The Craft of Generalism clinical skills and attitudes for whole person care

Where the joy comes from: a qualitative exploration of deep GP-patient relationships

BACKGROUND

Relationship-based, whole person care is foundational to quality general practice. Previous research has identified several characteristics of deep General Practitioner (GP)-patient relationships and their association with improved patient concordance, satisfaction and perceived health outcomes. Psychological attachment theory has been used to understand therapeutic relationships, but has only been explored to a limited extent in the general practice context. Additionally, evolving changes in sociocultural and commercial practice contexts may threaten relationship-based care. In view of this, we aimed to explore the nature and experience of deep GP-patient relationships, as identified by patients, from GP and patient perspectives.

METHODS

Semi-structured interview design. An initial survey assessed patients' perceived depth of their relationship with their GP, using the Health Care Provider Attachment Figure Survey and Patient-Doctor Depth of Relationship Scale. Patients who reported a deep relationship, and their GPs, were purposively selected for individual interviews exploring their experience of these relationships. A post-interview survey assessed interviewees' attachment styles, using the Modified and Brief Experiences in Close Relationships Scale. Patient interviewees also rated the patient-centredness of their GP's clinic using the Person-Centred Primary Care Measure. Transcripts were analysed using thematic analysis.

RESULTS

Thirteen patients and five GPs were interviewed. Four themes characterised deep relationships: the 'professional'; human connection; trust; and 'above and beyond'. Patient, GP and practice team all contributed to their cultivation.

CONCLUSIONS

We present a revised conceptual framework of deep GP-patient relationships. Deep relationships come to the fore in times of patient trouble. Like attachment relationships, they provide a sense of safety, caring and support for patients experiencing vulnerability. They can stretch GP boundaries and capacity for self-care, but also provide joy and vocational satisfaction. Patients may not always desire or need deep relationships with their GP. However, findings highlight the importance of enabling and cultivating these for times of patient hardship, and challenges of doing so within current healthcare climates.

'They never mentioned this in medical school!' A qualitative analysis of medical students' reflective writings from general practice

OBJECTIVE

The aim of the study was to identify final-year medical students' experiences with thought-provoking and challenging situations in general practice.

DESIGN SETTING AND SUBJECTS

We conducted a qualitative analysis of 90 reflective essays written by one cohort of Norwegian final-year medical students during their internship in general practice in 2017. The students were asked to reflect upon a clinical encounter in general practice that had made a strong impression on them. A primary thematic content analysis was performed, followed by a secondary analysis of encounters that stood out as particularly challenging.

MAIN OUTCOME MEASURES

Clinical scenarios in general practice that make students feel professionally 'caught off guard'.

RESULTS

The analysis identified several themes of challenging student experiences. One of these was 'disorienting encounters' for which the students felt totally unprepared in the sense that they did not know how to think and act. Five different scenarios were identified: (1) patients with highly distracting appearances, (2) 'ordinary consultations' that suddenly took a dramatic turn, (3) patients who appeared unexpectedly confrontational or devaluating, (4) scornful rejection of the young doctor's advice, and finally, (5) confusion related to massive contextual complexity.

CONCLUSIONS

Disorienting encounters stood out as particularly challenging clinical experiences for medical students in general practice. These scenarios evoked an acute feeling of incapacitation: not knowing what to think and do. Further curriculum development will focus on preparing the students to 'know what to do when they don't know what to do'.

Whole person assessment for family medicine: a systematic review

OBJECTIVES

To identify and evaluate clinical approaches to whole person assessment (WPA) that are translatable to family medicine regarding feasibility, quality and alignment with theoretical models of whole person care (WPC).

DESIGN

Systematic literature review.

DATA SOURCES

MEDLINE, CINAHL, PsycINFO and ATLA Religion databases were searched through 9 March 2020, with additional handsearches.

ELIGIBILITY CRITERIA

English language clinical assessments of multiple domains; which involve patient-clinician interaction and are translatable to general practice (GP); from the fields of medicine, allied health, nursing, mental health and pastoral care. Tools designed for single diseases or symptoms, for outcome rather than clinical assessment or with outdated classification systems were excluded.

DATA EXTRACTION AND SYNTHESIS

We appraised the quality of included papers using Johanna Briggs' Institute Checklists and Terwee's criteria for validation studies. Clinical assessments' alignment with theoretical WPC, feasibility for adaptation to GP and quality were examined. We analysed extracted data using framework synthesis.

RESULTS

Searches retrieved 7535 non-duplicate items. Fifty-nine were included after screening, describing 42 WPA methods and representing multiple disciplines, purposes and formats. All included assessments aligned partially with models of WPC, but most did not adequately encompass all aspects of WPC. Robustness varied significantly and was often inadequately described. We judged none of the identified assessments to be ideal as a multipurpose WPA in GP. Some could be used for specific purposes, such as elicitation of patient perspectives or complexity assessment.

CONCLUSIONS

While no WPAs were found that were sufficient for broad implementation in GP, some approaches may be suitable with adaptation and evaluation. Strengths of existing approaches could inform WPA development in future.

PROSPERO REGISTRATION NUMBER

CRD42020164417.

The Role of Primary Care in Improving Population Health

Policy Points Systems based on primary care have better population health, health equity, and health care quality, and lower health care expenditure. Primary care can be a boundary-spanning force to integrate and personalize the many factors from which population health emerges. Equitably advancing population health requires understanding and supporting the complexly interacting mechanisms by which primary care influences health, equity, and health costs.

The impact of clinical experience on working tasks and job-related stress: a survey among 1032 Norwegian GPs

BACKGROUND

General practice is a generalist discipline fraught with complexity. For inexperienced physicians, it may be demanding to get to grips with the clinical challenges. The purpose of this article is to describe possible differences in the range of tasks between inexperienced and experienced general practitioners (GPs), and the extent to which clinical experience affects the way in which GPs perceive their daily work.

METHODS

An online questionnaire was sent to all regular GPs in Norway (N = 4784) in 2018. The study sought to document the tasks performed during a typical working day and how the GPs perceived their working situation. In this study, we compare the tasks, working situation and occurrence of potentially conflictual consultations among 'less experienced physicians' (≤ 5 years of experience in general practice) versus 'more experienced physicians' (> 5 years of experience). The findings are discussed in light of theories on development of expertise.

RESULTS

We received responses from 1032 GPs; 296 (29%) were less experienced and 735 (71%) more experienced. The two groups reported virtually the same number of consultations (19.2 vs. 20.5) and clinical problems handled (40.4 vs. 44.2) during the study day. The less experienced physicians reported a higher proportion of challenging and/or conflictual consultations, involving prescriptions for potentially addictive medication (5.7% vs. 3.1%), sickness certification (4.1% vs. 2.4%) and referral for medical investigations on weak clinical indication (8.1% vs. 5.6%). For other clinical issues there were minor or no differences. Both GP groups reported high levels of work-related stress with negative effect on self-perceived health (61.6% vs 64.6%). GPs who felt that high job demands harmed their health tended to handle a slightly higher number of medical issues per consultation and more consultations with elements of conflict.

CONCLUSIONS AND IMPLICATIONS

Inexperienced GPs in Norway handle a workload comparable to that of experienced GPs, but they perceive more conflictual consultations. These findings have relevance for training and guidance of future GP specialists. Irrespective of experience, the GPs report such high levels of negative work-related stress as to indicate an acute need for organisational changes that imply a reduced workload.