Communication about euthanasia in general practice: opinions and experiences of patients and their general practitioners

OBJECTIVE: Public opinion and professional organisations dominate the euthanasia debate, and there is a need to understand the opinions of people confronted with euthanasia. The aim of this study was to investigate whether patients and their GPs talk about euthanasia, and if so, how they communicate about this. METHODS: Qualitative, semi-structured interviews were held with 20 GPs and 30 of their patients in primary care in the Netherlands, where euthanasia is legalised. The patients had a life expectancy of less than 6 months, and cancer, heart failure or chronic obstructive pulmonary disease as underlying disease. RESULTS: Many patients did not communicate about euthanasia with their GP. Neither the patient nor the GP were clear in formulating their expectations concerning future decision making. CONCLUSION: The initial patient-GP communication consisted of an exchange of opinions about situations in which euthanasia would be desirable. GPs had different opinions about who should initiate communication, and found it difficult to judge the right moment to talk. PRACTICE IMPLICATIONS: It is essential to pay attention to education in communication about dying and euthanasia and to train the GPs to gain insight in the patient's end-of-life preferences, and to direct care at the best possible quality of life.     

Talking matters: abused women's views on disclosure of partner abuse to the family doctor and its role in handling the abuse situation

OBJECTIVE: We aimed to explore what women valued most in disclosing partner abuse to their doctor and whether disclosure played a role in handling their abuse situation. METHODS: A qualitative method was used to understand abused women's views and experiences with disclosure to their family doctor. Thirty-six women were interviewed within 4 weeks after disclosure to their family doctor. RESULTS: Most women went to see the doctor for some medical complaint, and only three women planned to disclose the abuse. Twenty-five women valued most their doctor's communicative approach with empathy or empowering and nine women valued most the instrumental approach. Eight women of the latter group wanted this combined with a communicative approach. After disclosure to the family doctor, a group of women (n=20) perceived a real change in their possibilities to handle their situation. They appeared to be in a position we named: 'in transition', a state in which they started or continued a process of change. Another group of women (n=13) appeared to be in a 'locked-up' position, a state without any prospect on change, feeling out of control and fearing the abuser. Three women reacted reserved towards change. CONCLUSION: A communicative approach, providing empathy and empowerment, is important to women in disclosing partner abuse. More than half of the women perceived possibilities for a change. PRACTICE IMPLICATIONS: Talking about abuse is an important step in a woman's process of change. Doctors should acknowledge the advantage of their position as a professional confidant and ask women about abuse.     

Receptionists' experiences of occupational violence in general practice: a qualitative study

Background

The significance of occupational violence in general practice is well established, but research has focused almost exclusively on the experiences of GPs.Only limited research has examined the role of general practice receptionists despite their acknowledged vulnerability to violent patient behaviour. No qualitative research has explored this problem.

Aim

To explore the experiences of general practice receptionists regarding occupational violence and the effects of violence on their psychological and emotional wellbeing and on their work satisfaction and performance.

Design of study

Qualitative study.

Setting

Constituent practices of an Australian network of research general practices. Practices were located in a range of socioeconomic settings.

Method

Semi-structured interviews were conducted with practice receptionists. The interviews were audiotaped, transcribed, and subjected to thematic analysis employing a process of constant comparison in which data collection and analysis were cumulative and concurrent. Qualitative written responses from a cross-sectional questionnaire-based study performed concurrently with the qualitative study were similarly analysed.

Results

Nineteen interviews were conducted and 12 written responses were received. Violence was found to be a common, sometimes pervasive, experience of many receptionists. Verbal abuse, both ‘across the counter’ and telephone abuse, was the most prominent form of violence, although other violence, including assault and threats with guns, was reported. Experiences of violence could have marked emotional and psychological effects and could adversely affect job satisfaction, performance, and commitment.

Conclusion

It is apparent that occupational violence is a whole-of-practice problem and strategies for GP and staff safety will need to take a whole-of-practice approach.     

