Balancing - an equilibrium act between different positions: an exploratory study on general practitioners' comprehension of their professional role

Factors correlating to the propensity of general practitioners to substitute borderline vitamin B12 deficiency

OBJECTIVE

This study aims to identify factors which correlate to the propensity of general practitioners (GPs) to prescribe supplementation for borderline vitamin B12 deficiency.

DESIGN

Cross-sectional surveys were distributed in person.

SETTING

Conferences held in Cairns, Palm Cove Beach, Mt Isa; educational meetings in Atherton; and meetings with individual general practices within the Cairns and Hinterland region. All located in Queensland, Australia.

SUBJECTS

128 practicing GP specialists and registrars (practitioners in training).

MAIN OUTCOME MEASURES

Responses to the Likert scale statements with its five options scaling from 'strongly disagree' to 'strongly agree' were recoded to have binary outcomes for analysis.

RESULTS

A survey response rate of 89% was achieved. Participants who felt patient demands influence the management of borderline vitamin B12 deficiency were more likely to prescribe supplementation (OR 2.4, p = 0.037). Participants who perceived an overuse of vitamin B12 were less likely to prescribe B12 (OR 0.39, p = 0.019). Participants who often saw patients with vitamin B12 deficiency were less likely to request for the complementary biomarkers plasma methylmalonic acid or total homocysteine (OR 0.41, p = 0.045).

CONCLUSIONS

The identified disparity to prescribe vitamin B12 for borderline deficiency may be described as an attempt in the GP collective to seek a balance between being the patient's or the society's doctor. We propose that relevant authorities try to reduce this disparity by describing a management strategy for borderline vitamin B12 deficiency. Key points General practitioners hold different thresholds for commencing supplementation in cases of borderline vitamin B12 deficiency. Participants from Australia were asked to fill out a cross-sectional survey to explore factors which correlate with the propensity to prescribe in clinical practice. Our study identified that patient demands and a practitioner's perception of whether there is an overuse of vitamin B12 in the community influenced the propensity to treat for deficiency. The results give insight into reasons for initiating supplementation, and will help inform general practitioners on their current management.

Balancing trust and power: a qualitative study of GPs perceptions and strategies for retaining patients in preventive health checks

OBJECTIVE

Little is known about how strategies of retaining patients are acted out by general practitioners (GPs) in the clinical encounter. With this study, we apply Grimens' (2009) analytical connection between trust and power to explore how trust and power appear in preventive health checks from the GPs' perspectives, and in what way trust and power affect and/or challenge strategies towards retaining patients without formal education.

DESIGN

Data in this study were obtained through semi-structured interviews with GPs participating in an intervention project, as well as observations of clinical encounters.

RESULTS

From the empirical data, we identified three dimensions of respect: respect for the patient's autonomy, respect for professional authority and respect as a mutual exchange. A balance of respect influenced trust in the relationship between GP and patients and the transfer of power in the encounter. The GPs articulated that a balance was needed in preventive health checks in order to establish trust and thus retain the patient in the clinic. One way this balance of respect was carried out was with the use of humour.

CONCLUSIONS

To retain patients without formal education in the clinical encounter, the GPs balanced trust and power executed through three dimensions of respect. In this study, retaining patients was equivalent to maintaining a trusting relationship. A strategic use of the three dimensions of respect was applied to balance trust and power and thus build or maintain a trusting relationship with patients. KEY POINTS   Little is known about how strategies for retaining patients are acted out by GPs in preventive health checks.  •  Retaining patients requires a balance of trust and power, which is executed through three dimensions of respect by the GPs.  •  Challenges of recruiting and retaining patients in public health initiatives might be associated with the balance of respect.

"I couldn't do this with opposition from my colleagues": a qualitative study of physicians' experiences as clinical tutors

BACKGROUND

Clinical contact in the early curriculum and workplace learning with active tutorship are important parts of modern medical education. In a previously published study, we found that medical students' tutors experienced a heavier workload, less reasonable demands and less encouragement, than students. The aim of this interview study was to further illuminate physicians' experiences as clinical tutors.

