Swedish General Practitioners Research Articles

Views on sick-listing practice among Swedish General Practitioners--a phenomenographic study.

BackgroundThe number of people on sick-leave started to increase in Sweden and several other European countries towards the end of the 20th century. Physicians play an important role in the sickness insurance system by acting as gate-keepers. Our aim was to explore how General Practitioners (GPs) view their sick-listing commission and sick-listing practice.MethodsSemi-structured interviews with 19 GPs in 17 Primary Health Care settings in four mid-Sweden counties. Interview transcripts were analysed with phenomenographic approach aiming to uncover the variation in existing views regarding the respondents' sick-listing commission and practice.ResultsWe found large qualitative differences in the GPs' views on sick-listing. The sick-listing commission was experienced to come either from society or from patients, with no responsibility for societal interests, or as an integration of these two views. All the GPs were aware of a possible conflict between the interests of society and patients. While some expressed feelings of strong conflict, others seemed to have solved the conflict, at least partly, between these two loyalties.Some GPs experienced carrying the full responsibility to decide whether a patient would get monetary sick-leave benefits or not and they were not comfortable with this situation. Views on the physician's and the patient's responsibility in sick-listing and rehabilitation varied from a passive to an empowering role of the physician.GPs expressing a combination of less inclusive views of the different aspects of sick-listing experienced strong conflict and appeared to feel distressed in their sick-listing role. Some GPs described how they had changed from less to more inclusive views.ConclusionThe clearer understanding of the different views on sick-listing generated in this study can be used in educational efforts to improve physicians' sick-listing practices, benefiting GPs' work situation as well as their patients' well-being. The GP's role as a gatekeeper in the social security system needs further exploration. Our findings could be used to develop a questionnaire to measure the distribution of different views in a wider population of GPs.

Smoking cessation in general practice: The effects of a quitline

This cross-sectional study assessed changes between 1999 and 2003 in attitudes among Swedish general practitioners (GPs) toward smoking cessation activities and also assessed the effect of a nationwide quitline on GPs' smoking cessation activities. A random sample of 621 Swedish GPs answered a questionnaire mailed to their home addresses in spring 2003. When possible, the results of the present study were compared with results from a similar study conducted in 1999. Main outcome measures were GPs' self-reported activities, perceived barriers to engaging in smoking cessation, and referrals to the quitline. Between 1999 and 2003, GPs increased their overall smoking cessation activities and were more aware of the complexity of smoking cessation support. Significantly more GPs experienced smoking cessation support as "too time consuming" and preferred to refer smokers to counselors specializing in smoking cessation. GPs referring patients to the quitline were more likely to be active in other smoking cessation activities. One out of five GPs had advised their patients to use oral smokeless tobacco as a means to stop smoking. A paradigm shift regarding awareness of the complexity of smoking cessation support may be ongoing amongst Swedish GPs. The nationwide smoking cessation quitline appears to have had a positive effect on GPs' engagement in smoking cessation.

ATTITUDES OF SWEDISH GENERAL PRACTITIONERS AND NURSES TO WORKING WITH LIFESTYLE CHANGE, WITH SPECIAL REFERENCE TO ALCOHOL CONSUMPTION

To explore the attitudes of Swedish general practitioners (GPs) and nurses to secondary alcohol prevention (early identification of, and intervention for, alcohol-related problems) and compare it to their attitudes to other important lifestyle behaviours such as smoking, stress, exercise, and overweight. An adjusted version of The WHO Collaborative Study Questionnaire for General Practitioners was posted to all GPs and nurses in the County of Skaraborg, Sweden; 68 GPs and 193 nurses responded. The importance of drinking alcohol moderately, counselling skills on reducing alcohol consumption and perceived current effectiveness in helping patients change lifestyle behaviours ranked lower than working with all the other lifestyle behaviours. The nurses rated their potential effectiveness in helping patients change lifestyle higher than that of GPs for all the lifestyle behaviours. Nurses receiving more alcohol-related education had more positive attitudes than nurses with less education. For alcohol, the GPs assessed their role adequacy, role legitimacy and motivation higher than that of the nurses. The main obstacles for the GPs to carry out alcohol intervention were lack of training in counselling for reducing alcohol consumption, time constraints, and the fact that the doctors did not know how to identify problem drinkers who have no obvious symptoms of excess consumption. GPs and the nurses estimated their alcohol-related competence as lower than working with many other health-related lifestyles. These results can be explained by lack of practical skills, lack of training in suitable intervention techniques, and unsupportive working environments. All these elements must be considered when planning secondary alcohol prevention programs in primary health care.

