Norwegian general practitioners’ collaboration with municipal care providers – a qualitative study of structural conditions

Purpose: The purpose of this study was to explore the structural mechanisms that facilitate or counteract collaboration between general practitioners (GPs) and other providers of municipal healthcare. Good collaboration between these actors is crucial for high-quality care, especially for persons in need of coordinated services.

Material and methods: The study is based on semistructured interviews with 12 healthcare providers in four Norwegian municipalities: four GPs, six nurses and two physiotherapists.

Results: GPs are key collaborating partners in the healthcare system. Their ability to collaborate is affected by a number of structural conditions. Mostly, this leads to GPs being too little involved in potential collaborative efforts: (i) individual GPs prioritize with whom they want to collaborate among many possible collaborative partners, (ii) inter-municipal constraints hamper GPs in contacting collaboration partners and (iii) GPs fall outside the hospital-municipality collaboration.

Conclusions: We argue a common leadership for primary care services is needed. Furthermore, inter-professional work must be a central focus in the planning of primary care services. However, a dedicated staff, sufficient resources, adequate time and proper meeting places are needed to accomplish good collaboration.     

COPD management by Swedish general practitioners – baseline results of the PRIMAIR study

Background: Chronic obstructive pulmonary disease (COPD) is a common cause of suffering and death. Evidence-based management of COPD by general practitioners (GPs) is crucial for decreasing the impact of the disease. Efficient strategies include early diagnosis, smoking cessation and multimodal treatment.

Aim: To describe knowledge about and skills for managing COPD in GPs in Sweden.

Methods: Prior to COPD education (the PRIMAIR Study), GPs at primary health care centers (PHCCs) in Stockholm replied to 13 written, patient-case based, multiple choice and free-text questions about COPD. Their knowledge and practical management skills were assessed by assigned points that were analyzed with non-parametric tests.

Results: Overall, 250 GPs at 34 PHCCs replied (89% response rate). Total mean score was 9.9 (maximum 26). Scores were highest on ‘management of smoking cessation’, ‘follow-up after exacerbation’ and ‘diagnostic procedures’. Spirometry was used frequently, although interpretation skills were suboptimal. ‘Management of maintenance therapy’, ‘management of multimorbidity’ and ‘interprofessional cooperation’ had mediocre scores. Scores were unrelated to whether there was a nurse-led asthma/COPD clinic at the PHCC.

Conclusions: Swedish GPs’ knowledge of COPD and adherence to current guidelines seem insufficient. A nurse-led asthma/COPD clinic at the PHCC does not correlate with sufficient COPD skills in the GPs. The relevance of this study to participants’ actual clinical practice and usefulness of easy-to-access clinical guides are interesting topics for future investigation. To identify problem areas, we suggest using questionnaires prior to educational interventions.

• Key Points

• General practitioners (GPs) play a crucial role in providing evidence-based care for patients with chronic obstructive pulmonary disease (COPD) who are treated in primary care.

• Swedish GPs’ knowledge about COPD and adherence to current guidelines seem insufficient.

• Areas in greatest need of improvement are spirometry interpretation, management of maintenance therapy, management of multimorbidity in patients with COPD and interprofessional cooperation.

     

Consumer preferences regarding physiotherapy practitioners and nurse practitioners in emergency departments – a qualitative investigation

Workforce reform has led to Nurse Practitioners (NP) and Physiotherapy Practitioners (PP) employed in Emergency Departments (ED) to see patients alongside doctors. This qualitative study gathered consumer opinions and preferences regarding NPs, PPs, and doctors, and the attributes desired of them. Twenty-two members of the organization’s Consumer Representative Program participated in one of three focus groups which were audio-recorded and transcribed verbatim. Data were subsequently collected using an emergent-systematic design that enabled ideas to be explored and refined in sequential focus groups. Data analysis, utilizing the principles of thematic analysis, identified four themes. First, consumers understand and accept that reform is necessary to improve care, better utilize available resources and create sustainable services. Second, although consumers accept the rationale for employing NPs and PPs, preferences vary regarding who they want as their primary clinician. Some consumers do not mind who provides care as long as they receive the care they need; others believe doctors provide superior care and preferred a doctor; a third group indicated that not everyone who presents to an ED needs to see a doctor and specialized care would be provided by NPs and PPs for certain conditions. Some consumers expressed incomplete or inaccurate understanding of ED staff roles, responsibilities, and skillsets, which influenced their care preferences. Third, consumers identified a core set of desirable staff attributes that apply to everyone irrespective of professional demarcation; all staff should embody these attributes, though the expression of the attributes will vary according to circumstances and the staff member’s scope of practice. Fourth, consumers expect effective governance over ED services so that all staff, irrespective of their profession provides safe and effective care. In conclusion, these results can be used by health-care administrators and clinicians to inform workforce reform in EDs, helping to ensure that consumers’ opinions and preferences are acknowledged and appropriately addressed.     

