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

Background

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

Aim

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

Design and setting

Qualitative study in the general practice consultation context.

Method

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

Results

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

Conclusion

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

Caring for people living with,and beyond,cancer: an online survey of GPs in England

Background

Increasing numbers of people are living with, and beyond, cancer. They are at risk of long-term morbidity and premature mortality due to the consequences of their disease and its treatment. Primary care can contribute to providing ongoing care.

Aim

To determine the current practice and views of GPs in England regarding cancer survivorship care.

Design and setting

Online survey of a sample of 500 GPs, stratified by NHS region in England.

Method

The survey included questions adapted from prior surveys assessing physician knowledge and attitudes regarding care of patients with cancer.

Results

In total, 500 GPs responded; approximately half reported often providing care to people living beyond cancer for treatment-related side effects (51%), psychological symptoms (65%), and lifestyle advice (55%). Only 29% felt very confident managing treatment-related side effects compared with 46% and 65% for psychological symptoms and lifestyle advice respectively. Half reported usually receiving cancer treatment summaries and survivorship care plans but most of the sample felt these would improve their ability to provide care (76%). Only 53% were convinced of the usefulness of cancer care reviews. Although most felt that primary and specialist care should share responsibility for managing bone (81%) and cardiovascular (77%) health consequences, fewer than half reported often taking previous history of cancer or cancer treatment into consideration when assessing bone health; only one-fifth did this in relation to cardiovascular health. Most responders were interested in receiving education to improve their knowledge and expertise.

Conclusion

GPs have a potentially important role to play in caring for people following cancer treatment. This study has highlighted areas where further support and education are needed to enable GPs to optimise their role in cancer survivorship care.     

GPs and involuntary admission: a qualitative study

Background

In many countries, medical authorities are responsible for involuntary admissions of mentally ill patients. Nonetheless, very little is known about GPs'' experiences with involuntary admission.

Aim

The aim of the present study was to explore GP''s experiences from participating in involuntary admissions.

Setting

General practice, Aarhus, Denmark.

Method

One focus group interview and six individual interviews were conducted with 13 Danish GPs, who had recently sectioned one of their own patients.

Results

GPs experienced stress and found the admission procedure time consuming. They felt that sectioning patients was unpleasant, and felt nervous, but experienced relief and professional satisfaction if things went well. The GPs experienced the doctor–patient relationship to be at risk, but also reported that it could be improved. GPs felt that they were not taken seriously by the psychiatric system.

Conclusion

The unpleasant experiences and induced feelings resulting from involuntary admissions reflect an undesirable and stressful working environment.     

Prodromal schizophrenia in primary care: a randomised sensitisation study

Background

GPs are often the first point of contact for patients with prodromal schizophrenia. Early intervention, and therefore early detection, of schizophrenia is pivotal for the further disease course. However, recent studies have revealed that, due to its low prevalence in general practice and its insidious features, prodromal schizophrenia often remains unnoticed.

Aim

To test whether a repeated sensitisation method using clinical vignettes can improve diagnostic knowledge of GPs.

Design of study

Postal survey using anonymous questionnaires.Repeated sensitisation model using clinical vignettes.

Setting

GPs in three distinct regions in Switzerland covering a general population of 1.43 million.

Method

The study was conducted between September 2008 and October 2009. Questionnaires were sent to 1138 GPs at baseline, and at 6 and 12?months. After randomisation, 591 GPs were sensitised at 1, 3, and 5?months, while no sensitisation was carried out in the remaining 547 GPs.

Results

The overall response rate was 66% (750 GPs).Sensitised GPs demonstrated a highly significant increase in diagnostic knowledge at 6 and at 12?months when compared to their own baseline knowledge scores and also to non-sensitised GPs (P<0.001). In particular, awareness of insidious features, such as functional decline and social withdrawal as signs of prodromal schizophrenia, accounted for this effect.

Conclusion

Theoretical knowledge of prodromal schizophrenia among GPs can successfully be increased by repeated sensitisation models using clinical vignettes.     

