1,721,125 research outputs found
Still a difficult business? Negotiating alcohol-related problems in general practice consultations
No full textThis paper describes general practitioners’ (GPs) experiences of detecting and managing alcohol and alcohol-related problems in consultations. We undertook qualitative research in two phases in the North-East of England. Initially, qualitative interviews with 29 GPs explored their everyday work with patients with alcohol-related issues. We then undertook group interviews—two with GPs and one with a primary care team—where they discussed and challenged findings of the interviews. The GPs reported routinely discussing alcohol with patients with a range of alcohol-related problems. GPs believed that this work is important, but felt that until patients were willing to accept that their alcohol consumption was problematic they could achieve very little. They tentatively introduced alcohol as a potential problem, re-introduced the topic periodically, and then waited until the patient decided to change their behaviour. They were aware that they could identify and manage more patients. A lack of time and having to work with the multiple problems that patients brought to consultations were the main factors that stopped GPs managing more risky drinkers. Centrally, we compared the results of our study with [Thom, B., & Tellez, C. (1986). A difficult business—Detecting and managing alcohol-problems in general-practice. British Journal of Addiction, 81, 405–418] seminal study that was undertaken 20 years ago. We show how the intellectual, moral, emotional and practical difficulties that GPs currently face are quite similar to those faced by GPs from 20 years ago. As the definition of what could constitute abnormal alcohol consumption has expanded, so the range of consultations that they may have to negotiate these difficulties in has also expande
Seeing through the glass darkly? A qualitative exploration of GPs' drinking and their alcohol intervention practices
No full textBackground: brief alcohol intervention is influenced by patients' personal characteristics as well as their clinical risk. Risk-drinkers from higher social-status groups are less likely to receive brief intervention from GPs than those from lower social-status groups. Thus GPs' perception of social similarity or distance may influence brief intervention.Objective: to explore the role that GPs' drinking behaviour plays in their recognition of alcohol-related risk in patients.Method: a qualitative interview study with 29 GPs recruited according to maximum variation sampling. All interviews were audio-recorded and transcribed verbatim. Analysis was inductive with constant comparison within and between themes plus deviant case analysis. Analysis developed until category saturation was reached.Results: GPs described a range of personal drinking practices that broadly mirrored population drinking patterns. Many saw themselves as part of mainstream society, sharing in culturally sanctioned behaviour. For some GPs, shared drinking practices could increase empathy for patients who drank, and facilitate discussion about alcohol. However, several GPs regarded themselves as distinct from ‘others’, separating their own drinking from that of patients. Several GPs described a form of bench-marking, wherein only patients who drank more, or differently, to themselves were felt to be ‘at risk’.Conclusion: alcohol is clearly a complex and emotive health and social issue and GPs are not immune to its effects. For some GPs' shared drinking behaviour can act as a window of opportunity enabling insight on alcohol issues and facilitating discussion. However, other GPs may see through the glass more darkly and selectively recognize risk only in those patients who are least like the
Clinical reasoning, clinical trials and risky drinkers in everyday primary care: a qualitative study of British general practitioners
No full textAlcohol and other substance misuse problems have historically been seen as refractory in primary care, but in the past 20 years Brief Interventions have come to be seen as an important and effective response to a range of problems around 'risky drinking'. Proponents of brief interventions have argued that these interventions are best accomplished in the community, but that primary health care professionals resist using them. This qualitative study investigated responses to alcohol problems in a maximum variation sample of 28 primary care professionals in and around a northern English city. We found clinicians negotiating alcohol problems using interactional techniques that integrated elements of brief interventions, and which fitted these to the interactional and temporal order of clinical encounters and physician-patient relationships in primary care. Central to these accounts was the problem of finding an interactional solution that drew together notions of what was both ethically and practically possible in any given encounte
Abstract: An Evidence and Practice based regional musculoskeletal examination for school aged children - pREMS
No full textpREMS - pediatric regional examination of the musculoskeletal system - a practice and consensus based approach