General practitioners’ and students’ experiences with feedback during a six-week clerkship in general practice: a qualitative study

Objective: Feedback may be scarce and unsystematic during students' clerkship periods. We wanted to explore general practitioners' (GPs) and medical students' experiences with giving and receiving supervision and feedback during a clerkship in general practice, with a focus on their experiences with using a structured tool (StudentPEP) to facilitate feedback and supervision. Design: Qualitative study. Setting: Teachers and students from a six-week clerkship in general practice for fifth year medical students were interviewed in two student and two teacher focus groups. Subjects: 21 GPs and nine medical students. Results: We found that GPs first supported students' development in the familiarization phase by exploring the students' expectations and competency level. When mutual trust had been established through the familiarization phase GPs encouraged students to conduct their own consultations while being available for supervision and feedback. Both students and GPs emphasized that good feedback promoting students' professional development was timely, constructive, supportive, and focused on ways to improve. Among the challenges GPs mentioned were giving feedback on behavioral issues such as body language and insensitive use of electronic devices during consultations or if the student was very insecure, passive, and reluctant to take action or lacked social or language skills. While some GPs experienced StudentPEP as time-consuming and unnecessary, others argued that the tool promoted feedback and learning through mandatory observations and structured questions. Conclusion: Mutual trust builds a learning environment in which supervision and feedback may be given during students' clerkship in general practice. Structured tools may promote feedback, reflection and learning.

• Key Points

• Observing the teacher and being supervised are essential components of Medical students' learning during general practice clerkships.

• Teachers and students build mutual trust in the familiarization phase.

• Good feedback is based on observations, is timely, encouraging, and instructive.

• StudentPEP may create an arena for structured feedback and reflection.

     

General practitioners’ experiences using cognitive behavioural therapy in general practice: A qualitative study

Abstract

Objective. To explore GPs’ experiences using cognitive behavioural therapy (CBT), with a focus on factors that promote or limit the use of CBT in general practice. Design. Qualitative study using data from written evaluation reports and focus-group interviews. Setting. Norwegian general practice. Subjects. GPs who participated in a longitudinal CBT course in the continuous medical education (CME) programme for GPs in Norway, of whom 19 filled in evaluation forms and 15 participated in focus-group interviews. Main outcome measures. Experiences with the use of CBT in general practice. Results. GPs used CBT mainly in the treatment of patients with anxiety disorders and depression. Factors that promoted the use of CBT in general practice were structured supervision and group counselling, receiving feedback on individual video-recorded consultations, and experiencing that one mastered the therapeutic techniques. Limiting factors were that it took some time before one mastered the techniques, lack of eligible patients, constraints related to attending group supervision during office hours, and the lack of financial incentives to use CBT in general practice. Conclusion. Tailored training programmes in CBT for GPs may contribute to more frequent use of CBT in general practice. A formal recognition of CBT in the reimbursement scheme for GPs might counter limiting factors to an increased use of CBT in general practice.     

What happens when the doctor denies a patient’s request? A qualitative interview study among general practitioners in Norway

Objective: To explore general practitioners (GPs’) experiences from consultations when a patient’s request is denied, and outcomes of such incidents.

Design and participants: We conducted a qualitative study with semi-structured individual interviews with six GPs in Norway. We asked them to tell about experiences from specific encounters where they had refused a patient’s request. The texts were analysed with Systematic Text Condensation, a method for thematic cross-case analysis.

Main outcome measures: Accounts of experiences from consultations when GPs refused their patients’ requests.

