[Quality assurance and review in general practice]

Local procedures for quality assurance are needed to provide safe and reliable health care services. Fjellsiden Health Centre has since 1997 developed a system for quality assurance, which includes an annual review of selected quality items. This article presents the basic elements of the system, supplemented by experiences gained from its implementation. A local manual for essential procedures is the basis for the quality system. Other quality assurance activities are weekly practice meetings based on an annual plan for professional updating, including assessment of new guidelines, audits, cross-disciplinary meetings; reviews of "nearly-mistakes", resuscitation training, user surveys, and surveillance of the working environment. Specified routines are available for information safety. Local medication and equipment are regularly reviewed. Lab quality is regulated by a special system. A simple checklist based on locally developed specifications--relevant and vital issues that can be operationalized and assessed in a simple way--is used for annual quality review. The checklist specifications have lead to discussions about what is good enough and why. It has been easy to compile and summarize the data used for the annual review. We have experienced that our dedication to relevance, reality, and flexible format has contributed to giving quality assurance a natural place in a busy general practice office.

[Whirlpool and pseudomonas infection--a local outbreak]

BACKGROUND

Hot tubs and whirlpools are popular in Norway, but related health risks are not well-known. Manifestations of bathing-associated Pseudomonas aeruginosa-infections can be seen in many organ systems. The most common of these, Pseudomonas folliculitis, is a self-limiting disease in otherwise healthy people, and does not require antibiotic treatment.

MATERIAL AND METHODS

We describe a local outbreak involving 6 people who had used the same hot whirlpool. The disease manifestations were different, and were initially confused with impetigo and mastitis/mammary tumour.

RESULTS AND INTERPRETATION

Signs and symptoms are described, documented with photos and discussed in relation to knowledge about Pseudomonas infection and its manifestations. After suspecting the hot tub as a source of infection, diagnosis was made highly probable by bacteriological specimens from the tub. Hot tub-associated infections with Pseudomonas aeruginosa are probably more common than previously anticipated, and can easily be confused with conditions of different aetiology. They indicate unsatisfactory routines in tub maintenance. Improved guidelines for hot-tub-owners and the use of dip-slide cultures to secure routines are likely to prevent bathing-associated Pseudomonas infections.

Avoiding humiliations in the clinical encounter

OBJECTIVES

To explore potentials for avoiding humiliations in clinical encounters, especially those that are unintended and unrecognized by the doctor. Furthermore, to examine theoretical foundations of degrading behaviour and identify some concepts that can be used to understand such behaviour in the cultural context of medicine. Finally, these concepts are used to build a model for the clinician in order to prevent humiliation of the patient.

THEORETICAL FRAME OF REFERENCE

Empirical studies document experiences of humiliation among patients when they see their doctor. Philosophical and sociological analysis can be used to explain the dynamics of unintended degrading behaviour between human beings. Skjervheim, Vetlesen, and Bauman have identified the role of objectivism, distantiation, and indifference in the dynamics of evil acts, pointing to the rules of the cultural system, rather than accusing the individual of bad behaviour. Examining the professional role of the doctor, parallel traits embedded in the medical culture are demonstrated. According to Vetlesen, emotional awareness is necessary for moral perception, which again is necessary for moral performance.

CONCLUSION

A better balance between emotions and rationality is needed to avoid humiliations in the clinical encounter. The Awareness Model is presented as a strategy for clinical practice and education, emphasizing the role of the doctor's own emotions. Potentials and pitfalls are discussed.

How do patients at risk portray candidates for coronary heart disease? A qualitative interview study

OBJECTIVE

To explore how patients at risk of coronary heart disease (CHD) portray candidates for CHD.

DESIGN

Qualitative interview study.

SETTING

Norway.

SUBJECTS

A total of 20 men and 20 women diagnosed with heterozygous familial hypercholesterolemia (FH) recruited through a lipid clinic.

MAIN OUTCOME MEASURES

Participants' beliefs concerning persons who are considered candidates for CHD.

