Good cancer follow-up for socially disadvantaged patients in general practice? Perspectives from patients and general practitioners.

One of the core principles of providing care in general practice is giving more to those who need it most. We investigate some of the complexities of this ambition in the context of cancer care for patients defined as socially disadvantaged by their general practitioner (GP). We do this by exploring how care is sought, how it is offered, and what expectations patients and GPs carry with them when receiving and providing cancer care in the Danish welfare state. We carried out semi-structured interviews with eight GPs and seven socially disadvantaged cancer patients living with different types and stages of cancer. The interviews focused on needs and challenges in cancer follow-up in general practice and were thematically coded. Drawing on theoretical concepts of morality and Nordic individualism, we point to how one of the main challenges in cancer care and follow-up is to figure out how the doctor-patient relationship should be established, practiced, and maintained. Both GPs and patients stressed the importance of the relationship, but how it should be practiced amidst social norms about being a patient, a citizen and how care-seeking should unfold seems less clear. In conclusion we argue that giving more to those who need it the most is a difficult and ill-defined task that is shaped by the cultural, social, and political expectations of both GPs and patients.

Turning Towards the Affective: Medical Semiotics of Child Maltreatment in Denmark.

Signs of child maltreatment may be physical and detectable by clinical examination but may also arise as a feeling of strangeness that sparks uncertainty. Based on fieldwork in Danish general practice, and thinking along recent discussions around semiotics and affect, the article explores how feelings of "strangeness" arise in child consultations. It focuses on how subjective, embodied, and interpersonal reactions arise, how signs, however tactile and arbitrary, are felt and experienced, and how engaging with affective aspects when doing diagnosis, could expand the medical semiotics of child maltreatment.

Standardized Protocol for the Preparation of Precision-Cut Kidney Slices: A Translational Model of Renal Fibrosis.

Renal fibrosis is a hallmark of progressive renal diseases. To date, there is a lack of effective therapeutics for the treatment of renal fibrosis, in part due to the scarcity of clinically relevant translational disease models. Since the early 1920s, hand-cut tissue slices have been used as a means to better understand organ (patho)physiology in a variety of scientific fields. From that time, the equipment and methodology for the preparation of tissue slices has continuously improved, thereby expanding the applicability of the model. Nowadays, precision-cut kidney slices (PCKS) have been demonstrated to be an extremely valuable translation model for renal (patho)physiology, bridging the gap between preclinical and clinical research. A key feature of PCKS is that the slices contain all cell types and acellular components of the whole organ in the original configuration while preserving cell-cell and cell-matrix interactions. In this chapter, we describe how to prepare PCKS and how the model can be implemented in fibrosis research.

Management of child maltreatment suspicions in general practice: a mixed methods study.

BACKGROUND: Maltreated children have many long-term consequences throughout their lives, but often maltreated children are not recognised in time by professionals. General practice could be central to the early recognition of child maltreatment due to the long-term relationship with families. OBJECTIVE: How do general practitioners (GPs) and practice nurses (PNs) deal with suspected maltreatment in children below 18 years of age, and which factors influence them to report cases to social authorities. DESIGN AND SETTING: A mixed methods study set in general practice in Denmark. METHOD AND SUBJECTS: We combined data from a nationwide questionnaire with observations from five clinics and 20 interviews with GPs and PNs. We explored our data using the concept of uncertainty as a driver that shapes action and decision-making in general practice. RESULTS: Most GPs (94%) said they would discuss cases of suspected child maltreatment with social services, but in many cases they would prefer to discuss their suspicions with a colleague first (83%) - most likely where there are no clear-cut signs. The qualitative data added nuance to these findings by highlighting the difficulty of communicating across sectors, the importance of maintaining a connection with the child's family, and practicing watchful waiting. CONCLUSION: General practice has an opportunity to act early in cases of suspected child maltreatment if uncertainty is accepted as a critical part of the process of reaching a diagnosis. Communication across sectors is key, as is support for GPs with suspicions and for families in need of help.Key pointsGPs are often thought to underreport child maltreatment but despite low levels of reporting, this does not mean they ignore it.Building on the connection with the family, making follow appointments, and discussing suspicions with colleagues are typical of how GPs manage suspicions of child abuse.Accepting uncertainty as a condition of raising the alarm could help GPs to act quickly to support children at risk of abuse.