Results: Subjects of dispute included clinical topics like investigation and treatment, certification regarding welfare benefits and medico-legal issues, and administrative matters. The arguments took different paths, sometimes settled by reaching common ground but more often as unresolved disagreement with anger or irritation from the patient, sometimes with open hostility and violence. The aftermath and outcomes of these disputes lead to strong emotional impact where the doctors reflected upon the incidents and sometimes regretted their handling of the consultation. Some long-standing and close patient–doctor relationships were injured or came to an end.

Conclusions: The price for denying a patient’s request may be high, and GPs find themselves uncomfortable in such encounters. Skills pertaining to this particular challenge could be improved though education and training, drawing attention to negotiation of potential conflicts. Also, the notion that doctors have a professional commitment to his or her own autonomy and to society should be restored, through increased emphasis on core professional ethics in medical education at all levels.     

Rural GPs’ attitudes toward participating in emergency medicine: a qualitative study

Objective: Health authorities want to increase general practitioner (GP) participation in emergency medicine, but the role of the GP in this context controversial. We explored GPs’ attitudes toward emergency medicine and call outs.

Design: Thematic analysis of focus group interviews.

Setting: Four rural casualty clinics in Norway.

Participants: GPs with experience ranging from one to 32 years.

Results: The GPs felt that their role had changed from being the only provider of emergency care to being one of many. In particular, the emergency medical technician teams (EMT) have evolved and often manage well without a physician. Consequently, the GPs get less experience and feel more uncertain when encountering emergencies. Nevertheless, the GPs want to participate in call outs. They believed that their presence contributes to better patient care, and the community appreciates it. Taking part in call outs is seen as being vital to maintaining skills. The GPs had difficulties explaining how to decide whether to participate in call outs. Decisions were perceived as difficult due to insufficient information. The GPs assessed factors, such as distance from the patient and crowding at the casualty clinic, differently when discussing participation in call outs.

Conclusion: Although their role may have changed, GPs argue that they still play a part in emergency medicine. The GPs claim that by participating in call outs, they maintain their skills and improve patient care, but further research is needed to help policy makers and clinicians decide when the presence of a GP really counts.

Norwegian health authorities want to increase participation by general practitioners (GPs) in emergency medicine, but the role of the GP in this context is controversial.

• KEY POINTS

• The role of the GP has changed, but GPs argue that they still play an important role in emergency medicine.

• GPs believe that their presence on call outs improve patient care, but they find it defensible that patients are tended to by emergency medical technicians (EMTs) only.

• GPs offered different assessments regarding whether to participate in call outs in seemingly similar cases.

     

A qualitative study of older people’s experience of living with neurogenic claudication to inform the development of a physiotherapy intervention

Purpose: The aim of this study was to explore older people’s experiences of living with neurogenic claudication (NC), their preferences for physiotherapy treatment provision and associated outcomes in order to inform an intervention to be tested in a clinical trial.

Method: Patients with a diagnosis of NC and/or lumbar spinal stenosis were recruited through a UK NHS tertiary care center. Semi-structured interviews and self-report questionnaires were used to obtain data. A thematic analysis was conducted.

Results: 15 participants were recruited; half were classed as frail older adults. Pain and the threat of pain was a prominent feature of participants’ experience of NC. This led to a loss of engagement in meaningful activities and sense of self. Discourses of ageing influenced experiences as well as treatment preferences, particularly the acceptability of walking aids. A combination of one-to-one and group setting for treatment was preferred. Outcome preferences related to re-engagement in meaningful activities and pain reduction. Limitations relate to generalisability of the findings for NC patients not under physiotherapy treatment.

Conclusion: We have obtained important findings about older people’s experiences of living with NC and preferences for physiotherapy treatment and outcomes. These will be incorporated into an evidence-based intervention and evaluated in a randomized controlled trial.

• Implications for rehabilitation

• Older people living with NC want to get back to meaningful activities and learn how to live with the threat of pain.

• Allied health professionals (AHPs) should be sensitive to the complex and ambiguous ways in which older people live with ageing and age-related decline.

• AHPs are in a position to support patients’ successful transition to the use of walking aids thereby reducing stigmatizing effects and increasing activity.

• AHPs should consider a mixture of one-to-one and group classes to enable rehabilitation for older NC patients.

