GPs' negotiation strategies regarding sick leave for subjective health complaints

OBJECTIVES

To explore general practitioners' (GPs') specific negotiation strategies regarding sick-leave issues with patients suffering from subjective health complaints.

DESIGN

Focus-group study.

SETTING

Nine focus-group interviews in three cities in different regions of Norway.

PARTICIPANTS

48 GPs (31 men, 17 women; age 32-65), participating in a course dealing with diagnostic practice and assessment of sickness certificates related to patients with subjective health complaints.

RESULTS

The GPs identified some specific strategies that they claimed to apply when dealing with the question of sick leave for patients with subjective health complaints. The first step would be to build an alliance with the patient by complying with the wish for sick leave, and at the same time searching for information to acquire the patient's perspective. This position would become the basis for the main goal: motivating the patient for a rapid return to work by pointing out the positive effects of staying at work, making legal and moral arguments, and warning against long-term sick leave. Additional solutions might also be applied, such as involving other stakeholders in this process to provide alternatives to sick leave.

CONCLUSIONS AND IMPLICATIONS

GPs seem to have a conscious approach to negotiations of sickness certification, as they report applying specific strategies to limit the duration of sick leave due to subjective health complaints. This give-and-take way of handling sick-leave negotiations has been suggested by others to enhance return to work, and should be further encouraged. However, specific effectiveness of this strategy is yet to be proven, and further investigation into the actual dealings between doctor and patients in these complex encounters is needed.

Shame, honor and responsibility in clinical dialog about lifestyle issues: a qualitative study about patients' presentations of self

OBJECTIVE

To explore how patients enact presentations of self in consultations dealing with lifestyle in general practice.

METHODS

We conducted a qualitative observational study with thematic, cross-case analysis of video-recorded consultations inspired by discourse analysis.

RESULTS

Patients presented themselves with an orientation toward responsibility in dialog about lifestyle. They described how they were taking care of themselves and doing their best. In this respect, they demonstrated their achievements as matters of honor. If one lifestyle issue was considered problematic, in some cases patients shifted attention to another, of which they were more proud. In areas where they were not doing well, some patients revealed shame for not acting responsibly. In such cases, patients spoke of themselves in terms of self-deprecation or admitted not living up to expected standards.

CONCLUSION

Negotiations of shame and honor, revolving around personal responsibility, are embedded in clinical discourse about lifestyle. Patients take a proactive role in presenting and defending the self against shame.

PRACTICE IMPLICATIONS

GPs should pay more attention to the tacit role of shame in consultations. Failure to do so could lead to distance and hostility while a strategy to acknowledge the impact of shame could help develop and strengthen the doctor-patient relationship.

How can a brief intervention contribute to coping with back pain? A focus group study about participants’ experiences

Background: Our aim was to explore how individuals who had participated in a brief back and neck pain intervention perceived connections between the intervention and their subsequent coping. Methods: Three focus group discussions were conducted with a sample of ten employees aged 20–67 years, who had participated in a brief intervention for back and neck pain, perceived the intervention as helpful and had returned or remained at work subsequent to the intervention. Participants were invited to share stories of how the intervention had made a positive difference to their work situation and everyday life and helped them cope with their complaints. Systematic text condensation was used for analysis. Results: Analysis revealed several aspects of how the participants considered the intervention to be helpful. They emphasized the importance of having the information delivered in a comprehensible way, with the use of practical examples and images of the spine. Discussions revealed the significance of trusting the lecturers and perceiving them as experts. Understanding why they felt the pain and that it was not a sign of serious disease changed the participants’ perception of how they could live with the complaints. They told stories of how they had exceeded their previous limits and dared to undertake activities they previously had avoided due to fear. Conclusions: Having confidence in the lecturers and seeing them as experts that delivered the information in a comprehensible way helped participants to cope with their pain and was seen as the most important aspects of the brief back and neck pain intervention.

End-of-life expectations and experiences among nursing home patients and their relatives--a synthesis of qualitative studies

OBJECTIVE

Synthesize research about patients' and relatives' expectations and experiences on how doctors can improve end-of-life care in nursing homes.

METHODS

We systematically searched qualitative studies in English in seven databases (Medline, Embase, PsycINFO, CINAHL, Ageline, Cochrane Systematic Reviews and Cochrane Trials). We included 14 publications in the analysis with meta-ethnography.