Living with asthma in Sweden—the ALMA study

Background: Recently performed studies have found a number of limitations in the daily lives of asthmatics, and a large disparity between the perception of the sufferers and what health care professionals believe matters to asthmatics. Aim: What matters to Swedish asthma patients, what medicines do they use, and are they compliant with given prescriptions? A further aim was to compare perceptions about asthma and asthma management in asthmatics and among Swedish general practitioners (GP). Design: A structured telephone interview of a representative sample of Swedish asthmatics, and a mailed questionnaire survey among GPs from different parts of Sweden. Methods: Screening by telephone of a random sample of 10,350 subjects aged 18–45. Of those, 240 were subsequently selected for a detailed structured telephone interview about their asthma. A mailed structured questionnaire containing similar questions to those asked of the asthmatics was sent to 600 GPs, and 139 returned completed answers. Results: 16% of the asthmatics reported (asthma) symptoms occurring every day during the previous month. Nocturnal symptoms at least twice per week were reported by 19%. Both these were reported by considerably higher proportions of the asthmatics than the GPs had expected. A large majority classified their disease as mild or very mild, although great majority reported frequent symptoms. Activities or situations which caused symptoms of asthma often or “now and then” were physical exertion, 67%; bad weather, 59%; contact with animals/pets, 58%; and visits to cafés or restaurants, 36%; and several asthmatics avoided these activities due to their asthma. Conclusion: A great majority of asthmatics report a large number of symptoms and limitations in their daily living in proportions which were roughly expected by the GPs.

Computerisation, coding, data retrieval and related attitudes among Swedish general practitioners—a survey of necessary conditions for a database of diseases and health problems

Objective: To investigate necessary conditions for the establishment of a database of diseases and health problems for research and health care planning, based on electronic patient records in everyday clinical use among general practitioners (GPs). Design: Postal questionnaire study. Setting: Primary health care in Sweden. Subjects: Three hundred randomly selected GPs. Main outcome measures: Degree of computerisation of patient records. User frequency and characteristics of diagnosis classification systems and coding tools. Frequency of coding activities and retrieval of codes, and related attitudes. Opinions on a primary health care version of ICD-10. Results: A total of 184 GPs (61% of the 300 GPs) were included in the study. About 92% used an electronic record system, some type of diagnostic classification was used by 93%, and ICD based classifications by 88%. The classification in use was computerised for 74%. Mainly simple tools were used to retrieve diagnostic codes. About 76% of GPs reported classifying at least one symptom or disease per encounter. The codes were retrieved ‘once a month’ or more by 19%. Classification of diseases was considered important for follow-up by 83%, and for the care of the patient by 75% of the GPs. The primary health care version of ICD-10 with a total of 972 codes was considered too limited in size by 31%. Conclusion: Electronic patient records in everyday clinical use in Swedish general practice provide several fundamentals for a database of diagnostic data. However, there are several barriers to the establishment of such a database that is both valid and reliable.

Attitudes of Primary Care Physicians Toward Older Drivers: A Finnish-Swedish Comparison

Finnish and Swedish general practitioners'(GPs) activities, knowledge, and attitudes related to aging and driving were compared using a mail survey to evaluate the effects of the two countries' different driver licensing policies. The hypothesis was that the existence of an obligatory medical screening system in Finland would make the Finnish GPs more active or knowledgeable concerning aging and driving than their Swedish colleagues with no experience of such a system. The survey was sent to a random sample of registered GPs who worked in primary health care centers in Sweden ( n = 1,500) and in Finland ( n = 1,527); 1,682 respondents completed the form and were included in final analysis. The results did not support the hypothesis: The Swedish GPs reported more activities than did their Finnish colleagues. The level of knowledge was similar in both countries, but the Finnish GPs had higher confidence in their diagnostic competence and more restrictive attitudes than did the Swedish GPs. The existence of an obligatory medical screening system hence did not make the Finnish GPs more active or knowledgeable concerning aging and driving compared to their Swedish colleagues. In contrast, it may contribute to the Finnish GPs' unrealistic confidence in their own assessment skills and in the adequacy of the present screening system in Finland.