RESULTS

Some participants believed that CHD could happen to anyone, while the majority conveyed detailed notions of persons they considered to be likely victims of CHD. Participants often portrayed the coronary candidate as someone who was different from themselves. Among those who mentioned gender, all presented the candidate as a man. Some women said that they had to reconcile themselves to being at risk of CHD, since they at first had conceived CHD as a man's disease. While some participants considered their notions to be valid for assessing people's risk of CHD, others questioned how valid their notions were.

CONCLUSION

Doctors should recognize that distancing is a way patients cope with risk and that such a strategy may have psychological and moral reasons. When communicating about risk, doctors should take into account that patients' notions of risk may differ from medical notions of risk.

Patients' written life stories: a gateway for understanding

OBJECTIVE

To explore how statements drawn from patients' written life stories can help general practitioners understand their patients' maladaptive thought patterns and their negative schemata.

DESIGN

Qualitative study of written life stories.

SETTING

General practice in Copenhagen, Denmark.

SUBJECTS

A total of 22 consecutive patients aged 23-49 years, who were invited by their GP to participate in cognitive therapy owing to depressive or anxiety-related disorders, including unexplained bodily symptoms.

THEORETICAL FRAME OF REFERENCE

Beck's information-processing model of anxiety.

RESULTS

Analysis of the written life stories disclosed aspects of negative expectations of life, the self, or the values and capabilities of others or of the patient him- or herself. Three main beliefs were identified: (1) the world is evil, (2) only the perfect is of value, and (3) emotions are dangerous. The patients describe events and experiences in negative terms that others might have interpreted as neutral or positive. For some this translated into a sort of all-or-nothing kind of thinking. Anger and other strong feelings were forbidden. Responsibility for the life of others was a dominant feature.

CONCLUSIONS

Written life stories reveal knowledge of the patient's dysfunctional thought patterns. This may be a useful shortcut in therapy.

Being lesbian--does the doctor need to know?

BACKGROUND

A lesbian woman will have to choose whether to disclose or not in every new encounter, including when consulting her general practitioner (GP). She may fear a negative reaction in the doctor, based on knowledge of marginalization and prejudice of homosexuals throughout history.

OBJECTIVES

To explore patients' experiences concerning disclosure of their lesbian orientation to general practitioners (GPs), focusing on why they find it important, and what GPs can do to promote disclosure.

METHODS

One group interview was conducted, audiotaped, and transcribed verbatim. Qualitative analysis was conducted by systematic text condensation inspired by Giorgi's phenomenological approach. Six women aged 28-59 years, who self-identified as lesbian, were recruited through a web-based, publicly accessible network for research on homosexuality. Main outcome measures. Accounts of experiences where the patient thought that information of a lesbian sexual orientation was of importance in the consultation with a GP.

RESULTS

Disclosure can imply information of medical relevance, explain circumstances, and generate a feeling of being seen as one's true self. The intentional use of common consultation techniques may facilitate disclosure.

CONCLUSION

Lesbian patients may want to disclose their sexual orientation to the general practitioner but they experience certain barriers. These can be overcome when the GP provides an open and permissive context. GPs can benefit from knowledge concerning sexual orientation in their work with lesbian patients.

[Has the obesity epidemic reached Norway?]

BACKGROUND

The prevalence of obesity has increased worldwide during the last decades. The goal of this article is to explore whether the obesity epidemic has reached Norway.

MATERIAL AND METHODS

We have conducted a literature review where we identified and summarized recent population studies of prevalence, distribution and development trends of obesity among adults in Norway. We searched for articles from the last 5 years in PubMed, Google, Kvasir and Yahoo, with the search words "obes*", "prevalence" and "BMI". We included seven Norwegian population studies.

RESULTS

In the studies from 2000-2003, the prevalence of obesity (BMI > or = 30) was 11-29% (median 19.5%) for men and 9-38% (median 20%) for women. The prevalence of obese men aged 40-45 years has increased steadily from 1965-69 until today. The prevalence of obese women decreased from 1965-69 to 1984 before it started to increase steadily up till 2000-2003.

INTERPRETATION

Our review shows that the obesity epidemic has reached Norway, but the prevalence among all age groups should be established before we can determine the epidemic's extent.

