Shame in medical clerkship: “You just feel like dirt under someone’s shoe”

Introduction This study explores how senior medical students’ experience and react to shame during clinical placements by asking them to reflect on (1) manifestations of shame experiences, (2) situations and social interactions that give rise to shame, and (3) perceived effects of shame on learning and professional identity development. Methods In this interpretive study, the authors recruited 16 senior medical students from two classes at a Norwegian medical school. In three focus group interviews, participants were invited to reflect on their experiences of shame. The data were analyzed using systematic text condensation, producing rich descriptions about students’ shame experiences. Results All participants had a range of shame experiences, with strong emotional, physical, and cognitive reactions. Shame was triggered by a range of clinician behaviours interpreted as disinterest, disrespect, humiliation, or breaches of professionalism. Shame during clinical training caused loss of confidence and motivation, worries about professional competence, lack of engagement in learning, and distancing from shame-associated specialties. No positive effects of shame were reported. Discussion Shame reactions in medical students were triggered by clinician behaviour that left students feeling unwanted, rejected, or burdensome, and by humiliating teaching situations. Shame had deleterious effects on motivation, learning, and professional identity development. This study has implications for learners, educators, and clinicians, and it may contribute to increased understanding of the importance of supportive learning environments and supervisors’ social skills within the context of medical education.publishedVersio

Discovering strengths in patients with medically unexplained symptoms–a focus group study with general practitioners

Background: When patients suffer medically unexplained symptoms, consultations can be difficult and frustrating for both patient and GP. Acknowledging the patient as a co-subject can be particularly important when the symptoms remain unexplained. One way of seeing the patient as a co-subject is by recognizing any among their strong sides. Objectives: To explore GPs’ experiences with discovering strengths in their patients with medically unexplained symptoms and elicit GPs’ reflections on how this might be useful. Methods: Four focus-groups with 17 GPs in Norway. Verbatim transcripts from the interviews were analyzed by systematic text condensation. Results: Recollecting patients’ strengths was quiet challenging to the GPs. Gradually they nevertheless shared a range of examples, and many participants had experienced that knowing patients’ strong sides could make consultations less demanding, and sometimes enable the GP to provide better help. Identifying strengths in patients with unexplained symptoms required a deliberate effort on the GPs’ behalf, and this seemed to be a result of a strong focus on biomedical disease and loss of function. Conclusions: Acknowledging patients’ strong sides can bolster GPs’ ability to help patients with medically unexplained symptoms. However, the epistemic disadvantage of generalist expertise makes this hard to achieve. It is difficult for GPs to integrate person-centered perspectives with biomedical knowledge due to the privileged position of the latter. This seems to indicate a need for system-level innovations to increase the status of person-centered clinical work.publishedVersio

Patient experiences with depression care in general practice: a qualitative questionnaire study

Objective To investigate patient experiences and preferences regarding depression care in general practice. Design and setting A qualitative study based on free-text responses in a web-based survey in 2017. Participants were recruited by open invitation on the web page of a Norwegian patient organization for mental health. The survey consisted of four open-ended questions concerning depression care provided by general practitioners (GPs), including positive and negative experiences, and suggestions for improvement. The responses were analysed by Template Analysis. Subjects 250 persons completed the web-based survey, 86% were women. Results The analysis revealed five themes: The informants appreciated help from their GP; they wanted to be met by the GP with a listening, accepting, understanding and respectful attitude; they wanted to be involved in decisions regarding their treatment, including antidepressants which they thought should not be prescribed without follow-up; when referred to secondary mental care they found it wrong to have to find and contact a caregiver themselves; and they thought sickness certification should be individualised to be helpful. Conclusions Patients in Norway appreciate the depression care they receive from their GP. It is important for patients to be involved in decision-making regarding their treatment. KEY POINTS Depression is common, and GPs are often patients’ first point of contact when they seek help.  • Patients who feel depressed appreciate help from their GP.  • Patients prefer an empathetic GP who listens attentively and acknowledges their problems.  • Individualised follow-up is essential when prescribing antidepressants, making a referral, or issuing a sickness absence certificate.Pasienterfaringer med depresjonsomsorg i allmennpraksis: en kvalitativ spørreskjemastudiePatient experiences with depression care in general practice: a qualitative questionnaire studypublishedVersio