     

Who should provide care for patients receiving palliative chemotherapy? A qualitative study among Dutch general practitioners and oncologists

Abstract

Introduction: While close collaboration between general practitioners (GPs) and hospital specialists is considered important, the sharing of care responsibilities between GPs and oncologists during palliative chemotherapy has not been clearly defined.

Objective: Evaluate the opinions of GPs and oncologists about who should provide different aspects of care for patients receiving palliative chemotherapy.

Design: We conducted semi-structured interviews using six hypothetical scenarios with purposively sampled GPs (n?=?12) and oncologists (n?=?10) in the Netherlands. Each represented an example of a clinical problem requiring different aspects of care: problems likely, or not, related to cancer or chemotherapy, need for decision support, and end-of-life care.

Results: GPs and oncologists agreed that GPs should provide end-of-life care and that they should be involved in decisions about palliative chemotherapy; however, for the other scenarios most participants considered themselves the most appropriate provider of care. Themes that emerged regarding who would provide the best care for the patients in the different scenarios were expertise, continuity of care, accessibility of care, doctor–patient relationship, and communication. Most participants mentioned improved communication between the GP and oncologist as being essential for a better coordination and quality of care.

Conclusion: GPs and oncologists have different opinions about who should ideally provide different aspects of care during palliative chemotherapy. Findings raise awareness of the differences in reasoning and approaches and in current communication deficits between the two groups of health professionals. These findings could be used to improve coordination and collaboration and, ultimately, better patient care as results demonstrated that both disciplines can add value to the care for patients with advanced cancer.

• Key points

• This study identified contrasting opinions of GPs and oncologists about who should provide different aspects of care for patients receiving palliative chemotherapy.

• Important themes that emerged were expertise, continuity of care, doctor-patient relations, accessibility of care, and communication.

• Although frequently using the same arguments, GPs and oncologists often considered themselves to be the most appropriate providers of palliative care.

     

Patient education and basic body awareness therapy in hip osteoarthritis – a qualitative study of patients’ movement learning experiences

Background: Osteoarthritis (OA) is associated with pain, dysfunction and reduced quality of life. Patient education (PE) followed by 12 weekly sessions of Basic Body Awareness Therapy (BBAT) was offered to patients with hip OA, aiming to strengthen their ability to move and act functionally in daily life.

Aim: To explore how patients described their experiences and outcome from participating in PE and BBAT.

Method: Individual, semi-structured interviews with five patients, aged 52-78 years, were performed after PE and BBAT at four and ten months. Interview data were analyzed by systematic text condensation.

Results: Three main themes emerged. “Becoming motivated and involved” reflected experiences of encouragement and support from information given and communication with group members. In “Movement awareness learning” patients described becoming aware of and improving functional movement, alleviating symptoms and increasing daily functioning. “Movement and disease in a long-term perspective” reflected patient? experience of increased self-awareness and taking better care of themselves at 10 months after baseline. Practicing basic movement principles, they felt empowered to handle daily life challenges in more functional and energy-economical ways.

Conclusion: PE followed by BBAT in groups may be beneficial to patients with hip OA, and provide lasting benefits regarding daily life function.

• Implications for Rehabilitation

• Insight into disease process and relationship to functional movement gained through patient education may empower patients with hip osteoarthritis in management of daily life

• Movement awareness and exploration of movement quality using principles from Basic Body Awareness Therapy was found to support patients in finding resources for functional movement, implemented in daily actions

• Movement strategies characterized by adjustment rather than force was experienced by the patients to support their general functioning, despite of prevailing hip pain

• Implementing group therapeutic factors (Yalom) in physiotherapy was found to strengthen patients’ motivation and belief in functional improvement

     

General practitioners’ views on leadership roles and challenges in primary health care: a qualitative study

Objective: To explore general practitioners’ (GPs) views on leadership roles and leadership challenges in general practice and primary health care.

Design: We conducted focus groups (FGs) with 17 GPs.

Setting: Norwegian primary health care.

Subjects: 17 GPs who attended a 5 d course on leadership in primary health care.

