GPs’ perspectives of the patient encounter – in the context of standardized cancer patient pathways

Objective: We aim to explore how GPs assign meanings and act upon patients’ symptoms in primary care encounters in the context of standardized cancer patient pathways (CPPs).Design, setting and subjects: Thirteen individual interviews were conducted with GPs, at primary healthcare centers (n = 4) in one county in northern Sweden. Interviews were analyzed using grounded theory method. The results were then linked to symbolic interactionism.Main outcome measures: GPs’ perspectives about assigning meanings to patients’ presented symptoms and perception about CPPs.Results: In the encounter, GPs engaged in two simultaneous interactions, one with patients’ symptoms – and the other with CPPs. The core category Disentangling patients’ care trajectory consists of three categories, interpreted as GPs’ strategies developed to assign meaning to symptoms. These strategies are carried out not in a straightforward manner but rather in a conflicting way, illuminating the complexity of GPs’ daily work.Conclusions: Interacting with patients is vital for assigning meaning to presented symptoms. However, nowadays GPs are not only required to interact with patients, they are also required to interact with CPPs. These standardized routines might create pressure and demands on GPs, especially for those experiencing a lack of information about CPPs. Beside of carrying out the challenging patient/person-centered dialogues and interpreting presented symptoms, GPs also need to link the interpreted symptoms to CPPs. Therefore, it is essential that GPs are given opportunities at their workplaces to continuously be informed and be supported in order to practice CPPs and thereby optimize trajectories for patients undergoing cancer diagnostics.

Key points

•  Current awareness:
•  • GPs deliberation about patients’ trajectories is a complex process, often dealing with vague symptoms. How CPPs influence this process within the encounter has not been studied.
•  Main statements:  • GPs in our study were involved in two simultaneous interactions, one with patients’ symptoms in the encounter – and the other with CPPs within the healthcare organization.
•  • Symbolic interactionism helped capture how GPs deliberated about conflicting and paradoxical aspects of the encounter, in terms of balancing two contradictory ways of action that GPs face when providing patient/person-centered care and linking to CPPs.
•  • Based on our results, primary care needs support from healthcare organizations to build capacity about CPPs and how to use them.

     

‘Never change a winning team’: GPs’ perspectives on discontinuation of long-term antidepressants

BackgroundLong-term antidepressant use, much longer than recommended by guidelines, can harm patients and generate unnecessary costs. Most antidepressants are prescribed by general practitioners (GPs) but it remains unclear why they do not discontinue long-term use.AimTo explore GPs’ views and experiences of discontinuing long-term antidepressants, barriers and facilitators of discontinuation and required support.Design and settingQualitative study in Belgian GPs.Method20 semi-structured face-to-face interviews with GPs. Interviews were analysed thematically.ResultsThe first theme, ‘Success stories’ describes three strong motivators to discontinue antidepressants: patient health issues, patient requests and a new positive life event. Second, not all GPs consider long-term antidepressant use a ‘problem’ as they perceive antidepressants as effective and safe. GPs’ main concern is the risk of relapse. Third, GPs foresee that discontinuation of antidepressants is not an easy and straightforward process. GPs weigh up whether they have the necessary skills and whether it is worth the effort to start this process.ConclusionDiscontinuation of long-term antidepressants is a difficult and uncertain process for GPs, especially in the absence of a facilitating life-event or patient demand. The absence of a compelling need for discontinuation and fear of relapse of symptoms in a stable patient are important barriers for GPs when considering discontinuation. In order to increase GPs’ motivation to discontinue long-term antidepressants, more emphasis on the futility of the actual effect and on potential harms related to long-term use is needed.

KEY POINTS

• Current awareness:
  • Long-term antidepressant use, much longer than recommended by guidelines, can harm patients and generate unnecessary costs.
• Main statements:
•  • Discontinuation of long-term antidepressants is a difficult and uncertain process for GPs.
•  • More emphasis on the futility of the actual effect of antidepressants and on potential harms related to long-term use is needed.