Placebo interventions in practice: a questionnaire survey on the attitudes of patients and physicians

Background

Few studies have investigated whether patients and physicians differ in their attitudes regarding placebo interventions in medical practice.

Aim

To compare the proportions of patients and physicians who would accept therapies that do not work through specific pharmacological or physiological action but by enhancing self-healing capacities and by exploiting contextual factors.

Design of study

Survey of a random sample of GPs and patients consecutively attending in primary care practices.

Setting

Four hundred and seventy-seven patients and 300 GPs from primary care practices of the Canton Zurich of Switzerland were approached.

Method

Two questionnaires on responders'' attitudes regarding non-specific therapies.

Results

The response rates were 87% for patients and 79% for GPs. Eighty-seven per cent of patients and 97% of GPs thought that physical complaints can get better by believing in the effectiveness of the therapy. Overall there was more support for placebo interventions among patients than among GPs, yet 90% of the physicians admitted to actively proposing treatments intended to take advantage of non-specific effects. Seventy per cent of the patients wanted to be explicitly informed when receiving a non-specific intervention, whereas physicians thought this was the case for only 33% of their patients. Fifty-four per cent of patients would be disappointed when learning they had unknowingly been treated with pure placebo (‘sugar pill’), while only 44% would feel that way after treatment with impure placebo (for example, herbal medicine).

Conclusion

GPs rather underestimate the openness of their patients to non-specific therapies. However, patients want to be appropriately informed. Developing specific professional standards could help physicians to harness the ‘power of the placebo’, while remaining authentic and credible.     

Work-related sickness absence negotiations: GPs' qualitative perspectives

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.     

Exploration of GPs' views and use of the fit note: a qualitative study in primary care

Background

Sickness certification constitutes daily clinical practice for GPs. In April 2010, the UK sickness certification system changed to reflect the evidence that work is generally good for health and a new Statement of Fitness for Work — the ‘fit note’ — was introduced. Sickness certification is a contentious topic among GPs and the proposed fit note generated mixed reviews.

Aim

To explore GPs'' views and use of the fit note during its first year of operation.

Design and setting

Qualitative interview study of GPs based in different geographical locations across the UK.

Method

GPs (n = 15), who were recruited from a national sample, participated in semi-structured telephone interviews which were subject to constant comparative analysis.

Results

Overall, the fit note was well received. GPs recognised that work is generally good for health and felt the fit note facilitated using an earlier return to work as a negotiation tool. GPs perceive employers as the major obstacle to early return to work. There were reports of scepticism towards the system that negatively impacted on some GPs'' operation of sickness certification. Feedback over the fit note''s impact on employer behaviour and the return of a mechanism that enables GPs to request early independent assessments would be welcomed.

Conclusion

A revised approach is needed to address the scepticism towards the sickness certification system that persists among some GPs. New strategies need to be designed to engage employers in facilitating an early return to work and to enable the objectives of the medical statement reforms to be achieved.     

GPs' views on the practice of physician-assisted suicide and their role in proposed UK legalisation: a qualitative study

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.     

Patients' needs following colorectal cancer diagnosis: where does primary care fit in?

Background

Colorectal cancer is the third most common cancer in the UK. Patients with colorectal cancer spend most of their time in the community, but the role of primary care in their management and follow-up is unclear.

Aim

To explore colorectal cancer patients'' experiences of psychosocial problems and their management in primary and specialist care.

Design and setting

Longitudinal qualitative study of participants recruited from three hospitals in the west of Scotland and interviewed in their own homes.

Method

In-depth interviews with 24 participants with a new diagnosis of colorectal cancer, and then follow-up interviews 12 months later.

Results

Participants'' needs following a diagnosis for colorectal cancer included physical, psychological, and social issues. GPs played a key role in diagnosis, after which they were less involved. Participants valued GPs making unsolicited contact and offering support. Participants described being well supported by clinical nurse specialists who are expert in the illness, and who provide continuity of care and psychological support. A year after diagnosis, when there was less contact with GPs and clinical nurse specialists, participants still faced challenges associated with the ongoing impact of colorectal cancer

Conclusion

While some patients enjoyed straightforward recoveries from surgery, others experienced longer-term implications from their disease and treatment, particularly bowel-function issues, fatigue, anxiety, and sexual problems. The potential for primary care to contribute more to the ongoing care of colorectal cancer patients was identified.     