Residents’ perceptions of their own sadness - a qualitative study in Norwegian nursing homes

Background: Mood symptoms are highly prevalent among frail old people residing in nursing homes. Systematic diagnostics of depression is scarce, and treatment is not always in accordance with best evidence. The distinction between non-pathological sadness and depression may be challenging, and we know little of the older peoples’ perspectives. The aim of this qualitative interview study was to explore residents’ perceptions of their own sadness. Methods: We performed individual, semi-structured interviews with twelve older people residing in nursing homes with no dementia. The interview guide comprised questions on what made the informants sad and what prevented sadness. We recorded, transcribed verbatim and analysed the interviews using systematic text condensation. Results: The interviews revealed three main themes. I. Decay and loss of agency. The informants perceived their sadness to be caused by loss of health and functional ability, reliance on long-term care, dysfunctional technical aids and poor care. II. Loneliness in the middle of the crowd. Loss of family and friends, and lack of conversations with staff members and fellow patients were also sources of sadness. III. Relating and identity. The informants kept sadness at bay through: acceptance and re-orientation to their current life situation, maintaining narratives about their identity and belonging, and religiosity. Conclusions: Nursing home nurses and doctors should identify and respond to sadness that is a rational response to manageable causes. Further, identifying and supporting residents’ resources and coping strategies is a salutogenetic approach that may alleviate sadness

Shame in medical clerkship: “You just feel like dirt under someone’s shoe”

Introduction This study explores how senior medical students’ experience and react to shame during clinical placements by asking them to reflect on (1) manifestations of shame experiences, (2) situations and social interactions that give rise to shame, and (3) perceived effects of shame on learning and professional identity development. Methods In this interpretive study, the authors recruited 16 senior medical students from two classes at a Norwegian medical school. In three focus group interviews, participants were invited to reflect on their experiences of shame. The data were analyzed using systematic text condensation, producing rich descriptions about students’ shame experiences. Results All participants had a range of shame experiences, with strong emotional, physical, and cognitive reactions. Shame was triggered by a range of clinician behaviours interpreted as disinterest, disrespect, humiliation, or breaches of professionalism. Shame during clinical training caused loss of confidence and motivation, worries about professional competence, lack of engagement in learning, and distancing from shame-associated specialties. No positive effects of shame were reported. Discussion Shame reactions in medical students were triggered by clinician behaviour that left students feeling unwanted, rejected, or burdensome, and by humiliating teaching situations. Shame had deleterious effects on motivation, learning, and professional identity development. This study has implications for learners, educators, and clinicians, and it may contribute to increased understanding of the importance of supportive learning environments and supervisors’ social skills within the context of medical education

Dilemmas of medical overuse in general practice - A focus group study

Objective: To obtain first-hand in-depth accounts of overtesting amongst GPs in Norway, as well as the GPs’ perspectives on drivers of overtesting and strategies that can prevent overtesting. Design and setting: Four focus groups with GPs were conducted. All participants were asked to share examples of unnecessary testing from their everyday general practice, to identify the driving forces involved in these examples and discuss any measures that might prevent excessive testing. All authors collaborated on the analysis, conducted as systematic text condensation, using critical incident technique. Results: This study reveals two main positions regarding overtesting in general practice. In the categorical position there is no such thing as overtesting and GPs are obliged to perform extensive investigations on the suspicion that any person can carry a fatal disease, no matter how minor or absent their symptoms are. In contrast, in the dilemmatic position, the GPs acknowledge that investigations can cause significant harm, but still feel pressured to discover disease at the earliest opportunity and to meet patients’ demands. The GPs’ strategies for resolving this dilemma are often demanding and not always successful, but sharing uncertainty and fallibility with patients and colleagues appears to be the most promising strategy. Conclusions: Our study indicates that GPs in Norway experience a strong pressure to discover any instance of disease and to meet patients’ demands for investigations. One way of preventing the harm that accrues from overtesting is openly sharing uncertainty and fallibility with patients and colleagues

