Why are doctors opting out of general practice? / Hvorfor velger leger seg bort fra allmennmedisin?

BACKGROUND: There has been a sustained focus on the lack of recruitment to general practice in Norwegian politics, media and research. We have little knowledge of the reasons that have been prominent for doctors who have actively opted out of general practice. We therefore wished to investigate what types of doctors choose not to work in general practice and why. MATERIAL AND METHOD: The data are based on a questionnaire that was sent to the 2 195 members of the Medical Panel in 2016/17. The response rate was 73.1 %. We used graphics and descriptive analyses to study inter-group differences between those who had considered general practice but made another choice, and those who had quit general practice. RESULTS: Of the 1 153 doctors who were not general practitioners, 44.1 % had not considered this as an option. 39.9 % had considered it, but chosen differently, and 16.0 % had previously worked as GPs, but quit. The administrative burden and small professional community were the main reasons for doctors to opt out of general practice. INTERPRETATION: The administrative burden and small professional community were key reasons why doctors opted out of general practice or quit the specialty. A number of other factors also played a role, and the efforts to recruit and retain GPs should therefore be seen in a wider and more overarching context.

Between authoritarian and dialogical approaches: Attitudes and opinions on coercion among professionals in mental health and addiction care in Norway.

More knowledge is needed on how to reduce the prevalence of formal and informal coercion in Norwegian mental health care. To explore possible reasons for the widespread differences in coercive practice in psychiatry and drug addiction treatment in Norway, and the poor compliance to change initiatives, we performed a nationwide survey. Six vignettes from concrete and realistic clinical situations where coercive measures were among the alternative courses of action, and where the difference between authoritarian (paternalistic) and dialogical (user participation) practices was explicitly delineated, were presented in an electronic questionnaire distributed to five groups of professionals: psychiatrists, psychologists, nurses, other professionals and auxiliary treatment staff. Non-coercive dialogical resolutions were more likely than coercive authoritative. However, there is a clear professional hierarchy with regard to authoritarian approaches, with the psychiatrists on top, followed by nurses and other professionals, and with psychologists as the least authoritarian. The majority of the respondents sometimes prefer actions that are illegal, which suggests that individual opinions about coercion often overrule legislation. The variation between and within professional groups in attitudes and opinions on coercion is extensive, and may account for some of the hitherto meagre results of two ministerial action plans for coercion reduction.

The HPV vaccine: knowledge and attitudes among public health nurses and general practitioners in Northern Norway after introduction of the vaccine in the school-based vaccination programme.

OBJECTIVE: To investigate knowledge of and attitudes to human papillomavirus (HPV) infection, HPV vaccination, cervical cancer, related sources of information and factors associated with willingness to vaccinate one's own daughter among primary health care (PHC) personnel. DESIGN: Cross-sectional study. SETTING: PHC. SUBJECTS: All public health nurses (PHNs) and general practitioners (GPs) in Northern Norway were invited to answer a structured electronic questionnaire; 31% participated (N = 220). MAIN OUTCOME MEASURES: Self-reported and actual knowledge, information sources, attitudes and willingness to vaccinate their (tentative) daughter. RESULTS: 47% of respondents knew that HPV infection is a necessary cause of cervical cancer. PHNs had higher self-reported and actual knowledge about HPV vaccination and cervical cancer than GPs. PHNs used the Norwegian Institute of Public Health's numerous information sources on HPV, while GPs had a low user rate. 88% of PHNs and 50% of GPs acquired information from the pharmaceutical industry. 93% PHNs and 68% of GPs would vaccinate their 12-year-old daughter. In a multivariate logistic regression analysis, willingness to vaccinate one's daughter was positively associated with younger age, being PHN (OR = 5.26, 95%CI 1.74-15.94), little concern about vaccine side effects (OR = 3.61, 95%CI 1.10-11.81) and disagreement among experts (OR = 7.31, 95%CI 2.73-19.60). CONCLUSIONS: Increased knowledge about HPV infection and vaccination is needed, particularly among GPs. Those least concerned about side effects and disagreements among experts were most likely to vaccinate their daughter. These findings are of interest for public health authorities responsible for the Norwegian vaccination and cervix cancer screening programmes, and providers of training of PHC personnel. Key points One year after introduction of HPV vaccination among 12-year-old schoolgirls in Norway, a cross-sectional study in Northern Norway among general practitioners (GPs) and public health nurses (PHNs) showed that • barely half of PHC professionals knew the causal relationship between HPV infection and cervical cancer • PHNs and GPs had higher self-reported than actual knowledge about HPV vaccination and cervical cancer nearly all PHNs and two thirds of GPs wanted to vaccinate their 12-year-old daughter. Those most concerned about side effects and disagreement among experts were less likely to vaccinate.