     

Not just an information-delivery tool. An ethnographic study exploring Danish GPs’ perspectives on and experiences with the relational potential of email consultation

Objective To explore GPs’ perspectives on and daily experiences with the relational potential of email consultations.Design Qualitative study with data from participant observation and semi-structured interviewsSetting General practice setting in DenmarkSubjects Practice personnel from four clinics were observed and 16 GPs (seven women and nine men, between 35 and 70 years of age) interviewed. Field notes and interview data were analysed using an inductive thematic analysis approach.Main outcome measures Main themes and subthemes reporting GPs’ perspectives on and experiences with the relational potential of email consultations.Results The analyses showed that due to perceived interpretational shortcomings, the GPs generally experienced email consultation as unsuitable for communication about relational, socio-emotional and sensitive matters. In doctor–patient relationships founded on mutual knowledge and trust, the email consultation was however used as a supportive communication channel, as a way for the patient to express emotions and affect and for the GP to proactively show interest and compassion towards the patient.Conclusion Email consultations were highly context-variant. Within continuing relationships and in conjunction with face-to-face consultations, email consultation was used for supportive communication holding the potential for maintaining, strengthening and/or dissolving the GP-patient relationship. Therefore, email consultation is not simply an information-delivery tool but also holds more explicit relational potentials.

KEY POINTS

• Overall, the GPs perceived email consultation as unsuitable for non-medical, relationship-oriented purposes.
• Nonetheless, the GPs experienced that email consultations oftentimes comprised communication about relational and socio-emotional issues.
• Knowledge of the patient was a vital factor for the GP’s comfort in and acceptability of relational functions of email consultation.
• Email consultation is not simply an information-delivery tool as it holds the potential for maintaining, strengthening and/or dissolving the GP-patient relationship.

     

GPs’ suspicion of child abuse: how does it arise and what is the follow-up?

Background: Child abuse is widespread, occurs in all cultures and communities, remains undiscovered in 90% of cases and has serious long-term effects. Physicians generally underidentify and underreport child abuse. To understand this low reporting rate and how the suspicion of child abuse arises, we examined GPs’ experiences.Research questions: How does the suspicion of child abuse arise in GPs’ diagnostic reasoning? How do they act upon their suspicion and which barriers do they encounter in their management?Methods: Twenty-six GPs participated in four focus groups. We used purposive sampling to include GPs with different levels of experience. We performed a thematic content analysis.Results: Suspicion of child abuse arose from common triggers and a gut feeling that ‘something is wrong here’. GPs acted upon their suspicion by gathering more data, through history taking and physical examination. They often found it difficult to decide whether a child was abused, because parents, despite good intentions, may simply lack parenting skills and have different values. Clear signs of sexual abuse and physical violence were institutionally reported by GPs, whereas in less clear-cut cases they followed them up and built a supporting network of professionals around the family.Conclusions: A low child abuse reporting rate by GPs to CACRC does not mean a low detection rate. In trying to improve a child’s situation, GPs make use of patients’ trust in their doctor by involving other professionals. Awareness of the role of gut feelings in developing a suspicion may increase early detection and preventive actions.

Key points

• Physicians generally underidentify and underreport child abuse.
• Suspicion of child abuse arose from common triggers and a gut feeling that ‘something is wrong here’.
• GPs acted upon their suspicion by gathering more data, through history taking and physical examination.
• GPs found it difficult to decide whether a child was abused, because parents, despite good intentions, may lack parenting skills.

     

GP and patient predictions of sick-listing duration: How well do they correspond? A prospective observational study

Objective. To explore how well physicians and patients predict sick-listing duration and the correspondence between their respective predictions. To study possible gender differences concerning prediction accuracy. Design. Prospective observational study. Setting. Two medium-sized primary care centres (PCC) in western Sweden. Subjects. GPs at the PCCs and attending patients sick-listed for > 14 days. Main outcome measures. Sick-listing duration; patients’ and GPs’ predictions of the total duration of the individual patient''s sick-listing. Results. A total of 127 patients (93 women, 34 men, mean age 45 years) and 10 GPs participated in the study. Neither the GPs nor the patients were able to predict the interval until return to work with high accuracy. The GPs’ and the patients’ perceptions concurred in only 26% of cases. There was a significant difference in the correspondence between the GPs’ and patients’ respective predictions of sick-listing duration compared with the actual duration. GPs’ predictions were more accurate for medium-length duration (1.5–6 months), while patients’ predictions were more accurate for long-duration (> 6 months) sick-listing. Patients with less education predicted long duration of sick-listing more accurately than those with more education. There was no significant difference between male and female patients’ accuracy of prediction, or between GPs’ accuracy of prediction of male vs. female patients’ sick-listing duration. Conclusions. Prediction of total sick-listing duration was hard for both GP and patient; their respective predictions corresponded in only one-quarter of the cases. No gender differences were observed in the accuracy of prediction.Key Words: General practice, prediction, primary care, sickness absence, sickness certification, sick-listing, SwedenSick-listing is frequent and costly, and often experienced as problematic for the physician. It is difficult to predict the duration of sick-listing.