Results: Our study suggests that the GPs experience a need for more preparation and formal training for the leadership role, and that they experienced tensions between the clinical and leadership role. GPs recognized the need to take on leadership roles in primary care, but their lack of leadership training and credentials, and the way in which their practices were organized and financed were barriers towards their involvement.

Conclusions: GPs experience tensions between the clinical and leadership role and note a lack of leadership training and awareness. There is a need for a more structured educational and career path for GPs, in which doctors are offered training and preparation in advance.

• KEY POINTS

• Little is known about doctors’ experiences and views about leadership in general practice and primary health care. Our study suggests that:

• There is a lack of preparation and formal training for the leadership role.

• GPs experience tensions between the clinical and leadership role.

• GPs recognize leadership challenges at a system level and that doctors should take on leadership roles in primary health care.

     

Thoracoscopic management of primary spontaneous pneumothorax – a comparative study

A retrospective study was performed to assess the advantages and disadvantages of a video-assisted thoracoscopic approach (VTS) to the surgical management of primary spontaneous pneumothorax compared with the standard posterolateral thoracotomy (PLT) or posterior muscle sparing (PMS) approaches. It was possible to make comparisons between 12 VTS, nine PLT and six PMS patients who underwent unilateral apical bullectomy/stapling with apical pleurectomy/abrasion for primary spontaneous pneumothorax. The groups were evenly matched with regards age, sex and incidence of pneumothorax. The operative time for VTS was significantly greater than for PLT (P = 0.014) but not for PMS (P = 0.297) procedures. VTS procedures resulted in significant decreases in the overall period of pleural drainage compared with PLT (P = 0.031) and PMS (P < 0.001) procedures. Patients having a VTS procedure had a median hospital stay of 3 days, significantly shorter than that associated with the other approaches (PLT, P < 0.001; PMS, P < 0.001). The daily in-hospital analgesic requirements were similar for all groups. Using VTS an identical operation can be performed with smaller incisions and shorter hospital stay. Long-term recurrence rates and length of time off work will eventually determine whether VTS is a more economic approach to pleurectomy.     

Variation in general practitioners’ information-seeking behaviour – a cross-sectional study on the influence of gender,age and practice form

Objective: To assess general practitioners’ (GPs’) information-seeking behaviour and perceived importance of sources of scientific medical information and to investigate associations with GP characteristics.

Design: A national cross-sectional survey was distributed electronically in December 2013.

Setting: Danish general practice.

Subjects: A population of 3440 GPs (corresponding to approximately 96% of all Danish GPs).

Main outcome measures: GPs’ use and perceived importance of information sources. Multilevel mixed-effects logit models were used to investigate associations with GP characteristics after adjusting for relevant covariates.

Results: A total of 1580 GPs (46.4%) responded to the questionnaire. GPs’ information-seeking behaviour is associated with gender, age and practice form. Single-handed GPs use their colleagues as an information source significantly less than GPs working in partnership practices and they do not use other sources more frequently. Compared with their younger colleagues, GPs aged above 44 years are less likely to seek information from colleagues, guidelines and websites, but more likely to seek information from medical journals. Male and female GPs seek information equally frequently. However, whereas male GPs are more likely than female GPs to find that pharmaceutical sales representative and non-refundable CME meetings are important, they are less likely to find that colleagues, refundable CME meetings, guidelines and websites are important.

Conclusion: Results from this study indicate that GP characteristics should be taken into consideration when disseminating scientific medical information, to ensure that patients receive medically updated, high-quality care.

• KEY POINTS

• Research indicates that information-seeking behaviour is associated with GP characteristics. Further insights could provide opportunities for targeting information dissemination strategies.

• Single-handed GPs seek information from colleagues less frequently than GPs in partnerships and do not use other sources more frequently.

• GPs aged above 44 years do not seek information as frequently as their younger colleagues and prefer other information sources.

• Male and female GPs seek information equally frequently, but do not consider information sources equally important in keeping medically updated.

     

‘Validation of ultrasound examinations performed by general practitioners’

Objective: The aim of this study was to evaluate the diagnostic agreement when a general practitioner and subsequently a specialist (radiologist/gynecologist) performed point-of-care ultrasound examinations for certain abdominal and gynecological conditions of low to moderate complexity.

Design: A prospective study of inter-rater reliability and agreement.

