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1.
Willemjan Slort Annette H Blankenstein Luc Deliens Henri?tte E van der Horst 《The British journal of general practice》2011,61(585):e167-e172
Background
Effective communication is considered to be essential for the delivery of high-quality care. Communication in palliative care may be particularly difficult, and there is still no accepted set of communication skills for GPs in providing palliative care.Aim
To obtain detailed information on facilitators and barriers for GP–patient communication in palliative care, with the aim to develop training programmes that enable GPs to improve their palliative care communication skills.Design of study
Qualitative study with focus groups, interviews, and questionnaires.Setting
GPs with patients receiving palliative care at home, and end-of-life consultants in the Netherlands.Method
GP (n = 20) focus groups discussing facilitators and barriers, palliative care patient (n = 6) interviews regarding facilitators, and end-of-life consultant (n = 22) questionnaires concerning barriers.Results
Facilitators reported by both GPs and patients were accessibility, taking time, commitment, and listening carefully. GPs emphasise respect, while patients want GPs to behave in a friendly way, and to take the initiative to discuss end-of-life issues. Barriers reported by both GPs and end-of-life consultants were: difficulty in dealing with former doctors'' delay and strong demands from patients'' relatives. GPs report difficulty in dealing with strong emotions and troublesome doctor–patient relationships, while consultants report insufficient clarification of patients'' problems, promises that could not be kept, helplessness, too close involvement, and insufficient anticipation of various scenarios.Conclusion
The study findings suggest that the quality of GP–patient communication in palliative care in the Netherlands can be improved. It is recommended that specific communication training programmes for GPs should be developed and evaluated. 相似文献2.
Koen Meeussen Lieve Van den Block Nathalie Bossuyt Johan Bilsen Michael Echteld Viviane Van Casteren Luc Deliens 《The British journal of general practice》2009,59(566):665-670
Background
Being able to die in one''s place of choice is an indicator of the quality of end-of-life care. GPs may play a key role in exploring and honouring patients'' preferences for place of death.Aim
To examine how often GPs are informed about patients'' preferred place of death, by whom and for which patients, and to study the expressed preferred place of death and how often patients die at their preferred place.Design of study
One-year nationwide mortality retrospective study.Setting
Sentinel Network of GPs in Belgium, 2006.Method
GPs'' weekly registration of all deaths (patients aged ≥1 year).Results
A total of 798 non-sudden deaths were reported. GPs were informed of patients'' preferred place of death in 46% of cases. GPs obtained this information directly from patients in 63%. GP awareness was positively associated with patients not being hospitalised in the last 3 months of life (odds ratio [OR] = 3.9; 95% confidence interval [CI] = 2.8 to 5.6), involvement of informal caregivers (OR = 3.3; 95% CI = 1.8 to 6.1), use of a multidisciplinary palliative care team (OR = 2.5; 95% CI = 1.8 to 3.5), and with presence of more than seven contacts between GP and patient or family in the last 3 months of life (OR = 3.0; 95% CI = 2.2 to 4.3). In instances where GPs were informed, more than half of patients (58%) preferred to die at home. Overall, 80% of patients died at their preferred place.Conclusion
GPs are often unaware of their patients'' preference for place of death. However, if GPs are informed, patients often die at their preferred location. Several healthcare characteristics might contribute to this and to a higher level of GP awareness. 相似文献3.