• General practitioners (GPs) and patients corresponded in one-quarter of cases concerning the prediction of total duration of sick-listing.
• Patients more often accurately predicted sick-listing duration than GPs.
• Less educated patients predicted sick-listing duration, in particular longer periods, more accurately than more educated patients, when both groups were compared with GPs’ prediction.

     

How to learn skilled communication in primary care MUS consultations: a focus group study

BackgroundMany general practitioners (GPs) experience communication problems in medically unexplained symptoms (MUS) consultations as they are insufficiently equipped with adequate communication skills or do not apply these in MUS consultations.ObjectiveTo define the most important learnable communication elements during MUS consultations according to MUS patients, GPs, MUS experts and teachers and to explore how these elements should be taught to GPs and GP trainees.MethodsFive focus groups were conducted with homogeneous groups of MUS patients, GPs, MUS experts and teachers. MUS patients and GPs formulated a list of important communication elements. MUS experts identified from this list the most important communication elements. Teachers explored how these elements could be trained to GPs and GP trainees. Two researchers independently analysed the data applying the principles of constant comparative analysis.ResultsMUS patients and GPs identified a list of important communication elements. From this list, MUS experts selected five important communication elements: (1) thorough somatic and psychosocial exploration, (2) communication with empathy, (3) creating a shared understanding of the problem, (4) providing a tangible explanation and (5) taking control. Teachers described three teaching methods for these communication elements: (1) awareness and reflection of GPs about their feelings towards MUS patients, (2) assessment of GPs’ individual needs and (3) training and supervision in daily practice.ConclusionTeachers consider a focus on personal attitudes and needs, which should be guided by opportunities to practice and receive supervision, as the best method to teach GPs about communication in MUS consultations.

KEY POINTS

• Many GPs experience difficulties in communication with patients with MUS.
• There is a need to equip GPs with communication skills to manage MUS consultations more adequately.
• Role-playing with simulation patients, reflection on video-consultations and joint consultations with the supervisor may increase the GPs’ awareness of their attitude towards MUS patients and may help GPs to identify their individual learning-points.

     

Physicians’ experiences of video consultation with patients at a public virtual primary care clinic: a qualitative interview study

ObjectiveTo describe physicians’ experiences of video consultation with new patients visiting a publicly owned virtual primary care clinic.DesignIn this qualitative study, data were collected from semi-structured individual interviews and analysed by systematic text condensation.SettingA publicly owned virtual primary care clinic in Region Västra Götaland, Sweden.SubjectsTen primary care physicians working at the clinic.ResultsConnecting with a patient over video could be either straightforward or deficient, depending on communication and the patient’s condition. Clinical experience, communication skills, and involving patients throughout the consultation and examination were crucial for assessments over video where patients were guided to perform self-examination. The flexibility of work and the regulated assignment online were positive for the physicians’ work situation and wellbeing. Providing video consultation within the same organisation as the patient’s regular health centre was considered to facilitate patient care and safety. Video consultation was considered suitable for some diagnoses and for some patients not able to reach a primary healthcare centre, though doubts were expressed about the healthcare and social benefits of this virtual care service.ConclusionFor the physicians, video consultation induced changes in the basis for assessment of primary care patients. The limitations on informational exchange demanded an extended form of patient involvement founded upon consultation skills, clinical experience and new skills for virtual examination. Combining virtual care with traditional general practice has the potential to reduce the workload for the individual physician and ensure medical competence in virtual primary care. Video consultation experienced suitable in some situations, but easy access to it expressed problematic in terms of medical prioritisation in healthcare.

KEY POINTS

• Video consultation is suitable for primary care visits for some patients, but physicians’ experiences of this are rarely studied.
• •Clinical experience and consultation skills are important for video assessment of primary care patients which involves physician-guided patient self-examination.
• •Video consultation facilitates care in some situations and could benefit from the provider being connected to patient’s regular health centre.
• •Virtual care offers a flexible way of working but challenges healthcare prioritisation from the primary care physician’s perspective.

