[Compulsory collegial guidance. What do candidates in general practice think about training of practical procedures?]. / Obligatorisk kollegaveiledning. Hva mener spesialistkandidatene i allmennmedisin om utdanningen i praktiske ferdigheter?

In 1994 a new module addressing the quality of practical procedures was added to the Norwegian general practice specialisation programme. Over a five-year period 31 practical procedures must be performed under the supervision of fellow GPs. In 1995 a survey was carried out by questionnaire among all specialist candidates registered in the new programme (n = 165, response rate 83%) and a control group consisting of all candidates registered in 1993 (n = 162, response rate 62%). The aims of the survey were to evaluate the candidates' motivation, self-rated level of competence, and the presence of barriers to programme implementation. The main group and control group were almost identical; mean age has 36.5 years, 37% were females. There were no differences in the self-rated levels of competence between the groups. The majority (80%) reported a need to improve their performance of practical procedures, and 93% stated that mutual guidance with colleagues would be of considerable benefit by improving technical performance, professional confidence and the quality of relationships with colleagues. The main barriers to mutual guidance were shortage of time, lack of structured opportunities for performing procedures in the presence of colleagues, and lack of instruction manuals or videos detailing the correct performance of procedures.

[Perception among Norwegian hospital physicians of physician-nurse cooperation]. / Oppfatninger blant norske sykehusleger om samarbeidet mellom lege og sykepleier.

It is generally agreed that a positive and cooperative atmosphere between nurses and doctors is of vital importance to the quality of medical services in hospitals. In this study 1,278 Norwegian hospital doctors were asked how they perceived the working atmosphere between doctors and nurses. 75% replied that the doctors-nurse relationship was characterized by openness and dialogue and half of them felt that there was generally not much competition with regard to medical responsibility. Only 14% found communicating difficult, 20% stated that conflicts between the two groups were seldom discussed openly. Psychiatrists were found to view the relationship in the most positive light, whereas surgeons and non-specialists (mostly residents and interns) perceived the working atmosphere less favourably. Young doctors had a more negative view of the relationship than older ones. Neither gender nor job position were of any significance in predicting the perceptions. A high level of autonomy and a low level of stress were factors which contributed positively to the doctor-nurse relationship.

The communication atmosphere between physician colleagues: competitive perfectionism or supportive dialogue? A Norwegian study.

Open and supportive communication is probably one of the most important promotors of learning, coping and satisfaction at the workplace. The aim of this paper is to describe and predict the communication atmosphere between Norwegian physicians. Twenty statements describing communication, as perceived by the physicians themselves, were presented to a random sample of the members of the Norwegian Medical Association of which more than 90% of the physicians in the country are members (N = 2628). In general, this investigation indicates that the communication atmosphere among Norwegian physicians is characterised by support and mutual respect. More than half of the respondents fully agreed that communication between colleagues in the workplace is marked by solidarity, and that experienced colleagues show respect for the less experienced in both personal and professional matters. Physicians working in hospitals described the communication atmosphere as substantially more selfish and competitive than non-hospital physicians, whilst general practitioners considered the atmosphere between colleagues to be more supportive than non-specialists. In addition, high perceived stress was associated with the perception of a less supportive atmosphere. However, the strongest predictor of the communication atmosphere was clearly the physician's perceived autonomy. The comprehensive retrenchment programmes implemented in Norwegian hospitals during recent years have increased stress and restricted professional autonomy among both physicians and other occupational groups. Our findings indicate that the communication atmosphere necessary to secure continuity of knowledge within the medical profession may have been jeopardised by this process. In the long term, this may prove hazardous to the quality of medical care.

[Mutual evaluation of teaching hospital departments. A way to improve the quality of specialist education]. / Gjensidig evaluering av utdanningsavdelinger ved sykehus. En velegnet metode for å bedre kvaliteten på spesialistutdanningen.

In cooperation with four hospital departments, the Norwegian Medical Association piloted a method for combining internal and external evaluation of the departments' educational programmes for residents. The aim was to improve the quality of education in the departments. The ophthalmologic departments at two university hospitals and two pediatric departments at local hospitals have participated in the project. Written reports describing internal and external evaluations, based on reciprocal visits by representatives of the different departments have served as guidelines for improvement. The evaluation revealed inadequate opportunities for resident education in all the participating departments. The interesting and positive experiences were that, despite these findings, the reciprocal evaluations seemed to encourage and inspire the departments that were evaluated to develop better educational programmes for their residents. This paper shows the advantages reciprocal evaluation seems to have as a supplementary method for quality improvement in departments that educate residents.

[Physicians as leaders. Evaluation of a leadership training program for physicians (Medled)]. / Leger i ledelse. Evaluering av et lederutviklingsprogram for leger (Medled).

In September 1990, 40 doctors started a two year management training programme consisting of six one week courses organised by the Norwegian Medical Association. The programme was evaluated, and this article presents the results of two of the methods, used for evaluation: the first an interview with 12 participants, and the second a questionnaire answered by participants, colleagues at the same department and colleagues at other hospitals (a control group) before and after the course. Compared with colleagues from the same department and from the control group the participants had changed their attitude towards important questions of management. They had become more concerned about the importance of motivating the staff, that the department should give priority to the hospital's objectives in preference to own interests, and that the ultimate responsibility for the department should reside in one person and this person should be a doctor with a relevant specialty. The results of the questionnaire survey are confirmed by the results of the interviews. In addition the results of the interviews suggest that, during the management training programme, the participants had changed from an individual-oriented to a more group-oriented style of management.