Distilling the essence of general practice: a learning journey in progress

Over the past 5 years, general practice in the UK has undergone major change. Starting with the introduction of the new GMS contract in 2004, it has continued apace with the establishment of Postgraduate Medical Education Training Board, a GP training curriculum, and nMRCGP. The NHS is developing very differently in the four countries of the UK. Regulation of the profession is under review, and a system of relicensing, recertification, and revalidation is being introduced. The Essence project, initiated by RCGP Scotland in conjunction with International Futures Forum 4 years ago is a constructive response to these changes. It has included learning journeys, a discussion day for GPs, and commissioned short pieces of 100 words from GPs and patients. From an analysis of these, some characteristics of the essence of general practice have been defined. These include key roles and core personal qualities for GPs. It is argued that general practice has important and unique advantages — trust, coordination, continuity, flexibility, universal coverage, and leadership — which mean that it should continue to be central to the development of primary care throughout the UK.     

Development and feasibility of a patient feedback programme to improve consultation skills in general practice training

OBJECTIVE: To develop an attractive and effective patient feedback training programme for general practice trainees (GPTs). METHODS: First, an exploratory study was conducted in which patients and GPTs were interviewed after they had worked with patient feedback. This contributed to the development of the patient feedback training programme. Subsequently, in a feasibility study, first-year GPTs asked patients to give feedback on their consultation skills by completing a questionnaire. The outcomes of group discussions with the GPTs and the results of the evaluation forms filled in by the GPTs were analysed. RESULTS: Forty-eight GPTs collected 878 questionnaires. GPTs and patients alike expected patient feedback to be a major tool for acquiring consultation skills. The GPTs encountered several obstacles in the organisation of this programme in their practice. They reported that the learning effects were more limited than they had expected because patients gave positively biased answers and because not all consultations provided an appropriate source of patient feedback. CONCLUSION: The new patient feedback programme on consultation skills is feasible for patients and GPTs. PRACTICE IMPLICATIONS: To optimise the educational potential and benefits of patient feedback, GPTs should ask for feedback from patients after challenging consultations, and should stimulate patients to be critical in their answers.     

Patient and family member perspectives on searching for cancer clinical trials: A qualitative interview study

ObjectiveClinical trials are vital in the context of ovarian cancer and may offer further treatment options during disease recurrence, yet enrollment remains low. Understanding patient and family member experiences with identifying trials can inform engagement and education efforts.MethodsInterviews were conducted with 33 patients who had experience with clinical trial conversations and 39 nominated family members. Thematic analysis examined experiences and generated findings for clinical practice.ResultsTrial conversations with providers at diagnosis were uncommon and often overwhelming. Most participants delayed engagement until later in the disease course. With hindsight, though, some wished they considered trials earlier. Difficulty identifying appropriate trials led some to defer searching to providers, but then they worried about missed opportunities. Most family members felt unqualified to search.ConclusionTrial conversations during clinical encounters should start early and include specifying search responsibilities of providers, patients, and family. Patients and family members can be engaged in searches but need guidance.Practice implicationsTrials should be discussed throughout the disease course, even if patients are not ready to participate or are not making a treatment decision. Education should focus on identifying trials that meet search criteria. Transparency regarding each individual’s role in identifying trials is critical.     

Complex health care decisions with older patients in general practice: Patient-centeredness and prioritization in consultations following a geriatric assessment

Objective

To examine to what extent general practitioners in consultations after a geriatric assessment set shared health priorities with older patients experiencing multimorbidity and to what extent this was facilitated through patient-centered behavior.

Methods

Observation of consultations embedded in a cluster randomized controlled trial,¹ in which 317 patients from 41 general practices received the STEP assessment followed by a care planning consultation with their GPs. GPs in the intervention group used a structured procedure for setting health (care) priorities in contrast to control GPs. A sample of 43 consultations (24 intervention; 19 control) were recorded, transcribed and analyzed with regard to priority setting and patient-centeredness.

Results

Patient-centeredness was only moderately apparent in consultations dealing with complex care plans for older patients with multimorbidity. The shared determination of health priorities seemed unusual for both doctors and patients and was rarely practiced, albeit more frequently in intervention consultations.

Conclusion

Setting health care priorities with patients experiencing multimorbidity is ethically desirable and medically appropriate. Yet a short structured guide for doctors cannot easily achieve this.

Practice implications

More research is needed in regard to handling complex health needs of older patients. It requires a professional approach and training in patient-centered holistic care planning.     

Experiences of using email for general practice consultations: a qualitative study

Background

Reports suggest approximately 21–23% of GPs in the UK have consulted with patients using email, but little is known about the nature of this use and what it means for clinicians and patients in general practice.