Does the University of Tromsø - The Arctic University of Norway educate doctors to work in rural communities? / Utdanner Universitetet i Tromsø ­ Norges arktiske universitet leger til å arbeide i distrikter?

BACKGROUND: When Storting (the Norwegian Parliament) resolved in 1968 to build the University of Tromsø, the purpose of the study model was to promote recruitment and a stable GP density throughout North Norway. We wanted to shed light on the degree to which GPs and doctors in health trusts who were graduates of the University of Tromsø work in rural and central municipalities, and at university hospitals and other hospitals respectively. MATERIAL AND METHOD: We used de-identified data covering 406 GPs and 909 doctors in health trusts who had graduated from the University of Tromsø in the period 1979 ­ 2012. RESULTS: A larger share of GPs educated at the University of Tromsø (30 %) worked in rural municipalities compared with all GPs in Norway (19 %). GPs educated at the University of Tromsø staffed 57 % of the positions in central municipalities and 34 % of the positions in rural municipalities in North Norway. A larger share of doctors in health trusts (64 %) educated at the University of Tromsø worked at a university hospital compared with all doctors in health trusts in Norway (56 % worked at a university hospital). Over half (53 %) of the doctors at the University Hospital of North Norway were graduates of the University of Tromsø. In Nordland and Finnmark, the corresponding percentage at health trusts varied between 14 and 28 %. INTERPRETATION: Our data suggest that medical studies at the University of Tromsø make a considerable contribution to GP density in rural communities and to solid recruitment to the University Hospital of North Norway.

The good doctor - strong and persevering. / Den gode legen ­ sterk og utholdende.

BACKGROUND: In today's society, doctors are confronted with a number of opposing interests, from other colleagues, patients and employers. The development and regulation of the medical profession have been widely studied. However, less research has been devoted to the doctors' own perception of what it means to be a good doctor. MATERIAL AND METHOD: We conducted eight focus-group interviews and three individual interviews among senior consultants and specialty registrars in the areas of surgery, psychiatry and internal medicine in two different hospitals. Total N = 48, of which 56 % were women. The interviews were analysed with the aid of systematic text condensation. RESULTS: «Professional dedication¼ demonstrated through «a high degree of attendance in the workplace¼ and «a high work capacity¼ were key topics for good doctors. Having a «high work capacity¼ was defined as being willing to go to great lengths, work overtime and work effectively. The senior consultants perceived their job as doctors more as a «lifestyle¼, while the specialty registrars more frequently regarded their work as a «job¼. INTERPRETATION: Norwegian hospital doctors wish to appear dedicated to their profession. They can demonstrate this by showing great willingness to work intensively and effectively with patients, while also going to great lengths to be available beyond normal working hours.

The hospital doctor of today - still continuously on duty. / Dagens sykehuslege ­ fremdeles alltid på vakt.

