The "unknown territory" of goal-setting: Negotiating a novel interactional activity within primary care doctor-patient consultations for patients with multiple chronic conditions.

Goal-setting is widely recommended for supporting patients with multiple long-term conditions. It involves a proactive approach to a clinical consultation, requiring doctors and patients to work together to identify patient's priorities, values and desired outcomes as a basis for setting goals for the patient to work towards. Importantly it comprises a set of activities that, for many doctors and patients, represents a distinct departure from a conventional consultation, including goal elicitation, goal-setting and action planning. This indicates that goal-setting is an uncertain interactional space subject to inequalities in understanding and expectations about what type of conversation is taking place, the roles of patient and doctor, and how patient priorities may be configured as goals. Analysing such spaces therefore has the potential for revealing how the principles of goal-setting are realised in practice. In this paper, we draw on Goffman's concept of 'frames' to present an examination of how doctors' and patients' sense making of goal-setting was consequential for the interactions that followed. Informed by Interactional Sociolinguistics, we used conversation analysis methods to analyse 22 video-recorded goal-setting consultations with patients with multiple long-term conditions. Data were collected between 2016 and 2018 in three UK general practices as part of a feasibility study. We analysed verbal and non-verbal actions for evidence of GP and patient framings of consultation activities and how this was consequential for setting goals. We identified three interactional patterns: GPs checking and reframing patients' understanding of the goal-setting consultation, GPs actively aligning with patients' framing of their goal, and patients passively and actively resisting GP framing of the patient goals. These reframing practices provided "telling cases" of goal-setting interactions, where doctors and patients need to negotiate each other's perspectives but also conflicting discourses of patient-centredness, population-based evidence for treating different chronic illnesses and conventional doctor-patient relations.

Learning or leaving? An international qualitative study of factors affecting the resilience of female family doctors.

​BACKGROUND: Many countries have insufficient numbers of family doctors, and more females than males leave the workforce at a younger age or have difficulty sustaining careers. Understanding the differing attitudes, pressures, and perceptions between genders toward their medical occupation is important to minimise workforce attrition. ​AIM: To explore factors influencing the resilience of female family doctors during lifecycle transitions. ​DESIGN & SETTING: International qualitative study with female family doctors from all world regions. ​METHOD: Twenty semi-structured online Skype interviews, followed by three focus groups to develop recommendations. Data were transcribed and analysed using applied framework analysis. ​RESULTS: Interview participants described a complex interface between competing demands, expectations of their gender, and internalised expectations of themselves. Systemic barriers, such as lack of flexible working, excessive workload, and the cumulative impacts of unrealistic expectations impaired the ability to fully contribute in the workplace. At the individual level, resilience related to: the ability to make choices; previous experiences that had encouraged self-confidence; effective engagement to obtain support; and the ability to handle negative experiences. External support, such as strong personal networks, and an adaptive work setting and organisation or system maximised interviewees' professional contributions. ​CONCLUSION: On an international scale, female family doctors experience similar pressures from competing demands during lifecycle transitions; some of which relate to expectations of the female's 'role' in society, particularly around the additional personal pressures of caring commitments. Such situations could be predicted, planned for, and mitigated with explicit support mechanisms and availability of workplace choices. Healthcare organisations and systems around the world should recognise this need and implement recommendations to help reduce workforce losses. These findings are likely to be of interest to all health professional staff of any gender.

Setting goals with patients living with multimorbidity: qualitative analysis of general practice consultations.

