General Practitioners In Norway Research Articles

To be or not to be supervisors for medical students in general practice clinical placements: a questionnaire study from Norway

Objective Many countries experience challenges in recruiting and retaining general practitioners (GPs) as supervisors for medical students in clinical placements. We aimed to investigate the opportunities, capacities and limitations of Norwegian GPs to become supervisors. Design Web-based cross-sectional questionnaire study. Setting Norwegian general practice. Subjects All GPs in Norway, including locums and those on leave, both active supervisors, and GPs who are not presently supervising medical students. Main outcome measures GPs’ terms of salary, office facilities, limiting factors, capacity and needs for becoming or continuing as supervisors. Results Among 5145 GPs, 1466 responded (29%), of whom 498 (34%) were active supervisors. Lack of a dedicated student office was the most reported limitation for both active supervisors (75%) and other GPs (81%). A high proportion (67%) of active supervisors reported that they could host more students per year, given financial support for equipped offices and higher salaries. With this kind of support, 48% (n = 461) of the GPs who were not supervisors for medical students were positive about a future supervisor role. By adjusted regression analysis, female GPs had lower likelihood of being supervisors, OR (95% CI) 0.75 (0.59–0.95) than male colleagues. GPs in the North, Mid and West regions had higher odds (OR 3.89, 3.10 and 2.42, respectively) than those in the South-East region. Teaching experience also increased the odds (2.31 (1.74–3.05). Conclusions There seems to be capacity among both active and potential supervisors if increased salaries and financial support for office facilities are made available.

Self-perceived learning outcomes of virtual and in-person academic detailing among general practitioners in Norway.

Self-perceived learning outcomes of virtual academic detailing (AD) are poorly studied. We compared self-perceived learning outcomes of virtual and in-person AD among general practitioners (GPs). GPs from the Western region of Norway received a questionnaire before and after AD concerning rational pharmacotherapy of migraine in the autumn 2022. Five statements addressing specific knowledge and two statements addressing general knowledge and skills in pharmacotherapy of migraine were rated in both questionnaires. A 7-point Likert scale ranging from 1: Strongly disagree to 7: Strongly agree was applied to all the statements. Histograms that showed the difference in the mean composite scores before and after AD were used to compare learning outcomes of virtual and in-person AD. Positive self-perceived learning outcomes were observed among 80%-88% of the GPs. No significant differences between virtual and in-person AD were observed.

Web-Based Public Ratings of General Practitioners in Norway: Validation Study.

Understanding the complex relationships among multiple strategies for gathering users' perspectives in the evaluation of the performance of services is crucial for the interpretation of user-reported measures. The main objectives were to (1) evaluate the psychometric performance of an 11-item web-based questionnaire of ratings of general practitioners (GPs) currently used in Norway (Legelisten.no) and (2) assess the association between web-based and survey-based patient experience indicators. We included all published ratings on GPs and practices on Legelisten.no in the period of May 5, 2012, to December 15, 2021 (N=76,521). The questionnaire consists of 1 mandatory item and 10 voluntary items with 5 response categories (1 to 5 stars), alongside an open-ended review question and background variables. Questionnaire dimensionality and internal consistency were assessed with Cronbach α, exploratory factor, and item response theory analyses, and a priori hypotheses were developed for assessing construct validity (chi-square analysis). We calculated Spearman correlations between web-based ratings and reference patient experience indicators based on survey data using the patient experiences with the GP questionnaire (n=5623 respondents for a random sample of 50 GPs). Web-based raters were predominantly women (n=32,074, 64.0%), in the age range of 20-50 years (n=35,113, 74.6%), and reporting 5 or fewer consultations with the GP each year (n=28,798, 64.5%). Ratings were missing for 18.9% (n=14,500) to 27.4% (n=20,960) of nonmandatory items. A total of 4 of 11 rating items showed a U-shaped distribution, with >60% reporting 5 stars. Factor analysis and internal consistency testing identified 2 rating scales: "GP" (5 items; α=.98) and "practice" (6 items; α=.85). Some associations were not consistent with a priori hypotheses and allowed only partial confirmation of the construct validity of ratings. Item response theory analysis results were adequate for the "practice" scale but not for the "GP" scale, with items with inflated discrimination (>5) distributed over a narrow interval of the scale. The correlations between the web-based ratings GP scale and GP reference indicators ranged from 0.34 (P=.021) to 0.44 (P=.002), while the correlation between the web-based ratings practice scale and reference indicators ranged from 0.17 (not significant) to 0.49 (P<.001). The strongest correlations between web-based and survey scores were found for items measuring practice-related experiences: phone availability (ρ=0.51), waiting time in the office (ρ=0.62), other staff (ρ=0.54-0.58; P<.001). The practice scale of the web-based ratings has adequate psychometric performance, while the GP suffers from important limitations. The associations with survey-based patient experience indicators were accordingly mostly weak to modest. Our study underlines the importance of interpreting web-based ratings with caution and the need to further develop rating sites.