Annemarie Money Louise Hussey Kevan Thorley Susan Turner Raymond Agius 《The British journal of general practice》2010,60(579):721-728
Background
GPs can find their role as issuers of sickness certification problematic, particularly in trying to maintain a balance between certifying absence and preserving the doctor–patient relationship. Little research has been published on consultations in which sickness absence has been certified.Aim
To explore negotiations between GPs and patients in sickness absence certification, including how occupational health training may affect this process.Method
A qualitative study was undertaken with GPs trained in occupational health who also participate in a UKwide surveillance scheme studying work-related ill-health. Telephone interviews were conducted with 31 GPs who had reported cases with associated sickness absence.Results
Work-related sickness absence and patients'' requests for a ‘sick note’ vary by diagnosis. Some GPs felt their role as patient advocate was of utmost importance, and issue certificates on a patient’s request, whereas others offer more resistance through a greater understanding of issues surrounding work and health aquired through occupational health training. GPs felt that their training helped them to challenge beliefs about absence from work being beneficial to patients experiencing ill-health; they felt better equipped to consider patients’ fitness for work, and issued fewer certificates as a result of this.Conclusion
Complex issues surround GPs'' role in the sickness-certification process, particularly when determining the patient''s ability to work while maintaining a healthy doctor–patient relationship. This study demonstrates the potential impact of occupational health training for GPs, particularly in light of changes to the medical statement introduced in 2010. 相似文献4.
Anne-C��cile Schieber Michelle Kelly-Irving Christine Rolland Anissa Afrite Chantal Cases Paul Dourgnon Pierre Lombrail Jean Pascal Thierry Lang 《The British journal of general practice》2011,61(584):e105-e111
Background
Understanding interactions between patients and GPs may be important for optimising communication during consultations and improving health promotion, notably in the management of cardiovascular risk factors.Aim
To explore the agreement between physicians and patients on the management of cardiovascular risk factors, and whether potential disagreement is linked to the patient''s educational level.Design of study
INTERMEDE is a cross-sectional study with data collection occurring at GPs'' offices over a 2-week period in October 2007 in France.Method
Data were collected from both patients and doctors respectively via pre- and post-consultation questionnaires that were ‘mirrored’, meaning that GPs and patients were presented with the same questions.Results
The sample consisted of 585 eligible patients (61% females) and 27 GPs. Agreement between patients and GPs was better for tangible aspects of the consultation, such as measuring blood pressure (κ = 0.84, standard deviation [SD] = 0.04), compared to abstract elements, like advising the patient on nutrition (κ = 0.36, SD = 0.04), and on exercise (κ = 0.56, SD = 0.04). Patients'' age was closely related to level of education: half of those without any qualification were older than 65 years. The statistical association between education and agreement between physicians and patients disappeared after adjustment for age, but a trend remained.Conclusion
This study reveals misunderstandings between patients and GPs on the content of the consultation, especially for health-promotion outcomes. Taking patients'' social characteristics into account, notably age and educational level, could improve mutual understanding between patients and GPs, and therefore, the quality of care. 相似文献5.
Alice Malpass David Kessler Deborah Sharp Alison Shaw 《The British journal of general practice》2011,61(583):e63-e71
Background
Patient participation in primary care treatment decisions has been much debated. There has been little attention to patients'' contributions to primary care consultations over a period of time, when consulting about depression and its treatment with antidepressants.Aim
To explore: (1) what issues remain unsaid during a primary care consultation for depression but are later raised by the patient as important during a research interview; (2) patients'' reasons for non-disclosure; (3) whether unvoiced agendas are later voiced; and (4) the nature of the GP–patient relationship in which unvoiced agendas occur.Design of study
Qualitative interview study.Setting
Primary health care.Method
Patients were recruited through six general practices in the south west of England. Qualitative interviews were carried out with 10 ‘pairs’ of GPs and patients who presented with a new or first episode of moderate to severe depression and were prescribed antidepressants. Follow-up patient interviews were conducted at 3 and 6 months. Throughout the 6-month period, patients were invited to record subsequent consultations (with GPs'' consent), using a patient-held tape recorder.Results
Twenty-three unvoiced agendas were revealed, often within decision-making relationships that were viewed in positive terms by patients. Unvoiced agendas included: a preference for immediate treatment, a preference to increase dosage, and the return or worsening of suicidal thoughts. In some cases, patients were concerned that they were ‘letting the GP down’ by not being able to report feeling better.Conclusion
Unvoiced agendas are not necessarily an indication that ‘shared decision making’ is absent but may in some cases represent patients'' attempts to ‘protect’ their GPs. 相似文献6.
