General practice–a fertile lagoon in the ocean of medical knowledge

General practitioners (GPs) often find that linear, deductive knowledge does not provide a sufficient map for clinical management. But experience, accompanied by enduring familiarity with individual patients, may offer unique complementary skills to interpret a patient’s symptoms and navigate skilfully through diagnosis, treatment, follow-up and prevention. In this article, we draw attention to the nature of this tacit knowing that is executed by many GPs every day. We argue that the nonlinear, unpredictable complexity of this domain nurtures a particular logic of clinical knowing. This kind of knowledge is not intuition and can to some extent be intersubjectively accessible. We substantiate and discuss how and why general practice research can contribute to knowledge development by transforming reflection-in-action to reflection-on-action. We briefly present some concepts for reflection-on-action of clinical knowing in general practice. The VUCA model (volatility, uncertainty, complexity, ambiguity) embraces dynamic and confusing situations in which agile work (adaptive, flexible and responsive behaviour and cognitive creativity) is assumed to be an appropriate response. Using such perspectives, we may sharpen our gaze and apply reflexivity and analytic elaboration to interpret unique incidents and experiences and appreciate the complexity of general practice. In this way, exploratory research can fertilize general practice and offer innovation to the entire domain of clinical knowledge.publishedVersio

Mener han, at somatisering er noe, jeg gjør? En pragmatisk begrepsanalyse

Praktiserende leger møter mange pasienter, som har subjektive symptomer, uten at legen kan påvise objektive funn. Sykdomsårsaken er ukjent, og det er vanskelig å finne fram til en tradisjonell medisinsk diagnose. De ’ubestemte’ plagene – ’medically unexplained physical symptoms’ – er tilstander, som preges av kronisk lidelse og funksjonshemning, og som i årenes løp har fått mange diagnostiske betegnelser. I denne artikkelen vil jeg undersøke og drøfte betyd-ningen av det diagnostiske begrepet ’somatisering’. Vi skal se nærmere på de kulturelle og språklige røttene, som har gitt innhold til denne diagnosen og spesielt studerere de sosiale og medisinske konsekvenser av dette for klinisk praksis i dag. I en kunn-skapsarkeologisk tilnærming kombineres teoretiske perspektiver fra medisinsk nosografi og pragmatisk filosofi

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

Why do doctors in Norway choose general practice and remain there? A qualitative study about motivational experiences

Objective: To explore experiences motivating doctors to become and remain GPs. Design and contributors: Qualitative analysis of written responses from an open-ended question about motivational experiences posted on an internet discussion list for GPs in Norway. Texts from 25 contributors were analysed with Systematic Text Condensation, supported by theories about calling as motivation. Results: Analysis revealed numerous aspects of motivation to become and remain a general practitioner. Inspirations from early experiences and skilled role models had conveyed values and offered insight into a fascinating world of care, gratitude and respect. Close and continuous relationships with patients provided GPs with humbling experiences and learning moments. Contributors described how these encounters became rewarding sources of insight and mutual trust, improving interpersonal skills. Also, the extensive variety of tasks during the workday and the space for autonomy and independence was emphasised. Implications: Understanding motivational experiences influencing GPs’ choice of medical career is necessary to develop strategies for recruitment and stability and contribute to prevention of burn-out and improper work-life balance. GPs’ professional identities and commitments should be recognized and developed in dialogues between authorities and GPs to enhance communication, improve the structural frames of work environment and thereby sustainable recruitment. Key points GPs regard their choice of medical career as strongly influenced by motivational experiences in childhood, adolescence and as medical students Role models, diversity of work, feelings of being able to contribute and rewarding and continuous relationships with patients were mentioned to activate and maintain general practice commitment Knowledge about motivational influences, professional identities and commitment for GPs is crucial for medical education and dialogue to promote general practice as a career choice and prevent dangers of work overload and burnoutpublishedVersio

I am not the kind of woman who complains of everything’: illness stories on self and shame in women with chronic pain. Soc Sci Med