BACKGROUND: Norwegian hospital doctors emphasise the value of working hard and efficiently and of a high degree of attendance in the workplace. This helps establish social norms that guide behaviour within the professional culture. It is important to examine what consequences these values may entail when the doctor also needs to cater to his or her own needs. MATERIAL AND METHOD: We conducted eight focus-group interviews and three individual interviews among a total of 48 senior consultants and specialty registrars working in the areas of surgery, psychiatry and internal medicine. Total N = 48; 56 % women. The interviews were analysed with the aid of systematic text condensation. RESULTS: When Norwegian hospital doctors wish to appear as good doctors, they see that this entails consequences for the interrelationships with colleagues, the management and the work-life balance. Conflicts of interest arose between senior consultants and specialty registrars. Management initiatives to deal with absence, adaptation of the job to the life stage of each individual doctor and increased management involvement among doctors were among the measures proposed. INTERPRETATION: Better mutual knowledge between doctors and management with regard to each other's values and responsibilities could constitute key premises for structural changes, for example in terms of better planning of leaves of absence and opportunities for adaptation of work schedules to the life stage of the persons concerned.

Doctors' working hours and time spent on patient care in the period 1994 - 2014. / Legers arbeidstid og tid til pasientarbeid i perioden 1994 - 2014.

BACKGROUND: There is always a keen interest in the qualitative and quantitative aspects of doctors' working hours. In this study developments are described in terms of total weekly working hours and time spent on direct patient care from 1994 to 2014 by doctors working in different job categories and medical disciplines in Norway. MATERIAL AND METHOD: All data has been obtained from LEFO's reference panel of doctors, a near representative sample of approximately 1 600 practising doctors who have been followed up with questionnaires every second year since 1994. In the course of this period, doctors have come off the panel as they retired and new young doctors have been included in replacement. Questions relating to how they spend their time have always featured in the questionnaire. This article is based on data from 1994, 2000, 2006, 2010 and 2014. RESULTS: Response rates were between 67 and 95 %. From 1994 to 2014, total weekly working hours remained the same for all categories of doctors, except those working in academia. Time spent on direct patient care has fallen, but not significantly, for general practitioners, specialists working in private practice and doctors working in academia and administration. Meanwhile, community medical officers and hospital doctors have seen their time spent on patient care fall significantly over the 20-year period. There is however great variation, particularly between the different medical disciplines in hospitals. INTERPRETATION: Differences and changes in the amount of time spent by doctors on direct patient care are caused by both structural and cultural factors relating to the working situation, and not least by a considerable increase in the number of hospital doctors.

Peer counsellors' views on the collegial support scheme for doctors.

BACKGROUND: The health condition and health-related behaviour of doctors are important to the doctors themselves as well as for their treatment of patients. The collegial support scheme is a county-based and easily accessible health and care service for doctors. We therefore wanted to describe the framework and functions of this scheme and examine its utility. MATERIAL AND METHOD: Fourteen focus-group interviews with a total of 61 peer counsellors from all the counties were conducted. The interviews were recorded, transcribed and analysed with the aid of systematic text condensation. RESULTS: The framework--easy accessibility, a readily available offer of up to three sessions, a high degree of confidentiality and informal contact--was emphasised as crucial for doctors to make use of the scheme. The peer counsellors described their role as that of a listener and supportive helper. They helped bring clarity and discuss possible needs for further follow-up or treatment of numerous different and frequently complex issues. The peer counsellors highlighted three benefits in particular: the scheme helps raise awareness by legitimising help-seeking behaviour among doctors, it is a contingency scheme, and it eases the burden by lowering the threshold to seeking out further advice and treatment. INTERPRETATION: A systematic evaluation of the collegial support scheme is important for an understanding of the totality of the collegial health and care services. The collegial support scheme may lower the threshold to seeking help, and encourage some doctors to seek necessary treatment.

Decisions on statin therapy by patients' opinions about survival gains: cross sectional survey of general practitioners.