Perceived vulnerability to heart disease in patients with familial hypercholesterolemia: a qualitative interview study

PURPOSE

Knowledge about the ways patients perceive their vulnerability to disease is important for communication with patients about risk and preventive health measures. This interview study aimed to explore how patients with a diagnosis of heterozygous familial hypercholesterolemia understand and perceive their vulnerability to coronary heart disease.

METHODS

We did a qualitative study of 40 patients with familial hypercholesterolemia who were recruited through a lipid clinic in Norway. We elicited participants' perceptions about their vulnerability to heart disease in semistructured interviews. Data were analyzed by systematic text condensation inspired by Giorgi's phenomenological method.

RESULTS

We found that participants negotiated a personal and dynamic sense of vulnerability to coronary heart disease that was grounded in notions of their genetic and inherited risk. Participants developed a sense of their vulnerability in a 2-step process. First, they consulted their family history to assess their genetic and inherited risk, and for many a certain age determined when they could expect to develop symptoms of coronary heart disease. Second, they negotiated a personal sense of vulnerability by comparing themselves with their family members. In these comparisons, they accounted for individual factors, such as sex, cholesterol levels, use of lipid-lowering medications, and lifestyle. Participants' personal sense of vulnerability to heart disease could shift dynamically as a result of changes in situational factors, such as cardiac events in the family, illness experiences, or becoming a parent.

CONCLUSIONS

Patients with a diagnosis of familial hypercholesterolemia negotiate a personal and dynamic sense of vulnerability to coronary heart disease that is grounded in their understanding of their genetic and inherited risk. Doctors should elicit patients' understanding of their family history and their personal vulnerability to individualize clinical management.

Women at risk of coronary heart disease experience barriers to diagnosis and treatment: a qualitative interview study

OBJECTIVE

To explore barriers in the health service to diagnosis and treatment experienced by women at increased risk of coronary heart disease (CHD).

DESIGN

Qualitative study using semi-structured interviews.

SETTING

Norway.

SUBJECTS

Twenty women diagnosed with heterozygous familial hypercholesterolemia (FH) recruited through a lipid clinic.

RESULTS

Women reported three specific barriers related to diagnosis and treatment of CHD. They had to struggle to take a cholesterol test; they experienced that their risk was being downplayed by doctors; and that their symptoms of CHD were misinterpreted when they consulted doctors for evaluation and treatment.

CONCLUSION

Stereotyping CHD as a man's disease may result in barriers to diagnosis and treatment for women. Doctors should ask the patient about the family history of CHD if a concern about heart disease is on the patient's agenda.

Coping with headache

OBJECTIVE

To describe self-initiated actions and cognitive strategies used for coping by women who suffer from episodic tension-type headache.

DESIGN

Qualitative data from focus-group interviews were analysed according to Giorgi's phenomenological approach, inspired by Lazarus's theory of coping.

SUBJECTS

A total of 15 women with tension-type headache, 20-60 years old, were recruited to three different focus groups through newspaper advertising.

RESULTS

To cope with episodic tension-type headache, rhythm and balance in actions like eating, drinking, and sleeping were essential. Several women used thermal modulation. Exercise was important. Taking charge of their own time, pace, and level of commitment and accepting the fact that they had to live with their headache were cognitive strategies used.

IMPLICATIONS

The general practitioner should identify the woman's choice of actions and cognitive strategies to manage her headache, and support her coping skills.

Making the invisible body visible. Bone scans, osteoporosis and women's bodily experiences

The imaging technology of bone scans allows visualization of the bone structure, and determination of a numerical value. Both these are subjected to professional interpretation according to medical (epidemiological) evidence to estimate the individual's risk of fractures. But when bodily experience is challenged by a visual diagnosis, what effect does this have on an individual? The aim of this study was to explore women's bodily experiences after a bone scan and to analyse how the scan affects women's self-awareness, sense of bodily identity and integrity. We interviewed 16 Danish women (aged 61-63) who had had a bone scan for osteoporosis. The analysis was based on Merleau-Ponty's perspective of perception as an embodied experience in which bodily experience is understood to be the existential ground of culture and self. Women appeared to take the scan literally and planned their lives accordingly. They appeared to believe that the 'pictures' revealed some truth in themselves. The information supplied by the scan fostered a new body image. The women interpreted the scan result (a mark on a curve) to mean bodily fragility which they incorporated into their bodily perception. The embodiment of this new body image produced new symptom interpretations and preventive actions, including caution. The result of the bone scan and its cultural interpretation triggered a reconstruction of the body self as weak with reduced capacity. Women's interpretation of the bone scan reorganized their lived space and time, and their relations with others and themselves. Technological information about osteoporosis appeared to leave most affected women more uncertain and restricted rather than empowered. The findings raise some fundamental questions concerning the use of medical technology for the prevention of asymptomatic disorders.

