Diagnostic knowing in general practice: interpretative action and reflexivity

Background: Getting the right diagnosis is supposed to provide an explanation of a patient’s health problem and inform health care decisions. As a core element of clinical reasoning, diagnosis deserves systematic and transparent analysis. Conceptual tools can make doctors become aware of and explore diagnostic knowing. Methods: We demonstrate diagnostic knowing analysed as interpretative and contextualised activity. Our analysis is based on Lonergan’s theory of knowing, constituting the cognitive structures as experiencing, understanding, and judging, in a general practice case. Findings: Analysis makes the complexity of diagnostic knowing in this context more transparent, in this case concluding with four diagnostic labels: a corn, constipation, headache and atrial fibrillation. We demonstrate how a medically significant diagnosis does not necessarily evolve deductively from complaints. The opening lines from the patient give ideas of where to look for possible explanations – questions for understanding – rather than diagnostic hypotheses. Such questions emerge from the GP’s experiences from meeting the patient, including imaginations and interpretations. When ideas and questions regarding diagnoses have been developed, they may be judged and subjected to reflection. Questioning may also emerge as transitory concerns, not extensively ruled out. Lonergan’s theory demonstrated a strong fit with these aspects of diagnostic knowing in general practice. Implications: Analysis demonstrated systematic, transparent approaches to diagnostic knowing, relevant for clinical teaching. We argue that an interpretative understanding of diagnosis can change clinical practice, complementing hypothetico-deductive strategies by recognising additional substantial diagnostic modes and giving access to scholarly reflection.publishedVersio

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

Følelser i sundhed og sygdom - genbesøgt

Er mennesket grundlæggende styret af fornuft eller følelse? Det ældgamle spørgsmål: Er følelser konstruktive størrelser eller uhensigtsmæssige forstyrrelser i et menneskeliv? Hvordan beriger følelserne vores liv, og spiller de en rolle i vores sundhed og sygdom? . I Jane Austens roman Fornuft og følelse, som finder sted i den engelske overklasse i forrige århundrede, udspilles et drama om betydningen af fornuft og følelse i tilgangen til livet og kærligheden. Dilemmaet mellem fornuft eller følelse illustreres ved at portrættere storesøsteren Elinor Dashwood, som lader sig lede af fornuften og lillesøsteren Marianne Dashwood, som er impulsiv og i sine følelsers vold. I lyset af dette dilemma udspindes en kærlighedshistorie om kvindernes tilgang til livet og deres relationer, og det giver brændstof til handlingen, at netop følelserne enten får overtaget eller bliver behersket og undertrykt.Det grundlæggende spørgsmål om fornuft og følelse har dannet baggrund for dette temanummer, og en række professionelle og forskere med forskellige disciplinære baggrunde belyser med deres bidrag en række dimensioner og aspekter af emotioner eller her benævnt følelser; deres rolle i nutiden og i forhold til individ, relationer, sygdom og samfund

At spise – ikke kun et spørgsmål om mad

Forholdet mellem kost og sundhed er emne for debat, forskning og praksis i og udenfor sundhedsvæsenet. Men det at spise – ikke blot kostens indhold, men den faktiske praksis hvor mad indtages som en integreret del af vores daglige liv – diskuteres mindre. Ikke desto mindre udgør denne aktivitet på forskellige måder en kontaktflade mellem menneskers sociale liv og deres helbred. Det er denne kontaktflade vi ønsker at sætte fokus på med dette temanummer

Guidance for implementing video consultations in Danish general practice:Rapid cycle coproduction study

