"I think this is maybe our Achilles heel..." exploring GPs' responses to young people presenting with emotional distress in general practice: a qualitative study.

OBJECTIVE: An exploratory study to investigate general practitioners' (GPs') views and experiences of consulting with young people (aged 12-19 years) presenting with emotional distress in general practice. DESIGN: A qualitative study using grounded theory and situational analysis. Empirical data were generated through in-depth interviews based on a topic guide developed from the literature, and augmented with a series of situational maps. Continuous field notes and theoretical memos were recorded during data collection and analysis. The data were analysed using the constant comparative method of grounded theory. There were three levels of analysis. The first level developed the open codes and is presented here. SETTING: 18 general practices located in the north east of England. The practices recruited included rural, urban and mixed populations of patients who were predominantly living in socioeconomically disadvantaged communities. PARTICIPANTS: 19 GPs (10 women) aged between 29 and 59 years participated. The modal age range was 40-49 years. Theoretical sampling was used to guide recruitment and continued until theoretical saturation was reached. RESULTS: The overarching finding was that anxiety about practice dominated clinical consultations involving young people presenting with emotional distress. GPs responded differently to anxiety and to related uncertainties about professional practice, independent of GP age or gender. Anxiety occurred in the consultation, at an external level, across disciplinary boundaries, in relation to communication with young people and secondary to the complexity of presentations. CONCLUSIONS: Adolescent emotional distress presents professional challenges to GPs who feel ill-equipped and inadequately prepared to address early need. Medical education needs to prepare doctors better. More research is needed to look at what factors facilitate or prohibit greater GP engagement with emotionally distressed young people.

Improving primary health care services for young people experiencing psychological distress and mental health problems: a personal reflection on lessons learnt from Australia and England.

BACKGROUND: Australia and England show high rates of psychological distress and mental health problems in young people. Both are high-income countries and have stated their intention to improve the delivery of health care to young people in primary care settings. Australia has an international reputation for improving care through innovative services and educational initiatives. England has taken a different direction and has concentrated more on developing policy and making recommendations to improve access for young people. AIM: To describe a Churchill Fellowship visit to Australia to observe initiatives in primary care based youth-friendly mental health care and to reflect upon the observations, comparing and contrasting with the English model. METHODS: The observations and reflections presented draw on field notes from site visits and meeting with key players, accessing web resources and referring to the literature, both grey and published. FINDINGS: Australia offers plurality in health care delivery and innovative responses to addressing youth mental health. There are two key approaches. The first is the development of services specializing in youth mental health. The second approach is to build capacity of existing primary care services to recognize the particular bio-psychosocial needs of adolescents (and their families). In contrast, England has tended to focus primarily on policy development and improving youth access. CONCLUSIONS: The paper draws attention to a number of political, clinical and educational developments in both Australia and England. Both countries demonstrate different strategies in response to the high levels of psychological distress in young people. Learning from colleagues in other settings can inform our own practice. Ultimately responding to young people's mental health needs is best served by youth-friendly policy which prepares clinicians for effective practice, informed by applied research and supported by adequate resources. Investment in young people's health must be a priority for us all.

'Can he have the test for bipolar, doctor? His dad's got it': exploring the potential of general practitioners to work with children and young people presenting in primary care with common mental health problems - a clinical initiative.

Background General practitioners (GPs) play a key role in assessing and managing adult mental health problems, but this input is not seen in their management of child and adolescent mental health. Mental health problems in 5-19-year-olds are common, yet detection rates in primary care are low. The symptoms of most adult diagnoses of mental health problems are present by mid-adolescence, yet the typical time from onset to diagnosis is 5-15 years. The role of general practice in this area has been underexplored. Aim This pilot study explores the potential of GPs to respond to common mental health problems in children and adolescents. Design Children and young people who would have ordinarily been referred to Child and Adolescent Mental Health Services (CAMHS) were seen in a GP setting. In a UK general practice surgery serving a disadvantaged population. Method Children and young people were seen for an initial biopsychosocial assessment and formulation of the presenting concerns. GP-based interventions were offered as appropriate or referred to CAMHS. Results Data from the first 50 children (2-19 years) are presented. Twenty younger children (10 years and under) and 30 older children (11 years and above) were seen. Eighteen referrals were made to CAMHS. GP interventions included watchful waiting, brief behavioural interventions, non-directive counselling, brief cognitive- behavioural therapy (CBT) and liaison with colleagues in education, CAMHS and the voluntary sector. Conclusion This clinical pilot demonstrates that with adequate time, access to supervision and practice support, children and young people experiencing emotional and behavioural problems associated with common mental health issues can be helped in primary care.