Patient perspectives on data sharing regarding implementing and using artificial intelligence in general practice - a qualitative study.

BACKGROUND: Due to more elderly and patients with complex illnesses, there is an increasing pressure on the healthcare system. General practice especially feels this pressure as being the first point of contact for the patients. Developments in digitalization have undergone fast progress and data-driven artificial intelligence (AI) has shown great potential for use in general practice. To develop AI as a support tool for general practitioners (GPs), access to patients' health data is needed, but patients have concerns regarding data sharing. Furthermore, studies show that trust is important regarding the patient-GP relationship, data sharing, and AI. The aim of this paper is to uncover patient perspectives on trust regarding the patient-GP relationship, data sharing and AI in general practice. METHOD: This study investigated 10 patients' perspectives through qualitative interviews and written vignettes were chosen to elicit the patients (interviewees) perspectives on topics that they were not familiar with prior to the interviews. The study specifically investigated perspectives on 1) The patient-GP relationship, 2) data sharing regarding developing AI for general practice, and 3) implementation and use of AI in general practice using thematic analysis. The study took place in the North Denmark Region and the interviewees included had to be registered in general practice and be above 18 years in age. We included four men between 25 to 74 years in age and six women between 27 to 46 years in age. RESULTS: The interviewees expressed a high level of trust towards their GP and were willing to share their health data with their GP. The interviewees believed that AI could be a great help to GPs if used as a support tool in general practice. However, it was important for the interviewees that the GP would still be the primary decision maker. CONCLUSION: Patients may be willing to share health data to help implement and use AI in general practice. If AI is implemented in a way that preserves the patient-GP relationship and used as a support tool for the GP, our results indicate that patients may be positive towards the use of AI in general practice.

Epigenetic Silencing of LRP2 Is Associated with Dedifferentiation and Poor Survival in Multiple Solid Tumor Types.

More than 80% of human cancers originate in epithelial tissues. Loss of epithelial cell characteristics are hallmarks of tumor development. Receptor-mediated endocytosis is a key function of absorptive epithelial cells with importance for cellular and organismal homeostasis. LRP2 (megalin) is the largest known endocytic membrane receptor and is essential for endocytosis of various ligands in specialized epithelia, including the proximal tubules of the kidney, the thyroid gland, and breast glandular epithelium. However, the role and regulation of LRP2 in cancers that arise from these tissues has not been delineated. Here, we examined the expression of LRP2 across 33 cancer types in The Cancer Genome Atlas. As expected, the highest levels of LRP2 were found in cancer types that arise from LRP2-expressing absorptive epithelial cells. However, in a subset of tumors from these cancer types, we observed epigenetic silencing of LRP2. LRP2 expression showed a strong inverse correlation to methylation of a specific CpG site (cg02361027) in the first intron of the LRP2 gene. Interestingly, low expression of LRP2 was associated with poor patient outcome in clear cell renal cell carcinoma, papillary renal cell carcinoma, mesothelioma, papillary thyroid carcinoma, and invasive breast carcinoma. Furthermore, loss of LRP2 expression was associated with dedifferentiated histological and molecular subtypes of these cancers. These observations now motivate further studies on the functional role of LRP2 in tumors of epithelial origin and the potential use of LRP2 as a cancer biomarker.

Suspicion of child maltreatment: Knowledge and experiences with mandatory reports to social services among general practitioners in Denmark in 2019-20.