Patient and professional views of open access hysterosalpingography for the initial management of infertility in primary care

Background

Hysterosalpingography (HSG) is recommended as a first-line investigation for tubal assessment of infertile women. This investigation is not routinely available to GPs.

Aim

To explore the perceptions and attitudes of patients and health professionals to open access HSG for the initial management of infertile couples in general practice.

Design of study

A nested qualitative study using in-depth interviews with GPs, fertility specialists, and infertile couples.

Setting

Northumberland, Newcastle upon Tyne, North Tyneside, South Tyneside, and Gateshead.

Method

Participants were 39 interviewees: 12 GPs, five fertility specialists, and 13 infertile couples (nine interviewed with their partner).

Results

Four themes emerged: personal factors; will it benefit patients, GPs, and fertility specialists?; professional factors; does it fit the role of a GP?; local context; do the skills exist in general practice?; and wider context; will it benefit the NHS? GPs who had used open access HSG, felt it was appropriate for general practice and would continue to use the service. All GPs, fertility specialists, and infertile couples who had experienced open access HSG wished the service to remain in place. The main barriers to its uptake were: infrequency with which infertility presents; lack of clarity on perceived responsibilities; difficulty keeping up to date, including assimilating guidelines; low clinical priority; and lack of support in authoritative guidance.

Conclusion

Providing GPs with open access to HSG would allow a full initial assessment of the infertile couple and refer women with blocked tubes directly to tertiary care. While there is general support for the provision of such a facility, the majority of GPs perceive its use as being by a limited number of GPs who have a special interest in infertility. The study findings can inform future development of infertility services at the interface between primary and secondary/tertiary care.     

Developing a curriculum statement based on clinical practice: genetics in primary care

Background

Advances in medical genetics are increasingly being incorporated into clinical management outside specialist genetic services. This study was therefore undertaken to develop learning outcomes in genetics for general practice specialty training, using methods to ensure the knowledge, skills, and attitudes relevant to genetics in primary care were identified.

Aim

To identify key knowledge, skills, and attitudes in genetics and to synthesise these into learning outcomes to assist training in genetics for primary care.

Design of study

Delphi survey and review by expert group.

Setting

Primary care practices and Regional Genetics Centre in the West Midlands region of the UK.

Method

A modified Delphi survey involved GP trainers, programme directors, and geneticists (n = 60). The results, along with results from a survey of GP registrars, were reviewed by an expert group, which included GPs, geneticists, and educationalists.

Results

Core genetics topics for GPs were identified, prioritised, and developed into competency statements in the style of the curriculum structure of the Royal College of General Practitioners.

Conclusion

The development of the GP curriculum statement Genetics in Primary Care was based on a study of educational needs, incorporating the views of practitioners (GP trainers, programme directors, and registrars) and specialists (clinical geneticists). This inclusive approach has enabled the identification of learning outcomes which directly reflect clinical practice.     

Offering antenatal sickle cell and thalassaemia screening to pregnant women in primary care: a qualitative study of GPs' experiences

Background

Timely antenatal sickle cell and thalassaemia (SC&T) screening for all women in primary care facilitates informed decision making, but little is known about its implementation.

Aim

To assess the feasibility of offering antenatal SC&T screening in primary care at the time of pregnancy confirmation.

Design of study

Cross-sectional investigation of GPs'' beliefs and perceived practices.

Method

Informal face-to-face interviews with 34 GPs.

Setting

Seventeen inner-city general practices that offered antenatal SC&T screening as part of a trial.