Institutional marginalisation and student resistance: barriers to learning about culture, race and ethnicity.

Although education about culture, race and ethnicity has increasingly been viewed as an important addition to the medical undergraduate curriculum, internationally the evidence of its effectiveness is mixed. Research to date fails to show why. We chose to explore how contrasting approaches to learning about cultural diversity impacted on medical students. The views of second year students towards teaching about cultural diversity at two UK medical schools, with differently structured curricula, were explored using a series of focus groups (7). The findings, using a methodology based on a combination of grounded theory and thematic analysis identified two potentially competing views espoused by the students at both sites. First, they claimed that although cultural diversity was important, their medical schools marginalised and failed to adequately support effective teaching. Second, in contrast, they claimed that the medical school was an 'inappropriate' setting for successful teaching about cultural diversity. Students did not consider the subject matter to be of central relevance to biomedicine. They felt it should be learnt experientially in the workplace and socially among peers. These narratives represent two potentially conflicting standpoints, which might be understood through the sociological concept of 'habitus', where students conform to the institution's dominant values in order to succeed. The tensions identified in this study cannot be ignored if effective learning about race, ethnicity and culture is to be achieved. Early introduction to understanding the delivery of health care to diverse populations is needed. This should be accompanied by more open collaborative debate between tutors and students on the issues raised.

Structural violence and emotional health: a message from Easington, a former mining community in northern England.

This discussion paper, written by a UK general practitioner and graduate student of anthropology, explores the uncomfortable relationship between institutionalised inequalities of wealth and opportunities, and emotional health, in a disadvantaged community in the north-east of England. The author begins by locating the thesis in the corpus of anthropological literature which acknowledges human suffering and refuses to adopt a position of cultural relativism. The complex and elusive phenomenon of structural violence is unpacked, followed by a description of the setting and the author's methodology. Clinical observations are presented as contextualised narratives located around three themes: alcohol misuse; gendered violence; and inter-generational violence. The vignettes portray how the consequences of institutionalised inequalities are manifest in the embodied and emotional lives of many who live in economically marginalised communities. The author concludes with a discussion of the dilemma at the heart of a morally engaged practitioner's clinical practice as one who eschews the dominant ideology of individual responsibility for health and recognises that agency is compromised by structural violence.

Students' perceptions of race, ethnicity and culture at two UK medical schools: a qualitative study.

CONTEXT: Globalisation has profoundly affected health care by increasing the diversity of clinicians and their patients. Worldwide, medical schools highlight the need for students to understand and show respect for patients and peers of different ethnicities. Yet a sound theoretical approach and robust methods for learning about cultural awareness are lacking. The reasons for this are unclear. OBJECTIVE: To explore Year 2 medical students' understanding of the concepts of race, ethnicity and culture. METHODS: This study was set in 2 universities in the north of England. The student population of each was of a similar ethnic mix but the universities differed in terms of local demography (a wide patient ethnic mix versus a predominantly White patient population with experience of social deprivation) and curricula (a curriculum involving problem-based learning and paper-based cases versus a curriculum involving early contact with patients). Participants comprised 49 Year 2 medical students (mean age 20.8 years), 40% of whom came from ethnic minority groups. Seven focus groups were held across the 2 universities to explore students' understanding of cultural awareness. Students were asked to discuss the terms 'race', 'ethnicity', 'culture' and 'cultural diversity'. Interviews were transcribed and analysed qualitatively using grounded theory. Themes were identified and validated by an independent researcher. RESULTS: Four overarching themes emerged: 'White fears' at discussing race-related issues; ethnic minority discomfort at being viewed as 'different'; difficulties in relating to professional boundaries, and barriers against talking about race beyond legitimate disease-related discourse. CONCLUSIONS: For students, discussion of race beyond the confines of medical discourse was problematic. If students are to develop professional holistic values towards patient care, they need more support in understanding their own personal values and uncertainties.