Relation of Federal Taxation to the Financing of Small Business

Aims. To explore general practitioners’ (GPs’) descriptions of their thoughts and action when prescribing cardiovascular preventive drugs. Methods. Qualitative content analysis of transcribed group interviews with 14 participants from two primary health care centres in the southeast of Sweden. Results. GPs’ prescribing of cardiovascular preventive drugs, from their own descriptions, involved “the patient as calculated” and “the inclination to prescribe,” which were negotiated in the interaction with “the patient in front of me.” In situations with high cardiovascular risk, the GPs reported a tendency to adopt a directive consultation style. In situations with low cardiovascular risk and great uncertainty about the net benefit of preventive drugs, the GPs described a preference for an informed patient choice. Conclusions. Our findings suggest that GPs mainly involve patients at low and uncertain risk of cardiovascular disease in treatment decisions, whereas patient involvement tends to decrease when GPs judge the cardiovascular risk as high. Our findings may serve as a memento for clinicians, and we suggest them to be considered in training in communication skills

Leadership in rural medicine: The organization on thin ice?

Objective. To explore the personal experiences of and conceptions regarding leading rural primary care in Northern Norway. Design. Qualitative content analysis of focus-group interviews. Setting. Lead primary care physicians in the three northernmost counties. Subjects. Four groups with 22 out of 88 municipal lead physicians in the region. Results. Three main categories were developed and bound together by an implicit theme. Demands and challenges included the wide leadership span of clinical services and public health, placed in a merged line/board position. Constraints of human resources and time and the ever changing organizational context added to the experience of strain. Personal qualifications indicates the lack of leadership motivation and training, which was partly compensated for by a leader role developed through clinical undergraduate training and then through the responsibilities and experiences of clinical work. In Exercising the leadership, the participants described a vision of a coaching and coordinating leadership and, in practice, a display of communication skills, decision-making ability, result focusing, and ad hoc solutions. Leadership was made easier by the features of the small, rural organization, such as overview, close contact with cooperating partners, and a supportive environment. There was incongruence between demands and described qualifications, and between desired and executed leadership, but nevertheless the organization was running. Leadership demonstrated a “working inadequacy”. Conclusion. Under resource constraints, leadership based on clinical skills favours management by exception which, in the long run, appears to make the leadership less effective. Leadership training which takes into account the prominent features of rural and decentralized primary care is strongly needed

A qualitative study of final-year medical students’ perspectives of general practitioners’ competencies

Objectives: To investigate final-year medical students' perspectives of general practitioners' competencies. A further aim of the study was to investigate which type of clinical problems is properly managed by GPs according to students. Methods: We conducted a qualitative study of 49 final year medical students from two programmes. Reflective writing statements were used to collect data. Qualitative content analysis was employed to analyse data. Results: Three themes were identified to explain the conditions of a general practitioner (GP). They are: 'prerequisites', 'patients´ problems' and 'competence and clinical judgment' which reflect the specific features of primary care, presentation of symptoms by patient and the way that GPs approach an actual encounter. Conclusions: The students valued the importance of unselected patient problems, straightforwardness in contact and care as the characteristics of a competent GP. They viewed patients with different approaches and related their observations to problems of fragmentation within this large area of medical care. This is a period in the training of students in which students' views of general practice are formed

Usability of computerised physician order entry in primary care: assessing ePrescribing with a new evaluation model

Background The incorrect use of medications may result from improper prescribing. The poor interface and design of computerised physician order entry (CPOE) systems may contribute. To improve the quality of electronic drug prescription, ePrescribing, there is a need for an evaluation model that is able to assess the quality of the CPOE, focusing on usability. Objective To develop and apply a model to evaluate the usability of different CPOEs used for ePrescribing in electronic health records (EHRs) in primary care. Method An evaluation model for CPOEs was designed by assembling existing quality criteria for ePrescribing, supplemented with new criteria. The evaluation model was used to assess CPOEs from seven EHRs in primary care. Results The evaluation model included five categories comprising 73 single criteria. The model was found to be easy to use, and facilitated the assessment process. Evaluation of the EHRs revealed differences and similarities between the systems. None of the CPOEs was perfect in that all of them had distinct shortcomings. The most prominent deficiencies were a non-intuitive interface and incorrect dosage function. Conclusion The model developed might be used not only to evaluate usability in ePrescribing, but also as a basis for studying the usability of other CPOEs. To reduce the risk of drugs being prescribed with incorrect dosages, the most urgent improvement is the development of a more consistent and intuitive interface for the EHRs and an improvement in the dosage function

Atención psicosocial a víctimas de delito en la Red de Derivación Departamental de Sololá y la Asociación Nacional contra el Maltrato Infantil -CONACMI-

El Ejercicio Profesional Supervisado Atención psicosocial víctimas de delito en la Red de Derivación Departamental de Sololá y la Asociación Nacional Contra el Maltrato Infantil –CONACMI- Se realizó a través del sub-programa de servicio, que brindó atención psicosocial, a casos que fueron referidos por la Red de Derivación donde se tuvo como objetivo la recuperación de la dignidad y el acceso a justicia de las víctimas. Se les brindó acompañamiento en la “Ruta Crítica” lo que significa un recorrido por las diferentes instituciones al momento de presentarse un delito e interponer una denuncia ya sea por violencia psicológica, física y sexual. En el caso de CONACMI se atendió a grupos de jóvenes y familias con antecedentes de conexión en calle, a quienes se les brindó acompañamiento psicosocial. En el sub-programa de Docencia se realizaron talleres para socializar el trabajo que se hace en la “Ruta Crítica” se dirigió a lideresas, representantes de Oficinas Municipales de la Mujer (OMM) con el fin de asesorar y acompañar de la mejor manera a las víctimas de delito, además se brindó información de las leyes que respaldan el cumplimiento de derecho. En CONACMI se ofrecieron talleres a un grupo de niños sobre derechos y temas de prevención. Con el subprograma de investigación, se analizó las implicaciones psicosociales que tiene para la víctima de violencia contra la mujer, el interponer una denuncia. Concluye que, las mujeres que presentan una denuncia por violencia sufrida por parte de sus esposos, por falta de conocimiento de las consecuencias que les conllevará, desisten de continuar con el proceso legal, debido a la presión social del entorno