Aurélie Mauerhofer André Berchtold Pierre-André Michaud Joan-Carles Suris 《The British journal of general practice》2009,59(566):e308-e314
Background
Among young people, about one in three females and one in five males report experiencing emotional distress but 65–95% of them do not receive help from health professionals.Aim
To assess the differences among young people who seek help and those who do not seek help for their psychological problems, considering the frequency of consultations to their GP and their social resources.Design of study
School survey.Setting
Post-mandatory school.Method
Among a Swiss national representative sample of 7429 students and apprentices (45.6% females) aged 16–20 years, 1931 young people reported needing help for a problem of depression/sadness (26%) and were included in the study. They were divided into those who sought help (n = 256) and those who did not (n = 1675), and differences between them were assessed.Results
Only 13% of young people needing help for psychological problems consulted for that reason and this rate was positively associated with the frequency of consultations to the GP. However, 80% of young people who did not consult for psychological problems visited their GP at least once during the previous year. Being older or a student, having a higher depression score, or a history of suicide attempt were linked with a higher rate of help seeking. Moreover, confiding in adults positively influenced the rate of help seeking.Conclusion
The large majority of young people reporting psychological problems do not seek help, although they regularly consult their GP. While young people have difficulties in tackling issues about mental health, GPs could improve the situation by systematically inquiring about this issue. 相似文献7.
8.
Dekker F Neven AK Andriesse B Kernick D Ferrari MD Assendelft WJ 《The British journal of general practice》2012,62(597):e268-e274
Background
Despite the considerable impact of migraine, the use of preventive medication in primary care is limited. Only about 5% of migraine patients who qualify for prophylaxis actually receive it, and adherence is far from optimal.Aim
To explore the opinions of GPs regarding preventive medication for migraine.Design and setting
A qualitative focus group study in Dutch general practice.Method
Four focus groups (six GPs each) were formed. GPs were purposively sampled to acquire a range of participants, reflecting the more general GP population.Results
GPs perceived patients'' concerns about the impact of migraine and the potential benefits of prophylaxis. However, some were hesitant to start prescribing prophylaxis due to doubts about effectiveness, potential side effects, and the risk of developing drug dependency. GPs'' decisions were often based on considerations other than those presented in national guidelines, for example, the patient''s need to control their own problem. Many GPs placed responsibility for initiating prophylaxis with the patient.Conclusion
Various considerations hamper GPs from managing migraine with preventive medication, and various patient-related concerns cause GPs to deviate from national headache guidelines. 相似文献9.
Mette B Larsen Rikke P Hansen Frede Olesen Peter Vedsted 《The British journal of general practice》2011,61(586):e215-e222
Background
General practice plays an important role in the cancer care pathway. The initial diagnostic phase may be crucial for the relationship between the patient and the GP.Aim
The aim was to describe whether patients'' confidence in their GP changed after a cancer diagnosis, and analyse whether the change in confidence was associated with doctor delay.Design and setting
Population-based cohort study with 1892 questionnaires sent to patients and their GPs in general practices in the former Aarhus County, Denmark.Method
Information on patients'' confidence in their GP was obtained from the patient questionnaire. Information on doctor delay was obtained from the GPs and defined as a period of 14 days or more from the date of first symptom presentation to the GP until cancer-specific investigation was initiated.Results
Before the cancer diagnosis, 88.4% of the patients had confidence in their GP, which decreased to 80.0% after the diagnosis (P<0.001); 15.8% of the patients who experienced no doctor delay reported a decrease in confidence after the cancer diagnosis, compared with 29.1% of the patients with a doctor delay (P<0.001). Patients presenting with alarm symptoms and experiencing doctor delay were 3.8 times more likely to lose confidence compared with those presenting with alarm symptoms who experienced no doctor delay (P = 0.048).Conclusion
The majority of the patients had high levels of confidence in their GP before, as well as after, the cancer diagnosis. Nevertheless, a substantial amount had low confidence in the GP, especially when experiencing doctor delay in the initial phase of the pathway. 相似文献10.