Aim

To understand the use of email consultation in general practice by investigating the experiences of existing users and views of experts.

Design and setting

A qualitative study conducted in 2010 using purposive sampling and semi-structured interviews in general practice and community settings in some London boroughs.

Method

A maximum variation sample of GPs and patients who had used email for consultation in general practice were recruited, as were policy and/or implementation experts. Interviews continued until saturation was achieved.

Results

In total 10 GPs, 14 patients, and six experts were interviewed. Consultation by email was often triggered by logistic or practical issues; motivators for ongoing use were the benefits, such as convenience, for GPs and patients. Both GPs and patients reported concerns about safety and lack of guidance about the ‘rules of engagement’ in email consultations, with GPs also concerned about workload. In response, both groups attempted to introduce their own rules, although this only went some way to addressing uncertainty. Long term, participants felt there was a need for regulation and guidance.

Conclusion

Consultations by email in general practice occur in an unregulated and unstructured way. Current UK policy is to promote consultations by email, making it crucial to consider the responsibility and workload faced by clinicians, and the changes required to ensure safe use; not doing so may risk safety breaches and result in suboptimal care for patients.     

Difficulties in disclosing the diagnosis of dementia: a qualitative study in general practice

Background

Dementia is an insidious and stigmatised condition, and research indicates that GPs find communicating this diagnosis particularly problematic. Delays in diagnosis may impede optimal patient care. Little research has been published on Australian GPs’ perceptions of barriers to disclosing the diagnosis of dementia.

Aim

To explore GPs’ perceptions of barriers to disclosing the diagnosis of dementia.

Design and setting

Qualitative study in the general practice consultation context.

Method

Semi-structured, audiorecorded interviews were conducted with GPs from three capital cities and one regional centre in Australia. Interviews were transcribed verbatim and thematic analysis was conducted.

Results

GPs’ lack of confidence in having a correct diagnosis, concern to act in patients’ best interests, and the stigma associated with the ‘dementia’ label influenced the disclosure process. GPs found it challenging to identify dementia in the consultation context. It was difficult to raise the issue when both the patient and their family/carer(s) ignore/are unaware of symptoms of cognitive decline. Referral to a specialist was favoured to confirm suspicions, although this did not always result in a definitive diagnosis. Opinions differed as to whether the GP or the specialist was better placed to deliver the diagnosis. GPs preferred disclosure to the patient with his/her family/carer(s) present; associated issues of confidentiality and the importance of offering hope emerged. The severity of the patient’s dementia also guided the diagnostic disclosure process. GPs often used euphemisms for dementia when disclosing the diagnosis, to soften the message.

Conclusion

Complex issues surround the disclosure of dementia. Communicating this diagnosis remains particularly challenging for many GPs.     

How doctors recognise that their patients are worried: A qualitative study of patient cues

ObjectivesRecognising patient cues indicating worry is essential for successful reassurance. To obtain more insight into the variety and nature of patient cues that may arise in practice, this study explores doctors’ reflections on patient cues they recognise during consultations.MethodsWe performed a qualitative study during which GPs participated in stimulated recall interviews, using their own video-recorded consultations to enhance reflection. First, we reanalysed an existing dataset of 15 interviews during which GPs elaborated on the doctor-patient interaction. Additionally, 12 GPs were interviewed specifically about recognising patients’ cues.ResultsGPs described four categories of patient cues that indicate worry. GPs recognised worry based on non-verbal cues such as visible bodily reactions, and verbal cues that can be further categorised by type of worry (e.g. about serious disease). Moreover, GPs described behavioural cues, e.g. the patient bringing a list of symptoms. Lastly, GPs recognise worry based on prior knowledge about the patient.ConclusionsGPs reflections have given insight into a wide variety of non-verbal -, verbal -, behavioural- and foreknowledge-based cues.Practice implicationsThe identified cues can guide other clinicians in recognising worries and inform medical communication training and future research on the effectiveness of recognising cues and patient reassurance.     

The health professional-patient-relationship in conventional versus complementary and alternative medicine. A qualitative study comparing the perceived use of medical shared decision-making between two different approaches of medicine

Objective

To explore differences between conventional medicine (COM) and complementary and alternative medicine (CAM) regarding the attitude toward and the perceived use of shared decision-making (SDM) from the health professional perspective.

