Experiences of guilt and shame in patients with familial hypercholesterolemia: a qualitative interview study

OBJECTIVE

To explore patients' experiences of guilt and shame with regard to how they manage familial hypercholesterolemia.

METHODS

We interviewed 40 men and women diagnosed with heterozygous familial hypercholesterolemia. Data were analyzed by systematic text condensation inspired by Giorgi's phenomenological method.

RESULTS

Participants disclosed their condition as inherited and not caused by an unhealthy lifestyle. They could experience guilt or shame if they violated their own standards for dietary management, or if a cholesterol test was not favorable. Participants had experienced health professionals who they felt had a moralizing attitude when counseling on lifestyle and diets. One group took this as a sign of care. Another group conveyed experiences of being humiliated in consultations.

CONCLUSION

Patients with familial hypercholesterolemia may experience guilt and shame related to how they manage their condition. Health professionals' counseling about lifestyle and diet may induce guilt and shame in patients.

PRACTICE IMPLICATIONS

Health professionals should be sensitive to a patient's readiness for counseling in order to diminish the risk of unintentionally inducing guilt and shame in patients.

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.

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.

The Zero-vision: potential side effects of communicating health perfection and zero risk

Public health education may have harmful side effects: generate fear, give rise to healthism and contribute to a medical sorting society. To prevent these adverse reactions a new deal for public health communication is presented. It is commended to move public health from omnipotence to moderation, from life style to living conditions, from risk to the bright sides of health, from statistical clone to the holy individual. Furthermore public health communication ought to include uncertainty as authoritarian truth mongering erodes trust. The public health educator must convey compassion and dedication. Rational techno-info is not sufficient. The last golden rule for a new public health is to respect the people. The people are not an inferior mass subjected to basic instincts and irrational fears. Common sense and lay experiences may contribute to the wise management of risk. Therefore public health should develop a people-centered method, recognizing people's own values, perceptions and potentials for preventing disease and promoting health.

Medicine and the arts in the undergraduate medical curriculum at the University of Oslo Faculty of Medicine, Oslo, Norway

The authors describe a course titled Medicine and the Arts, established in 1996, that is part of the first semester of the undergraduate medical curriculum at the University of Oslo Faculty of Medicine. The course comprises four two-hour seminars on literature, visual arts, architecture, and music. The core objectives of the course are to demonstrate how art can be a source of personal and professional development, and also how art represents a source of insight into patients' experiences and the social, cultural, and historical context of medical practice. The course emphasizes that art is ambiguous and many layered and that its interpretation requires sensitivity, engagement, imagination, and reflection. Fostering these skills is a major aim of the course because these skills are also essential for clinical competence and professional development. The course's seminars are integrated into the curriculum but are not compulsory. Although the topics covered by the course have not been explicitly addressed in the formal examination of students, there has been some discussion about doing so, which would be a signal that those topics are as important as others in the curriculum.

Labelling and patient knowledge of dispensed drugs as quality indicators in primary care in Botswana

OBJECTIVES

To assess the quality of dispensing and patient knowledge of drugs dispensed in primary care in Botswana.

SETTING

Thirty randomly assigned primary healthcare facilities in three districts of Botswana.

PARTICIPANTS

Patients visiting clinics and health posts.

DESIGN

Analysis of data from prospective participative observations of the drug dispensing process and interview of patients about their knowledge of drugs received immediately after dispensing. The quality of drug labelling was assessed by calculating mean labelling scores composed of five dispensing attributes: name of patient, and name, strength, dosage, and volume of the drug (incorrect or no labelling=0, 1 point for each correct labelling attribute; maximum score=5). Mean knowledge scores were obtained immediately after dispensing from patient recall of name and dosage of drug, duration of treatment, and reason for prescription (incorrect recall=0, 1 point for each correct recall attribute; maximum score=4).

