "The Symptom Iceberg".

BACKGROUND: Research has illustrated that the decision-making process regarding healthcare seeking for symptoms is complex and associated with a variety of factors, including gender differences. Enhanced understanding of the frequency of symptoms and the healthcare seeking behaviour in the general population may increase our knowledge of this complex field. The primary objective of this study was to estimate the prevalence of self-reported symptoms and the proportion of individuals reporting GP contact, in a large Danish nationwide cohort. A secondary objective was to explore gender differences in GP contacts in response to experiencing one of the 44 predefined symptoms. METHODS: A Danish nationwide cohort study including a random sample of 100,000 individuals, representative of the adult Danish population aged 20 years or above. A web-based questionnaire survey formed the basis of this study. A total of 44 different symptoms covering a wide area of alarm symptoms and non-specific frequently occurring symptoms were selected based on extensive literature search. Further, items regarding contact to the GP were included. Data on socioeconomic factors were obtained from Statistics Denmark. RESULTS: A total of 49,706 subjects completed the questionnaire. Prevalence estimates of symptoms varied from 49.4% (24,537) reporting tiredness to 0.11% (54) reporting blood in vomit. The mean number of reported symptoms was 5.4 (men 4.8; women 6.0). The proportion of contact to the GP with at least one symptom was 37%. The largest proportion of GP contacts was seen for individuals reporting blood in the urine (73.2%), whereas only 11.4% of individuals with increase in waist circumference reported GP contact. For almost 2/3 of the symptoms reported, no gender differences were found concerning the proportion leading to GP contacts. CONCLUSION: Prevalence of symptoms and GP contacts are common in this overview of 44 different self-reported symptoms. For almost 2/3 of the reported symptoms no gender differences were found concerning the proportion leading to GP contacts. An enhanced understanding of healthcare seeking decisions may assist healthcare professionals in identifying patients who are at risk of postponing contact to the GP and may help development of health campaigns targeting these individuals.

Juggling efficiency. An ethnographic study exploring healthcare seeking practices and institutional logics in Danish primary care settings.

This article explores the mutually constituting relationship between healthcare seeking practices and the socio-political context of clinical encounters. On the basis of ethnographic fieldwork carried out in the context of Danish primary care (general practice) and inspired by recent writings on institutional logics, we illustrate how a logic of efficiency organise and give shape to healthcare seeking practices as they manifest in local clinical settings. Overall, patient concerns are reconfigured to fit the local clinical setting and healthcare professionals and patients are required to juggle efficiency in order to deal with uncertainties and meet more complex or unpredictable needs. Lastly, building on the empirical case of cancer diagnostics, we discuss the implications of the pervasiveness of the logic of efficiency in the clinical setting and argue that provision of medical care in today's primary care settings requires careful balancing of increasing demands of efficiency, greater complexity of biomedical knowledge and consideration for individual patient needs.

Global Health Care-seeking Discourses Facing Local Clinical Realities: Exploring the Case of Cancer.

Using cancer as an example and drawing on Pierre Bourdieu's concepts of field and on prolonged fieldwork in Danish general medical practice settings, we examine how discourses about what counts as legitimate help-seeking practices are negotiated in local clinical encounters. Overall, we identify competition between two discourses on help-seeking practices. This competition is present most when people seek help with unspecific, vague, or diffuse illness complaints, voicing uncertainty as to what counts as signs of illness, characteristic of proactive discourses emanating from global, scientific biomedicine. Such indistinct help-seeking conflicts with the dominant discourse in the local clinical setting and is characterized by an overt focus on identification of the chief complaint. The analysis illustrates how competing discourses may result in conflicting expectations to the clinical encounter and prove counterproductive to ensuring early diagnosis of cancer.