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

Tegning som trædesten til at nærme os svære og tabubelagte emner i forskningsprojekter med børn

Studier af belastende socioøkonomiske forhold i barndommen peger på en sammenhæng mellem dette og en øget risiko for at udvikle sygdomme senere i livet. Forskning peger desuden på, at børn af syge forældre både er mere syge og mere ensomme end jævnaldrene med raske forældre. Sammenhængen støttes af studier, som viser, at børns sociale relationer har afgørende betydning både for oplevelsen af deres barndom og for deres aktuelle og senere sundhedsprofil. Med afsæt i de sociale relationers betydning for børnenes sundhed har vi ønsket at undersøge, hvordan børn i ressourcesvage familier oplever deres relationer og familieliv, men hvordan undersøger man det metodisk? Denne artikel viser gennem eksempler fra et feltarbejde blandt socioøkonomisk udsatte børnefamilier med en multisyg forælder på Lolland-Falster, hvordan tegning som metode kan være med til at facilitere samtaler om svære og tabubelagte emner med børn. Metodens styrker ligger dels i den konkretiserende form, der er med til at materialisere tanker og følelser, dels i måden den muliggør et fællesskab mellem barn og forsker, der ofte er udfordret i etnografisk børneforskning. Støttet af tegningerne var børnene i stand til at give udtryk for følelser, stemninger og oplevelser, som indholdsmæssigt var vanskelige at sætte ord på, men som ikke på samme måde var svære at genkalde sig i kroppen eller at tegne på papir. Bl.a. hjalp tegningerne med at illustrere et gennemgående ønske blandt de deltagende børn, der centrerer sig om normalitet, rutiner og stabilitet i familien. Artiklen understreger, at det er vigtigt, at tolkningen af det tegnede akkompagneres af feltarbejdets anden data og et velfunderet kontekstindblik

Tegning som trædesten til at nærme os svære og tabubelagte emner i forskningsprojekter med børn

Studier af belastende socioøkonomiske forhold i barndommen peger på en sammenhæng mellem dette og en øget risiko for at udvikle sygdomme senere i livet. Forskning peger desuden på, at børn af syge forældre både er mere syge og mere ensomme end jævnaldrene med raske forældre. Sammenhængen støttes af studier, som viser, at børns sociale relationer har afgørende betydning både for oplevelsen af deres barndom og for deres aktuelle og senere sundhedsprofil. Med afsæt i de sociale relationers betydning for børnenes sundhed har vi ønsket at undersøge, hvordan børn i ressourcesvage familier oplever deres relationer og familieliv, men hvordan undersøger man det metodisk? Denne artikel viser gennem eksempler fra et feltarbejde blandt socioøkonomisk udsatte børnefamilier med en multisyg forælder på Lolland-Falster, hvordan tegning som metode kan være med til at facilitere samtaler om svære og tabubelagte emner med børn. Metodens styrker ligger dels i den konkretiserende form, der er med til at materialisere tanker og følelser, dels i måden den muliggør et fællesskab mellem barn og forsker, der ofte er udfordret i etnografisk børneforskning. Støttet af tegningerne var børnene i stand til at give udtryk for følelser, stemninger og oplevelser, som indholdsmæssigt var vanskelige at sætte ord på, men som ikke på samme måde var svære at genkalde sig i kroppen eller at tegne på papir. Bl.a. hjalp tegningerne med at illustrere et gennemgående ønske blandt de deltagende børn, der centrerer sig om normalitet, rutiner og stabilitet i familien. Artiklen understreger, at det er vigtigt, at tolkningen af det tegnede akkompagneres af feltarbejdets anden data og et velfunderet kontekstindblik

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

Klassifikation og oplevelse af kronisk sygdom. Patientens møde med medicinsk teknologi - vejen mod kronisk sygdom

Kronisk sygdom er fokus for sundhedsvæsenets samlede indsats. En af udfordringerne er, at medicinsk teknologi skaber nye muligheder for påvisning af abnorme tilstande i kroppen. Artiklen beskriver og diskuterer brug af medicinsk teknologi og kategorisering af sygdom samt forholdet mellem medicinsk teknologi, kronisk sygdom og kvinders kropslige erfaringer. Artiklen er baseret på en kvalitativ empirisk undersøgelse, der undersøgte 60-70-årige kvinders opfattelser og erfaringer med osteoporose. Forholdet mellem teknologien og kroppen kan ses som en transformation, hvor kroppen såvel som kategorien kronisk sygdom bliver konstrueret på forskellige sociale arenaer. Teknologiens klassifikation af kronisk sygdom bliver en ny kontekst, som mange mennesker må forstå og erfare deres krop i. Artiklen viser eksempler på, hvordan lægfolks opfattelse af deres krop ændrer sig som følge af nye biomedicinske klassifikationer og diagnoser. Opfattelsen og oplevelsen af kropslige symptomer bliver et produkt af denne sociale teknologi udtrykt i nye sygdomserfaringer. Artiklen opfordrer til, at man i sundhedsvæsenet påtager sig et ansvar for at overveje brugen af medicinsk teknologi og formidlingen af denne viden, så den ikke skaber kronisk sygdom og skrøbelighed; men tværtimod handlemuligheder og bedre sundhed. Det er vigtigt, at læger går ind i en dialog med patienten om fortolkningen af den viden, der genereres af teknologien

Relational Coordination and Organisational Social Capital Association with Characteristics of General Practice

Background. Relational coordination (RC) and organisational social capital (OSC) are measures of novel aspects of an organisation’s performance, which have not previously been analysed together, in general practice. Objectives. The aim of this study was to analyse the associations between RC and OSC, and characteristics of general practice. Methods. Questionnaire survey study comprising 2074 practices in Denmark. Results. General practitioners (GPs) rated both RC and OSC in their general practice higher than their secretaries and nurses. The practice form was statistically significantly associated with high RC and OSC. RC was positively associated with the number of patients listed with a practice per staff, where staff is defined as all members of a practice including both owners and employees. Conclusion. The study showed that RC and OSC were significantly associated with type of profession and practice type. RC was also found to be significantly positively associated with number of patients per staff. However, the low response rate must be taken into consideration when interpreting the self-reported results of this study

A cultural models approach to osteoporosis prevention and treatment

This article identifies cultural models of osteoporosis, as shared by community-dwelling older women in southeastern Australia, and compares these with cultural knowledge conveyed through social marketing. Cultural models are mental constructs about specific domains in everyday life, such as health and illness, which are shared within a community. We applied domain analyses to data obtained from in-depth interviews and stakeholder-identified print materials. The response domains identified from our case studies made up the shared cultural model &ldquo;Osteoporosis has low salience,&rdquo; particularly when ranked against other threats to health. The cultural knowledge reflected in the print materials supported a cultural model of low salience. Cultural cues embedded in social marketing messages on osteoporosis may be internalized and motivating in unintended ways. Identifying and understanding cultural models of osteoporosis within a community may provide valuable insights to inform the development of targeted health messages.<br /