RESULTS

Patients and families emphasized the importance of health personnel anticipating illness trajectories and recognizing the information and palliation needed. Family members who became proxy decision-makers reported uncertainty and distress when guidance from health personnel was lacking. They worried about staff shortage and emphasized doctor availability. Relatives and health personnel seldom recognized patients' ability to consent, and patients' preferences were not always recognized.

CONCLUSION

Nursing home patients and their relatives wanted doctors more involved in end-of-life care. They expected doctors to acknowledge their preferences and provide guidance and symptom relief.

PRACTICE IMPLICATIONS

High-quality end-of-life care in nursing homes relies on organization, funding and skilled staff, including available doctors who are able to recognize illness trajectories and perform individualized Advance Care Planning.

Patients with persistent medically unexplained physical symptoms: a descriptive study from Norwegian general practice

BACKGROUND

Further research on effective interventions for patients with peristent Medically Unexplained Physical Symptoms (MUPS) in general practice is needed. Prevalence estimates of such patients are conflicting, and other descriptive knowledge is needed for development and evaluation of effective future interventions. In this study, we aimed to estimate the consultation prevalence of patients with persistent MUPS in general practice, including patients' characteristics and symptom pattern, employment status and use of social benefits, and the general practitioners' (GPs) management strategy.

METHOD

During a four-week period the participating Norwegian GPs (n=84) registered all consultations with patients who met a strict definition of MUPS (>3 months duration and function loss), using a questionnaire with simple tick-off questions. Analyses were performed with descriptive statistics for all variables and split analysis on gender and age.

RESULTS

The GPs registered 526 patients among their total of 17 688 consultations, giving a consultation prevalence of persistent MUPS of 3%. The mean age of patients was 46 years, and 399 (76%) were women. The most frequent group of symptoms was musculoskeletal problems, followed by asthenia/fatigue. There was no significant gender difference in symptom pattern. Almost half of the patients were currently working (45%), significantly more men. The major GP management strategy was supportive counseling.

CONCLUSION

A consultation prevalence rate of 3% implies that patients with persistent MUPS are common in general practice. Our study disclosed heterogeneity among the patients such as differences in employment status, which emphasizes the importance of personalized focus rather than unsubstantiated stereotyping of "MUPS patients" as a group.

Case definitions for chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME): a systematic review

OBJECTIVE

To identify case definitions for chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME), and explore how the validity of case definitions can be evaluated in the absence of a reference standard.

DESIGN

Systematic review.

SETTING

International.

PARTICIPANTS

A literature search, updated as of November 2013, led to the identification of 20 case definitions and inclusion of 38 validation studies.

PRIMARY AND SECONDARY OUTCOME MEASURE

Validation studies were assessed for risk of bias and categorised according to three validation models: (1) independent application of several case definitions on the same population, (2) sequential application of different case definitions on patients diagnosed with CFS/ME with one set of diagnostic criteria or (3) comparison of prevalence estimates from different case definitions applied on different populations.

RESULTS

A total of 38 studies contributed data of sufficient quality and consistency for evaluation of validity, with CDC-1994/Fukuda as the most frequently applied case definition. No study rigorously assessed the reproducibility or feasibility of case definitions. Validation studies were small with methodological weaknesses and inconsistent results. No empirical data indicated that any case definition specifically identified patients with a neuroimmunological condition.

CONCLUSIONS

Classification of patients according to severity and symptom patterns, aiming to predict prognosis or effectiveness of therapy, seems useful. Development of further case definitions of CFS/ME should be given a low priority. Consistency in research can be achieved by applying diagnostic criteria that have been subjected to systematic evaluation.

Sickness absence, marginality, and medically unexplained physical symptoms: a focus-group study of patients' experiences

PURPOSE

Medically unexplained physical symptoms (MUPS) form a major cause of sickness absence. The purpose of this study was to explore factors which may influence further marginalization among patients with MUPS on long-term sickness absence.

METHODS

Two focus-group discussions were conducted with a purposive sample of 12 participants, six men and six women, aged 24-59 years. Their average duration of sickness absence was 10.5 months. Participants were invited to share stories about experiences from the process leading to the ongoing sickness absence, with a focus on the causes being medically unexplained. Systematic text condensation was applied for analysis. Inspired by theories of marginalization and coping, the authors searched for knowledge of how patients' positive resources can be mobilized to counteract processes of marginality.

RESULTS

Analysis revealed how invisible symptoms and lack of objective findings were perceived as an additional burden to the sickness absence itself. Factors that could counteract further marginalization were a supportive social network, positive coping strategies such as keeping to the daily schedule and physical activity, and positive attention and confidence from professionals.