RESULTS

2994 consecutive patient consultations were analysed. The mean labelling score was 2.75. Family welfare educators and pharmacy technicians scored highest (3.15 and 2.98, respectively) and untrained staff lowest (2.60). Factors independently associated with the labelling score were analgesics v other drugs, district, health posts v clinics, education of prescriber (nurse best), and years of experience of prescriber (4-11 years best). The mean patient knowledge score was 2.50. The reason for prescription of the drug(s), dosage, duration of treatment, and name of the drug(s) was recalled by 92%, 83%, 44%, and 31% of patients, respectively. The qualification level of the dispenser was the strongest factor independently associated with the knowledge score. Antibiotics had the second lowest score, both for labelling (2.39) and patient knowledge (2.39).

CONCLUSION

Only trained dispensing staff provided satisfactory quality of labelling. Patients had a fair knowledge of the drugs dispensed. The knowledge of drugs dispensed by family welfare educators was less than satisfactory. The labelling score is a useful indicator of the quality of dispensing, and the knowledge score of both the quality of prescribing and of dispensing. These indicators should be added to the WHO list of patient care indicators.

[Local and global environmental medicine--assessment by Norwegian physicians]

BACKGROUND

Local and global environmental problems are challenges to our societies and affect human health. This study examines how Norwegian physicians see these problems.

MATERIAL AND METHODS

1,260 physicians were sent a questionnaire on their knowledge, attitudes and practice related to this subject. The response rate was 88%.

RESULTS

Four out of five physicians believe that the global environmental situation is a big threat to human health. Three out of five believe that physicians have a particular responsibility to contribute to a sustainable environment and development and should set an example by a sustainable lifestyle. Half of them believe that the health service has a greater responsibility for sustainability than other institutions. Only one out of three report that environmentally acceptable conditions have been focused in their workplace. Half of the general practitioners and one third of the specialists are faced with environmental health problems every week. More than every third doctor experience patients with "environmental hypochondria". Physicians feel that they need to know more about environmental medicine; mass media is their most important source of information.

INTERPRETATION

The study indicates that Norwegian physicians understand the significance of the environmental situation and recognise the responsibility of the profession. However, this knowledge is to a lesser extent translated into practice.

Adherence to treatment guidelines in primary health care facilities in Botswana

OBJECTIVES

To assess the quality of nurses' prescribing through an assessment of their prescription in relation to diagnosis, and to investigate trends in drug use in Botswana primary health care.

METHODS

Key data regarding nurses' adherence to national prescription and treatment guidelines were obtained through participatory observation using a questionnaire, related to each consultation. Adherence was categorized into (i) Full adherence, (ii) acceptable adherence, (iii) acceptable adherence, but one or more useless, but not dangerous, drugs and (iv) insufficient or dangerous treatment. The study comprises data on nurses' prescriptions, diagnoses and quality of dispensing in 2994 consecutive consultations in 30 primary health care facilities in three districts of Botswana: Ngami East, Gaborone and Kgalagadi North.

RESULTS

The average number of drugs prescribed per patient was 2.3. Antibiotics were prescribed in 27% of all encounters. Full adherence was found in 44%, acceptable compliance in 20%, 'acceptable, but one or more useless, but not dangerous, drugs' in 33% and 'insufficient or dangerous treatment' in 3% of the consultations. Four factors were found to be independently associated with full adherence: patient age 16-31 years, specified diagnosis, type of health facility and nurses' years of practice (4-11 years best).

CONCLUSION

Although Botswana's health workers perform relatively well in terms of drug use indicators, there is a clear potential for improving health workers' adherence to national treatment guidelines.

[Health--people's perspective]

In 1997--2000, we conducted a study of people's concept of health. 80 persons aged 16 - 93 years were invited to a qualitative interview taken on five different locations in Norway. Included in the material was a group of former and present top athletes. We identified six essential elements in people's conceptualization of health: well-being, function, nature, a sense of humour, coping, and energy. The lay perspective on health is characterized by three qualities: WHOLENESS: Health is a holistic phenomenon. Health is related to all aspects of life and society. PRAGMATISM: Health is a relative phenomenon. Health is experienced and evaluated according to what people find reasonable to expect, given their age, medical condition and social situation. INDIVIDUALISM: Health is a personal phenomenon. Every human being is unique, and health and strategies for health must be individualized.

[Health and quality of life among long-term unemployed]

BACKGROUND

Many studies have shown an association between unemployment and poor health.