Long-term impact of elevated cardiovascular risk detected by screening. A qualitative interview study

OBJECTIVE

To explore how persons with an elevated cardiovascular risk score (CRS) balanced health-related advice against the life they wanted to live or were able to live.

SETTING

2000 Danes aged 30-50 were invited to participate in a health-screening project in general practice. Screenings were conducted at baseline and after one and five years, and included among other screening procedures a calculation of CRS (see Figure 1).

DESIGN

Participants with an elevated CRS were asked to participate in a qualitative semi-structured interview. They were selected by stratified purposeful sampling reflecting variations in age, sex. and perceived health.

SUBJECTS

Nine men and five women aged 33-50 years. THEORETICAL FRAMES OF REFERENCE: Bandura's theory of self-efficacy and the Health Belief Model's consideration of individuals' cues to act against a health threat supported analysis.

RESULTS

Being informed about an elevated CRS had a considerable impact on the informants. They initiated significant lifestyle changes, though only to a limited degree when such changes would affect their quality of life adversely. In cases where other results of the multiphasic screening were normal, interpreted as such, or if there were stressful circumstances in the informant's life, the elevated CRS receded into the background.

INTERPRETATION

Doctors, who inform individuals about the impact of risk factors, need to know that the consequences and health advice are not always interpreted by laypeople as supposed by the medical culture.

Why did I get chronic fatigue syndrome? A qualitative interview study of causal attributions in women patients

OBJECTIVES

To explore causal attributions among women with chronic fatigue syndrome (CFS).

DESIGN

Qualitative study where data from individual semi-structured interviews were analysed according to Malterud's systematic text condensation.

SETTING

Bergen, Norway.

SUBJECTS

A purposeful sample of eight women aged 25-55, recruited among members of a self-help organization.

MAIN OUTCOME MEASURES

Accounts of causal attribution for CFS among the informants, focusing on gender.

RESULTS

The participants agreed that their way of living could have increased the vulnerability of their resistance resources. Pressure they put upon themselves, workload burdens without subsequent relaxation, emotional conflicts, or preparing for assumed problem-solving were mentioned as gendered dimensions. They presented different explanations regarding potential triggers encountering their fragile immune systems, most often a virus infection. The participants thought women might have a weaker immune system than men, or that CFS was caused by a virus that women are more likely to catch. In their experience, their symptoms were activated when people put pressure on them, such that they might be nervous as to whether they could live up to the demands of their surroundings, and in the case of emotional strain related to family and work.

CONCLUSION

More studies are needed exploring hypotheses concerning the complex interplay between molecular predispositions and more or less gendered lifestyle issues in CFS. Doctors need to challenge their strong beliefs regarding medically unexplained conditions, where facts still remain unresolved. Recognizing this, the doctor may provide realistic support and advice, and contribute to the establishment of common ground for understanding and managing the condition.

The doctor who cried: a qualitative study about the doctor's vulnerability

PURPOSE

We wanted to explore those clinical events when doctors had exposed their vulnerability toward patients in a potentially beneficial way.

METHODS

We undertook a qualitative study based on memory work, a structured approach to transform memories into written texts. Study participants were 9 members of a research group who had known each other a couple of years. They were asked in advance to recall a clinical event during which vulnerability was perceived and exposed in a way appreciated positively by the patient. During a group meeting, participants wrote their individual memory stories recalling these events, and the subsequent group discussion was audiotaped, transcribed, and analyzed using a phenomenological approach, applying specific linguistic cues to reveal points of special interest. The main outcome measure was the vulnerability expressed by practitioners.