BACKGROUND: Establishing patient goals is widely recommended as a way to deliver care that matters to the individual patient with multimorbidity, who may not be well served by single-disease guidelines. Though multimorbidity is now normal in general practice, little is known about how doctors and patients should set goals together. AIM: To determine the key components of the goal-setting process in general practice. DESIGN AND SETTING: In-depth qualitative analysis of goal-setting consultations in three UK general practices, as part of a larger feasibility trial. Focus groups with participating GPs and patients. The study took place between November 2016 and July 2018. METHOD: Activity analysis was applied to 10 hours of video-recorded doctor-patient interactions to explore key themes relating to how goal setting was attempted and achieved. Core challenges were identified and focus groups were analysed using thematic analysis. RESULTS: A total of 22 patients and five GPs participated. Four main themes emerged around the goal-setting process: patient preparedness and engagement; eliciting and legitimising goals; collaborative action planning; and GP engagement. GPs were unanimously positive about their experience of goal setting and viewed it as a collaborative process. Patients liked having time to talk about what was most important to them. Challenges included eliciting goals from unprepared patients, and GPs taking control of the goal rather than working through it with the patient. CONCLUSION: Goal setting required time and energy from both parties. GPs had an important role in listening and bearing witness to their patients' goals. Goal setting worked best when both GP and patient were prepared in advance.

Can goal-setting for patients with multimorbidity improve outcomes in primary care? Cluster randomised feasibility trial.

INTRODUCTION: Goal-setting is recommended for patients with multimorbidity, but there is little evidence to support its use in general practice. OBJECTIVE: To assess the feasibility of goal-setting for patients with multimorbidity, before undertaking a definitive trial. DESIGN AND SETTING: Cluster-randomised controlled feasibility trial of goal-setting compared with control in six general practices. PARTICIPANTS: Adults with two or more long term health conditions and at risk of unplanned hospital admission. INTERVENTIONS: General practitioners (GPs) underwent training and patients were asked to consider goals before an initial goal-setting consultation and a follow-up consultation 6 months later. The control group received usual care planning. OUTCOME MEASURES: Health-related quality of life (EQ-5D-5L), capability (ICEpop CAPability measure for Older people), Patient Assessment of Chronic Illness Care and healthcare use. All consultations were video-recorded or audio-recorded, and focus groups were held with participating GPs and patients. RESULTS: Fifty-two participants were recruited with a response rate of 12%. Full follow-up data were available for 41. In the goal-setting group, mean age was 80.4 years, 54% were female and the median number of prescribed medications was 13, compared with 77.2 years, 39% female and 11.5 medications in the control group. The mean initial consultation time was 23.0 min in the goal-setting group and 19.2 in the control group. Overall 28% of patient participants had no cognitive impairment. Participants set between one and three goals on a wide range of subjects, such as chronic disease management, walking, maintaining social and leisure interests, and weight management. Patient participants found goal-setting acceptable and would have liked more frequent follow-up. GPs unanimously liked goal-setting and felt it delivered more patient-centred care, and they highlighted the importance of training. CONCLUSIONS: This goal-setting intervention was feasible to deliver in general practice. A larger, definitive study is needed to test its effectiveness. TRIAL REGISTRATION NUMBER: ISRCTN13248305; Post-results.

Professional learning during the transition from trainee to newly qualified general practitioner.

BACKGROUND: The transition from training to qualified practice is inherently challenging. Structured support following training was once available, but this no longer exists and the current climate of primary care places increasing demands on GPs. Professional learning, and the transition to independent practice, may thus be problematic. AIM: To explore newly qualified GPs' experiences of professional learning following transition into qualified practice. DESIGN AND SETTING: Qualitative study using semi-structured interviews and a focus group, conducted between December 2010 and April 2011. Participants were GPs within five years of qualification, working in the East of England. METHOD: Interviews were conducted with nine participants. These were followed by a focus group with four additional participants. Data collection, transcription and analysis were simultaneous, allowing iterative evolution of the topic guide to test emerging themes. RESULTS: New GPs wished to relinquish 'dependency' and become self-directed learners, yet still wanted guidance when needed. They described a situated experience of learning, in which inclusion in a practice community afforded greater learning opportunities. Social interactions also affected the issue of constructing an independent professional identity; a transitional process through which new GPs could become self-aware 'experts' with confidence in self-directed learning. CONCLUSION: Potential harms of the transitional period may be mitigated by support, which needs to emphasise inclusion, validation, affirmation and the provision of feedback. Preferences for adult learning should be encouraged, but guidance needs to be available when requested. Recent proposals for enhanced GP training introduce an opportunity for a focus on independent practice during training.