Mette A Neergaard Peter Vedsted Frede Olesen Ineta Sokolowski Anders B Jensen Jens S?ndergaard 《The British journal of general practice》2009,59(566):671-677
Background
Most cancer patients die at institutions despite their wish for home death. GP-related factors may be crucial in attaining home death.Aim
To describe cancer patients in palliative care at home and examine associations between home death and GP involvement in the palliative pathway.Design of study
Population-based, combined register and questionnaire study.Setting
Aarhus County, Denmark.Method
Patient-specific questionnaires were sent to GPs of 599 cancer patients who died during a 9-month period in 2006. The 333 cases that were included comprised information on sociodemography and GP-related issues; for example knowledge of the patient, unplanned home visits, GPs providing their private phone number, and contact with relatives. Register data were collected on patients'' age, sex, cancer diagnosis, place of death, and number of GP home visits. Associations with home death were analysed in a multivariable regression model with prevalence ratios (PR) as a measure of association.Results
There was a strong association between facilitating home death and GPs making home visits (PR = 4.3, 95% confidence interval [CI] = 1.2 to 14.9) and involvement of community nurses (PR = 1.4, 95% CI = 1.0 to 1.9). No other GP-related variables were statistically significantly associated with home death.Conclusion
Active involvement of GPs providing home visits and the use of home nurses were independently associated with a higher likelihood of facilitating home death for cancer patients. The primary care team may facilitate home death, accommodating patients'' wishes. Future research should examine the precise mechanisms of their involvement. 相似文献11.
Tania Winzenberg Pam Reid Kelly Shaw 《The British journal of general practice》2009,59(568):e359-e367
Background
GPs comply poorly to public health recommendations to routinely assess their patients'' physical activity. The reasons for this disconnect between recommended practice and GPs'' actual practice are unclear.Aim
To investigate GPs'' perceptions of assessing physical activity, and to explore how GPs assess their patients'' physical activity.Design of the study
Qualitative study.Setting
General practice.Method
Semi-structured interviews were performed with 15 randomly selected southern Tasmanian GPs, with stratification to include GPs with a range of demographic characteristics. Each interview was recorded, transcribed in full, and analysed using an iterative thematic approach to identify major themes.Results
GPs recognised the importance of assessing physical activity, but rather than assessing every patient, they target at-risk patients and those with conditions likely to benefit from increased physical activity. Depth of assessment and GPs'' definition of sufficient physical activity varied according to the clinical and social context of each patient. Major barriers were the time needed to perform an adequate assessment and lack of time to deal with physical inactivity in patients once it was identified.Conclusion
GPs'' assessment of physical activity is a complex and highly individualised process that cannot be divorced from the issue of managing physical inactivity once it is identified. Expectations that GPs will assess physical activity levels in all their patients are unlikely to be met. This must be taken into account when developing strategies to improve physical activity assessment in general practice, and should be considered in policy decisions about approaches to take to improve physical activity levels at a population level. 相似文献12.