Methods

Thirty guideline-based interviews with German GPs and nonmedical practitioners were conducted using qualitative analysis for interpretation.

Results

The health professional–patient-relationship in CAM differs from that in COM, as SDM is perceived more often. Reasons for this include external context variables (e.g. longer consultation time) and internal provider beliefs (e.g. attitude toward SDM). German health care policy was regarded as one of the most critical factors which affected the relationship between GPs and their patients and their practice of SDM.

Conclusion

Differences between COM and CAM regarding the attitude toward and the perceived use of SDM are attributable to diverse concepts of medicine, practice context variables and internal provider factors. Therefore, the perceived feasibility of SDM depends on the complexity of different occupational socialization processes and thus, different value systems between COM and CAM.

Practice implications

Implementation barriers such as insufficient communication skills, lacking SDM training or obedient patients should be reduced. Especially in COM, contextual variables such as political restrictions need to be eliminated to successfully implement SDM.     

全科医学中心SWOT分析与策略

目的:用现代管理学SWOT分析法理论,从管理学层面对全科医学中心工作开展中出现的现象和学科建设进行分析并找到应对策略。方法:通过SWOT分析法,对全科医学中心在三甲综合性医院开展全科医学继续教育以及与区域社区卫生服务中心开展双向转诊,技术服务指导等方面工作的内外部环境进行梳理,分析存在的优势和劣势,提出了全科医学中心在全科医生继续教育与双向转诊"中的相关问题。结果:通过分析,在克服劣势、把握机会、回避威胁的基础上对全科医学中心的发展提出未来可持续发展的应对策略。结论:采用现代企业管理SWOT理论分析三甲综合医院全科医学中心在双向转诊及全科医学继续教育中的优势、劣势,并提出四种应对策略分析,从而有效调动全科医学中心的优势力量,提高工作效果,取得显著效果。     

The impact of patient-generated contextual data on communication in clinical practice: A qualitative assessment of patient and clinician perspectives

BackgroundEffective communication is integral to patient-centered care, yet external pressures can impede the ability to discuss important topics. One strategy to facilitate communication is pre-visit collection and sharing of patient contextual data (PCD), including life circumstances such as their beliefs, needs, and concerns.ObjectiveTo understand how patients and care team members perceive the electronic collection of PCD and its impact on communication in the context of a large academic health system that implemented PatientWisdom, a new technology that elicits PCD from patients and integrates within the electronic health record (EHR).MethodsWe conducted focus groups with patients (n = 26) and semi-structured interviews with primary care team members (n = 20). Qualitative analysis of focus group/interviews included an iterative and reflexive inductive technique to uncover emergent themes.ResultsFour themes were reflected among both patient and care team: (1) the technology enhances the patient’s voice; (2) the technology creates a safe space for patients to share sensitive topics; (3) PCD facilitates rapport not only between patient and provider but the entire care team; (4) PCD aligns patient and clinician goals. Two unique themes emerged among patients: (1) PCD provides opportunity for reflection; (2) PCD humanizes patients in the clinical context. One theme was evident in provider comments: collecting PCD may potentially undermine trust if not reviewed by clinical teams.ConclusionPCD collected directly from patients and available within the EHR was seen by patients and care team members as beneficial to communication. PCD collection supports a paradigm shift towards coproduction of health information and a shared responsibility for information gathering but requires investment from patients and care team to ensure the data are effectively utilized.Practice valuePCD may be useful for team-based care, enabling physicians and non-physician staff to more quickly and responsively connect with patients.     

Multisource feedback questionnaires in appraisal and for revalidation: a qualitative study in UK general practice

Background

UK revalidation plans for doctors include obtaining multisource feedback from patient and colleague questionnaires as part of the supporting information for appraisal and revalidation.

Aim

To investigate GPs'' and appraisers'' views of using multisource feedback data in appraisal, and of the emerging links between multisource feedback, appraisal, and revalidation.

Design and setting

A qualitative study in UK general practice.

Method

In total, 12 GPs who had recently completed the General Medical Council multisource feedback questionnaires and 12 appraisers undertook a semi-structured, telephone interview. A thematic analysis was performed.

