Insights into the impact of clinical encounters gained from personal accounts of living with advanced cancer.

Aim To describe the impact of interactions with health care professionals revealed by people’s accounts of living and dying with cancer; to explore reasons for the observed effects; and thus, to consider the implications for practice. Background The importance of practitioner–patient interactions is enshrined within professional values. However, our understanding of how and why the consultation impacts on outcomes remains underdeveloped. Stories recounted by people living and dying with cancer offer important insights into illness experience, including the impact of contact with health services, framed within the context of the wider social setting in which people live their lives. From our recent study of distress in primary palliative care patients, we describe how people’s accounts revealed both therapeutic and noxious effects of such encounters, and discuss reasons for the observed effects. Method A qualitative study with a purposive sample of 19 primary palliative care patients: (8 men, 11 at high risk of depression). In-depth interviews were analysed using the iterative thematic analysis described by Lieblich. Findings Living with cancer can be an exhausting process. Maintaining continuity of everyday life was the norm, and dependent on a dynamic process of balancing threats and supports to people’s emotional well-being. Interactions with health care professionals were therapeutic when they provided emotional, or narrative, support. Threats arose when the patient’s perception of the professional’s account of their illness experience was at odds with the person’s own sense of their core self and what was important to them. Our findings highlight the need for a framework in which clinicians may legitimately utilize different illness models to deliver a personalized, patient-centred assessment of need and care. The work provides testable hypotheses supporting development of understanding of therapeutic impact of the consultation

The effect of strategies of personal resilience on depression recovery in an Australian cohort : a mixed methods study

Strategies of personal resilience enable successful adaptation in adversity. Among patients experiencing depression symptoms, we explored which personal resilience strategies they find most helpful, and tested the hypothesis that use of these strategies improves depression recovery. We used interview and survey data from the Diagnosis, Management and Outcomes of Depression in Primary Care 2005 cohort of patients experiencing depression symptoms in Victoria, Australia. 564 participants answered a computer assisted telephone interview question at 12 months follow-up, about what they found most helpful for their depression, stress or worries. Depressive disorder and severity were measured at annual follow-up using the Composite International Diagnostic Interview and the PHQ-9 self-rating questionnaire. Using interview responses we categorised participants as users or not of strategies of personal resilience, specifically, drawing primarily on expanding their own inner resources or pre-existing relationships: 316 (56%) were categorised as primarily users of personal resilience strategies. Of these, 193 (61%) reported expanding inner resources, 79 (25%) drawing on relationships, and 44 (14%) reported both. There was no association between drawing on relationships and depression outcome. There was evidence supporting an association between expanding inner resources and depression outcome: 25% of users having major depressive disorder one year later compared to 38% of non-users (adjusted OR 0.59, CI 0.36-0.97). This is the first study to show improved outcome for depression for those who identify as most helpful the use of personal resilience strategies. The difference in outcome is important as expanding inner resources includes a range of low intensity, yet commonly available strategies

Determination of poly-β-hydroxyalkanoate in Peat

Poly-β-hydroxyalkanoate (PHA) is a prokaryotic energy reserve material that has been used as an indicator of environmental stress in aquatic bacteria. The following technique has been used to quantify PHA in peatland microorganisms. Peat samples were dried, digested in sulphuric acid to convert PHA into crotonic acid, and the resulting acid determined using organic acid high performance liquid chromatography (HPLC) and ultraviolet (UV) detection at 214 nm. This technique is suggested to have potential value as an indicator of environmental stress on peatland microorganisms, such as that caused by summer drought, or changes in soil nutrient availability, which are predicted consequences of climatic change

Modes of Interaction in Naturally Occurring Medical Encounters with General Practitioners: The ´One in a Million´ Study

In this article, we qualitatively explore the manner and style in which medical encounters between patients and general practitioners (GPs) are mutually conducted, as exhibited in situ in 10 consultations sourced from the One in a Million: Primary Care Consultations Archive in England. Our main objectives are to identify interactional modes, to develop a classification of these modes, and to uncover how modes emerge and shift both within and between consultations. Deploying an interactional perspective and a thematic and narrative analysis of consultation transcripts, we identified five distinctive interactional modes: question and answer (Q&A) mode, lecture mode, probabilistic mode, competition mode, and narrative mode. Most modes are GP-led. Mode shifts within consultations generally map on to the chronology of the medical encounter. Patient-led narrative modes are initiated by patients themselves, which demonstrates agency. Our classification of modes derives from complete naturally occurring consultations, covering a wide range of symptoms, and may have general applicability

‘I’d best take out life insurance, then.’ Conceptualisations of risk and uncertainty in primary care consultations, and implications for shared decision-making

The main objective of this study is to gain knowledge about interactional factors that support and obstruct mutual risk-assessments and shared decision-making (SDM) in clinical consultations. Through a narrative analysis of verbatim tran- scripts of 28 naturally occurring consultations performed in English National Health Service practices, we explore the ways in which patients and general practitioners conceptualise, construct and negotiate risks related to diagnostic tests and medical treatments. Consultations were sampled from a corpus of 212 consultation transcripts from the One in a Million: Primary care consultations archive on the basis that they contained the word ‘risk(s)’. Most sampled cases relate to cardiovascular conditions and cancer. Drawing on a social constructionist perspective and the relational theory of risk, we found that while GPs talked about mathematical-probabilistic population risk, patients expressed their own experiences of possible future dangers, conceptualised through words like ‘worried’, ‘scared’ and ‘concerned’. Risk objects, defined here as entities to which harmful consequences are conceptually attached, were constructed differently by patients and GPs, especially in relation to cardiovascular risks. Their different rationalities sometimes obstructed any form of mutual risk-assessments. The relational theory of risk proved to be a useful theoretical frame for exploring layers and configurations of risk constructions among patients and clinicians, and for capturing interactional factors that support and obstruct mutual risk-assessments and SDM. For patients to be able to engage in genuine dialogues and make informed decisions about their care, it is paramount for patients and doctors to co-construct patients’ health-risks during clinical encounters

From mental disorder to shared understanding: a non-categorical approach to support individuals with distress in primary care.

This article argues that, rather than aiming for a psychiatric diagnosis, generalist professionals such as those working in primary care, as well as in other hospital and community settings, should use a non-diagnostic framework when encountering distress. The conceptual and empirical limitations of the psychiatric diagnostic system and evidence that psychological phenomena are dimensional suggest the need for an alternative approach; one that might also address problems of overdiagnosis and overmedication.1 There are three key problems with the current Diagnostic Statistical Manual (DSM) and International Classification of Diseases (ICD) systems of psychiatric classification. The process can be stigmatising; diagnoses are not adequate representations of reality; and they are inadequate for informing an individualised management plan. The current categorical diagnostic system encourages the patient to understand their distress as a disease, rather than as an understandable response to current problems, genetic inheritance, and past experience of trauma, loss, and problematic attachments. Although some patients are comforted by labels, we propose that a more scientifically valid and individualised assessment can provide a deeper understanding, a sense of being understood, and access to specialised services and benefits if required