Conditions for gatekeeping when GPs consider patient requests unreasonable: a focus group study

Background Requests from patients that are regarded by GPs as unreasonable are a source of conflict between GPs and patients. This makes gatekeeping challenging, as GPs negotiate a struggle between maintaining the doctor–patient relationship, protecting patients from the harms of medical overuse and acting as stewards of limited health care resources. More knowledge of how GPs can succeed in these difficult consultations is needed. Objective To explore Norwegian GPs’ perceptions of conditions that can promote their ability to act as gatekeepers when facing patient requests which they consider ‘unreasonable’. Methods A qualitative study based on three focus groups with Norwegian GPs conducted in 2019, exploring consultations in which the patient made a seemingly unreasonable request, but the GP was able to navigate the consultation in a clinically appropriate manner. Thematic cross-case analysis of verbatim transcripts from the focus groups was carried out using Systematic Text Condensation. Results The analysis revealed three major themes among the conditions that the GPs considered helpful when faced with an ‘unreasonable’ patient request: (i) professional communication skills; (ii) a long-term perspective; (iii) acknowledgement and support of GPs’ gatekeeping role among peers and from authorities. Conclusion Professional communication skills and relational continuity need to be prioritized for GPs to maintain their role as gatekeepers. However, support for the gatekeeping role within the profession as well as from society is also required

Conditions for gatekeeping when GPs consider patient requests unreasonable: a focus group study

Background Requests from patients that are regarded by GPs as unreasonable are a source of conflict between GPs and patients. This makes gatekeeping challenging, as GPs negotiate a struggle between maintaining the doctor–patient relationship, protecting patients from the harms of medical overuse and acting as stewards of limited health care resources. More knowledge of how GPs can succeed in these difficult consultations is needed. Objective To explore Norwegian GPs’ perceptions of conditions that can promote their ability to act as gatekeepers when facing patient requests which they consider ‘unreasonable’. Methods A qualitative study based on three focus groups with Norwegian GPs conducted in 2019, exploring consultations in which the patient made a seemingly unreasonable request, but the GP was able to navigate the consultation in a clinically appropriate manner. Thematic cross-case analysis of verbatim transcripts from the focus groups was carried out using Systematic Text Condensation. Results The analysis revealed three major themes among the conditions that the GPs considered helpful when faced with an ‘unreasonable’ patient request: (i) professional communication skills; (ii) a long-term perspective; (iii) acknowledgement and support of GPs’ gatekeeping role among peers and from authorities. Conclusion Professional communication skills and relational continuity need to be prioritized for GPs to maintain their role as gatekeepers. However, support for the gatekeeping role within the profession as well as from society is also required

Conditions for gatekeeping when GPs consider patient requests unreasonable: a focus group study

Background Requests from patients that are regarded by GPs as unreasonable are a source of conflict between GPs and patients. This makes gatekeeping challenging, as GPs negotiate a struggle between maintaining the doctor–patient relationship, protecting patients from the harms of medical overuse and acting as stewards of limited health care resources. More knowledge of how GPs can succeed in these difficult consultations is needed. Objective To explore Norwegian GPs’ perceptions of conditions that can promote their ability to act as gatekeepers when facing patient requests which they consider ‘unreasonable’. Methods A qualitative study based on three focus groups with Norwegian GPs conducted in 2019, exploring consultations in which the patient made a seemingly unreasonable request, but the GP was able to navigate the consultation in a clinically appropriate manner. Thematic cross-case analysis of verbatim transcripts from the focus groups was carried out using Systematic Text Condensation. Results The analysis revealed three major themes among the conditions that the GPs considered helpful when faced with an ‘unreasonable’ patient request: (i) professional communication skills; (ii) a long-term perspective; (iii) acknowledgement and support of GPs’ gatekeeping role among peers and from authorities. Conclusion Professional communication skills and relational continuity need to be prioritized for GPs to maintain their role as gatekeepers. However, support for the gatekeeping role within the profession as well as from society is also required.publishedVersio