No full textIntroduction: competent examination of the pediatric musculoskeletal (pMSK) system is a vital component of clinical assessment of children presenting with MSK complaints. The aim was to develop a regional MSK examination for school-aged children that is age appropriate and reflects clinical practice.Methods: qualitative and quantitative analyses involving video observation of clinical examination technique, systematic review, and expert consensus were employed to reveal descriptions, frequencies and variations in technique for joint regions in various clinical scenarios. Systematic review and data from clinical observation were combined with feedback from a group of pMSK experts through a web-based survey. All results were collated and discussed by consensus development groups to derive pREMS (the pediatric Regional Examination of the MSK System)Results: a total of 48 pMSK expert clinicians were involved to derive pREMS. Systematic review revealed a paucity of evidence about regional pMSK examination. Video observations of MSK examinations (a total of 2901 maneuvers) performed by pMSK experts (doctors n=11; therapists n=8) of 89 school-aged children attending outpatient clinics in 7 UK pediatric rheumatology centres, were followed by semi-structured interviews with 14/19 clinicians. Video observation showed variation in examination techniques, most frequently at the hip and knee in the context of mechanical and inflammatory clinical scenariosConclusions: pREMS is the first practice and consensus based regional pMSK examination for school aged children. The structured approach is an important step towards improved pMSK clinical skills relevant to clinical training<br/
Technogovernance: evidence, subjectivity, and the clinical encounter in primary care medicine
No full textTechnological solutions to problems of knowledge and practice in health care are routinely advocated. This paper explores the ways that new systems of practice are being deployed as intermediaries in interactions between clinicians and their patients. Central to this analysis is the apparent conflict between two important ways of organizing ideas about practice in primary care. First, a shift away from the medical objectification of the patient, towards patient-centred clinical practice in which patients’ heterogeneous experiences and narratives of ill-health are qualitatively engaged and enrolled in decisions about the management of illness trajectories. Second the mobilization of evidence about large populations of experimental subjects revealed through an impetus towards evidence-based medicine, in which quantitative knowledge is engaged and enrolled to guide the management of illness, and is mediated through clinical guidelines. The tension between these two ways of organizing ideas about clinical practice is a strong one, but both impulses are embodied in new ‘technological’ solutions to the management of heterogeneity in the clinical encounter. Technological solutions themselves, we argue, embody and enact these tensions, but may also be opening up a new array of practices—technogovernance—in which the heterogeneous narratives of the patient-centred encounter can be resituated and guide
Patients or research subjects? A qualitative study of participation in a randomised controlled trial of a complex intervention
No full textObjective: to explore participants’ understandings regarding treatment decisions, made within an efficacy randomised controlled trial (RCT) of decision-support tools.Methods: qualitative study: interviews (audio-recorded) with participants. Participants were interviewed 3–5 days after using a decision-support tool (n = 30) and again at 3 months (n = 26). Transcripts were analysed using a constant comparative approach.Results: participants’ understandings were shaped by the ways in which they made sense of their participation. Participants made attributions about their trial identity that fell on a continuum. At one end we found participants who identified as ‘experienced medical volunteers’, and at the other those who identified as ‘real patients’. In the participants’ accounts, a trial identity of ‘patient’ accompanied an expectation that the decision-support tools offered a means of making treatment decisions. ‘Volunteers’, however, saw the interventions as tasks to be completed for the purposes of the trial team.Conclusion: in our study, trial identity shaped participants’ understandings regarding treatment decisions and all other aspects of the trial.Practice implications: different understandings regarding the appropriate response to trial tasks may affect behaviour and therefore outcomes in some trials. Further research is required to unravel the relationship between trial identities, understanding and behaviou
Education for people with ankylosing spondylitis: perspectives from patients, rheumatologists and allied health professionals
No full textDoctor–patient interaction in a randomised controlled trial of decision-support tools
No full textIn this paper, we draw on the analytic perspectives of ethnomethodology to explore doctor–patient encounters in an experimental trial of a complex intervention: an efficacy randomised controlled trial (RCT) of decision-support tools in the UK. We show how the experimental context in which these encounters take place pervades the interactions within them. We argue that two interactional orders were at work in the encounters that we observed: (i) the ceremonial order of the consultation and (ii) the assemblage of the decision-support tool trial. We demonstrate how doctors in the trial oscillate between positions as authoritative clinician and neutralistic decision-support tool-implementer, and patients move between positions as passive recipients of clinical knowledge and as active subjects required to render their experience as calculable in terms of the demands of the decision-support tools and the broader trial they are embedded in. We demonstrate how the RCT coordinates the world of the clinical environment and the world of experimental evidenc
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