BACKGROUND: Child maltreatment has many consequences through the lifespan. The general practitioners (GPs) are in longitudinal contact with the family and can play an important role in identifying children in danger and reporting to the social services. OBJECTIVE: To explore how GPs manage suspicions of child maltreatment and to investigate potential demographic and geographic differences in reporting practices among Danish GPs. PARTICIPANTS AND SETTING: All registered GPs in Denmark retrieved from Medcom, a state-financed non-profit organization. METHODS: We mailed a questionnaire to all registered GPs with demographics, experiences, knowledge, and attitudes in the context of child maltreatment. RESULTS: We received 1252 completed questionnaires (response rate: 38 %). Most of the participants had suspected child maltreatment during their professional life (90 %) and had made a mandatory report (85 %). More than half had received feedback after the report (56 %) and said that their report led to action (56 %). Most GPs reported feeling confident in dealing with child maltreatment (79 %) and being willing to get involved in case of suspicion (8.9 on a 0-10 scale). We observed no geographical differences in reporting neither across the Danish regions nor among rural and urban practices, but GPs working in single practices made fewer reports to the social services. CONCLUSIONS: Participant GPs in this study are aware of their role in child protection, have experiences with mandatory reports, and are willing to get involved. Possible areas for attention include collaboration and support between different settings, especially between GP practice, hospitals, justice sector, and social services.

[Social inequality in health].

Social inequality is a significant challenge in the Danish healthcare system, and in general practice the inequality has many faces. To give more to those who need most is a difficult task, and research shows the diversity of the challenges experienced in the primary healthcare sector. However, as argued in this review, through innovative research we may be able to find new directions in how to provide patient centered healthcare, and in taking on this task general practice is centrally positioned as the place at which most patients are seen on a regular basis.

Guidance for Implementing Video Consultations in Danish General Practice: Rapid Cycle Coproduction Study.

BACKGROUND: The COVID-19 pandemic has changed various spheres of health care. General practitioners (GPs) have widely replaced face-to-face consultations with telephone or video consultations (VCs) to reduce the risk of COVID-19 transmission. Using VCs for health service delivery is an entirely new way of practicing for many GPs. However, this transition process has largely been conducted with no formal guidelines, which may have caused implementation barriers. This study presents a rapid cycle coproduction approach for developing a guide to assist VC implementation in general practice. OBJECTIVE: The aim of this paper is to describe the developmental phases of the VC guide to assist general practices in implementing VCs and summarize the evaluation made by general practice users. METHODS: The development of a guide for VC in general practice was structured as a stepped process based on the coproduction and prototyping processes. We used an iterative framework based on rapid qualitative analyses and interdisciplinary collaborations. Thus, the guide was developed in small, repeated cycles of development, implementation, evaluation, and adaptation, with a continuous exchange between research and practice. The data collection process was structured in 3 main phases. First, we conducted a literature review, recorded observations, and held informal and semistructured interviews. Second, we facilitated coproduction with stakeholders through 4 workshops with GPs, a group interview with patient representatives, and individual revisions by GPs. Third, nationwide testing was conducted in 5 general practice clinics and was followed by an evaluation of the guide through interviews with GPs. RESULTS: A rapid cycle coproduction approach was used to explore the needs of general practice in connection with the implementation of VC and to develop useful, relevant, and easily understandable guiding materials. Our findings suggest that a guide for VCs should include advice and recommendations regarding the organization of VCs, the technical setup, the appropriate target groups, patients' use of VCs, the performance of VCs, and the arrangements for booking a VC. CONCLUSIONS: The combination of coproduction, prototyping, small iterations, and rapid data analysis is a suitable approach when contextually rich, hands-on guide materials are urgently needed. Moreover, this method could provide an efficient way of developing relevant guide materials for general practice to aid the implementation of new technology beyond the pandemic period.

A qualitative study on dyad practice in a clinical setting.