Samuel William David Merriel Christopher Salisbury Chris Metcalfe Matthew Ridd 《The British journal of general practice》2015,65(637):e545-e551
Background
Patient–doctor continuity is valued by both parties, yet the effect of the depth of the patient–doctor relationship on the content of consultations in general practice is unknown.Aim
To assess whether differences in the depth of relationship between a patient and their GP affects the length of consultations, and the number and type of problems and issues raised during a consultation.Design and setting
Cross-sectional study in 22 GP practices in the UK.Method
GP consultations (n = 229) were videotaped and the number of problems and aspects of those problems and issues identified. Patients completed the Patient–Doctor Depth of Relationship (PDDR) and General Practice Assessment Questionnaire-communication (GPAQc) scales. Associations were explored using multivariable linear and logistic regression.Results
Complete data were available on 190 participants consulting 30 GPs. In unadjusted analysis, patients with a deep relationship with their GP discussed more problems (mean 2.8) and issues (mean 4.7) compared with those with a moderate (2.4 problems; 4.0 issues) or shallow (2.3 problems; 3.8 issues) relationship. Patients with deep relationships had consultations that were on average 118 seconds (95% CI = 1 to 236) longer than those with shallow relationships. Adjustment for participant and GP factors attenuated these relationships, although the main trends persisted.Conclusion
A greater number of problems and issues may be raised in a consultation when patients have a deeper relationship with their GP. Over several clinical encounters each year, this may be associated with significant benefits to patients and efficiencies in GP consultations and warrants further investigation. 相似文献13.
14.
Background
Camera phones have become ubiquitous in the digital age. Patients are beginning to bring images recorded on their mobile phones to share with their GP during medical consultations.Aim
To explore GP perceptions about the effect of patient-initiated camera phone images on the consultation.Design and setting
An interview study of GPs based in rural and urban locations in Australia.Methods
Semi-structured telephone interviews with nine GPs about their experiences with patient-initiated camera phone images.Results
GPs described how patient-initiated camera phone photos and videos contributed to the diagnostic process, management and continuity of care. These images gave GPs in the study additional insight into the patient’s world. Potential harm resulting from inappropriate use of camera phones by patients was also identified.Conclusion
Patient-initiated camera phone images can empower patients by illustrating their narratives, thus contributing to improved communication in general practice. Potential harm could result from inappropriate use of these images. GPs shown images on patients’ camera phones should make the most of this opportunity for improved understanding of the patient’s world. There are however, potential medicolegal implications such as informed consent, protection of patient and doctor privacy, and the risk of misdiagnosis. 相似文献15.
Background
A bill to legalise assisted dying in the UK has been proposed in Parliament''s House of Lords three times since 2003. The House of Lords Select Committee concluded in 2005 that ‘the few attempts to understand the basis of doctors'' views have shown equivocal data varying over time’. Fresh research was recommended to gain a fuller understanding of health sector views.Aim
To examine GPs'' views of the practice of physician-assisted suicide as defined by the 2005/2006 House of Lords (Joffe) Bill and views of their role in the proposed legislation; and to explore the influences determining GPs'' views on physician-assisted suicide.Design of study
Qualitative interview study.Setting
Primary care in South London, England.Method
Semi-structured interviews with GPs were conducted by a lead interviewer and analysed in a search for themes, using the framework approach.Results
Thirteen GPs were interviewed. GPs who had not personally witnessed terminal suffering that could justify assisted dying were against the legislation. Some GPs felt their personal religious views, which regarded assisted dying as morally wrong, could not be the basis of a generalisable medical ethic for others. GPs who had witnessed a person''s suffering that, in their opinion, justified physician-assisted suicide were in favour of legislative change. Some GPs felt a specialist referral pathway to provide assisted dying would help to ensure proper standards were met.Conclusion
GPs'' views on physician-assisted suicide ranged from support to opposition, depending principally on their interpretation of their experience of patients'' suffering at the end of life. The goal to lessen suffering of the terminally ill, and apprehensions about patients being harmed, were common to both groups. Respect for autonomy and the right of self-determination versus the need to protect vulnerable people from the potential for harm from social coercion were the dominant themes. 相似文献16.
17.