Factors associated with general practitioners' routines and comfortability with assessing female genital cutting: a cross-sectional survey

BackgroundFemale genital cutting (FGC) may cause a series of health problems that require specialized healthcare. General practitioners (GPs) are gatekeepers to specialized healthcare services in Norway. To refer girls and women subjected to FGC to appropriate services, GPs need to assess whether the health problems reported by these patients are related to FGC. However, we do not know to what degree GPs assess FGC as a potential cause of the patients' health problems. We also know little about the GPs' patterns of training and knowledge of FGC and their effect on the GPs' assessment of FGC as a potential cause of health problems.MethodWe employed a cross-sectional online survey among GPs in Norway to examine: 1) patterns of received training on FGC, self-assessed knowledge, and experiences with patients with FGC-related problems and 2) the association between these three factors and the GPs' assessment of FGC as a potential cause of patients' health problems. A total of 222 GPs completed the survey. Data were analysed using binary logistic regression, where we also adjusted for sociodemographic characteristics.ResultsTwo-third of the participants had received training on FGC, but only over half received training on FGC-related health problems. Over 75% of the participants stated a need for more knowledge of FGC typology and Norwegian legislation. While the majority of the participants assessed their knowledge of FGC medical codes as inadequate, this was not the case for knowledge of the cultural aspects of FGC. Female GPs were more likely to have experience with patients with FGC-related health problems than male GPs. Among GPs with experience, 46% linked health problems to FGC in patients unaware of the connection between FGC and such health problems. GPs were more likely to assess FGC as a potential cause of health problems when they had experience with patients having FGC-related problems and when they assessed their knowledge of FGC typology and FGC-related medical codes as adequate.ConclusionTo improve their assessment of FGC as a potential cause of patients' health problems, GPs should receive comprehensive training on FGC, with particular emphasis on typology, health problems, and medical codes.

Older patients’ experiences of access to and use of e-consultations with the general practitioner in Norway: an interview study

Objective To explore older patients’ experiences with accessing and using e-consultations to send text-based clinical inquiries to the general practitioner (GP) online. Design Qualitative study based on semi-structured interviews. Results were analysed through a six-phase thematic analysis and interpreted through Levesque’s framework of patient-centred access to health care. Setting General practice in Norway. Subjects Patients aged over 65 years (n = 16) with experience in using e-consultations. Results Respondents considered e-consultations as an integrated part of general practice which helped them achieve better access to health care. We identified four themes describing older patients’ access to and use of e-consultations: 1) the importance of digital health literacy to learn about and use the service – and the fear of losing it, 2) the high availability of the service as the main advantage, due to the perceived unavailability of physical GP services, 3) the importance of voluntary use of e-consultations, 4) the importance of a trusting relationship with the GP. Implications Information about e-consultations and guidelines for suitable use are recommended to ensure equal access to all patients, regardless of their digital health literacy. Availability problems and high work burdens for the GPs could affect the patients’ choice for using e-consultations. If e-consultations are used for triage purposes, caution should be taken to avoid a shift in workload from the health secretary to the GP. Key points of article The extended use of e-consultations with the general practitioner has raised concerns that the service may not be accessible and suitable for older patients. For older users, e-consultations can represent a positive addition to physical consultation forms due to the high availability of the service in a general practice setting characterised by long waiting times. Digital health literacy is essential to learn about and use the service. Information about the service and how to use it should be available to all patients to ensure equal access. A trusting relationship with the GP is described as essential for older patients to perceive the outcome of e-consultations as appropriate and safe.