INTRODUCTION: General practice in Denmark is at risk of experiencing an educational capacity problem in which the quality of medical students' clinical stays is compromised due to reduced tutor capacity. Dyad practice, in which students work and acquire competencies in pairs, is known from simulation and ultrasound training to be as effective with regard to learning outcome as single practice despite reduced hands-on time. This study aimed to explore the experience of dyad practice during a group of medical students' first clinical stay in general practice. METHODS: A focus group interview was conducted with eight medical students who had attended clinical stays in general practice in four dyads. Individual semi-structured interviews were held with three general practitioners who tutored the medical students during the clinical stays. Data were transcribed by the interviewer and analysed using systematic text condensation. RESULTS: Both the medical students and general practitioners described how dyad practice enhanced the students' self-reflection and introduced new learning experiences. Furthermore, the medical students experienced shared memory with their peer and a broader overview before, during and after the consultation with the patient. CONCLUSIONS: Dyad practice was experienced by both medical students and general practitioners as suitable for medical students' first-time clinical stay in general practice. Dyad practice may thus reduce the capacity problems with regard to medical education in general practice. FUNDING: This study was funded in part by the PLU Foundation. TRIAL REGISTRATION: not relevant.

Identifying signs of child neglect and abuse in general practice.

INTRODUCTION: Children who live with neglect and abuse are often identified late in the process. At the front line of Danish healthcare, where most children are seen regularly, general practice is well placed to raise concerns about child health and wellbeing. Little is known about the role general practitioners (GPs) play in suspecting and reporting child neglect and abuse. We explored challenges GPs are facing in identifying such children and illustrated some of the barriers preventing GPs from reporting on these cases. METHODS: This was an explorative pilot study, preceding a larger multidisciplinary project. We conducted eight semi-structured interviews with selected Danish GPs. The interviews were transcribed verbatim and coded using thematic analysis. RESULTS: GPs rarely experienced concrete signs of child neglect and abuse, and reporting to the social services was often a way of helping families to get the support they needed. When GPs suspected that "something was wrong", this was based on a gut feeling, triggered by non-measurable and intangible signs such as changes in health-seeking behaviour or in the relationship between caregivers and children. CONCLUSIONS: The intangibility of signs provoking suspicion of neglect and abuse made acting or reporting difficult and GPs felt that they lacked opportunities to take action. More knowledge is needed on how to approach matters of child protection and wellbeing across health professions and specialities. FUNDING: The study was funded by the Danish Victims Fund. TRIAL REGISTRATION: not relevant.

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.

Exploring targeted preventive health checks in a socially disadvantaged neighborhood in Denmark.

Recently studies have focused on how health promotion interventions sometimes sideline issues of social context, framing health as a matter of individual choice and, by implication, a personal responsibility. Part of this criticism is that health promotion interventions often do not draw on situated understandings of the contextual aspects of health and illness practices. Theoretically, this study departs in practice theory and contemporary public heath discussions on targeted health promotion. Based on semi-structured interviews with 18 people living in a social housing association we explored the significance of participating in a preventive health check and how participation configured into everyday life. All participants in our study had been identified with a 'risk' health profile. Overall, we found that they were well aware of their health risks and challenges, and that they reflected a great deal on how their health status was intrinsically linked with their lifestyle and health practices, such as lack of exercise or smoking. The health checks were, however, not able to support or improve their general health, and did not seem to address the challenges the participants seemed to struggle with in life. By way of conclusion, we suggest that we implement a more practice-oriented form of public health that focus on the 'lives' that people live, and the problems that they face. Moreover, attention should be paid to how and to whom health promotion initiatives are offered, in order to ensure the relevance of targeted interventions.

Association between GPs' suspicion of cancer and patients' usual consultation pattern in primary care: a cross-sectional study.