To make a difference – how GPs conceive consultation outcomes. A phenomenographic study

<p>Abstract</p> <p>Background</p> <p>Outcomes from GPs' consultations have been measured mainly with disease specific measures and with patient questionnaires about health, satisfaction, enablement and quality. The aim of this study was to explore GPs' conceptions of consultation outcomes.</p> <p>Methods</p> <p>Interviews with 17 GPs in groups and individually about consultation outcomes from recently performed consultations were analysed with a phenomenographic research approach.</p> <p>Results</p> <p>The GPs conceived outcomes in four ways: patient outcomes, GPs' self-evaluation, relationship building and change of surgery routines.</p> <p>Conclusion</p> <p>Patient outcomes, as conceived by the GPs, were generally congruent with those that had been taken up in outcome studies. Relationship building and change of surgery routines were outcomes in preparation for consultations to come. GPs made self-assessments related to internalized norms, grounded on a perceived collegial professional consensus. Considerations of such different aspects of outcomes can inspire professional development.</p

Physicians' messages in problematic sickness certification: a narrative analysis of case reports

<p>Abstract</p> <p>Background</p> <p>Many physicians find sickness certification tasks problematic. There is some knowledge about situations that are experienced as problematic, whereas less is understood about how physicians respond to the problems they face. One way to acquire such knowledge is to consider "reflection-in-action", aspects of which are expressed in the physician's interpretation of the patient's story. The aim of this study was to gain knowledge about the meaning content of case reports about problematic sickness certification. Specifically, we looked for possible messages to the colleagues intended to read the reports.</p> <p>Methods</p> <p>A narrative approach was used to analyse reports about problematic sickness certification cases that had been written by GPs and occupational health service physicians as part of a sickness insurance course. The analysis included elements from both thematic and structural analysis. Nineteen case reports were used in the actual analysis and 25 in the validation of the results. Main narrative qualities and structural features of the written case reports were explored.</p> <p>Results</p> <p>Five types of messages were identified in the case reports, here classified as "a call for help", "a call for understanding", "hidden worries", "in my opinion", and "appearing neutral". In the reports, the physicians tried to achieve neutrality in their writing, and the patients' stories tended to be interpreted within a traditional biomedical framework. In some cases there was an open request for help, in others it was not obvious that the physician had any problems. Overall, the messages were about having problems as such, rather than the specific features of the problems.</p> <p>Conclusions</p> <p>The case reports clearly demonstrated different ways of writing about problems that arise during sickness certification, from being neutral and not mentioning the problems to being emotionally involved and asking for help. The general character of the messages suggests that they are also relevant for case reports in problematic areas other than sickness certification. If pertinent relationships can be found between reflection-in-practice and the narrative writing about practice, they will provide an approach to further research concerning consultations perceived as problematic and also to medical education.</p

Satisfaction is not all – patients' perceptions of outcome of general practice consultations, a qualitative study

BACKGROUND: Evaluation of outcome in general practice can be seen from different viewpoints. In this study we focus on the concepts patients use to describe the outcome of a consultation with a GP. METHOD: Patients were interviewed within a week after a consultation with a GP. The interviews were made with 20 patients in 5 focus groups and 8 individually. They were analysed with a phenomenographic research approach. RESULTS: From the patient's perspective, the outcome of a consultation is about cure or symptom relief, understanding, confirmation, reassurance, change in self-perception and satisfaction. CONCLUSION: General practice consultations are often more important for patients than generally supposed. Understanding is the most basic concept

"I did not intend to stop. I just could not stand cigarettes any more." A qualitative interview study of smoking cessation among the elderly

<p>Abstract</p> <p>Background</p> <p>Every year, more than 650,000 Europeans die because they smoke. Smoking is considered to be the single most preventable factor influencing health. General practitioners (GP) are encouraged to advise on smoking cessation at all suitable consultations. Unsolicited advice from GPs results in one of 40-60 smokers stopping smoking. Smoking cessation advice has traditionally been given on an individual basis. Our aim was to gain insights that may help general practitioners understand why people smoke, and why smokers stop and then remain quitting and, from this, to find fruitful approaches to the dialogue about stopping smoking.</p> <p>Methods</p> <p>Interviews with 18 elderly smokers and ex-smokers about their smoking and decisions to smoke or quit were analysed with qualitative content analysis across narratives. A narrative perspective was applied.</p> <p>Results</p> <p>Six stages in the smoking story emerged, from the start of smoking, where friends had a huge influence, until maintenance of the possible cessation. The informants were influenced by "all the others" at all stages. Spouses had vital influence in stopping, relapses and continued smoking. The majority of quitters had stopped by themselves without medication, and had kept the tobacco handy for 3-6 months. Often smoking cessation seemed to happen unplanned, though sometimes it was planned. With an increasingly negative social attitude towards smoking, the informants became more aware of the risks of smoking.</p> <p>Conclusion</p> <p>"All the others" is a clue in the smoking story. For smoking cessation, it is essential to be aware of the influence of friends and family members, especially a spouse. People may stop smoking unplanned, even when motivation is not obvious. Information from the community and from doctors on the negative aspects of smoking should continue. Eliciting life-long smoking narratives may open up for a fruitful dialogue, as well as prompting reflection about smoking and adding to the motivation to stop.</p