Setting: Patients were recruited and initially scanned in general practice. The validation examinations were conducted in a hospital setting.

Subjects: A convenient sample of 114 patients presenting with abdominal pain or discomfort, possible pregnancy or known risk factors toward abdominal aortic aneurism were included.

Main outcome measures: Inter-rater agreement (Kappa statistic and percentage agreement) between ultrasound examinations by general practitioner and specialist for the following conditions: gallstones, ascites, abdominal aorta >5?cm, intrauterine pregnancy and gestational age.

Results: An overall Kappa value of 0.93 (95% confidence interval (CI): 0.87–0.98) was obtained. Ascites, abdominal aortic diameter >5cm, and intrauterine pregnancy showed Kappa values of 1.

Conclusion: Our study showed that general practitioners performing point-of-care ultrasound examinations with low-to-moderate complexity had a very high rate of inter-rater agreement compared with specialists.     

Does physiotherapy management of low back pain change as a result of an evidence-based educational programme?

RATIONALE: The concept of evidence-based medicine is important in providing efficient health care. The process uses research findings as the basis for clinical decision making. Evidence-based practice helps optimize current health care and enables the practitioners to be suitably accountable for the interventions they provide. Little work has been undertaken to examine how allied health professionals change their clinical practice in light of the latest evidence. The use of opinion leaders to disseminate new evidence around the management of low back pain into practice has been proposed. AIMS: The aim of this study was to investigate if physiotherapists' clinical management of patients with low back pain would change following an evidence-based education package, which utilized local opinion leaders and delivered the best evidence. METHOD: Thirty musculoskeletal physiotherapists from a Community Trust in North Staffordshire were cluster randomized by location of work, to two groups. The intervention group received an evidence-based programme on the management of low back pain, including advice regarding increasing activity levels and return to normal activity and challenging patients' fears and beliefs about their pain. The control group received a standard in-service training package on the management of common knee pathologies. The physiotherapists' clinical management of patients with low back pain was measured prior to training and 6 months post training. Outcome measures were based on physiotherapists completing 'discharge summary' questionnaires, which included information relating to the use and importance of therapies for treating their low back pain patients. RESULTS: There were few significant differences in treatment options between the intervention and control groups post training. Whilst there was some indication that physiotherapists were already utilizing aspects of psychosocial management for patients with low back pain, there was little change in what physiotherapists perceived to be important to patient recovery and actual clinical practice following the intervention. CONCLUSIONS: Psychosocial factors have been identified as an important factor in the recovery of patients with low back pain. This project incorporated the latest evidence on the management of low back pain and utilized the theory of opinion leaders to disseminate this evidence into clinical practice. Whilst there were some limitations in the overall size of the study, the results help to give an insight into the challenges faced by the health care system and researchers alike to ensure quality evidence is actually utilized by practitioners for the benefits of patient care.     

Everyday life for users of electric wheelchairs – a qualitative interview study

Purpose: The aim of this paper is to explore how users of electric wheelchairs experience their everyday life and how their electric wheelchairs influence their daily occupation. Occupation is defined as a personalized dynamic interaction between person, task and environment, and implies the value and meaning attached. Method: Nine semi-structured interviews were conducted with experienced electric wheelchair users. ValMo was used as the theoretical framework for both interviewing and the analysis. The transcribed interviews were analysed using thematic analysis. Results: Findings revealed key elements in electric wheelchair users’ experience of how the use of a wheelchair influences everyday life and occupation. Four central themes emerged from the participants’ experiences 1) The functionality of the wheelchair, 2) The wheelchair as an extension of the body, 3) The wheelchair and social life, and 4) The wheelchair and identity issues. The themes were interrelated and show how all levels of occupation were influenced both in a positive and negative way, and how it affected identity. Conclusions: It is essential that professionals working with electric wheelchair users are aware of how all levels of occupation and identity are influenced by using a wheelchair. This will assist professionals in supporting the users living an autonomous and meaningful life.

Implications for Rehabilitation

• All levels of occupation and identity are influenced by using a wheelchair.

• It is important that the electric wheelchair functions as an extension of the user’s body and that surroundings are made as accessible as possible.

• When choosing an electric wheelchair it is important that professionals make assessments that embrace all levels of the user’s occupation.