From biomedical teaching to biopsychosocial education: a process of change in a Finnish medical school

A group of clinicians, teachers and researchers in the University of Oulu have been worried for years about the predominantly biomedical orientation in the local Faculty of Medicine. Therefore, a project group was founded in 1992 to develop the medical degree programme towards a more comprehensive model. This article introduces the main strategies used in the process of change and describes the challenges encountered during the process. There are still many problems in the education of medical students towards a patient and family orientation and in the effort to change the whole medical culture of the university from a biomedical to a biopsychosocial approach. However, in the postgraduate education of general practitioners, we no longer prefer to teach only doctors, but education on the biopsychosocial model will also be arranged to the interdisciplinary teams working in the municipalities in the Province of Oulu in Finland.     

"A planned baby is a rarity:" monitoring and planning pregnancy in Russia

Russia provides an interesting case for comparative research of maternity care due to the rapid social change and steep fertility decline since the collapse of the Soviet Union. I analyze out-patient maternity care in public sector women's clinics in St. Petersburg on the basis of qualitative observation and interview data. Gynecologists' role in monitoring pregnancy is central, resulting in an emphasis on medical expertise and risk management. Ideally, gynecologists see themselves as medical experts and maternal caretakers, but the latter role seldom materializes in practice. Gynecologists' ideas of pregnancy planning demonstrate a wish for further medicalization of maternity care.     

Towards interprofessional family-oriented teamwork in primary services: the evaluation of an education programme

A 2-year interprofessional family-oriented training programme for professionals working in the field of primary services (e.g. health care, social welfare, schools, day care) started in Oulu Province, Finland, in 2000. It aimed to provide the trainees with skills to work with families in interprofessional teams, to support them to cope better and to encourage them to develop new models for helping clients. Seventy-six trainees from 13 professions participated. This paper describes the structure, methods and the content of the programme and evaluates its success. Material was content analysed from participants' evaluations at the end of the programme and discussion during a focus group in which three trainees and three trainers participated. During the programme trainees' working methods moved from being detached experts towards client and family-orientation. Job satisfaction also improved. They began to appreciate interprofessional teamwork and found that client and family-oriented working methods supported families in using their own resources in solving problems. The study indicated that the sufficiently long process of education where the interprofessional collaboration has been put in practice already during the education is needed to change the theoretical framework and practical working methods of the trainees.     

The patient-centred interview: the key to biopsychosocial diagnosis and treatment

The article reports on some ideas and experiences gained from a holistic approach to working with patients and introduces a viewpoint that includes opinions on how postmodernism, the biopsychosocial model and a patient-centred interviewing style can change traditional, biomedical-oriented medicine. During the past 10 years, we have been instructing medical students in the use of this patient-centred interviewing model and have trained experienced general practitioners (GPs) in adopting it in 2-year family-oriented continuing medical education courses. We believe that doctors and other health care providers, particularly in primary care settings, need a comprehensive concept of human health and illness, and that skill in patient-centred interviewing is the product of a deep learning process. In conclusion, we have learned that a successful patient-centred interview helps the GP to better understand the patient and helps to explain the data that the patient presents. Patient-centred orientation and interviewing also change the communication between doctor and patient in a direction which supports the patient's and his/her family members' own resources in the healing process.     

Evaluation of a family-oriented continuing medical education course for general practitioners

OBJECTIVE: To explore the long-term effects of a 2-year Family Systems Medicine course. Fifteen experienced GPs participated in the training programme. SETTING: Continuing Education Centre, University of Tampere, Department of Public Health Science and General Practice, University of Oulu, Finland. METHODS: The participants assessed the development of their professional skills on the Doherty-Baird scale and filled in 2 questionnaires. The material obtained from the application form and 2 questionnaires was analysed using the grounded theory method. RESULTS: The reasons for taking part in the course seemed to be the constant increase in the workload, problems caused by the demands for change and adaptation, stress and exhaustion. Furthermore, 10 health centres out of 15 had adopted the population-based practice, which requires different working methods compared to the old routines. Some trainees reported that their family-centred working methods improved during the course. A year after the end of the training, all of the GPs who had participated were using such methods in their daily practice. Half of the participants felt that they had also improved the functioning of their working group by making it more family-oriented. The significance of multi-professional collaboration was one of the most important insights during the course. CONCLUSION: The 2-year family-oriented training programme provided GPs with systemic thinking and with new skills, including the ability to work with families. The programme raised awareness of the need for multi-professional collaboration in the primary care settings.     