CONCLUSIONS

Confidence from both personal and professional contacts is crucial. GPs have an important and appreciated role in this aspect.

Systematic text condensation: a strategy for qualitative analysis

AIMS

To present background, principles, and procedures for a strategy for qualitative analysis called systematic text condensation and discuss this approach compared with related strategies.

METHODS

Giorgi's psychological phenomenological analysis is the point of departure and inspiration for systematic text condensation. The basic elements of Giorgi's method and the elaboration of these in systematic text condensation are presented, followed by a detailed description of procedures for analysis according to systematic text condensation. Finally, similarities and differences compared with other frequently applied methods for qualitative analysis are identified, as the foundation of a discussion of strengths and limitations of systematic text condensation.

RESULTS

Systematic text condensation is a descriptive and explorative method for thematic cross-case analysis of different types of qualitative data, such as interview studies, observational studies, and analysis of written texts. The method represents a pragmatic approach, although inspired by phenomenological ideas, and various theoretical frameworks can be applied. The procedure consists of the following steps: 1) total impression - from chaos to themes; 2) identifying and sorting meaning units - from themes to codes; 3) condensation - from code to meaning; 4) synthesizing - from condensation to descriptions and concepts. Similarities and differences comparing systematic text condensation with other frequently applied qualitative methods regarding thematic analysis, theoretical methodological framework, analysis procedures, and taxonomy are discussed.

CONCLUSIONS

Systematic text condensation is a strategy for analysis developed from traditions shared by most of the methods for analysis of qualitative data. The method offers the novice researcher a process of intersubjectivity, reflexivity, and feasibility, while maintaining a responsible level of methodological rigour.

Phenomena associated with sick leave among primary care patients with Medically Unexplained Physical Symptoms: a systematic review

OBJECTIVE

To explore and synthesize the literature on phenomena associated with sick leave among patients with Medically Unexplained Physical Symptoms (MUPS).

DESIGN

A systematic review of the literature was undertaken in three phases: (1) a search of the following databases: Medline, Embase, Psych Info, Cochrane Collaboration Library, Digital Dissertations, DiVA, SweMed +, NORART, and ISI Web of Science, (2) selection of studies based on pre-specified inclusion criteria was undertaken, extracting study design and results, (3) quality assessment was undertaken independently by two reviewers. Due to heterogeneity in study designs, populations, interventions, and outcome measures, a mixed research synthesis approach was used. Results were assessed in a pragmatic and descriptive way; textual and numerical data were extracted from the included studies, and classified into patient- and doctor-related factors.

RESULTS

Sixteen studies were included. With regard to patients, an association was found between sick leave and psychiatric comorbidity as well as total symptom burden. With regard to doctors, knowledge of the patient, sympathy, and trust appeared to increase the probability of the patient being sick-listed. None of the interventions in the educational programmes aiming to improve doctors' management of MUPS patients succeeded in lowering sick leave.

IMPLICATIONS

Despite MUPS being a leading cause of sickness absence, the review identified only a small number of studies concerning phenomena associated with sick leave. The authors did not identify any studies regarding the impact of the working conditions on sick leave among MUPS patients. This is an important area for further studies.

Alcohol-related hospital admissions: missed opportunities for follow up? A focus group study about general practitioners' experiences

AIMS

To explore general practitioners' (GPs') follow-up experiences with patients discharged from hospital after admittance for alcohol-related somatic conditions.

DESIGN AND PARTICIPANTS

Two focus groups with GPs (four women and 10 men), calling for stories about whether the intervention given in the hospital had been recognised by the GP and how this knowledge affected their follow up of the patient's alcohol problem. Systematic text condensation was applied for analysis.

FINDINGS

A majority of the GPs had experienced patients with already recognised alcohol problems being rediscovered by the hospital staff. Still, they presented examples of how seeing the patient in a different context might present new opportunities. Few participants had received adequate information from the hospital about their patient's alcohol status, and they emphasised that a report about what had happened and what was planned was needed for follow up. Care pathways for patients with alcohol problems were seen as fragmented. Yet they described how alcohol-related hospital admissions might function as an eye-opener for the patient and a window of opportunity for lifestyle change.