The impact of clinical experience on working tasks and job-related stress: a survey among 1032 Norwegian GPs

BackgroundGeneral practice is a generalist discipline fraught with complexity. For inexperienced physicians, it may be demanding to get to grips with the clinical challenges. The purpose of this article is to describe possible differences in the range of tasks between inexperienced and experienced general practitioners (GPs), and the extent to which clinical experience affects the way in which GPs perceive their daily work.MethodsAn online questionnaire was sent to all regular GPs in Norway (N = 4784) in 2018. The study sought to document the tasks performed during a typical working day and how the GPs perceived their working situation. In this study, we compare the tasks, working situation and occurrence of potentially conflictual consultations among ‘less experienced physicians’ (≤ 5 years of experience in general practice) versus ‘more experienced physicians’ (> 5 years of experience). The findings are discussed in light of theories on development of expertise.ResultsWe received responses from 1032 GPs; 296 (29%) were less experienced and 735 (71%) more experienced. The two groups reported virtually the same number of consultations (19.2 vs. 20.5) and clinical problems handled (40.4 vs. 44.2) during the study day. The less experienced physicians reported a higher proportion of challenging and/or conflictual consultations, involving prescriptions for potentially addictive medication (5.7% vs. 3.1%), sickness certification (4.1% vs. 2.4%) and referral for medical investigations on weak clinical indication (8.1% vs. 5.6%). For other clinical issues there were minor or no differences. Both GP groups reported high levels of work-related stress with negative effect on self-perceived health (61.6% vs 64.6%). GPs who felt that high job demands harmed their health tended to handle a slightly higher number of medical issues per consultation and more consultations with elements of conflict.Conclusions and implicationsInexperienced GPs in Norway handle a workload comparable to that of experienced GPs, but they perceive more conflictual consultations. These findings have relevance for training and guidance of future GP specialists. Irrespective of experience, the GPs report such high levels of negative work-related stress as to indicate an acute need for organisational changes that imply a reduced workload.

General practitioners’ management of depression symptoms in Somali refugee and Norwegian patients: a film vignette experiment

ObjectivesRefugees in comparison with non-refugee patients may face higher unmet mental healthcare needs. The mechanisms underlying these disparities are still poorly understood. The general practitioner (GP) plays a vital role...

The management and clinical knowledge of headache disorders among general practitioners in Norway: a questionnaire survey

BackgroundGeneral practitioners (GPs) diagnose and manage a majority of headache patients seeking health care. With the aim to understand the potential for clinical improvement and educational needs, we performed a study to investigate Norwegian GPs knowledge about headache and its clinical management.MethodsWe invited GPs from a random sample of 130 Norwegian continuous medical education (CME) groups to respond to an anonymous questionnaire survey.Results367 GPs responded to the survey (73% of invited CME groups, 7.6% of all GPs in Norway). Mean age was 46 (SD 11) years, with an average of 18 (SD 10) years of clinical experience. In general the national treatment recommendations were followed, while the International Classification of Headache Disorders and other international guidelines were rarely used. Overall, 80% (n = 292) of the GPs suggested adequate prophylactic medication for frequent episodic migraine, while 28% (n = 101) suggested adequate prophylactic medication for chronic tension-type headache (CTTH). Half (52%, n = 191)) of the respondents were aware that different types of acute headache medication can lead to medication-overuse headache (MOH), and 59% (n = 217) knew that prophylactic headache medication does not lead to MOH. GPs often used MRI in the diagnostic work-up. GPs reported that lack of good treatment options was a main barrier to more optimized treatment of headache patients.ConclusionThe knowledge of management of CTTH and MOH was moderate compared to migraine among Norwegian GPs.

Patients’ use and experiences with e-consultation and other digital health services with their general practitioner in Norway: results from an online survey

ObjectivesTo explore patients’ use and experiences with four digital health services implemented in Norway to enable electronic communication between patients and their general practitioner (GP): (1) electronic booking of appointments;...