Results

GPs identified both barriers and facilitators. Organisational barriers included inflexible appointment systems and lack of interpreters for women whose first language was not English. Professional barriers included concerns about raising possible adverse outcomes in the first antenatal visit. Perceived patient barriers included women''s lack of awareness of SC&T. Hence, GPs presented the test to women as routine, rather than as a choice. Organisational facilitators included simple and flexible systems for offering screening in primary care, practice cohesion, and training. Professional facilitators included positive attitudes to screening for SC&T. Perceived patient facilitators included women''s desire for healthy children.

Conclusion

GPs reported barriers, as well as facilitators, to successful implementation but the extent to which screening could be regarded as offering ‘informed choice’ remained fundamental when making sense of these barriers and facilitators.     

Touch in primary care consultations: qualitative investigation of doctors’ and patients’ perceptions

Background

Good communication skills are integral to successful doctor–patient relationships. Communication may be verbal or non-verbal, and touch is a significant component, which has received little attention in the primary care literature. Touch may be procedural (part of a clinical task) or expressive (contact unrelated to a procedure/examination).

Aim

To explore GPs’ and patients’ experiences of using touch in consultations.

Design and setting

Qualitative study in urban and semi-rural areas of north-west England.

Method

Participating GPs recruited registered patients with whom they felt they had an ongoing relationship. Data were collected by semi-structured interviews and subjected to constant comparative qualitative analysis.

Results

All participants described the importance of verbal and non-verbal communication in developing relationships. Expressive touch was suggested to improve communication quality by most GPs and all patients. GPs reported a lower threshold for using touch with older patients or those who were bereaved, and with patients of the same sex as themselves. All patient responders felt touch on the hand or forearm was appropriate. GPs described limits to using touch, with some responders rarely using anything other than procedural touch. In contrast, most patient responders believed expressive touch was acceptable, especially in situations of distress. All GP responders feared misinterpretation in their use of touch, but patients were keen that these concerns should not prevent doctors using expressive touch in consultations.

Conclusion

Expressive touch improves interactions between GPs and patients. Increased educational emphasis on the conscious use of expressive touch would enhance clinical communication and, hence, perhaps patient wellbeing and care.     

Factors influencing European GPs' engagement in smoking cessation: a multi-country literature review

Background

Smoking cessation advice by GPs is an effective and cost-effective intervention, but is not implemented as widely as it could be.

Aim

This wide-ranging Europe-wide literature review, part of the European Union (EU) PESCE (General Practitioners and the Economics of Smoking Cessation in Europe) project, explored the extent of GPs'' engagement in smoking cessation and the factors that influence their engagement.

Method

Two searches were conducted, one for grey literature, across all European countries, and one for academic studies. Data from eligible studies published from 1990 onwards were synthesised and reported under four categories of influencing factors: GP characteristics, patient characteristics, structural factors, and cessation-specific knowledge and skills.

Results

The literature showed that most GPs in Europe question the smoking status of all new patients but fewer routinely ask this of regular patients, or advise smokers to quit. The proportion offering intensive interventions or prescribing treatments is lower still. Factors influencing GPs'' engagement in smoking cessation include GPs'' own smoking status and their attitudes towards giving smoking cessation advice; whether patients present with smoking-related symptoms, are pregnant, or heavy smokers; time, training, and reimbursement are important structural factors; and some GPs lack knowledge and skills regarding the use of specific cessation methods and treatments, or have limited awareness of specialist cessation services. No single factor or category of factors explains the variations in GPs'' engagement in smoking cessation.

Conclusion

Strategies to improve the frequency and quality of GPs'' engagement in smoking cessation need to address the multifaceted influences on GPs'' practice and to reflect the widely differing contexts across Europe.     

Domestic violence: knowledge,attitudes, and clinical practice of selected UK primary healthcare clinicians

Background

Domestic violence affects one in four women and has significant health consequences. Women experiencing abuse identify doctors and other health professionals as potential sources of support. Primary care clinicians agree that domestic violence is a healthcare issue but have been reluctant to ask women if they are experiencing abuse.

Aim

To measure selected UK primary care clinicians’ current levels of knowledge, attitudes, and clinical skills in this area.