MATERIAL AND METHODS

This cross-sectional survey from 1993-94 using structured interviews and questionnaires describes health and quality of life among 148 long-term unemployed in Lillesand, Norway.

RESULTS

Compared with the general population, somatoform conditions and anxiety symptoms were twice as common among the unemployed, and depression three times as common. There was a higher frequency of depression among unemployed men than among unemployed women. The unemployed had a lower quality of life score than the general population; the difference was more than twice as large among men as among women. Unemployed aged 30-39 reported the strongest symptoms of anxiety and depression.

INTERPRETATION

The reason why unemployed men are more often stricken by depression and report lower quality of life than women, may be that men experience the job-loss more existentially threatening than do women.

[Courage--the mother of all virtues]

To be a physician requires courage. To engage in the patient as a person calls for social courage. Courage is needed to act rapidly and firmly in unclear clinical situations. The noble art of saying no to patients, bureaucrats and politicians calls upon courageous doctors. To resist follies and fallacies in medicine requires courage. The same virtue is necessary for the brave colleagues who try to diagnose and heal the perils within the medical fraternity. The autonomy, renewal and sustainability of medicine depend on courageous physicians. This article highlights the concept of courage, how this virtue may be promoted in the making of doctors and how courage should be facilitated in our professional culture.

General practitioners' knowledge of their patients' socioeconomic data and their ability to identify vulnerable groups

OBJECTIVE

To explore general practitioners' knowledge of their patients' socioeconomic data and their ability to identify vulnerable groups.

DESIGN

A multipractice survey of consecutive adult patients consulting general practitioners during one regular workday. Doctors and patients independently completed mirrored questionnaires.

SETTING

A geographically defined population of patients and doctors in Buskerud county, Norway.

SUBJECTS

1401 patients attending 89 general practitioners during the last two weeks of March 1995.

MAIN OUTCOME MEASURES

The doctors' ability to state the patients' socioeconomic situation correctly using sensitivity and specificity. Results for patients scarcely and well known to the doctors are compared.

RESULTS

Sensitivity ranged from 0.93 for work as main income source to 0.04 for not having WC/bathroom inside the dwelling. Specificity ranged from 1.00 for several factors to 0.73 for low educational level. Information on household composition and income source was correct for more than half of patients scarcely known to the doctors.

CONCLUSIONS

General practitioners' knowledge of various socioeconomic data of their patients differs substantially and are collected at different stages in the relationship. Among socioeconomic data defining vulnerable groups, the patients' self-perceived work disability is the variable general practitioners are best at evaluating.

[Physicians and other practitioners of acupuncture in Norway--education, theoretical orientation and practice]

We conducted a survey for the purpose of obtaining information on training, theoretical orientation and practice among various categories of practitioners of acupuncture in Norway. Particular attention was paid to physicians, compared with other groups of practitioners. A questionnaire was sent to 161 persons who had attended Norwegian Medical Acupuncture Seminars (Norske legers akupunkturkurs) and to 274 persons found under "Acupuncture" in the Yellow Pages of the telephone directory. The response rate was 80%, questionnaires being returned by 298 practitioners. A significantly higher percentage of physicians, as opposed to other practitioners, had less than 120 hours of acupuncture training. 30% of the physicians, compared to 60% in other groups, had more than 10 acupuncture consultations a week. Physicians performed only a relatively small number of different acupuncture methods. There was a relatively high number of men among the acupuncturists. Hence, acupuncture seems to be a practice with masculine appeal. 67% of the physicians used one or more Chinese medical concepts associated with acupuncture. 45% stated that they found non-scientific explanations for how acupuncture works reliable. We therefore argue that one can identify parallel processes in the development of acupuncture. Some elements of acupuncture have been integrated in a scientifically defined reality. At the same time, this survey indicates another process: it shows that many practitioners use traditional Chinese medical concepts. This may indicate that some practitioners have changed their view on what constitutes a reliable picture of reality.

Influence of social problems on management in general practice: multipractice questionnaire survey

OBJECTIVES

To find how often social problems influence clinical management in general practice, how management is changed, and how the characteristics of patients, doctors, and the doctor-patient relationship influence this management.