Attitudes of Primary Care Physicians Toward Older Drivers: A Finnish-Swedish Comparison

Finnish and Swedish general practitioners'(GPs) activities, knowledge, and attitudes related to aging and driving were compared using a mail survey to evaluate the effects of the two countries' different driver licensing policies. The hypothesis was that the existence of an obligatory medical screening system in Finland would make the Finnish GPs more active or knowledgeable concerning aging and driving than their Swedish colleagues with no experience of such a system. The survey was sent to a random sample of registered GPs who worked in primary health care centers in Sweden (n = 1,500) and in Finland (n = 1,527); 1,682 respondents completed the form and were included in final analysis. The results did not support the hypothesis: The Swedish GPs reported more activities than did their Finnish colleagues. The level of knowledge was similar in both countries, but the Finnish GPs had higher confidence in their diagnostic competence and more restrictive attitudes than did the Swedish GPs. The existence of an obligatory medical screening system hence did not make the Finnish GPs more active or knowledgeable concerning aging and driving compared to their Swedish colleagues. In contrast, it may contribute to the Finnish GPs' unrealistic confidence in their own assessment skills and in the adequacy of the present screening system in Finland.

Unfavourable working conditions for female GPs. A comparison between Swedish general practitioners and district nurses

Objective - The aim was to analyse gender and occupational differences in the psychosocial working conditions of general practitioners (GPs) and district nurses (DNs) in Sweden. Design - A stratified random sample of GPs (n = 566) and DNs (n =554) from four county councils in Sweden. The overall participation rate was 83%. Setting - Primary health care. Main outcome measures - A mailed questionnaire comprising 10 items providing demographic data and 36 items on psychosocial working conditions was used. The questionnaire had been tested for validity and reliability. A factor analysis included five items: strains and symptoms, professional content, social support at work, workload and job control. Results - Professional content was the most positively rated aspect, whereas workload was the most negatively rated. GPs perceived a higher workload and lower social support than did the DNs. Female GPs scored significantly more negatively than both male GPs and female DNs did in four out of the five factors. Female GPs reported a high workload, low job control and low social support at work. Female DNs, too, reported a high workload, relatively low job control but fairly strong social support. Conclusion - Female GPs perceived more unfavourable psychosocial working conditions than both male GPs and female DNs did in the same organisational setting.

Vitamin B12 in primary health care and geriatrics--attitudes, knowledge and competence.

The objective of the study was to test attitudes, knowledge and competence of Swedish general practitioners and geriatricians concerning B12-associated problems in 1998. Postal questionnaires were sent to a random sample of 485 GPs and a total sample of 613 geriatricians. The response rates were 70% in the GP group and 69% in the geriatrician group. The questionnaire contained 24 statements to be evaluated by a visuo-analogue scale. There were small numerical differences between the two physician groups. The geriatricians were more aware of risk groups for B12 deficiency. GPs were less categorical concerning low hit rate in the laboratory testing of clinical conclusions. There were statistical differences in both directions for statements on pitfalls in laboratory diagnostics. GPs were somewhat less prone to give risk groups prophylactic B12 therapy. GPs and geriatricians appeared to be familiar with the current debate on B12-associated problems, suggesting that health care quality will be unaffected by patient transfer from hospital care to primary health care.

Swedish general practitioners' awareness of elderly patients at risk of or actually suffering from elder abuse.

The aim of this study was to describe the awareness among Swedish general practitioners (GPs) of elderly patients at risk of or suffering from abuse during a 12-month period. A questionnaire was sent to 110 GPs working in one regional health care district in Sweden, and 59% answered and returned the questionnaire. Seventy-seven per cent of the GPs reported having one patient at risk of abuse and or neglect, and 25% were aware of patients who were subjected to verified or suspected elder abuse. Risk situations commonly involved patients with dementia, carers with problems of their own or who felt angry about the burden of caring, or paid carers who were unable to meet the needs of the elderly person. There were GPs who had contact with colleagues, district nurses and others, as well as those who had few or no contacts at all. It is important to take seriously the large number of GPs who have elderly patients in situations where there is a risk of abuse or neglect. If elder abuse is not primarily a medical problem--it is essential that there should be a clearly identified authority to which GPs can refer cases.