CONCLUSIONS

Hospital admittances provide important opportunities for change, but hospital care is seen as fragmented and poorly communicated to the GPs. For shared responsibility and follow up, all participating agents, including the patient, must be sufficiently informed about what has happened and what will follow. For the patient, hospital admittance is usually brief, while the relationship with their GP is long term, even lifelong. GPs are therefore key partners for programme development.

Lesbian women's experiences with healthcare providers in the birthing context: a meta-ethnography

OBJECTIVE

to explore research knowledge about lesbian women's experiences with health-care providers in the birthing context.

METHOD

a systematic search for relevant qualitative studies in selected databases identified 13 articles of sufficient quality. The findings were synthesized using a meta-ethnographic approach as described by Noblit and Hare. SYNTHESIS AND FINDINGS: issues related to covert or overt homophobia and prejudice were demonstrated and were sometimes mediated by subtle mechanisms that were difficult to understand and to manage. On the other hand, small gestures of support were described to make a huge difference. A lack of knowledge was demonstrated, contrasted by staff showing a positive and informed attitude. Disclosure was an important issue, but due to the risk involved the women demonstrated a need to be in control. Finally, being acknowledged, both as individuals and as family were considered vital. In this regard, it was essential to recognize and include co-mother as equal parent and to look upon lesbian sexuality as normal and natural.

KEY CONCLUSIONS

midwives' emotional involvement in the situation is significant for moral perception of the women's intimate citizenship, even when they are distressed by lesbian sexuality.

IMPLICATIONS FOR PRACTICE

our findings reveal the importance of including sexuality as an issue deserving reflection in maternity wards, whether or not this might cause unrest in midwives who do not feel comfortable with intimate citizenships beyond mainstream.

General practitioners' strategies to identify alcohol problems: a focus group study

OBJECTIVE

To explore general practitioners' (GPs') experiences with addressing alcohol in the consultation without prior invitation from the patient.

DESIGN AND SETTING

Two focus group interviews were conducted with a purposive sample of 13 Norwegian GPs in the Stavanger region. Participants were invited to talk about situations where the doctor initiated discussion of alcohol. Systematic text condensation was applied for analysis.

RESULTS

Participants presented a broad range of examples of what made GPs initiate discussion of alcohol, how they brought up the subject, and what happened when they did so. Sometimes they were just acting on a hunch. Family members were also occasionally prompting the doctor to act, or recent serious incidents worked as cues for asking. Routinely taking or creating an opportunity to explore was also common. Directly confronting the patient was a challenging task, and the participants disclosed experiences of how this had been achieved.

CONCLUSIONS

Pragmatic case-finding appears to be a field of competence which can be further developed, but should be adapted to the clinical setting and the GP's personal style. It is suggested that strategies for dealing with alcohol problems in general practice should be based on a proper understanding of this specific medical context, and be adaptable to different clinical situations and the individual patient.

Lesbian women coping with challenges of minority stress: A qualitative study

Aims: Even though homosexuality is apparently widely accepted, minority stress prevails. Successful coping may reduce the negative impact of minority stress on health. We wanted to explore lesbian women’s positive coping experiences related to sexual minority stress. Methods: A convenience sample of self-defined lesbian women living in Norway was recruited mainly via internet. Qualitative data about coping strategies were obtained as written answers to a web-based, open-ended questionnaire. Data were analysed with systematic text condensation supported by theories of stress and coping, and salutogenesis. Results: Openness about the lesbian orientation, and how disclosure was carried out, were means to counter anticipated prejudice. Maintaining dignity when prejudice appeared could be accomplished by actions to demand one’s rights or claim respect, or by unexpressed thoughts boosting self-respect when unable to talk back. Prejudice within family relations lead to compromises to enable contact, but never compromising self-respect. Underlying successful coping strategies we identified a personal conviction that being lesbian is respectable and worthy – lesbian confidence. Conclusions: Promoting lesbian confidence, a healthcare provider can contribute to psychological wellbeing and enhance health among lesbian women. Open lesbian women in the community, who are responded to in a positive or every-day-like manner, may nurture lesbian confidence and contribute to coping and health.

Obesity, stigma, and responsibility in health care: A synthesis of qualitative studies

Objective

To synthesize research findings on experiences and attitudes about obesity and stigma in health care.

Methods

We compiled qualitative studies and applied Noblitt & Hare's meta ethnography to identify, translate, and summarize across studies. Thirteen qualitative studies on experiences and attitudes about obesity and stigma in health care settings were identified and included.