Anna Sallis Richard Birkin Fehmidah Munir 《The British journal of general practice》2010,60(573):245-250
Background
The Department for Work and Pensions (DWP) has designed a trial medical statement.Aim
To compare fitness for work assessment outcomes and written advice across current and trial medical statements. To examine the use of and suggestions to improve the trial medical statement.Design of study
Comparative study with a two-way mixed design using questionnaire-based vignettes presenting GPs with three hypothetical sick leave cases (back pain, depression, combined back pain and depression) and medical statements (current or trial). The questionnaire also gathered GP views of using the trial Med 3.Setting
Nine primary care organisations (PCOs) in England, Scotland, and Wales.Method
Five hundred and eighty-three GPs employed in PCOs in summer 2008 were randomised to receive a current or trial Med 3 postal questionnaire. GPs assessed vignette patients'' fitness for work using the questionnaire medical statements.Results
GPs using the trial Med 3 were less likely to advise refraining from work and more likely to provide written fitness for work advice compared to GPs using the current Med 3 form. Date sections of the trial Med 3 were used inconsistently, and a return to work date was unclear. GPs wanted further clarification of the implications of assessing a case as ‘fit for some work’ and its relationship to employers'' willingness to follow GP advice about work.Conclusion
The study indicates a revised form may reduce the number of patients advised to refrain from work and increase the provision of written fitness for work information. 相似文献18.
Jenny C Ingram Michael W Calnan Rosemary J Greenwood Terry Kemple Sarah Payne Michael Rossdale 《The British journal of general practice》2009,59(558):e16-e24
Background
Emergency admissions to hospital at night and weekends are distressing for patients and disruptive for hospitals. Many of these admissions result from referrals from GP out-of-hours (OOH) providers.Aim
To compare rates of referral to hospital for doctors working OOH before and after the new general medical services contract was introduced in Bristol in 2005; to explore the attitudes of GPs to referral to hospital OOH; and to develop an understanding of the factors that influence GPs when they refer patients to hospital.Design of study
Cross-sectional comparison of admission rates; postal survey.Setting
Three OOH providers in south-west England.Method
Referral rates were compared for 234 GPs working OOH, and questionnaires explored their attitudes to risk.Results
There was no change in referral rates after the change in contract or in the greater than fourfold variation between those with the lowest and highest referral rates found previously. Female GPs made fewer home visits and had a higher referral rate for patients seen at home. One-hundred and fifty GPs responded to the survey. Logistic regression of three combined survey risk items, sex, and place of visit showed that GPs with low ‘tolerance of risk’ scores were more likely to be high referrers to hospital (P<0.001).Conclusion
GPs'' threshold of risk is important for explaining variations in referral to hospital. 相似文献19.
Catherine A O'Donnell Maria Higgins Rohan Chauhan Kenneth Mullen 《The British journal of general practice》2008,58(557):e1-e11
Background
The UK has substantial minority populations of short-term and long-term migrants from countries with various types of healthcare systems.Aim
This study explored how migrants'' previous knowledge and experience of health care influences their current expectations of health care in a system relying on clinical generalists performing a gatekeeping role.Design of study
Two qualitative methods.Setting
Glasgow, UK.Method
Focus groups or semi-structured interviews were conducted with 52 asylum seekers. Analyses identified several areas where previous experience affected current expectations. An overview of health systems in each country of origin was established by combining responders'' accounts with World Health Organization statistics.Results
Asylum seekers had previous experience of a diverse range of healthcare systems, most of which were characterised by a lack of GPs and direct access to hospital-based specialists. For some responders, war or internal conflict resulted in a complete breakdown of healthcare systems. Responders'' accounts also highlighted the difficulties that marginalised groups had in accessing health care. Although asylum seekers were generally pleased with the care they received from the NHS, there were areas where they experienced difficulties: confidence in their GP and access to hospital-based specialists and medication. These difficulties encountered might be explained by previous experience.Conclusion
GPs and other healthcare professionals need to be aware that experience of different systems of care can have an impact on individuals'' expectations in a GPled system. If these are not acknowledged and addressed, a lack of confidence and trust in the GP may undermine the effectiveness of the clinical consultation. 相似文献20.
Sanjiv Ahluwalia Elizabeth Murray Fiona Stevenson Cicely Kerr Jo Burns 《The British journal of general practice》2010,60(571):88-94