Dementia in primary care: why the low detection rate?

Objective - The aim of the present study was to find reasons for the low detection rate of dementia in primary care. Another aim was to investigate the attitudes and knowledge on dementia among Swedish general practitioners (GPs). Design - Two-hundred-and-twenty-eight postal questionnaires were distributed to GPs in the county of Östergötland. Setting - Primary care in Sweden. Main outcome measures - The opinions of GPs on dementia management in primary care. Results - The response rate was 67%. GPs showed a good knowledge of dementia diseases but underestimated the occurrence of dementia. They presented a positive attitude towards managing patients with dementia and considered that existing drug therapy justified an active search for patients with dementia in primary care, but they believed the efficacy of the drugs to be limited. Assessing the social environment of patients and organising social support were regarded as the most difficult tasks in the management of demented patients. Conclusion ? The study indicates that the main obstacles are a lack of resources and a sceptical attitude to the benefits of drug treatment. Co-operation between the community services, specialist clinics and the primary care team should be improved.

High demand, low control, and impaired general health: working conditions in a sample of Swedish general practitioners.

This cross-sectional survey of 1,004 Swedish general practitioners (GPs) aged 32 64 years analyses the extent to which low control, high work demand, and other work-related conditions are associated with self-rated impaired general health and impaired quality of life among Swedish GPs. The first part of the questionnaire contained "SF-36 Health Survey", from which we chose five psychosocial multi-item scales as dependent variables. The second part of the questionnaire had questions about working conditions from "The Swedish Survey of Living Conditions". Unconditional logistic regression was used. Female and male GPs with high job strain, i.e. low control and high work demand, exhibited a more than threefold increased risk of impaired general health compared with those with medium job strain. Low job strain among male GPs was associated with a low risk of impaired health. The finding of significant associations between psychosocial working conditions and impaired general health and impaired, quality of life in GPs in 1996 highlights the need to improve working conditions in Swedish primary healthcare, for example, by reducing number of inhabitants per full-time GP to 1,500.

High demand, low control, and impaired general health: working conditions in a sample of Swedish general practitioners

High demand, low control, and impaired general health: working conditions in a sample of Swedish general practitioners

Prescribing benzodiazepines—a critical incident study of a physician dilemma

Use of benzodiazepines has been discussed extensively both among the public and within the medical society. The aim of this study was to explore the quality of dilemmas experienced by physicians when prescribing benzodiazepines. A questionnaire was sent to 213 Swedish General Practitioners. The critical incident technique was chosen as an appropriate method for surveying professional experiences. Concern for the patient and threats to the integrity of the physician were common dilemmas. The physicians did not believe that the patients were telling the truth or did not trust the patients' ability to handle the medicine. The most frequent consequences of the dilemmas were worry about a disturbed relationship with patients indicating an uncertainty as to how to create a good relationship with them. The participants in the study were aware of the national guidelines for prescribing benzodiazepines, but due to insufficient time a prescription was often chosen as a way to handle the dilemmas. Improvement in the rational use of benzodiazepines is not achieved by the medical board making new rules but rather by offering physicians education in communication and negotiating skills as well as more time with the individual patient who is requesting benzodiazepines.

Ways of experiencing asthma management: Variations among general practitioners in Sweden

Objective - To identify and describe variations in ways of experiencing asthma management among general practitioners (GPs) in Sweden. Design - Descriptive and explorative study using a phenomenographic approach. Semi-structured tape-recorded face-to-face interviews, focusing on the GP's own experiences regarding asthma management. Setting - Primary health care. Subjects - Twenty GPs (12 men, eight women) from 16 health centres in seven counties in central Sweden, 15 from rural areas and small cities and five from medium sized cities or Stockholm suburbs. Main outcome measures - Descriptions of ways of experiencing asthma management. Results - Four categories were identified, which described qualitatively different ways of experiencing asthma management: A. The GP focuses on transferring factual knowledge to the patient; B. The GP primarily addresses the patients' application of knowledge in management of the disease; C. The GP aims at improving the patients' understanding of the disease and its management as a prerequisite for self-management; D. The GP concentrates on how to maintain/improve the patient's quality of life despite the asthma disease. Conclusion - The GPs describe their ways of experiencing asthma management in qualitatively different ways, likely to have implications for patient care and educational programmes on asthma for GPs.