[Specialists without qualification. An interview study among general practitioners]. / Uten spesialisttittel. En intervjuundersøkelse blant allmennpraktikere.

50 Norwegian doctors selected at random from the population of general practitioners who were neither recognized specialists nor enrolled in the specialist training programme, were interviewed by telephone about their own postgraduate training and their attitude towards the system of specialist training for general practitioners. Their educational activities and needs differed very little from those described in previous surveys among Norwegian practitioners. All the younger doctors were determined to enroll in the specialist training programme, but many thought that this might be difficult for family reasons. Most of the doctors above the age of 40 lacked the motivation for specialist training. The doctors expressed a variety of different attitudes towards the system of specialist training, including certain conflicts of loyalties and values.

[Standards as basis for medical audit]. / Standarder som grunnlag for medical audit.

Medical audit usually implies evaluation of medical practice in order to control whether certain standards are complied with. Research on decision making has disclosed, however, that standards for clinical problem solving are not always easy to establish. It has been difficult to influence doctors to adhere to standards defined by experts. We therefore propose that medical audit should focus more on education than on control. If standards are to be used, the doctors participating in medical audit projects should also help to define the standards. We suggest the following procedure for medical audit projects: observe practice--reflect on it--identify changes--formulate standards--implement changes--evaluate changes--give feedback to the group about the outcome. Standards defined by experts working remote from medical practice, must be replaced by standards based on practical knowledge acquired by doctors with common experience.

Fever: management and self-medication. Results from a Norwegian population study.

A representative sample of the Norwegian population was interviewed in 1988 as part of a monthly national opinion poll to investigate lay management and self-medication of fever. Six hundred and nineteen women and 592 men over the age of 15 were interviewed in their homes. Approximately one-fifth reported inappropriate measuring of body temperature. A variety of management and self-medication was found. In cases of common cold or influenza with fever, 35% would use antipyretics. Forty per cent would start to use antipyretics at a temperature below 39.0 degrees C. Forty-four per cent did not know any antipyretic brand names at all. The results indicate a need for more definite and consistent information to make fever management and self-medication more rational. Such information should be discussed and given by general practitioners, nurses at child welfare centers and pharmacists.

Fever: knowledge, perception and attitudes. Results from a Norwegian population study.

To investigate the layman's knowledge, perception and attitudes regarding normal body temperature, fever, infections and the effect of penicillin on virus infections a representative sample of the Norwegian population (619 women and 592 men over the age of 15) was interviewed in 1988 as part of a monthly national opinion poll. One-third thought body temperatures up to 40.5 degrees C to be life-threatening, but the results do not justify the application of the term 'fever phobia' as described in other studies based on non-representative samples. More respondents were afraid of viral infections (48%) than bacterial infections (9%), which may be due to the media focus upon the HIV/AIDS epidemic. Thirty-five per cent believed penicillin to be effective against virus infections. Educational programmes on fever should also include information about virus infections and their treatment.

[Cholesterol measurement in general practice--Norwegian general practitioners' attitudes and estimation of their own practice]. / Kolesterolmåling i allmennpraksis--norske primaerlegers holdning og oppfatning av egen praksis.

In 1988 a group of Norwegian experts published a programme for treatment of patients with increased cholesterol. The programme recommended dietary counselling when plasma cholesterol exceeded 5 mmol/l. In the autumn 1988 the Norwegian National Health Association started a campaign on cholesterol for health personnel. In order to find out to what extent general practitioners adhered to the recommendations of the programme, a random sample of 100 general practitioners were sent a questionnaire before and after the campaign. The results showed no significant differences in the doctors' attitudes towards diagnosis and treatment of patients with increased plasma cholesterol. Both before and after the campaign the plasma cholesterol levels at which they would initiate follow-up, dietary counselling or drug therapy were 1-2 mmol/l above the levels recommended by the expert group. The attitude of the general practitioners was more conservative than the recommendations of the programme. The interval between the information meeting and the post study was only six months. It is a complicated process to change attitudes and practice routines, and the time required may be longer than six months. Furthermore, the recommendations of the programme were questioned by other doctors, which reduced its impact.

Group training of general practitioners: evaluation based on participants' expectations of an educational programme.

Since 1985, the Norwegian Medical Association (NMA) has offered a 5-year specialist training programme in general practice. For two of these years the doctors take part in a group-based educational programme with bi-weekly meetings of 3 hours' duration. The evaluation study reported here had a dual purpose: to provide the groups with a method for exploring the group members' expectations of the programme, and to measure to what extent the programme had actually met these expectations within the first of the 2 years. Thirty-one of 38 groups, first established in spring 1986, responded on a postal inquiry where they were asked to list up to 10 features they expected to find in the educational programme. These expectations were rated by the groups on a five-point scale, where 5 denoted a fully met expectation. The four most frequent features analysed were: (1) increased comprehension of the characteristics and practice of general medicine; (2) good group collaboration; (3) facilitating the acquisition of medical knowledge; and (4) evaluation of clinical problems and patient management. Expectations for the first two of these features were nearly fully met, while the two others were met to a lesser degree. This type of evaluation seemed to be a useful tool for improving the group's way of functioning.