Results

The study reveals how stigmatizing attitudes are enacted by health care providers and perceived by patients with obesity. Second-order analysis demonstrated that apparently appropriate advice can be perceived as patronizing by patients with obesity. Furthermore, health care providers indicate that abnormal bodies cannot be incorporated in the medical systems—exclusion of patients with obesity consequently happens. Finally, customary standards for interpersonal respect are legitimately surpassed, and patients with obesity experience contempt as if deserved. Third-order analysis revealed conflicting views between providers and patients with obesity on responsibility, whereas internalized stigma made patients vulnerable for accepting a negative attribution. A theoretical elaboration relates the issues of stigma with those of responsibility.

Conclusion

Contradictory views on patients’ responsibility, efforts, knowledge, and motivation merge to internalization of stigma, thereby obstructing healthy coping and collaboration and creating negative contexts for empowerment, self-efficacy, and weight management. Professionals need to develop their awareness for potentially stigmatizing attitudes towards vulnerable patient populations.

Why are general practitioners reluctant to enrol patients into a RCT on sick leave? A qualitative study

AIMS

To explore the reluctance of, and examine the arguments given by Norwegian general practioners (GPs), regarding their unwillingness to recruit their patients for a study where sick leave would be based on randomization.

METHODS

A qualitative study presenting individual arguments from 50 Norwegian GPs, as written responses to a web-based, open-ended questionnaire. The responses, ranging from 3-145 words, were analysed with systematic text condensation.

RESULTS

The GPs did not want to participate in a study where sick leave was decided by randomization. First, the complexity of clinical judgment was addressed. Would it be ethically acceptable to set the professional and medical assessment aside, and if so, was there any better judge than the regular GP in making this important decision? Second, the arguments dealing with sick leave as a human and legal right were addressed. Will patients feel they have a legitimate right to sick leave and will they be open for discussion with their GP? Third, the risk of jeopardizing the relationship between patient and doctor was emphasized. Would the patients be able to trust their GP if he or she offered the patient entry into a trial where sick leave would be decided by randomization?

CONCLUSIONS

Randomization of sick leave in general practice in Norway was not viewed as feasible by the GPs themselves because of the importance of clinical judgment, ethical obligations, and the belief that the patients would refuse participation, and thereby, that the doctor-patient relationship would be disturbed.

The Norwegian EUROPEP questionnaire for patient evaluation of general practice: data quality, reliability and construct validity

BACKGROUND

The EUROPEP is a widely used international instrument to evaluate general practice care from the perspective of patients, but measurement properties including reliability at the GP level are not sufficiently documented.

OBJECTIVE

The objectives of this study were to assess the psychometric properties of the Norwegian version of the EUROPEP and estimate GP-level reliability for scales and items.

METHODS

Nine hundred patients consulting nine GPs at a medical centre in Norway were invited to complete the Norwegian EUROPEP at home following a recent consultation. We assessed item missing and ceiling effects and used factor analysis to assess the structure of the 23 items of the EUROPEP. Scales were tested for reliability and construct validity, while reliability at the GP level was tested for items and scales.

RESULTS

Five hundred and fifty-seven patients (61.9%) returned the questionnaire. Seven of 23 items had missing responses >10% and 20% had high ceiling effects. Factor analysis identified two groups of questions that formed scales with satisfactory internal consistency reliability and validity. The clinical behaviour scale (12 items) and the organization of care scale (4 items) met the criterion of 0.7 for Cronbach's alpha. The GP-level reliability was >0.7 for both scales, but 9 of 23 items were below the criterion of 0.7.

CONCLUSIONS

The study identified two scales in the Norwegian EUROPEP instrument with satisfactory psychometric properties. However, high proportions of item non-response large ceiling effects and low GP-level reliability for several items indicate the need for further instrument refinement.

Finding the right balance of physical activity: a focus group study about experiences among patients with chronic fatigue syndrome

OBJECTIVE

To explore contexts of experiences of physical activity perceived as beneficial or harmful for CFS patients.

METHODS

A qualitative study with empirical data from two focus groups with purposive sampling. Mean age was 50, two of ten participants were male, and social demographics varied. Participants were invited to share stories of good as well as bad experiences concerning physical activity. Data were analysed with systematic text condensation.

RESULTS

Participants were not averse to physical activity, but specific preconditions would determine how the activity was perceived. Physical activity was experienced as helpful and enjoyable, especially related to leisure activities where flexible and individual adaptation was feasible. Non-customized activity may precipitate set-backs giving patients the impression of losing control and being betrayed by their bodies. Strategies to review energy usage in daily life could adjust expectations, diminish stress load and assist in approaching a more appropriate priority and balance.