BACKGROUND: Guidelines for primary prevention of cardiovascular disease provide little guidance on how patients' preferences should be taken into account. We wanted to explore whether general practitioners (GPs) are sensitive to patient preferences regarding survival gains from statin therapy. METHODS: In a cross sectional, online survey 3,270 Norwegian GPs were presented with a 55 year old patient with an unfavourable cardiovascular risk profile. He expressed preferences for statin therapy by indicating a minimum survival gain that would be considered a substantial benefit. This survival gain varied across six versions of the vignette: 8, 4 and 2 years, and 12, 6 and 3 months, respectively. Participants were randomly allocated to one version only. We asked whether the GPs would recommend the patient to take a statin. Subsequently we asked the GPs to estimate the average survival gain of life long simvastatin therapy for patients with a similar risk profile. RESULTS: We received 1,296 responses (40 %). Across levels of survival gains (8 years to 3 months) the proportion of GPs recommending statin therapy did not vary significantly (OR per level 1.07, 95 % CI 0.99 to 1.16). The GP's own estimate of survival gain was a statistically significant predictor of recommending therapy (OR per year adjusted for the GPs' age, sex, speciality attainment and number of patients listed 3.07, CI 2.55 to 3.69). CONCLUSION: GPs were insensitive to patient preferences regarding survival gain when recommending statin therapy. The GPs' recommendations were strongly associated with their own estimates of survival gain.

Confidentiality as a barrier to support seeking among physicians: the influence of psychosocial work factors in four European hospitals (the HOUPE study).

BACKGROUND: Concerns about protecting patient's privacy can interfere with proper stress adaptation which is associated with physician's health. It is important to investigate relevant organizational confounders to this phenomenon to enable interventions that can ameliorate the subjective burden of patient confidentiality. OBJECTIVES: This study investigates factors in the psychosocial work environment that can explain patient confidentiality's prominence in social support seeking among physicians, and if these factors covary differently with support seeking according to country. PARTICIPANTS: University hospital physicians in four European cities (N=2095) in Sweden, Norway, Iceland and Italy participated in a cross-sectional survey. METHODS: Questionnaire comprised items on psychosocial work environment, basic socio-demographics, presence of formal and informal meetings at work, and measurement of confidentiality as a barrier for support. RESULTS: High role conflict, availability of formal or informal meetings, lack of control over decisions, and lack of control over work pace were predictors of confidentiality as a barrier to support. There were differences between countries in how these factors covaried with confidentiality as a barrier to support. High role conflict was the strongest predictor of confidentiality as a barrier to support across all samples. CONCLUSIONS: Psychosocial work factors predicted confidentiality as a barrier to support seeking among physicians. It is important to create routines and an organizational framework that ensures both the patient's right to privacy and physician's ability to cope with emotional demanding situations from work.

[The Oslo96 reform and skills updating practices]. / Oslo96-reformen og faglig oppdateringspraksis.

BACKGROUND: We have previously shown that 2-3 years after completion of their studies, doctors who had followed the study programme Oslo96 spent somewhat more time on updating their skills than other doctors trained at the University of Oslo, but less time than doctors trained at the University of Bergen. The purpose of this study is to investigate whether these differences had changed 5.5-7 years after graduation. MATERIAL AND METHOD: We used questionnaire data collected from the last cohort to follow the old programme of study at UiO (graduated 2001), the second cohort to follow the Oslo96 programme (graduated 2003) and the cohort that graduated from the University of Bergen in 2003. Data were collected 5.5-7 years after graduation (T2) and compared to corresponding data collected 2-3 years after graduation (T1). The study included only respondents who had answered all questions at both T1 and T2. RESULTS: The response rate ranged from 55% to 59% in the three samples. At 5.5-7 years after graduation we found no differences with regard to the time spent on updating between Oslo96 doctors (median: 230 minutes/week) and doctors who had graduated before the Oslo96 reform or from the University of Bergen (median: 240 minutes/week in both groups). All three groups reported a statistically significant increase from T1 to T2 in their use of the Internet for purposes of skills updating. Training courses and conferences were the preferred forms of skills updating. INTERPRETATION: A correlation between the programme of study and the doctors' habits with regard to skills updating could not be detected.

Cultural and musical activity among Norwegian doctors.