     

GP strategies to avoid imaging overuse. A qualitative study in Norwegian general practice

ObjectivesThe aim of the study was to identify general practitioners’ (GPs) strategies to avoid unnecessary diagnostic imaging when encountering patients with such expectations and to explore how patients experience these strategies.Design, setting and subjectsWe conducted a qualitative study that combined observations of consultations and interviews with GPs and patients. A total of 24 patients visiting nine different GPs in two Norwegian urban areas were included in the study. Of these, 12 consultations were considered suitable for studying GP strategies and were therefore selected for a more thorough analysis.Main outcome measuresGPs’ communication strategies to avoid unnecessary medical imaging and patients’ experiences with such strategies.ResultsFive categories of strategies were identified: (1) wait and see – or suggest an alternative; (2) the art of rejection; (3) seek support from a professional authority; (4) partnership and shared decision-making and (5) reassurance, normalisation and recognition. The GPs often used multiple strategies. Factors related to a long-term doctor–patient relationship seemed to influence both communication and how both parties experienced the decision. Three important factors were evident: the patient trusted the doctor, the doctor knew the patient’s medical history and the doctor knew the patient as a person. The patients seemed to be generally satisfied with the outcomes of the consultations.ConclusionGPs largely combine different strategies when meeting patients’ expectations of diagnostic imaging that are not strictly medically indicated. Continuity of the doctor–patient relationship with good personal knowledge and trust between doctor and patient appeared crucial for patients to accept the doctors'' decisions.

Key points

• GPs usually combine a broad range of strategies to avoid unnecessary medical imaging
• The patients appeared generally satisfied regardless of the strategy the strategy used by the GPs and even where their referral request were rejected
• Factors related to a long-term doctor–patient relationship appeared decisive

     

To give the invisible child priority: Children as next of kin in general practice

Objective. To explore general practitioners’ (GPs’) experiences in helping children as next of kin of drug-addicted, mentally ill, or severely somatic ill adults. These children are at risk of long-term mental and somatic health problems. Design. Qualitative focus-group study. Setting. Focus-group interviews were conducted in western Norway with a total of 27 GPs. Participants were encouraged to share stories from clinical encounters with parents who had one of the above-mentioned problems and to discuss the GP''s role in relation to helping the patients’ children. Results. The GPs brought up many examples of how they could aid children as next of kin, including identifying children at risk, counselling the parents, and taking part in collaboration with other healthcare professionals and social workers. They also experienced some barriers in fulfilling their potential. There were time constraints, the GPs had their main focus on the patient present in a consultation, and the child was often outside the attention of the doctors, or the GPs could be afraid of hurting or losing their vulnerable patients, thus avoiding bringing up the patients’ children as a subject for discussion. Conclusions. Norwegian GPs are in a good position to help children as next of kin and doctors make a great effort to support many of them. Still, support of these children by GPs often seems to depend not on careful consideration of what is best for the patient and the child in the long run, but more on short-term convenience reasons.Key Words: Child of impaired parent, children as next of kin, disease prevention, family health, focus group, general practice, general practitioner, health promotion, Norway, qualitative researchChildren whose parents are suffering from mental health illness, substance abuse, or severe somatic disease are at risk of developing poor health and psychosocial problems. Meeting their special needs is important for health promotion and disease prevention.

• GPs are in a good position to identify children as next of kin, support parents in their parenting role, and take part in the multidisciplinary network.
• Lack of time and capacity problems are barriers for GPs in fulfilling this potential.
• GPs’ fear of jeopardizing the relationship with their patients represents an important barrier to introducing the children''s situation in consultations with the parents.

     

Should GPs ask patients about their financial concerns? Exploration through collaborative research

Objective: Health services should arguably be concerned about the financial situation of patients since health problems can cause financial concerns, which in turn can cause health problems. In this study, we explored the role of the general practitioner (GP) as a potential early discoverer of financial problems who can refer at-risk patients to financial counselling services.Design: A collaborative health service research experiment. For four weeks, GPs asked their patients predefined questions about financial concerns and health, by anonymous data mapping. GPs shared their experiences with the researchers after the experiment.Setting: One GP office in Norway.Subjects: A total of 565 patients were included in data mapping by 8 GPs.Main outcome measures: Patient prevalence data and GPs experimental data of patients’ health problems that caused financial concerns and financial concerns that affected patients’ health.Results: Of 565 GP patients, 11% (n = 63) indicated that they had health problems causing them financial concerns, or vice versa; 9% of patients reported health problems causing financial concerns and 8% of patients reported financial concerns that affected their health. Through the data mapping experiment GPs became aware of financial concerns of their patients and by this expanded and improved their therapeutic toolbox. Several months after the experiment the GPs reported that more patients received financial counselling since the GPs asked their patients about financial problems more often than before and because the patients had heard that GPs cared about such problems.Conclusion: Our results suggest that GPs can be early discoverers of financial problems interacting with their patients’ health. When there are no clear medical explanations for the health problems that prompted the consultation, the best therapy may thus be financial counselling.