Results

Participants supported multisource feedback for formative development, although most expressed concerns about some elements of its methodology (for example, ‘self’ selection of colleagues, or whether patients and colleagues can provide objective feedback). Some participants reported difficulties in understanding benchmark data and some were upset by their scores. Most accepted the links between appraisal and revalidation, and that multisource feedback could make a positive contribution. However, tensions between the formative processes of appraisal and the summative function of revalidation were identified.

Conclusion

Participants valued multisource feedback as part of formative assessment and saw a role for it in appraisal. However, concerns about some elements of multisource feedback methodology may undermine its credibility as a tool for identifying poor performance. Proposals linking multisource feedback, appraisal, and revalidation may limit the use of multisource feedback and appraisal for learning and development by some doctors. Careful consideration is required with respect to promoting the accuracy and credibility of such feedback processes so that their use for learning and development, and for revalidation, is maximised.     

The place of general practitioner in the management of patients with rare disease and intellectual disability: A qualitative study

The management of patients with rare diseases (RD) presents many challenges including diagnosis, coordination of care, and orientation in the health system. For these patients, the general practitioner (GP) is not always the referring physician. The aim of this study was to determine the place of the GP in management of patients with RD. We used a qualitative study by case-study. From March to October 2020, semi-structured interviews were conducted by telephone with the families of adult patients with RD and intellectual disability, and with the health professionals involved in their management. Patients were recruited through RD reference centres, patient associations or GPs. The interviews were transcribed and analysed by two independent investigators. A grounded theory-based analysis was performed. Eight case studies were conducted with 20 participants. Our results highlighted the trajectory of the patients through the development of the career of the primary informal caregiver. The caregivers developed skills required for the management of the care recipient. Within this trajectory, the GP found his place depended on the skills he could provide, their interest in the disease, the skills developed by the caregiver, and the caregiver/care recipient needs. The GP was mostly consulted for routine care and administrative procedures, but when a trusting relationship was established, they also accompanied the patient and their family by providing appropriate medical, social or psychological support. The GP will be all the more a privileged actor in the care process that he will be involved in the coordination of all other actors, professional as non-professionals.     

Developing and maintaining patients’ trust during general practice consultations: The case of smoking cessation advice

Objective

The aim of this paper is to describe how the process of developing and maintaining trust is related to how and if smoking cessation advice is given in general practice consultations.

Methods

The study consisted of interviews with six Danish GPs and with 11 of their patients, on the basis of observations of their consultations.

Results

According to the findings of this study, both the GPs and the patients expected GPs to demonstrate in interaction with the patients their intent to evaluate and possibly resolve the patient's health problem. The GPs were also expected to show that they recognized the patient's health problem. Both GPs and patients felt that this would help to develop patients’ trust in their GPs. Smoking cessation advice during consultations could negate these demonstrations of GPs intents. Smoking cessation advice, however, could demonstrate interest and a desire to help and so develop trust.

Conclusion

Smoking cessation advice has the potential both to put trust under strain and to strengthen trust. The outcome depends on whether the advice conforms to what both patients and GPs expect from the interaction in general practice consultations.

Practice implications

To develop and maintain patients’ trust GPs should consider the specific expectations from the interaction with patients during consultations when giving smoking cessation advice.     

Assessment of motivational interviewing with the VASE-(Mental) Healthcare: Mixed-methods study to examine feasibility and validity in the general practice setting

ObjectiveThe VASE-(M)HC is an instrument to evaluate Motivational Interviewing (MI) skills. We adjusted the previous version for use in the broader (mental) healthcare context, incorporated new MI insights, expanded the scoring system and created a parallel version. Feasibility and validity evidence in the general practice setting was explored.MethodsThe teaching staff of the GP specialty-training, GP-, and PN-trainees (N = 156) completed the VASE-(M)HC. In this mixed-methods study, we examined psychometric characteristics, compared parallel versions, and interviewed assessors.ResultsOur adjustments enable assessment of a wider range of MI skills, and allow differentiation of basic and advanced skills. Inter-rater reliability was excellent and internal consistency of the total scale was good for both versions. The parallel versions are comparable in terms of difficulty.ConclusionThe VASE-(M)HC is improved by our revisions and adds multiple advantages to the domain of available MI assessment tools.Practice implicationsDue to the adjustments, the instrument can be used in the GP setting (instead of sole focus on substance abuse). The parallel version is useful for research (pretest/posttest) and selective assessment (retake of a test). It is promising to further explore its applicability in the broader (mental) healthcare context and as training material.