BACKGROUND: The cultural and musical activity of Norwegian doctors was studied in 1993. We wished to re-examine their cultural and musical activity, analyse the development and study the correlation with satisfaction, health and other leisure activities. MATERIAL AND METHOD: In the autumn of 2010, a survey was undertaken among a representative sample of economically active Norwegian doctors. The survey asked the same questions as in 1993, and the responses were also compared to the population studies conducted by Statistics Norway. We also used a cultural index that we have developed ourselves. RESULTS: Altogether 1,019 doctors (70%) responded to the survey. They reported a higher level of cultural activity in 2010 than in 1993, measured in terms of reading of non-medical literature and visits to the cinema, theatre and concerts. The doctors engaged in musical activity of their own especially frequently: 58% reported to be able to play an instrument, and 21% reported to play on a regular basis, which is more than among other academic professions. We found a significant correlation between the doctors' level of cultural activity and their job satisfaction, general satisfaction, self-reported health and physical activity. The doctors who engage most frequently in cultural activities are thus most satisfied with their work and with life in general. Furthermore, they also have better self-reported health. INTERPRETATION: Norwegian doctors give priority to cultural and musical activities. The assertion that doctors are particularly fond of music is more than just a myth.

Moral distress and professional freedom of speech among doctors.

BACKGROUND: Previous studies indicate that Norwegian doctors experience distress in their encounter with differing and partly contradictory ideals, such as the obligation to criticise unethical and inappropriate practices. The objective of this study was to investigate the perception of moral distress and professional freedom of speech among Norwegian doctors as of today, as well as identify changes that have occurred since the previous study undertaken in 2004. MATERIAL AND METHODS: A total of 1,522 economically active doctors received a questionnaire listing various statements describing the perception of moral distress and professional freedom of speech. The responses were compared to responses to the 2004 study. RESULTS: Altogether 67% of the doctors responded to the questionnaire. The proportion who reported «fairly strong¼ or «strong¼ moral distress varied from 24% to 70% among the different statements. On the whole, the «rank and file¼ hospital doctors reported the highest degree of moral distress. Nevertheless, a decrease in the scores for moral distress could be observed from 2004 to 2010. During the same period, the perception of professional freedom of speech increased slightly. INTERPRETATION: A reduced level of distress associated with ethical conflicts in working life may be due to improved methods for handling distressing situations, or because the consequences of the health services reorganisations are perceived as less threatening now than in 2004, immediately after the introduction of the hospital reform. However, the perceived lower distress level may also be due to professional and ethical resignation. These findings should be followed up by a qualitative study.

What professional activities do general practitioners find most meaningful? Cross sectional survey of Norwegian general practitioners.

BACKGROUND: Health reforms in many countries affect the scope and nature of primary care. General Practitioners (GPs) are expected to spend more time developing public health, preventive health care, coordination of care and teamwork. We aimed to explore which professional activities GPs consider to be meaningful and how they would like to prioritise tasks. METHODS: In a cross sectional online survey 3,270 GPs were invited to consider twenty different activities in general practice. They were asked to rate each of them on a Likert scale anchored from 1 (not meaningful) to 5 (very meaningful). They then selected three activities from the item list on which they would like to spend more time and three activities on which they would like to spend less time. We used multinomial logistic regression to explore associations between the GPs' preferences for time spent on preventive health care activities and age, gender and practice characteristics. RESULTS: Approximately 40% (n=1,308) responded. The most meaningful activities were handling common symptoms and complaints (94% scored 4 or 5), chronic somatic diseases (93%), terminal care (80%), chronic psychiatric diseases (77%), risk conditions (76%) and on call emergency services (70%). In terms of priority the same items prevailed except that GPs would like to spend less time on emergency services. Items with low priority were health certificates, practice administration, meetings with local health authorities, medically unexplained symptoms, addiction medicine, follow up of people certified unfit for work, psychosocial problems, preventive health clinics for children and school health services. In multivariate regression models physician and practice characteristics explained no more than 10% of the variability in the GPs' preferences for time spent on preventive health care services. CONCLUSIONS: The GPs found diagnosis and treatment of diseases most meaningful. Their priorities were partly at odds with those of the health authorities and policy makers.