Key points

• Many people live on the edge of financial ruin and struggle to keep track of their finances, but limited research exists that investigates associations between finance and health.
• In a collaborative health services research experiment 11% of the patients at a Norwegian GP office had health problems that caused them financial concerns, or vice versa.
• GPs found it helpful to ask patients about their financial concerns when no clear medical explanations for their health problems was found. Then free financial counselling services could be offered.

     

Danish general practitioners’ management of patients with COPD: a nationwide survey

Background In Denmark, general practitioners (GPs) have the main responsibility for chronic obstructive pulmonary disease (COPD) management. Internationally, COPD appears to be significantly under-treated, which could be explained by ‘therapeutic nihilism’ or lack of knowledge.Aim To investigate: (1) To what extent COPD management provided by GPs includes the core elements of pharmacological treatment, smoking cessation and physical activity, and (2) To what extent GPs need educational support and consulting with a specialist in pulmonary medicine.Design A national cross-sectional web-based survey conducted in April–June 2019. The survey included items on COPD management and educational support needs.Setting Danish general practice.Subjects A population of approximately 3400 GPs (all GPs in Denmark).Results We received response from 470 GPs (14% response rate). Overall, the respondents reported that they offered COPD management including all relevant treatment elements. Smoking cessation was supported in 58% and physical activity was supported in 23% of the respondents. Future consultations on smoking cessation were planned by 35% and physical activity by 15% respondents. GPs responded to ‘needing educational support in COPD management’ to a ‘high degree’ in 8% and to ‘some degree’ in 43%.Conclusion The survey suggested that COPD maintenance support provided by GPs seemed to be inadequate regarding smoking cessation and physical activity. Moreover, some GPs expressed a need for educational support in COPD management. More research is needed to understand the potential barriers to evidence-based delivery of COPD-management.

Key points

• In Denmark, general practitioners (GPs) have the main responsibility for the management of chronic obstructive pulmonary disease (COPD).
• The present study shows that non-pharmacological interventions such as supporting smoking cessation and particularly promoting physical activity received less attention than pharmacological treatment.
• The study suggests a need for educational support of the GPs in COPD management.

     

Selection bias in general practice research: analysis in a cohort of pregnant Danish women

ObjectiveThe aim of the present study was to examine selection in a general practice-based pregnancy cohort.DesignSurvey linked to administrative register data.Setting and subjectsIn spring 2015, GPs were recruited from two Danish regions. They were asked to invite all pregnant women in their practice who had their first prenatal care visit before 15 August 2016 to participate in the survey.Outcome measuresThe characteristics of GPs and the pregnant women were compared at each step in the recruitment process – the GP’s invitation, their agreement to participate, actual GP participation, and the women’s participation – with an uncertainty coefficient to quantify the step where the largest selection occurs.ResultsSignificant differences were found between participating and non-participating practices with regards to practice characteristics such as the number of patients registered with the practice, the age and sex of doctors, and the type of practice. Despite these differences, the characteristics of the eligible patients differed little between participating and non-participating practices. In participating practices significant differences were, however, observed between recruited and non-recruited patients.ConclusionThe skewed selection of patients was mainly caused by a high number of non-participants within practices that actively took part in the study. We recommend that a focus on the sampling within participating practices be the most important factor in representative sampling of patient populations in general practice.

Key points

• Selection among general practitioners (GPs) is often unavoidable in practice-based studies, and we found significant differences between participating and non-participating practices. These include practice characteristics such as the number of GPs, the number of patients registered with the GP practice, as well as the sex and age of the GPs.
• •Despite this, only small differences in the characteristics of the eligible patients were observed between participating and non-participating practices.
• •In participating practices, however, significant differences were observed between recruited and non-recruited patients.
• •Comprehensive sampling within participating practices may be the best way to generate representative samples of patients.