Design and setting

Prospective observational cohort in 48 general practices from Hackney in London and Bristol, UK.

Method

Administration of the Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS), comprising five sections: responder profile, background (perceived preparation and knowledge), actual knowledge, opinions, and practice issues.

Results

Two hundred and seventy-two (59%) clinicians responded. Minimal previous domestic violence training was reported by participants. Clinicians only had basic knowledge about domestic violence but expressed a positive attitude towards engaging with women experiencing abuse. Many clinicians felt poorly prepared to ask relevant questions about domestic violence or to make appropriate referrals if abuse was disclosed. Forty per cent of participants never or seldom asked about abuse when a woman presented with injuries. Eighty per cent said that they did not have an adequate knowledge of local domestic violence resources. GPs were better prepared and more knowledgeable than practice nurses; they also identified a higher number of domestic violence cases.

Conclusion

Primary care clinicians’ attitudes towards women experiencing domestic violence are generally positive but they only have basic knowledge of the area. Both GPs and practice nurses need more comprehensive training on assessment and intervention, including the availability of local domestic violence services.     

Risk taking in general practice: GP out-of-hours referrals to hospital

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.     

Childhood long-term conditions in primary care: a qualitative study of practitioners’ views

Background

Improving child health and wellbeing in England was the key focus of the Chief Medical Officer’s Annual Report 2012, which recommended that all children with long-term conditions (LTCs) have a named GP responsible for their care. Little is known, however, about practitioners’ views and experiences of supporting children with LTCs in primary care.

Aim

To explore practitioners’ views of supporting children with LTCs and their families in primary care.

Design and setting

Qualitative interview study in primary care settings in South Yorkshire, England.

Method

Interviews explored practitioners’ views and experiences of supporting children with asthma, cystic fibrosis, type 1 diabetes, and epilepsy. Interviews were audiotaped, transcribed verbatim, and analysed using the framework approach.

Results

Nineteen practitioners were interviewed: 10 GPs, five practice nurses, and four nurse practitioners. The GPs’ clinical roles included prescribing and concurrent illness management; nurse practitioners held minor illness clinics; and practice nurses conduct asthma clinics and administer immunisations. GPs were coordinators of care and provided a holistic service to the family. GPs were often unsure of their role with children with LTCs, and did not feel they had overall responsibility for these patients. Confidence was dependent on experience; however, knowledge of GPs’ own limits and accessing help were felt to be more important than knowledge of the condition.

Conclusion

Primary care has a valuable role in the care of children with LTCs and their families. This study suggests that improving communication between services would clarify roles and help improve the confidence of primary care practitioners.     

Recognising Kawasaki disease in UK primary care: a descriptive study using the Clinical Practice Research Datalink

Background

Kawasaki disease is a rare childhood illness that can present non-specifically, making it a diagnostic challenge. The clinical presentation of Kawasaki disease has not been previously described in primary care.

Aim

To describe how children with an eventual diagnosis of Kawasaki disease initially present to primary care in the UK.

Design and setting

The Clinical Practice Research Datalink was used to find cases coded as Kawasaki disease. Hospital Episode Statistics, hospital admissions, and hospital outpatient attendances were used to identify the children with a convincing diagnosis of Kawasaki disease.

Method

Questionnaires and a request for copies of relevant hospital summaries, discharge letters, and reports were sent to GPs of the 104 children with a diagnosis of Kawasaki disease between 2007 and 2011.

Results

Most children presented with few clinical features typical of Kawasaki disease. Of those with just one feature, a fever or a polymorphous rash were the most common. By the time that most children were admitted to hospital they had a more recognisable syndrome, with three or more clinical features diagnostic of Kawasaki disease. Most GPs did not consider Kawasaki disease among their differential diagnoses, but some GPs did suspect that the child’s illness was unusual.

Conclusion

The study highlighted the difficulty of early diagnosis, with most children having a non-specific presentation to primary care. GPs are encouraged to implement good safety netting, and to keep Kawasaki disease in mind when children present with fever and rashes.