METHODS

Twelve tutors in the Early Professional Contact course were interviewed. In the explorative interviews, they were asked to reflect upon their experiences of working as tutors in this course. Systematic text condensation was used as the analysis method.

RESULTS

In the analysis, five main themes of physicians' experiences as clinical tutors in the medical education emerged: (a) Pleasure and stimulation. Informants appreciated tutorship and meeting both students and fellow tutors, (b) Disappointment and stagnation. Occasionally, tutors were frustrated and expressed negative feelings, (c) Demands and duty. Informants articulated an ambition to give students their best; a desire to provide better medical education but also a duty to meet demands of the course management, (d) Impact of workplace relations. Tutoring was made easier when the clinic's management provided active support and colleagues accepted students at the clinic, and (e) Multitasking difficulties. Combining several duties with those of a tutorship was often reported as difficult.

CONCLUSIONS

It is important that tutors' tasks are given adequate time, support and preparation. Accordingly, it appears highly important to avoid multitasking and too heavy a workload among tutors in order to facilitate tutoring. A crucial factor is acceptance and active organizational support from the clinic's management. This implies that tutoring by workplace learning in medical education should play an integrated and accepted role in the healthcare system.

General practitioners and tutors' experiences with peer group academic detailing: a qualitative study

Background

The Prescription Peer Academic Detailing (Rx-PAD) project is an educational intervention study aiming at improving GPs' competence in pharmacotherapy. GPs in CME peer groups were randomised to receive a tailored intervention, either to support a safer prescription practice for elderly patients or to improve prescribing of antibiotics to patients with respiratory tract infections. The project was based on the principles of peer group academic detailing, incorporating individual feedback on GPs' prescription patterns. We did a study to explore GPs and tutors' experiences with peer group academic detailing, and to explore GPs' reasons for deviating from recommended prescribing practice.

Methods

Data was collected through nine focus group interviews with a total of 39 GPs and 20 tutors. Transcripts from the interviews were analyzed by two researchers according to a procedure for thematic content analysis.

Results

A shared understanding of the complex decision-making involved in prescribing in general practice was reported by both GPs and tutors as essential for an open discussion in the CME groups. Tutors experienced that CME groups differed regarding structure and atmosphere, and in some groups it was a challenge to run the scheme as planned. Individual feedback motivated GPs to reflect on and to improve their prescribing practice, though feedback reports could cause distress if the prescribing practice was unfavourable. Explanations for inappropriate prescriptions were lack of knowledge, factors associated with patients, the GP's background, the practice, and other health professionals or health care facilities.

Conclusions

GPs and tutors experienced peer group academic detailing as a suitable method to discuss and learn more about pharmacotherapy. An important outcome for GPs was being more reflective about their prescriptions. Disclosure of inappropriate prescribing can cause distress in some doctors, and tutors must be prepared to recognise and manage such reactions.

'Aiming for the stars'--GPs' dilemmas in the prevention of cardiovascular disease in type 2 diabetes patients: focus group interviews

BACKGROUND

Studies have revealed low adherence to guidelines for treatment of diabetes and cardiovascular risk factors.

OBJECTIVE

To explore GPs' experiences regarding treatment practice in type 2 diabetes with specific focus on the prevention of cardiovascular disease.

METHODS

Fourteen experienced GPs from nine health care centres with group practices were interviewed in focus groups. The interviews were digitally recorded, transcribed verbatim and analysed by qualitative content analysis.

RESULTS

The overall theme was 'dilemmas' in GPs' treatment practice for type 2 diabetes patients. Five main dilemma categories were identified. First, the GPs were hesitant about labelling someone who feels healthy as ill. Second, regarding communicating a diabetes diagnosis and its consequences; should the patient be frightened or comforted? Third, the GPs experienced uncertainty in their role; were they to take responsibility for the care or not? Fourth, the GPs expressed a conflict between lifestyle changes and drug treatment. Fifth, the GPs described difficulties in integrating science into reality.

CONCLUSIONS

The five dilemmas in the GPs' approach to diabetes patients and the treatment of their cardiovascular risk were related to the GPs' professional role and communication with the patient. To consider these dilemmas in educational efforts is probably essential to achieve improved diabetes care and guideline adherence.