DESIGN

Multipractice survey of patients consulting general practitioners. Doctors completed a questionnaire for each patient.

SETTING

General practices in Buskerud county, Norway.

SUBJECTS

1401 consecutive adult patients attending 89 general practitioners.

MAIN OUTCOME MEASURES

How often management of patients was influenced by different types of social problem and main reasons for consultation; frequency and intercorrelation of different types of management applied; odds ratios for social problems' influence on management, controlled for by characteristics of doctors, patients, and their relationship.

RESULTS

In 17% of all consultations the doctors' knowledge of patients' social problems influenced their management, stressful working conditions being the most frequent influencing type of problem. Knowledge of social problems influenced management more often when the doctor knew a patient well, but less often the longer a doctor had worked in a practice. When social problems influenced management, the commonest types of management offered were extra time for consultation (51%), advice (42%), authorisation of sick leave (28%), and prescription of a psychotropic drug (20%), while referral to community services was used in 2.6% of these consultations. Prescription of a psychotropic drug was positively correlated with use of extra time, and was made more often by female doctors.

CONCLUSIONS

Patients' social problems influenced choice of management in at least a sixth of consultations. Prior knowledge of the patient, the doctor's time in present practice, age and sex of the patient, and sex of the doctor significantly influenced management of patients.

Work disability and health-affecting psychosocial problems among patients in general practice

Psychosocial problems are often ignored among patients in general practice. By identifying high risk groups this situation could possibly be altered. This study aimed to explore if patients in general practice perceiving themselves as work-disabled by at least 50% more often have health-affecting psychosocial problems than those not work-disabled. In a geographically defined population, 1,058 consecutive adult patients consulting 89 general practitioners were approached during one regular working day in March 1995. They completed a questionnaire at home, returning it directly to the department of general practice. Male patients considered themselves work-disabled more often than female patients. All psychosocial problems except having a demanding caregiving task were more common among the work-disabled. The doctors should bear in mind that work-disabled patients more often than other patients have concomitant health-affecting psychosocial problems. Granting long-term sick leave or a disability pension may not be the only management needed.

Clinical practice: between Aristotle and Cochrane

Health and disease consist of amino acids and self image, cell membranes and human ideals, muscles and politics. Only to a limited extent can clinical practice be based on science. It can never be carried on in isolation from political, and cultural forces that influence patients' health behaviour. Evidence-based medicine is essential but not sufficient. A continuous relationship with patients is a conditio sine qua non for general practice. The general practitioner must be a master of pragmatic medicine. Rationality, the dominant modern trend, may be dangerous for patients and doctors: (1) advances in technology can give patients and doctors the illusion of mastering the universe; (2) patients complain of being treated like biomachines, without human touch. Another symptom of modernity is the decline of religion. But patients and doctors are by no means rational beings. God, destiny and hope are replaced by modern medico-scientific megalomania. Modern medicine is also strongly influenced by commercialization and invasion by bureaucrats. Instead of becoming a biomedical robot, the general practitioner must learn to value the Aristotelian concept of phronesis. It means practical wisdom and can only be gained by personal experience; a form of learning by doing. Good clinical practice cannot come from science alone, or from personal experience alone. It is an amalgam of scientia and phronesis.

Psychosocial problems presented by patients with somatic reasons for encounter: tip of the iceberg?

BACKGROUND

Health-affecting psychosocial problems are inherent in general practice, present among one-third of the patients and constituting between 3 and 13% of reasons for encounter. Such problems are not always presented, and often overlooked by the doctors.

OBJECTIVES

We aimed to describe the frequency of psychosocial problems presented to the doctor by patients with somatic reasons for encounter, as a proportion of the patients' existing health-affecting problems, and to explore whether characteristics of the doctor, the patient, their relationship or reason for encounter influence the presentation of problems.

METHODS

A questionnaire survey of 1401 consecutive patients visiting 89 Norwegian GPs mapped the prevalence of nine commonly occurring psychosocial problems and the frequency by which they were disclosed during the consultation.