     

General practitioners’ self-reported competence in the management of sexual health issues – a web-based questionnaire study from Finland

Objective Although sexual problems are common, they are rarely brought up in appointments with general practitioners (GPs). We aimed to assess the barriers that hinder GPs from bringing up sexual health issues and to evaluate the need for education on sexual medicine. Design A web-based questionnaire was used. Setting Four fields were included: A) the self-reported competence in discussing sexual health and treating patients with these issues, B) the barriers to bringing up patients’ sexual health problems, C) the source of education on sexual medicine and D) the need for education on sexual medicine. Subjects A random sample of 1000 GPs in Finland (a response rate of 43.5%, n = 402). Main outcome measures GPs’ self-assessed competence in discussing and treating sexual health issues, related barriers to bringing up the topic and the reported need for education. Results The main reasons reported for not bringing up sexual health issues were shortness of the appointment time (85.6%), a lack of knowledge (83.6%) and a lack of experience with sexual medicine (81.8%). The male GPs reported better competence in discussing the issues and treating male patients, whereas the female GPs reported better competence in discussing the issues with female patients. No differences emerged between genders regarding treating female patients. Nearly 90% of the GPs expressed needing more education about sexual medicine. Conclusions Although the GPs reported good competence in discussing sexual health issues with their patients, several barriers to bringing up sexual health issues emerged. Continuing education was desired and could lessen these barriers.

Key points

• Only a few studies have evaluated the competence of general practitioners (GPs) in addressing sexual health issues with their patients.
• In our study, the GPs reported a high competence in discussing patients’ sexual health issues regardless of the patient’s gender.
• However, several barriers to bringing up sexual health issues in appointments emerged.
• A majority of the GPs expressed a need for continuing education about sexual medicine.

     

Why do doctors in Norway choose general practice and remain there? A qualitative study about motivational experiences

Objective: To explore experiences motivating doctors to become and remain GPs.Design and contributors: Qualitative analysis of written responses from an open-ended question about motivational experiences posted on an internet discussion list for GPs in Norway. Texts from 25 contributors were analysed with Systematic Text Condensation, supported by theories about calling as motivation.Results: Analysis revealed numerous aspects of motivation to become and remain a general practitioner. Inspirations from early experiences and skilled role models had conveyed values and offered insight into a fascinating world of care, gratitude and respect. Close and continuous relationships with patients provided GPs with humbling experiences and learning moments. Contributors described how these encounters became rewarding sources of insight and mutual trust, improving interpersonal skills. Also, the extensive variety of tasks during the workday and the space for autonomy and independence was emphasised.Implications: Understanding motivational experiences influencing GPs’ choice of medical career is necessary to develop strategies for recruitment and stability and contribute to prevention of burn-out and improper work-life balance. GPs’ professional identities and commitments should be recognized and developed in dialogues between authorities and GPs to enhance communication, improve the structural frames of work environment and thereby sustainable recruitment.

Key points

• GPs regard their choice of medical career as strongly influenced by motivational experiences in childhood, adolescence and as medical students
• Role models, diversity of work, feelings of being able to contribute and rewarding and continuous relationships with patients were mentioned to activate and maintain general practice commitment
• Knowledge about motivational influences, professional identities and commitment for GPs is crucial for medical education and dialogue to promote general practice as a career choice and prevent dangers of work overload and burnout

     

Knowledge of and support for cancer patient pathways among general practitioners and other physicians – a study from Sweden

ObjectiveTo investigate the expertise in and support of the implemented new method of cancer patient pathways (CPPs) among general practitioners (GPs) and other working physicians in Sweden.DesignA survey in the form of 10 knowledge-based multiple-choice questions (MCQs) and two general questions about CPPs.SettingPhysicians from two different regions in Sweden answered the survey between December 2018 and January 2019.SubjectsGPs in primary care compared to other physicians. 155 participants completed the survey and the response rate was 65%.Main outcome measuresPhysicians’ self-estimated knowledge of CPPs in general and opinion of CPPs effect on mortality and morbidity. Their scores on 10 different MCQs. Scores were analysed in subgroups related to the physicians medical specialty and experience.ResultsA majority of all physicians (63%) felt that they had insufficient knowledge regarding the procedure of CPPs, and the average score from the MCQs was 3.8 out of 10 correct answers. The results showed that GPs performed significantly better than specialists from other disciplines.ConclusionsThe low percentage of correctly answered MCQs shows that the information about the entry part of CPPs needs to be improved. The study demonstrates a support for the system with CPPs because the physicians believed in its’ positive effects on morbidity and mortality, however, it also reveals a lack of self-estimated knowledge about the system with CPPs.