BACKGROUND: The COVID-19 pandemic has changed various spheres of health care. General practitioners (GPs) have widely replaced face-to-face consultations with telephone or video consultations (VCs) to reduce the risk of COVID-19 transmission. Using VCs for health service delivery is an entirely new way of practicing for many GPs. However, this transition process has largely been conducted with no formal guidelines, which may have caused implementation barriers. This study presents a rapid cycle coproduction approach for developing a guide to assist VC implementation in general practice. OBJECTIVE: The aim of this paper is to describe the developmental phases of the VC guide to assist general practices in implementing VCs and summarize the evaluation made by general practice users. METHODS: The development of a guide for VC in general practice was structured as a stepped process based on the coproduction and prototyping processes. We used an iterative framework based on rapid qualitative analyses and interdisciplinary collaborations. Thus, the guide was developed in small, repeated cycles of development, implementation, evaluation, and adaptation, with a continuous exchange between research and practice. The data collection process was structured in 3 main phases. First, we conducted a literature review, recorded observations, and held informal and semistructured interviews. Second, we facilitated coproduction with stakeholders through 4 workshops with GPs, a group interview with patient representatives, and individual revisions by GPs. Third, nationwide testing was conducted in 5 general practice clinics and was followed by an evaluation of the guide through interviews with GPs. RESULTS: A rapid cycle coproduction approach was used to explore the needs of general practice in connection with the implementation of VC and to develop useful, relevant, and easily understandable guiding materials. Our findings suggest that a guide for VCs should include advice and recommendations regarding the organization of VCs, the technical setup, the appropriate target groups, patients’ use of VCs, the performance of VCs, and the arrangements for booking a VC. CONCLUSIONS: The combination of coproduction, prototyping, small iterations, and rapid data analysis is a suitable approach when contextually rich, hands-on guide materials are urgently needed. Moreover, this method could provide an efficient way of developing relevant guide materials for general practice to aid the implementation of new technology beyond the pandemic period

The role of diseases, risk factors and symptoms in the definition of multimorbidity:a systematic review

<p>Objective is to explore how multimorbidity is defined in the scientific literature, with a focus on the roles of diseases, risk factors, and symptoms in the definitions. Design: Systematic review. Methods: MEDLINE (PubMed), Embase, and The Cochrane Library were searched for relevant publications up until October 2013. One author extracted the information. Ambiguities were resolved, and consensus reached with one co-author. Outcome measures were: cut-off point for the number of conditions included in the definitions of multimorbidity; setting; data sources; number, kind, duration, and severity of diagnoses, risk factors, and symptoms. We reviewed 163 articles. In 61 articles (37%), the cut-off point for multimorbidity was two or more conditions (diseases, risk factors, or symptoms). The most frequently used setting was the general population (68 articles, 42%), and primary care (41 articles, 25%). Sources of data were primarily self-reports (56 articles, 42%). Out of the 163 articles selected, 115 had individually constructed multimorbidity definitions, and in these articles diseases occurred in all definitions, with diabetes as the most frequent. Risk factors occurred in 98 (85%) and symptoms in 71 (62%) of the definitions. The severity of conditions was used in 26 (23%) of the definitions, but in different ways. The definition of multimorbidity is heterogeneous and risk factors are more often included than symptoms. The severity of conditions is seldom included. Since the number of people living with multimorbidity is increasing there is a need to develop a concept of multimorbidity that is more useful in daily clinical work. Key Points</p><p>The increasing number of multimorbidity patients challenges the healthcare system. The concept of multimorbidity needs further discussion in order to be implemented in daily clinical practice.</p><p>Many definitions of multimorbidity exist and most often a cut-off point of two or more is applied to a range of 4–147 different conditions.</p><p>Diseases are included in all definitions of multimorbidity.</p><p>Risk factors are often included in existing definitions, whereas symptoms and the severity of the conditions are less frequently included.</p><p></p> <p>The increasing number of multimorbidity patients challenges the healthcare system. The concept of multimorbidity needs further discussion in order to be implemented in daily clinical practice.</p> <p>Many definitions of multimorbidity exist and most often a cut-off point of two or more is applied to a range of 4–147 different conditions.</p> <p>Diseases are included in all definitions of multimorbidity.</p> <p>Risk factors are often included in existing definitions, whereas symptoms and the severity of the conditions are less frequently included.</p