RESULTS

From 21% (loneliness) to 59% (occupational stress) of problems were disclosed to the doctors. Reason for encounter was the only factor to influence the disclosure from male patients, while reason for encounter, educational level and income source of the patient, gender of the doctor, and the doctor's previous general knowledge of the patient influenced the disclosure from female patients.

CONCLUSIONS

Less than half of health-affecting psychosocial problems are disclosed to GPs by patients with somatic reasons for encounter. Occupational stress is disclosed more often than other psychosocial problems. Female patients disclose non-occupational problems more often than male patients, especially if they know the doctor or if the doctor is a woman. Symptoms from the musculoskeletal system are the reasons for encounter most often preceding the disclosure of psychosocial problems.

[Norwegian physicians and alternative medicine. Knowledge, attitudes and experiences]

1272 members of the Norwegian Medical Association took part in a survey on knowledge about, attitudes towards and experience of acupuncture, reflexology, healing, homoeopathy and herbalism. The response rate was 91%. Knowledge about these five complementary methods of treatment was poor, particularly in regard to reflexology, healing and herbalism. Four out of five physicians, on the other hand, felt that they needed such knowledge to put them in a position to inform their patients. Furthermore, the physicians' attitudes were also fairly negative, except towards acupuncture. Only 4-11% regarded homoeopathy, reflexology or healing as valuable supplements to scientific medicine. 9% of the physicians had undergone acupuncture, and 4% practised this method. 65% referred their patients to acupuncture. Experience of the other four methods was less common. Poor knowledge and limited experience put Norwegian physicians in a weak position in the debate about complementary methods of treatment.

General practitioners' knowledge of their patients' psychosocial problems: multipractice questionnaire survey

OBJECTIVES

To evaluate general practitioners' knowledge of a range of psychosocial problems among their patients and to explore whether doctors' recognition of psychosocial problems depends on previous general knowledge about the patient or the type of problem or on certain characteristics of the doctor or the patient.

DESIGN

Multipractice survey of consecutive adult patients consulting general practitioners. Doctors and patients answered written questions.

SETTING

Buskerud county, Norway.

SUBJECTS

1401 adults attending 89 general practitioners during one regular working day in March 1995.

MAIN OUTCOME MEASURES

Doctors' knowledge of nine predefined psychosocial problems in patients; these problems were assessed by the patients as affecting their health on the day of consultation; odds ratios for the doctor's recognition of each problem, adjusted for characteristics of patients, doctors, and practices; and the doctor's assessment of previous general knowledge about the patient.

RESULTS

Doctors' knowledge of the problems ranged from 53% (108/203) of "stressful working conditions" to 19% (12/63) of a history of "violence or threats." Good previous knowledge of the patient increased the odds for the doctor's recognition of "sorrow," "violence or threats," "substance misuse in close friend or relative," and "difficult conflict with close friend or relative." Age and sex of doctor and patient, patient's educational level and living situation, and location of practice influenced the doctor's awareness.

CONCLUSIONS

Variation in the patients' communication abilities, the need for confidence in the doctor-patient relationship before revealing intimate problems, and a tendency for the doctors to be entrapped by their expectations may explain these findings.

General practitioners' drug prescribing practice and diagnoses for prescribing: the Møre & Romsdal Prescription Study

We have examined the prescribing patterns among general practitioners (GPs) in a Norwegian county in relation to the patients' age and sex and the diagnosis for prescribing. Altogether 69,843 contacts with patients were recorded during which 56,758 items were prescribed. The average number of items prescribed per patient contact was 0.81 (male 0.76, female 0.83). Diazepam, the compound analgesic of paracetamol (i.e. acetaminophen) and codeine, and triazolam were the three most frequently prescribed drugs for females as compared to phenoxymethylpenicillin, paracetamol/codeine and diazepam for males. Insomnia was the most frequently recorded diagnosis for prescribing. Listed second were upper respiratory tract infections (males) and anxiety (females). Hypertension was the number three diagnosis. The twenty most frequently prescribed items accounted for 48.5% of all drugs prescribed and the twenty most frequently recorded diagnoses for prescribing accounted for 61.7% of all diagnoses. This makes it possible to analyze a substantial part of the GPs' total prescribing by focusing on a few drugs or diagnoses.