Examining the practice of generalist expertise: a qualitative study identifying constraints and solutions.

OBJECTIVES: Provision of person-centred generalist care is a core component of quality primary care systems. The World Health Organisation believes that a lack of generalist primary care is contributing to inefficiency, ineffectiveness and inequity in healthcare. In UK primary care, General Practitioners (GPs) are the largest group of practising generalists. Yet GPs fulfil multiple roles and the pressures of delivering these roles along with wider contextual changes create real challenges to generalist practice. Our study aimed to explore GP perceptions of enablers and constraints for expert generalist care, in order to identify what is needed to ensure health systems are designed to support the generalist role. DESIGN: Qualitative study in General Practice. SETTING: UK primary care. MAIN OUTCOME MEASURES: A qualitative study - interviews, surveys and focus groups with GPs and GP trainees. Data collection and analysis was informed by Normalisation Process Theory. DESIGN AND SETTING: Qualitative study in General Practice. We conducted interviews, surveys and focus groups with GPs and GP trainees based mainly, but not exclusively, in the UK. Data collection and analysis were informed by Normalization Process Theory. PARTICIPANTS: UK based GPs (interview and surveys); European GP trainees (focus groups). RESULTS: Our findings highlight key gaps in current training and service design which may limit development and implementation of expert generalist practice (EGP). These include the lack of a consistent and universal understanding of the distinct expertise of EGP, competing priorities inhibiting the delivery of EGP, lack of the consistent development of skills in interpretive practice and a lack of resources for monitoring EGP. CONCLUSIONS: WE DESCRIBE FOUR AREAS FOR CHANGE: Translating EGP, Priority setting for EGP, Trusting EGP and Identifying the impact of EGP. We outline proposals for work needed in each area to help enhance the expert generalist role.

Age-related differential diagnosis of vaginal bleeding in postmenopausal women: a series of 3047 symptomatic postmenopausal women.

OBJECTIVE: The aim of this study is to identify the causes of vaginal bleeding in different age groups of postmenopausal women. Also, we attempt to estimate the incidence of postmenopausal vaginal bleeding and endometrial cancer in a defined geographical area. STUDY DESIGN: The study was conducted at a gynaecological oncology centre in the United Kingdom, between February 2006 and May 2009. Patients were investigated according to established evidence-based departmental guidelines. RESULTS: During the study period 3047 women were referred with postmenopausal vaginal bleeding. In 1356 women (44.5%) the endometrial thickness measured less than 5 mm on transvaginal ultrasound scan. Benign histology was found in 1144 women (37.5%). Benign endometrial polyps were the cause of bleeding in 10.1% of the cases. The incidence of endometrial cancer in our study population was 5%. The rate of postmenopausal vaginal bleeding during the study period peaks at the age of 55-59 years (25.9/1000 postmenopausal women/year) and declines thereafter. The peak incidence of endometrial cancer during the study period (12.6/10,000 postmenopausal women/year) was seen between the ages of 60 and 64 years and similarly declines with increasing age. CONCLUSION: To our knowledge, this is the first population-based estimation of the incidence of genital tract bleeding and endometrial cancer among postmenopausal women in the United Kingdom. The results of this study showing the age-related differential diagnosis can be used to inform clinical practice when counselling postmenopausal women with vaginal bleeding.

Severe metabolic acidosis as a consequence of acute starvation in pregnancy.

Ketoacidosis is most often due to uncontrolled diabetes mellitus. Similar metabolic changes can occur with poor dietary intake of carbohydrates or prolonged fasting. Metabolic acidosis due to prolonged fasting is rarely described in the literature. We report a case of severe metabolic acidosis as a result of prolonged fasting in pregnancy.