How can task shifting put patient safety at risk? A qualitative study of experiences among general practitioners in Norway

Objective: To describe experiences among general practitioners (GPs) in Norway regarding horizontal task shifting experiences associated with adverse events that potentially put patient safety at risk.Design and contributors: We conducted a qualitative study with data from a retrospective convenience sample of consecutive, already posted comments in a restricted Facebook group for GPs in Norway. The sample consisted of 43 unique posts from 38 contributors (23 women and 15 men), presenting thick and specific accounts of potentially adverse events in the context of horizontal task shifting. Analysis was conducted with systematic text condensation, a method for thematic cross-case analysis.Results: Contributing GPs reported several types of adverse events associated with horizontal task shifting that could put patient safety at risk. They described how spill-over work dispatched to GPs may generate administrative hassle and hazardous delay of necessary examinations. Overdiagnosis, reduced access and endangered accountability occur when time-consuming procedures and pre-investigation before referral are pushed upon GPs. Resource-draining chores beyond GPs’ proficiency is also dispatched without appropriate instruction or equipment. Furthermore, potential malpractice is imposed by hospital colleagues who overrule the GPs’ medical judgement.Implications: Patient safety is endangered when horizontal task shifting is initiated and performed without a systematic process involving all stakeholders that considers available resources. A risk and vulnerability analysis, securing competent staff, resources, time and equipment before launching such reforms is necessary to protect patient safety. Infrastructure comprised of local coordination groups may facilitate dialogue between health care service levels and negotiate responsibilities and workload.Key pointsTask shifting between different levels of health care is a relevant and legitimate strategy for planning and policy.GPs in Norway report adverse events related to task shifting from specialist colleagues without proper resource allocation.Patient safety may be put at risk by hazardous delay, overdiagnosis, endangered accountability and potential malpractice.Planning and implementation of task shifting must involve all system levels and relevant stakeholders to ensure patient safety.

Which doctors do we trust? A vignette experiment of how gender and ethnicity influence trust

Is people’s trust in doctors affected by their ethnicity or gender? It is often assumed that highly skilled migrants are protected from the worst effects of discrimination. Yet, they also report high degrees of discrimination. This study examines whether ethnic and gendered stereotypes influence trust in general practitioners in Norway. The question is investigated using a survey experiment. Respondents receive a brief resume of a general practitioner where the ethnicity and gender of the physician are randomly varied. Thereafter, the study focuses on investigating the interaction between the respondents' and fictive GPs' ethnicity and gender. The results show that while the majority population is indifferent to the ethnicity of the physicians, they prefer females. Non-Western minorities have a bias in favour of Pakistani-named GPs but are indifferent to the GP's gender.

General practitioners' perspectives on care coordination in primary health care: A qualitative study.

IntroductionTo explore Norwegian general practitioners’ experiences with care coordination in primary health care.MethodsQualitative study using data from five focus groups with 32 general practitioners in Norway. We analysed the data using systematic text condensation, a descriptive and explorative method for thematic cross-case analysis of qualitative data.ResultsThe general practitioners had different notions of care pathways. They expressed a wish and an obligation to be involved in planning and coordination of primary health-care services, but they experienced organisational and financial barriers that limited their involvement and contribution. General practitioners reported lack of information about and few opportunities for involvement in formal coordination initiatives, and they missed informal arenas for dialogue with other primary health-care professionals. They argued that the general practitioner’s role as coordinator should be recognised by other parties and that they needed financial compensation for contributions and attendance in meetings with the municipality.DiscussionGeneral practitioners need informal arenas for dialogue with other primary health-care professionals and access to relevant information to promote coordinated care. There might be an untapped potential for improving patient care involving general practitioners more in planning and coordinating services at the system level. Financial compensation of general practitioners contribution may promote increased involvement by general practitioners.