Key points

• Cancer patient pathways (CPPs) is a newly implemented method in Sweden that aims to equalize cancer care and reduce the time to diagnosis and treatment.
• The proficiency of when to initiate an investigation according to a specific CPP seems low. General practitioners (GPs) performed significantly better on knowledge-based questions than other specialists did.
• Physicians rated their knowledge as insufficient regarding the procedure of CPPs.
• A clear majority of physicians believed that CPPs promotes a lower mortality and morbidity in cancer.

     

Women’s experience with receiving advice on diet and Self-Monitoring of blood glucose for gestational diabetes mellitus: a qualitative study

ObjectiveWe aimed to explore how women with gestational diabetes mellitus (GDM) experience advice about diet and self-monitoring of blood glucose received in primary health care (PHC) and secondary health care (SHC) with a focus on how women perceived the care coordination and collaboration between healthcare professionals.Design, setting and subjectsIndividual interviews were conducted with 12 pregnant women diagnosed with GDM. Six women had immigrant backgrounds, and six were ethnic Norwegian. Women received GDM care in the area of Oslo, Norway. Interviews were analysed using thematic analysis.ResultsWomen described feeling shocked when they were diagnosed with GDM and feeling an immediate need for information about the consequences and management of GDM. Most of the women felt that their general practitioner (GP) had too little knowledge about GDM. Women with an immigrant background felt that the PHC midwives provided them with sufficient dietary advice related to GDM. Ethnic Norwegian women appreciated receiving more individually tailored dietary advice in SHC. Self-monitoring of blood glucose influenced women’s daily lives; however, they perceived the training in PHC and SHC as adequate. The women experienced poor collaboration between healthcare professionals in PHC and SHC, which implied that they sometimes had to initiate follow-up steps in their GDM care by themselves.ConclusionsIdeally, women diagnosed with GDM should meet healthcare professionals with sufficient knowledge about GDM as soon as possible after being diagnosed. The collaboration between healthcare professionals involved in the care of women with GDM should be improved to avoid having women feel that they need to coordinate their own care.

KEY POINTS

• Current awareness
• •The management of gestational diabetes mellitus requires appropriate follow-up by healthcare professionals
• Main statements
• •Pregnant women’s need for information about the consequences and management of gestational diabetes mellitus was highest immediately after diagnosis
• •Women perceived that they received more individually tailored information about diet and self-monitoring of blood glucose in secondary health care compared to primary health care
• •Women felt that general practitioners had insufficient knowledge about gestational diabetes mellitus
• •Based on our results, care coordination and collaboration between healthcare professionals involved in the care of women with gestational diabetes mellitus should be improved

     

Point-of-care ultrasound (POCUS) in Norwegian general practice

Objective: To assess the use of point-of-care ultrasound (POCUS) in Norwegian general practice.Design: Retrospective register study based on general practitioners’ (GPs’) reimbursement claims.Setting: Norwegian general practice excluding out-of-hours clinics in 2009, 2012 and 2016.Subjects: GPs who scanned patients for a given set of symptoms and medical conditions.Main outcome measures: Number and characteristics of GPs performing POCUS. Number and type of scans carried out.Results: The number of scanning GPs increased from 479 in 2009 to 2078 in 2016. The number of registered scans increased from 8962 to 55921. In 2016, approximately 30% of Norwegian GPs sent at least one reimbursement claim for POCUS. Seven out of 10 GPs did not scan every month. The gender distribution of scanning GPs was equal to that of the total GP population. Male GPs scanned four times more frequent than female GPs. Specialist in family medicine scanned twice as much as non-specialist. The use of POCUS among GPs in different counties varied from 31.6 to 198.5 per 10,000 citizens.Conclusions: The number of Norwegian GPs using POCUS and the number of scans have increased substantially from 2009 to 2016. The use of the various scans, based on the use of reimbursement claims, have evolved differently. The reasons for this are not known. The low number of scans carried out by most GPs raises a concern when it comes to the quality of the performed scans.