Impaired health status, and mental health, lower vitality and social functioning in women general practitioners in Sweden: A cross-sectional survey

Objective - The aim was to analyse differences between female and male general practitioners (GPs) in health status and lifestyle and compared with the general population in health-related quality of life. Design - A simple random sample of 1004 GPs from the whole of Sweden (71.2%) participated in a survey in May 1996 about self-reported health status, smoking habits, physical activity, and SF-36 quality of life survey. They were compared as regards SF-36 with the general population in Sweden in three approximately similar-sized age groups of women and men aged 30-44, 45-49, and 50-64. Results - Female GPs had a higher risk than male GPs of impaired health status. Of the female GPs aged 45-49, 22.8% reported that their health was impaired compared with 12.6% of male GPs. Less than 5% of the GPs younger than 45 were daily smokers. Female GPs had higher means for physical functioning but lower means for vitality, social functioning, and role emotional and mental health compared with the general population. Conclusions - The significant increased risk in poor health among female GPs, especially those aged 45-49, is worrying and argues for appropriate analysis and prevention that are tailored to their working conditions.

From teaching to learning: Experiences of small CME group work in general practice in Sweden

Objective - To describe the experiences of learning in small groups and the impact of small group continuing medical education (CME). Design - Literature review, personal communication and critical reflection. Setting - General practice in Sweden. Subjects - Small CME groups. Main outcome measures - Occurrence, themes and impact of small CME groups. Results - In 1998, there were approximately 230 small CME groups in Sweden, which means that nearly half of Swedish general practitioners (GPs) participated in such activities. Although widely used in Sweden, small CME groups are less practised than ?traditional? CME activities, such as lectures. Group work might enhance knowledge development, enable the assessment of individual learning needs and facilitate the adoption of national guidelines and agreements between primary and secondary care. A competent group leader is crucial. Conclusion - A transition from passive to interactive learning in small groups is recommended.

Loyalty conflicts in medical practice: A comparative study of general practitioners', paediatricians' and gynaecologists' assessments of three cases

Objective - To shed light on attitudes towards loyalty conflicts among general practitioners (GPs) compared with related specialists such as gynaecologists and paediatricians. Design - A postal questionnaire containing three case histories with arguments for and against different ways of acting in loyalty conflicts. The medical problems of the clinical cases varied, but the ethical ones were in principle similar. Setting - A random sample of all Swedish GPs, gynaecologists, and paediatricians. Subjects - GPs (n=313), paediatricians (n=197), and gynaecologists (n=236). Results - On average 71% of the doctors replied. The gynaecologists differed from the other groups by being markedly loyal to the individual patient especially in one case. The paediatricians tended to reply most consistently and they seemed to favour the family perspective, compared with the other doctors. The GPs' response pattern fell in between the other two groups. Conclusions - The study indicates that ethical reasoning depends on the doctors' different medical background with regard to speciality. This study should be followed by others in order to give further explanation of the findings.

Information needs and information seeking behaviour in primary health care.

A questionnaire survey of 186 general practitioners in Sweden showed that 67% saw the overall supply of medical information as less satisfactory or unsatisfactory, and that 80% experienced major hindrances in seeking relevant information. The most frequent need for information concerned general medicine, with respect to both diagnosis and choice of therapy. Of situations which required additional information, only every second was completely resolved. These results imply a need for a reorganization of the supply of information to general practitioners. As they cannot depend on conventional medical libraries for day-to-day information, personal libraries should be improved and updated regularly, and be readily to hand. Computer technology should be considered for communication between health care providers, and as support for differential diagnosis in general medicine.

How physicians choose their drugs

In this article the author described how general practitioners in Sweden make their choice of drugs. Habitual vs nonhabitual choice processes are discussed. The nonhabitual choice process is described in detail, one of the central components being the physician's disposition towards drugs for a specific disease. An account is given of a study in which the dispositions of doctors were measured in three dimensions: curing effect, side effects and cost. This was done for each physician and for each of the drugs in the sample. By using linear multiple regression analyses it was found that physicians tend to give the highest weight to the curing effect. Variations were associated with the disease in question, and with the age of the physician. No significant relationship was found between the drug chosen and the background variables of the physicians.