Self reported involvement in emergency medicine among GPs in Norway

Objective: To examine general practitioners’ (GPs’) perception of their role in emergency medicine and participation in emergency services including ambulance call outs, and the characteristics of the GPs and casualty clinics associated with the GPs’ involvement in emergency medicine.Design: Cross-sectional online survey.Setting: General practice.Subjects: General practitioners in Norway (n = 1002).Main outcome measures: Proportion of GPs perceiving that they have a large role in emergency medicine, regularly being on call, and the proportion of ambulance callouts with GP participation.Results: Forty six percent of the GPs indicated that they play a large role in emergency medicine, 63 percent of the GPs were regularly on call, and 28 percent responded that they usually took part in ambulance call outs. Multivariable logistic regression analyses indicated that these outcomes were strongly associated with participation in multidisciplinary training. Furthermore, the main outcomes were associated with traits commonly seen at smaller casualty clinics such as those with an absence of nursing personnel and extra physicians, and based on the distance to the hospital.Conclusion: Our findings suggest that GPs play an important role in emergency medicine. Multidisciplinary team training may be important for their continued involvement in prehospital emergencies.Key Points Health authorities and other stakeholders have raised concerns about general practitioner’s (GPs) participation in emergency medicine, but few have studied opinions and perceptions among the GPs themselves. • Norwegian GPs report playing a large role in emergency medicine, regularly being on call, and taking part in selected ambulance call outs. • A higher proportion of GPs who took part in team training perceived themselves as playing a large role in emergency medicine, regularly being on call, and taking part in ambulance call outs. • These outcomes were also associated with attributes commonly seen at smaller casualty clinics.

Do treatment decisions depend on physicians' financial incentives?

We study how General Practitioners (GPs) respond to fee changes with respect to the number of visits and treatment intensity. Our empirical strategy is to exploit within GP variation in the fee schedule due to specialisation in general medicine that implies a higher consultation fee, and to use only a narrow time window around the date of the fee change to identify the GPs' supply responses. Making use of detailed administrative claims data covering all GPs in Norway over a six-year period (2006-2011), we find that a higher consultation fee increases the number of visits (with an elasticity of 0.2), but reduces the treatment intensity per visit (and per patient). This is a pure substitution effect where GPs respond to the fee increase by seeing more patients but spending less time with each, without changing the total amount of time spent per month treating patients. Thus, our analysis suggests that fee-for-service is a powerful policy instrument that needs to be carefully designed in order to ensure optimal provision of care.

General practitioners' strategies in consultations with immigrants in Norway-practice-based shared reflections among participants in focus groups.

Immigrants comprise 16.8% of the population in Norway and meet General Practitioners (GPs) as their first point of contact with most health care services as do others in Norway. While Norwegian GPs are not trained in cultural competence, little is known about the extent to which they see good care for immigrants as relying on specific strategies. To explore the thoughts of GPs in Norway about strategies they might use with immigrant patients. We performed focus groups posing the question 'What strategies do you use when meeting immigrant patients?' to three groups of GPs working in Norway. Two groups comprised 10 trainee GPs each; the final group comprised eight certified GPs. Verbatim transcripts were analysed by systematic text condensation. Strategies for consultations with immigrants emerged gradually throughout the focus groups, coalescing around (i) Respect and learn about immigrant culture. (ii) Particularize diagnosis and care, accommodating epidemiological and cultural knowledge for a given group, while keeping a keen eye on the individual. (iii) Inform about Norwegian health care. (iv) Organize resources such as time, translators and interdisciplinary teams. Other core elements of cultural competence, including reflections on the GP's own cultural background, were conspicuously absent, however. Given the growing numbers of immigrants and the early transfer of refugees to general practice, our study points to the urgent need of supplementing teaching in patient-centred clinical method with cultural competence. Our study also highlights the potential of educational GP groups to develop strategies for cross-cultural consultations.