Abstract In this study, we explore issues of self and shame in illness accounts from women with chronic pain. We focused on how these issues within their stories were shaped according to cultural discourses of gender and disease. A qualitative study was conducted with in-depth interviews including a purposeful sampling of 10 women of varying ages and backgrounds with chronic muscular pain. The women described themselves in various ways as 'strong', and expressed their disgust regarding talk of illness of other women with similar pain. The material was interpreted within a feminist frame of reference, inspired by narrative theory and discourse analysis. We read the women's descriptions of their own (positive) strength and the (negative) illness talk of others as a moral plot and argumentation, appealing to a public audience of health personnel, the general public, and the interviewer: As a plot, their stories attempt to cope with psychological and alternative explanations of the causes of their pain. As performance, their stories attempt to cope with the scepticism and distrust they report having been met with. Finally, as arguments, their stories attempt to convince us about the credibility of their pain as real and somatic rather than imagined or psychological. In several ways, the women negotiated a picture of themselves that fits with normative, biomedical expectations of what illness is and how it should be performed or lived out in 'storied form' according to a gendered work of credibility as woman and as ill. Thus, their descriptions appear not merely in terms of individual behaviour, but also as organized by medical discourses of gender and diseases. Behind their stories, we hear whispered accounts relating to the medical narrative about hysteria; rejections of the stereotype medical discourse of the crazy, lazy, illness-fixed or weak woman.

Obesity, stigma, and responsibility in health care: A synthesis of qualitative studies

Objective: To synthesize research findings on experiences and attitudes about obesity and stigma in health care. Methods: We compiled qualitative studies and applied Noblitt & Hare's meta ethnography to identify, translate, and summarize across studies. Thirteen qualitative studies on experiences and attitudes about obesity and stigma in health care settings were identified and included. Results: The study reveals how stigmatizing attitudes are enacted by health care providers and perceived by patients with obesity. Second-order analysis demonstrated that apparently appropriate advice can be perceived as patronizing by patients with obesity. Furthermore, health care providers indicate that abnormal bodies cannot be incorporated in the medical systems—exclusion of patients with obesity consequently happens. Finally, customary standards for interpersonal respect are legitimately surpassed, and patients with obesity experience contempt as if deserved. Third-order analysis revealed conflicting views between providers and patients with obesity on responsibility, whereas internalized stigma made patients vulnerable for accepting a negative attribution. A theoretical elaboration relates the issues of stigma with those of responsibility. Conclusion: Contradictory views on patients’ responsibility, efforts, knowledge, and motivation merge to internalization of stigma, thereby obstructing healthy coping and collaboration and creating negative contexts for empowerment, self-efficacy, and weight management. Professionals need to develop their awareness for potentially stigmatizing attitudes towards vulnerable patient populations

Hope in action—facing cardiac death: A qualitative study of patients with life-threatening disease

Coping with existential challenges is important when struck by serious disease, but apart from cancer and palliative care little is known about how patients deal with such issues and maintain hope. To explore how patients with life-threatening heart disease experience hope when coping with mortality and other existential challenges, we conducted a qualitative study with semi-structured interviews. We made a purposive sample of 11 participants (26–88 years) who had experienced life-threatening disease: eight participants with serious heart disease, two with cancer, and one with severe chronic obstructive pulmonary disease. Analysis was by systematic text condensation. The findings showed that hope could enhance coping and diminish existential distress when patients were confronted with mortality and other existential challenges. Hope was observed as three types of dynamic work: to shift perception of mortality from overwhelming horror toward suppression or peaceful acceptance, to foster reconciliation instead of uncertainty when adapting to the new phase of life, and to establish go-ahead spirit instead of resignation as their identity. Meaning of life could, hence, be sustained in spite of serious threats to the persons' future, everyday life, and self-conception. The work of hoping could be supported or disturbed by relationships with family, friends, and health care professionals. Hope can be regarded as an active, dynamic state of existential coping among patients with life-threatening disease. Physicians may support this coping and thereby provide personal growth and alleviation of existential distress by skillfully identifying, acknowledging, and participating in the work of hoping performed by the patient

“Being Guided”: What Oncofertility Patients’ Decisions Can Teach Us About the Efficacy of Autonomy, Agency, and Decision-Making Theory in the Contemporary Critical Encounter

Recent research on patient decision-making reveals a disconnect between theories of autonomy, agency, and decision-making and their practice in contemporary clinical encounters. This study examines these concepts in the context of female patients making oncofertility decisions in the United Kingdom in light of the phenomenon of “being guided.” Patients experience being guided as a way to cope with, understand, and defer difficult treatment decisions. Previous discussions condemn guided decision-making, but this research suggests that patients make an informed, autonomous decision to be guided by doctors. Thus, bioethicists must consider the multifaceted ways that patients enact their autonomy in medical encounters