Differences in brief interventions on excessive drinking and smoking by primary care physicians: qualitative study

BACKGROUND: Brief interventions by primary care physicians have been shown to be effective in reducing both smoking and excessive drinking. However, physicians seem to target smoking more often than drinking. We aimed to explore this difference in health promotion practises for finding ways to improve alcohol interventions in primary health centres. METHODS: Qualitative semistructured interviews of 35 physicians in four health centres in Finland, and triangulation by audit of notes made by these doctors concerning alcohol drinking and smoking in medical records (n = 1200) of randomly selected 20-60 years old patients, who had visited their physician at least once in a 12-month study period. RESULTS:On the basis of the interviews, there were five main differences in preventive work between issues of alcohol use and smoking: recognition, perceived importance as a health risk factor, intervention tools available, stigmatising label, and expectations about the effectiveness of counselling. In 106 (8.8%) of medical records, there was a mention of smoking, and in 82 (6.8%) of alcohol use (P < 0,0001). Quantity of alcohol consumption was described obscurely. When one of the visits was made for hypertension, diabetes, dyspepsia, general health check or heart arrhythmias, smoking was recorded more often than alcohol consumption. CONCLUSIONS: Tobacco use was mentioned more often in medical records than alcohol drinking. Physicians were more comfortable in undertaking a preventive approach for smoking than for alcohol use. The factors contributing to this difference must be considered in any attempts to improve implementation of secondary prevention of alcohol misuse.     

Between a rock and a hard place: the question of money at St. Petersburg women's clinics.

The new financing mechanisms introduced into the Russian health care system since the beginning of the 1990s have not resolved its severe financial problems. This article examines the consequences for outpatient services and the daily work of individual doctors in St. Petersburg, using women's reproductive health services as a case example. Interview and observational data reveal a constant opposition between formal rules and informal practices at both the administrative and polyclinic levels. Polyclinics for women's reproductive health services have developed various strategies as a response to insufficient financing, but many of these strategies are questionable within the current mandatory health insurance system. Ordinary doctors perceive the development as mainly negative. The results raise the question of increasing arbitrariness, from patients' perspective, in the health services provided. The study illustrates how in a post-socialist context, the past constantly permeates the present in the form of novel adaptations to the new social context.     

Inequalities in health and health service utilisation among reproductive age women in St. Petersburg,Russia: a cross-sectional study

Background  

Russian society has faced dramatic changes in terms of social stratification since the collapse of the Soviet Union. During this time, extensive reforms have taken place in the organisation of health services, including the development of the private sector. Previous studies in Russia have shown a wide gap in mortality between socioeconomic groups. There are just a few studies on health service utilisation in post-Soviet Russia and data on inequality of health service use are limited. The aim of the present study was to analyse health (self-rated health and self-reported chronic diseases) and health care utilisation patterns by socioeconomic status (SES) among reproductive age women in St. Petersburg.     

Somatizing frequent attenders in primary health care

OBJECTIVE: The aim of this case-control study was to investigate the association of somatization with frequent attendance in primary health care. METHODS: Frequent attenders in a health center (FAs) (N=112) and age- and sex-matched controls (COs) (N=105) constituted the study series. Data were collected from annual statistics, medical records, postal questionnaires and personal interviews. Psychological distress was assessed using Symptom Checklist-36 (SCL-36), alexithymia was measured with Toronto Alexithymia Scale-20 (TAS-20) and hypochondriasis was screened with Whiteley Index (WI). RESULTS: About one-third of FAs were somatizers when a cut-off point of eight symptoms on the SCL-36 somatization subscale was used as a criterion. The significant association of somatization with frequent attendance disappeared in multivariate analyses when adjusted for age, sex and chronic somatic illnesses. Hypochondriacal beliefs and psychiatric comorbidity were connected with FAs' somatization. Hypochondriacal beliefs explained somatizers' frequent attendance. A significant interaction effect between somatization and hypochondriacal beliefs was found when explaining frequent attendance. CONCLUSION: The results emphasize the need to use a comprehensive approach of somatization, including hypochondriacal beliefs, when treating somatizing FA patients in primary health care.     

Factors influencing inquiry about patients' alcohol consumption by primary health care physicians: qualitative semi-structured interview study

BACKGROUND: Early recognition of and intervention in risky alcohol consumption has been shown to be an effective way to reduce the harm. However, primary care physicians are still not screening for and intervening sufficiently in their patients' alcohol misuse. OBJECTIVE: The purpose of this study was to explore factors having an effect on primary health care physicians inquiring about patients' alcohol consumption. METHOD: A qualitative study of primary care physicians' experiences and views based on tape recorded semi-structured interviews was carried out on all physicians (n = 35) working at four health centres in Eastern Finland. RESULTS: Seven main categories were identified that either prevent or promote discussion about alcohol consumption: the sensitive nature of alcohol drinking; the reason for consultation; awareness of a patient's alcohol problem; patient factors; availability of intervention tools; expectations of effectiveness of interventions; and lack of time. CONCLUSIONS: There still exist many barriers to initiating discussions about alcohol in the consultation room. Changing the frame of reference of the concept of alcohol drinking from an addictive disease to a general lifestyle risk factor could overcome many of these barriers.