Academic Detailing in Norway—Caring for GPS Where They Are

The Department for Clinical Pharmacology and the Regional Medicines Information and Pharmacovigilance Center (RELIS), St. Olavs Hospital, Trondheim has for many years offered educational outreach services towards primary health care, continuously searching for methods that is proven to make lasting changes in GPs behavior. After reading literature on the method Academic Detaling, and visits to The National Prescribing Service (NPS) in Australia and NaRCAD in Boston we realized that we wanted to try Academic Detailing as a method for an educational outreach towards general practitioners in Norway. We received a grant from the Norwegian Health authorities, and conducted a pilot project in the cities of Trondheim and Tromsoe in the spring of 2015. Our first pilot was on Wiser use of NSAIDs, with focus on reducing the widespread use of diclofenac in Norway, due to the high risk of cardiovascular disease associated with diclofenac. If the GP found it necessary to use a NSAID we advised him/her to use naproxen eventually under cover of a PPI due to the lower risk of cardiovascular adverse events. 213 family doctors of 247 were given a 20 minute one-on-one visit during office hours with a brochure developed for the campaign. The pilot was evaluated through electronic questionnaires to all participating doctors and data from The Norwegian Prescription Database (NorPD) to evaluate changes in prescribing of NSAIDs. The main outcome was reduction in prescribing rate for diclofenac and eventually an increase in the use of naproxen. The general practitioners gave a very high rating, with 98,5 % of the doctors welcoming a new visit with another campaign. The prescribing of diclofenac was reduced in Tromsoe and Trondheim and there was an increase in the use of naproxen compared to other areas in Norway. The results of the intervention was even better one year after. Table I. Average prevalence (users pr. 1000) for diclofenac (inclusive combinations with misoprostol).Tabled 1Diclofenac (incl. Combinationes)April-June 2014April-June 2015Change 2014-2015April-June 2016Change 2014-2016Tromsø7,25,9–17,8 %5,5–23,8 %Bodø10,19,6–4,7 %8,9–11,9 %Trondheim8,85,8–34,4 %5,1–42,3 %Bergen9,89,3–5,3 %8,6–12,4 %Norway9,59,0–5,6 %8,5–10,9 % Open table in a new tab Table II. Average prevalence (users pr. 1000) for naproxen (inclusive combinations with esomeprazole).Tabled 1Naproxen (incl. Combinationes)April-June 2014April-June 2015Endring 2014-2015April-June 2016Endring 2014-2016Tromsø3,85,338,8 %5,955,1 %Bodø4,85,29,4 %6,433,6 %Trondheim4,78,376,8 %9,297,3 %Bergen3,64,012,0 %4,731,2 %Norway4,14,919,0 %5,739,6 % Open table in a new tab Academic Detailing gives clinicians effective producer independent knowledge based therapeutic updating where they are – in their own offices. This method should be used all over Europe.

Abdominal symptoms in general practice: Frequency, cancer suspicions raised, and actions taken by GPs in six European countries. Cohort study with prospective registration of cancer.

BackgroundAbdominal symptoms are diagnostically challenging to general practitioners (GPs): although common, they may indicate cancer. In a prospective cohort of patients, we examined abdominal symptom frequency, initial diagnostic suspicion, and actions of GPs in response to abdominal symptoms.MethodsOver a 10-day period, 493 GPs in Norway, Denmark, Sweden, Belgium, the Netherlands, and Scotland, recorded consecutive consultations: sex, date of birth and any specified abdominal symptoms. For patients with abdominal symptoms, additional data on non-specific symptoms, GPs’ diagnostic suspicion, and features of the consultation were noted. Data on all cancer diagnoses among all included patients were requested from the GPs eight months later.FindingsConsultations with 61802 patients were recorded. Abdominal symptoms were recorded in 6264 (10.1%) patients. A subsequent malignancy was reported in 511 patients (0.8%): 441 (86.3%) had a new cancer, 70 (13.7%) a recurrent cancer. Abdominal symptoms were noted in 129 (25.2%) of cancer patients (P < 0.001), rising to 34.5% for the 89 patients with cancer located in the abdominal region. PPV for any cancer given any abdominal symptom was 2.1%.In symptomatic patients diagnosed with cancer, GPs noted a suspicion of cancer for 85 (65.9%) versus 1895 (30.9%) when there was no subsequent cancer (P < 0.001). No suspicion was noted in 32 (24.8%) cancer patients. The GP’s intuitive cancer suspicion was independently associated with a subsequent new cancer diagnosis (OR 2.11, 95% CI 1.15–3.89).Laboratory tests were ordered for 45.4% of symptomatic patients, imaging for 10.4%, referral or hospitalization for 20.0%: all were more frequent in subsequent cancer patients (P < 0.001).InterpretationAbdominal symptoms pointed to abdominal cancers rather than to other cancers. However, the finding of abdominal symptoms in only one third of patients with an abdominal cancer, and the lack of cancer suspicion in a quarter of symptomatic cancer patients, provide challenges for GPs’ diagnostic thinking and referral practices.