KEY POINTS

• 30% of Norwegian general practitioners (GPs) used point-of-care ultrasound (POCUS) in 2016.
• The use of POCUS increased six-fold from 2009 to 2016.
• Three out of four scanning GPs performed less than 10 scans annually.
• Male GPs performed 80% of the claimed scans.

     

General practitioners’ perspectives on campaigns to promote rapid help-seeking behaviour at the onset of rheumatoid arthritis

Objective. To explore general practitioners’ (GPs’) perspectives on public health campaigns to encourage people with the early symptoms of rheumatoid arthritis (RA) to seek medical help rapidly. Design. Nineteen GPs participated in four semi-structured focus groups. Focus groups were audio-recorded, transcribed verbatim, and analysed using thematic analysis. Results. GPs recognised the need for the early treatment of RA and identified that facilitating appropriate access to care was important. However, not all held the view that a delay in help seeking was a clinically significant issue. Furthermore, many were concerned that the early symptoms of RA were often non-specific, and that current knowledge about the nature of symptoms at disease onset was inadequate to inform the content of a help-seeking campaign. They argued that a campaign might not be able to specifically target those who need to present urgently. Poorly designed campaigns were suggested to have a negative impact on GPs’ workloads, and would “clog up” the referral pathway for genuine cases of RA. Conclusions. GPs were supportive of strategies to improve access to Rheumatological care and increase public awareness of RA symptoms. However, they have identified important issues that need to be considered in developing a public health campaign that forms part of an overall strategy to reduce time to treatment for patients with new onset RA. This study highlights the value of gaining GPs’ perspectives before launching health promotion campaigns.Key Words: General practice, general practitioner, health promotion, primary care, qualitative, rheumatoid arthritis, seeking help, United Kingdom

• Campaigns to encourage prompt help-seeking behaviour at rheumatoid arthritis (RA) onset are vital to ensure early treatment.
• This study explored general practitioners’ (GPs’) perspectives on the impact of public health campaigns on primary care services.
• GPs were concerned that poorly constructed campaigns unduly worried the public and pressurised primary care services and referral pathways.
• GPs described poor understandings of early RA symptoms, highlighting the need to strengthen the evidence base in this respect to inform campaigns.

     

Experiences and views of Dutch general practitioners regarding physician-assisted death for patients suffering from severe mental illness: a mixed methods approach

BackgroundIn the Netherlands, physician-assisted death (PAD) is allowed under certain conditions. Patients who suffer from mental illnesses are not excluded from this practice. In 2018, general practitioners (GPs) performed 20 out of a total of 67 cases of EAS for psychiatric sufferingObjectiveMore insight into GPs’ experiences and views with regard to PAD in psychiatry.DesignThe data for this study were obtained through a survey amongst 500 randomly selected Dutch GPs and by in-depth interviews with 20 Dutch GPs.SettingA survey study and in-depth interviews.SubjectsDutch GPs.Results86 out of 101 GPs found it conceivable to perform EAS in case of somatic disease, and 51 out of 104 GPs found it conceivable in the case a patient suffered from a mental illness only. The main reason given for refusing an PAD request was that the criteria of due care were not met. Reasons for supporting psychiatric PAD related to responsibility, self-determination, compassion, fairness, and preventing suicide. Reasons for not supporting psychiatric PAD were related to the scope of medicine, a perceived lack of experience, uncertainties regarding the criteria of due care and life-expectancy.ConclusionGPs are less likely to perform PAD for suffering from a mental illness, compared to somatic suffering. Some GPs apply an extra criterion of ‘life-expectancy’ in case of PAD for suffering from a mental illness. Refusing PAD based on a long life expectancy keeps open the possibility of recovery, but may also just prolong the suffering and add to the unbearableness of it.

KEY POINTS

• Currently, there is no qualitative research on what the views are of general practitioners regarding the subject of physician-assisted death (PAD) for patients suffering from severe mental disorders.
• General practitioners are less likely to consider a request for physician-assisted death by a patient suffering from a psychiatric disorder, compared to somatic suffering. Reasons for supporting psychiatric PAD related to responsibility, self-determination, compassion, fairness, and preventing suicide.
• Reasons for not supporting psychiatric PAD were related to the scope of medicine, a perceived lack of experience, uncertainties regarding the criteria of due care and life-expectancy.
• Significance for the reader: Although allowed in the Netherlands, PAD in case of severe mental suffering remains a controversial topic. We need in-depth information about the actual practice of it to have an informed debate with regard to this subject.