CONCLUSION

Self-management, body awareness and physical activity of choice combined with facilitation and advice from health care professionals is essential to achieve a positive outcome.

PRACTICE IMPLICATIONS

Exercise programmes should be adapted, paced, and self-managed in accordance with personal preferences and activity levels to be beneficial and empowering for CFS patients.

Hope in action-facing cardiac death: A qualitative study of patients with life-threatening disease

Coping with existential challenges is important when struck by serious disease, but apart from cancer and palliative care little is known about how patients deal with such issues and maintain hope. To explore how patients with life-threatening heart disease experience hope when coping with mortality and other existential challenges, we conducted a qualitative study with semi-structured interviews. We made a purposive sample of 11 participants (26–88 years) who had experienced life-threatening disease: eight participants with serious heart disease, two with cancer, and one with severe chronic obstructive pulmonary disease. Analysis was by systematic text condensation. The findings showed that hope could enhance coping and diminish existential distress when patients were confronted with mortality and other existential challenges. Hope was observed as three types of dynamic work: to shift perception of mortality from overwhelming horror toward suppression or peaceful acceptance, to foster reconciliation instead of uncertainty when adapting to the new phase of life, and to establish go-ahead spirit instead of resignation as their identity. Meaning of life could, hence, be sustained in spite of serious threats to the persons' future, everyday life, and self-conception. The work of hoping could be supported or disturbed by relationships with family, friends, and health care professionals. Hope can be regarded as an active, dynamic state of existential coping among patients with life-threatening disease. Physicians may support this coping and thereby provide personal growth and alleviation of existential distress by skillfully identifying, acknowledging, and participating in the work of hoping performed by the patient.

[Exercise therapy for patients with chronic fatigue syndrome]

BACKGROUND

Post-exertional fatigue is the main symptom of chronic fatigue syndrome. Evidence-based guidelines recommend cognitive behavioral therapy and graded exercise therapy. In this article, we present a systematic review of outcome studies and discuss procedures for individualized exercise therapy for patients with chronic fatigue syndrome.

MATERIAL AND METHODS

The effect of exercise treatment for these patients was assessed through a meta-analysis of randomized controlled trials which were identified through a systematic literature review. Effect size was calculated for fatigue, pain and health-related quality of life and the GRADE system was used to estimate the documentation level (quality of the evidence and strength of the recommendations).

RESULTS

Seven outcome studies were included in the meta-analysis. They demonstrated that exercise therapy seems to reduce fatigue, but the results were inconclusive for pain and health-related quality of life. The documentation level is moderate to low and further research can modify the results in positive or negative directions. We found no indications of adverse effects of individualized exercise programs which were adapted to the patients' functional level and included adequate follow-up.

INTERPRETATION

In light of general knowledge about positive health effects of exercise therapy and empirically based hypotheses about disease mechanisms in chronic fatigue syndrome, we conclude that further research has a high probability of confirming recommendations on individualized exercise therapy to these patients.

Obesity in general practice: a focus group study on patient experiences

OBJECTIVE

To explore obese patients' experiences with GPs' management of their weight problems.

METHODS

Focus-group study with a purposive sample of 13 participants (eight women and five men), aged 30-55 years, with BMI above 40, or BMI above 35 with additional weight-related problems. Two focus-group interviews were conducted, inviting the participants to speak about their health care experiences from general practice. Analysis applied Systematic Text Condensation inspired by Giorgi's approach, searching for issues describing or discussing participants' experiences of GPs' obesity management.

RESULTS

Obese patients want their GPs to put their weight problems on the agenda. When the patient appears reluctant, it may be a sign of embarrassment rather than rejection of the issue. However, restricted attention to obesity could lead to neglect of patients' problems. Participants complained that GPs often demonstrated insufficient engagement and knowledge regarding service resources for obesity treatment, leaving the responsibility for information on available referral resources to the patient. Finally, considerate attitudes in the GPs are needed for follow-up to be experienced as helpful by the patients. Vulnerable feelings of failure could be reinforced by well-intended advice. Degrading attitudes were perceived as especially subversive when they came from doctors.

CONCLUSIONS

The challenge for the GP is to increase his or her competence in individualized and evidence-based counselling, while acknowledging the efforts needed by the patient to achieve permanent change, and shifting attention from shame to coping.