BACKGROUND: Patients who rarely consult a GP in the 19-36 months before a cancer diagnosis have more advanced cancer at diagnosis and a worse prognosis. To ensure more timely diagnosis of cancer, the GP should suspect cancer as early as possible. AIM: To investigate the GP's suspicion of cancer according to the patient with cancer's usual consultation pattern in general practice. DESIGN AND SETTING: A cross-sectional study based on survey data from general practice of 3985 Danish patients diagnosed with cancer from May 2010 to August 2010, and linked to national register data. METHOD: Using logistic regression analysis with restricted cubic splines, the odds ratio (OR) of the GP to suspect cancer as a function of the patient's number of face-to-face consultations with the GP in the 19-36 months before a cancer diagnosis was estimated. RESULTS: GPs' cancer suspicion decreased with higher usual consultation frequency in general practice. A significant decreasing trend in ORs for cancer suspicion was seen across usual consultation categories overall (P<0.001) and for each sex (males: P<0.05; females: P<0.05). GPs' cancer suspicion was lower in patients aged <55 years in both rare and frequent attenders compared with average attenders. CONCLUSION: GPs suspect cancer more often in rare attenders ≥55 years. GPs' cancer suspicion was lower in younger patients (<55 years), in both rare and frequent attenders. GPs should be aware of possible missed opportunities for cancer diagnosis in young attenders and use safety netting to reduce the risk of missing a cancer diagnosis.

Contact to the out-of-hours service among Danish parents of small children - a qualitative interview study.

OBJECTIVE: In Denmark, parents with small children have the highest contact frequency to out-of-hours (OOH) service, but reasons for OOH care use are sparsely investigated. The aim was to explore parental contact pattern to OOH services and to explore parents' experiences with managing their children's acute health problems. DESIGN: A qualitative study was undertaken drawing on a phenomenological approach. We used semi-structured interviews, followed by an inductive content analysis. Nine parents with children below four years of age were recruited from a child day care centre in Aarhus, Denmark for interviews. RESULTS: Navigation, information, parental worry and parental development appeared to have an impact on OOH services use. The parents found it easy to navigate in the health care system, but they often used the OOH service instead of their own general practitioner (GP) due to more compatible opening hours and insecurity about the urgency of symptoms. When worried about the severity, the parents sought information from e.g. the internet or the health care professionals. The first child caused more worries and insecurity due to less experience with childhood diseases and the contact frequency seemed to decrease with parental development. CONCLUSION: Parents' use of the OOH service is affected by their health literacy levels, e.g. level of information, how easy they find access to their GP, how trustworthy and authorized health information is, as well as how much they worry and their parental experience. These findings must be considered when planning effective health services for young families. Key points The main findings are that the parents in our study found it easy to navigate in the healthcare system, but they used the OOH service instead of their own general practitioner, when this suited their needs. The parents sought information from e.g. the internet or the health care professionals when they were worried about the severity of their children's diseases. They sometimes navigated strategically in the healthcare system by e.g. using the OOH service for reassurance and when it was most convenient according to opening hours. The first child seemed to cause more worries and insecurity due to limited experience with childhood diseases, and parental development seems to decrease contact frequency. Overall, this study contributes with valuable insights into the understanding of parents' help seeking behaviour. There seems to be a potential for supporting especially first-time parents in their use of the out of hours services.

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.

Factors influencing GPs' choice between drugs in a therapeutic drug group. A qualitative study.

OBJECTIVE: To explore how GPs choose between drugs in a therapeutic drug group. DESIGN: A qualitative study based on semi-structured ethnographic interviews. SETTING AND SUBJECTS: General practitioners from the counties of both Funen and West Zealand in Denmark. A total of 15 general practitioners (GPs) were selected with reference to variation in organizational structure, age, and gender. MAIN OUTCOME MEASURES: GPs' description of drug choice in relation to specific patient encounters involving a prescription. RESULTS: All informants appeared to consider drug price important as it was a recurring theme during all interviews. External factors outside the GP's control such as governmental regulation on prescribing and the pharmaceutical industry influenced most GPs. Internal factors related to the actual consultation included characteristics of the GP and the patient, drug characteristics, and repeat prescriptions. These factors interact in a non-linear and unpredictable way similar to complex adaptive systems. CONCLUSION: GPs balance both internal and external factors when choosing between analogues. Drug choice is a regulated process in the realm of complex prescribing behaviour with drug costs as a major factor.