RESULTS

Vulnerability had been experienced and exposed by the participants on several occasions during which the patients had confirmed its potentially beneficial effect. All reported events could be interpreted as different ways of personal disclosure toward the patient. We identified two kinds of disclosure: spontaneously appearing emotions and considered sharing of experiences.

CONCLUSION

A spontaneous exposure of emotions from the doctor may help the patient, and sharing personal experiences may lead to constructive interaction. We need to know more about when and how personal disclosure and other aspects of vulnerability exposed by the doctor are experienced as beneficial by the patient.

[Is Norwegian public health policy going to be more individual-oriented?]

BACKGROUND

According to a recent Danish study, public health policies in Sweden and Denmark have become more oriented towards the individual over the last few years. We wanted to explore the development in Norway over the last decade.

MATERIAL AND METHODS

Changes in policy have been identified by comparing arguments about motives, definitions and strategies in two government white papers on public health from 1993 and 2003.

RESULTS AND INTERPRETATION

Both white papers discuss public health policy in a broad sense, not only the state of the health and social services. We find that the 2003 paper focused on the individual's responsibility for his or her own health; the 1993 paper was more about institutions and structures. We conclude that Norwegian policy in this field has an increasing focus on the individual. At the same time we observe a greater concern over social inequality in relation to health.

"I recognise myself in that situation..." Using photographs to encourage reflection in general practitioners

Photographs can elicit strong emotions and encourage reflection, but what effect can such self reflection have on a general practitioner's identity?

'I am not the kind of woman who complains of everything': illness stories on self and shame in women with chronic pain

In this study, we explore issues of self and shame in illness accounts from women with chronic pain. We focused on how these issues within their stories were shaped according to cultural discourses of gender and disease. A qualitative study was conducted with in-depth interviews including a purposeful sampling of 10 women of varying ages and backgrounds with chronic muscular pain. The women described themselves in various ways as 'strong', and expressed their disgust regarding talk of illness of other women with similar pain. The material was interpreted within a feminist frame of reference, inspired by narrative theory and discourse analysis. We read the women's descriptions of their own (positive) strength and the (negative) illness talk of others as a moral plot and argumentation, appealing to a public audience of health personnel, the general public, and the interviewer: As a plot, their stories attempt to cope with psychological and alternative explanations of the causes of their pain. As performance, their stories attempt to cope with the scepticism and distrust they report having been met with. Finally, as arguments, their stories attempt to convince us about the credibility of their pain as real and somatic rather than imagined or psychological. In several ways, the women negotiated a picture of themselves that fits with normative, biomedical expectations of what illness is and how it should be performed or lived out in 'storied form' according to a gendered work of credibility as woman and as ill. Thus, their descriptions appear not merely in terms of individual behaviour, but also as organized by medical discourses of gender and diseases. Behind their stories, we hear whispered accounts relating to the medical narrative about hysteria; rejections of the stereotype medical discourse of the crazy, lazy, illness-fixed or weak woman.

Women's needs and wants when seeing the GP in relation to menopausal issues

OBJECTIVE

To explore women's needs and wants when seeing the GP in relation to menopausal issues.

DESIGN

A qualitative interview study.

SETTING AND SUBJECTS

The study was part of a larger project, targeting menopause. It included in-depth interviews of 24 women aged 52-53 years who came from all over Denmark. The women showed a great variety of menopausal experience of symptoms and treatment.

MAIN OUTCOME MEASURES

An acquaintance with the women's agendas when seeing the GP about menopausal issues.

RESULTS AND CONCLUSION

Women consulting their GPs either wanted to discuss treatment for menopausal symptoms, to have an examination for diseases or to get a risk assessment. Their needs for medication or examination were satisfied but several women wanted more information, especially about the pros and cons of hormone therapy (HT). Risk assessment, if not requested, indicated problems, with some women feeling uncomfortable if the GPs started a discussion about HT and osteoporosis, if they only wanted an examination to be reassured that everything was normal. The authors' findings indicate that GPs encounter a subtle balance in considering the question of risk information to menopausal women who do not request it.