What happens when the doctor denies a patient’s request? A qualitative interview study among general practitioners in Norway

Objective: To explore general practitioners (GPs’) experiences from consultations when a patient’s request is denied, and outcomes of such incidents.Design and participants: We conducted a qualitative study with semi-structured individual interviews with six GPs in Norway. We asked them to tell about experiences from specific encounters where they had refused a patient’s request. The texts were analysed with Systematic Text Condensation, a method for thematic cross-case analysis.Main outcome measures: Accounts of experiences from consultations when GPs refused their patients’ requests.Results: Subjects of dispute included clinical topics like investigation and treatment, certification regarding welfare benefits and medico-legal issues, and administrative matters. The arguments took different paths, sometimes settled by reaching common ground but more often as unresolved disagreement with anger or irritation from the patient, sometimes with open hostility and violence. The aftermath and outcomes of these disputes lead to strong emotional impact where the doctors reflected upon the incidents and sometimes regretted their handling of the consultation. Some long-standing and close patient–doctor relationships were injured or came to an end.Conclusions: The price for denying a patient’s request may be high, and GPs find themselves uncomfortable in such encounters. Skills pertaining to this particular challenge could be improved though education and training, drawing attention to negotiation of potential conflicts. Also, the notion that doctors have a professional commitment to his or her own autonomy and to society should be restored, through increased emphasis on core professional ethics in medical education at all levels.

Practice variation in surgical procedures and IUD-insertions among general practitioners in Norway \u2013 a longitudinal study

BackgroundStudies of Primary Health Care (PHC) reveal considerable practice variations in terms of the range of services provided. In Norway, general practitioners (GPs) are traditionally expected to perform IUD-insertions and several surgical procedures as a part of comprehensive PHC. We aimed to investigate variation in the provision of surgical procedures and IUD-insertions across GPs and over time and explore determinants of such variation.MethodsRetrospective registry study of Norwegian GPs. From a comprehensive database of GPs’ reimbursement claims, we obtained procedure codes and GP characteristics such as age, gender, list size and municipality characteristics from 2006 through 2013. Multivariable logistic regression models were fitted to explore determinants of practice variation.ResultsWe extracted data from 4,828 GPs. In 2013, 91.0, 76.1 and 74.8% were reimbursed at least once for minor and major surgical procedures and IUD-insertion, respectively. Female GPs had lower odds for performing major surgical procedures (OR 0.38, 95% CI 0.32–0.45) and higher odds for performing IUD-insertions (OR 6.28, 95% CI 4.47–8.82) than male GPs. Older GPs and GPs with shorter patient lists were less likely to perform surgical procedures. GPs with longer patient lists had higher odds for performing IUD-insertions. The proportion of GPs performing surgical procedures increased over time, while the proportion decreased for IUD-insertions. The number of IUD-insertions in specialist care increased from 12,575 in 2011 to 15 216 (+21.0%) in 2014.ConclusionWe observed a large variation in the provision of surgical procedures and IUD-insertions amongst GPs in Norway. The GPs’ age, gender, list size and size of municipality were associated with performing the procedures. Our findings suggest a shift of IUD-insertions from primary to specialist care.

Explaining variations in general practitioners’ experiences of doing medically based assessments of work ability in disability benefit claims. A survey-based analysis

AbstractPurpose: Assessing patients’ work ability is a task that many general practitioners consider challenging. Increase of mental and musculoskeletal disorders further complicate the assessments. The purpose of this paper is to explain variation between general practitioners related to how they experience the assessment of work ability in disability cases. Methods: Combining data from an original postal survey among all general practitioners in Norway (N = 1,466; response rate = 32.5%) with characteristics of the municipality where they work, we use multilevel logistic regression to estimate the relationship between a set of dependent variables measuring how confident general practitioners feel when assessing patients’ work ability in disability cases, physician-related characteristics and structural factors. Results: A main finding is that length of service explains most of the variation between general practitioners (B = 0.492 [0.015, 0.970]–2.127 [1.457, 2.798]); in most of the regressions, this var...