Objectives

To investigate why symptoms indicative of early-stage lung cancer (LC) were not presented to general practitioners (GPs) and how early symptoms might be better elicited within primary care.

Design, setting and participants

A qualitative cross-sectional interview study about symptoms and help-seeking in 20 patients from three south England counties, awaiting resection of LC (suspected or histologically confirmed). Analysis drew on principles of discourse analysis and constant comparison to identify processes involved in interpretation and communication about symptoms, and explain non-presentation.

Results

Most participants experienced health changes possibly indicative of LC which had not been presented during GP consultations. Symptoms that were episodic, or potentially caused by ageing or lifestyle, were frequently not presented to GPs. In interviews, open questions about health changes/symptoms in general did not elicit these symptoms; they only emerged in response to closed questions detailing specific changes in health. Questions using disease-related labels, for example, pain or breathlessness, were less likely to elicit symptoms than questions that used non-disease terminology, such as aches, discomfort or ‘getting out of breath’. Most participants described themselves as feeling well and were reluctant to associate potentially explained, non-specific or episodic symptoms with LC, even after diagnosis.

Conclusions

Patients with early LC are unlikely to present symptoms possibly indicative of LC that they associate with normal processes, when attending primary care before diagnosis. Faced with patients at high LC risk, GPs will need to actively elicit potential LC symptoms not presented by the patient. Closed questions using non-disease terminology might better elicit normalised symptoms.

Background

Since 2006 the Quality Outcomes Framework (QOF) has rewarded GPs for carrying out standardised assessments of the severity of symptoms of depression in newly diagnosed patients.

Aim

To gain understanding of GPs' opinions and perceived impact on practice of the routine introduction of standardised questionnaire measures of severity of depression through the UK general practice contract QOF.

Design of study

Semi-structured qualitative interview study, with purposive sampling and constant comparative analysis.

Setting

Thirty-four GPs from among 38 study general practices in three sites in England, UK: Southampton, Liverpool, and Norfolk.

Method

GPs were interviewed at a time convenient to them by trained interviewers. Interviews were audiorecorded and transcribed verbatim in preparation for thematic analysis, to identify key views.

Results

Analysis of the interviews suggested that the use of severity questionnaires posed an intrusion into the consultation. GPs discursively polarised two technologies: formal assessment versus personal enquiry, emphasising the need to ensure the scores are used sensitively and as an aid to clinical judgement rather than as a substitute. Importantly, these challenges implicitly served a function of preserving GPs' identities as professionals with expertise, constructed as integral to the process of diagnosis.

Conclusion

GP accounts indicated concern about threats to patient care. Contention between using severity questionnaires and delivering individualised patient care is significantly motivated by GP concerns to preserve professional expertise and identity. It is important to learn from GP concerns to help establish how best to optimise the use of severity questionnaires in depression.

Background

Dipsticks are one of the most commonly used near-patient tests in primary care, but few clinical or dipstick algorithms have been rigorously developed.

Aim

To confirm whether previously documented clinical and dipstick variables and algorithms predict laboratory diagnosis of urinary tract infection (UTI).

Design of study

Validation study.

Setting

Primary care.

Method

A total of 434 adult females with suspected lower UTI had bacteriuria assessed using the European Urinalysis Guidelines.

Results

Sixty-six per cent of patients had confirmed UTI. The predictive values of nitrite, leucocyte esterase (+ or greater), and blood (haemolysed trace or greater) were confirmed (independent multivariate odds ratios = 5.6, 3.5, and 2.1 respectively). The previously developed dipstick rule — based on presence of nitrite, or both leucocytes and blood — was moderately sensitive (75%) but less specific (66%; positive predictive value [PPV] 81%, negative predictive value [NPV] 57%). Predictive values were improved by varying the cut-off point: NPV was 76% for all three dipstick results being negative; the PPV was 92% for having nitrite and either blood or leucocyte esterase. Urine offensive smell was not found to be predictive in this sample; for a clinical score using the remaining three predictive clinical features (urine cloudiness, dysuria, and nocturia), NPV was 67% for none of the features, and PPV was 82% for three features.

Conclusion

A clinical score is of limited value in increasing diagnostic precision. Dipstick results can modestly improve diagnostic precision but poorly rule out infection. Clinicians need strategies to take account of poor NPVs.

Research into the homeopathic consultation has largely focused on patients' experiences, although the practitioner is a crucial component of the therapeutic context and may have an important part in optimizing health outcomes. Therefore the aim of this qualitative research was to gain an in-depth understanding of homeopathic practitioners' perceptions and experiences of the consultation. Medical and non-medical homeopaths were sampled from the registers of the Faculty and Society of Homeopaths. Two phases of data collection were employed. Phase 1 used in depth face-to-face interviews enabling the development of an initial model of the homeopathic consultation. Phase 2 involved observations of homeopathic consultations and practitioner reflective diaries in order to confirm, refute, or enlarge the model. Using the constant comparative method of grounded theory five main categories emerged, exploring the journey, finding the level, responding therapeutically, understanding self, and connecting, forming a model entitled “a theoretical model of a UK classical homeopathic consultation” which describes how homeopaths view and enact the consultation process. This study suggests that the process of identifying and prescribing the remedy is embedded in the consultation, highlighting the interconnectedness of the whole homeopathic consultation and aspects of the consultation that are unique and specific to homeopathy.

Background

Urinary tract infection (UTI) is one of the commonest acute infections presenting to primary care. Little is known of women's experiences of UTI; self-care strategies and key triggers for their consulting behaviour are also little known.

Aim

To explore women's experiences of self-care and their journey to GP care, when faced with symptoms of a UTI.

Design of study

Qualitative semi-structured interview study with women recruited to a larger UK trial of different management strategies for UTI.

Setting

General practices across four counties in southern England.

Method

Twenty-one women were interviewed about the experiences they had prior to their GP visit, self-care strategies, and triggers for help seeking. Interviews were analysed thematically, using principles of analytic induction.

Results

Women reported a process of evaluation, monitoring, re-evaluation, and, finally, consulting in order to meet their needs. Four key triggers for consulting were identified: failure to alleviate symptoms through self-care; symptom duration and escalation; impeding normal functioning and the fulfilment of social roles; and concern that it may be or become a serious illness.

Conclusion

Although UTI is often self-limiting, when taking patient histories and formulating their management strategies clinicians need to take into account women's often painful experience, their efforts to resolve symptoms prior to consulting, and their fears that the symptoms may indicate something more serious than a UTI.

Objective To explore why cancer patients do not want or seek information about their condition beyond that volunteered by their physicians at times during their illness. Design Qualitative study based on in-depth interviews. Setting Outpatient oncology clinics at a London cancer center. Participants 17 patients with cancer diagnosed in previous 6 months. Main outcome measures Analysis of patients' narratives to identify key themes and categories. Results While all patients wanted basic information on diagnosis and treatment, not all wanted further information at all stages of their illness. Three overarching attitudes to their management of cancer limited patients' desire for and subsequent efforts to obtain further information : faith, hope, and charity.Faith in their doctor's medical expertise precluded the need for patients to seek further information themselves. Hope was essential for patients to carryon with life as normal and could be maintained through silence and avoiding information, especially too detailed or “unsafe” information.Charity to fellow patients, especially those seen as more needy than themselves, was expressed in the recognition that scarceresources—including information and explanations—had to be shared and meant that limited information was accepted as inevitable.Conclusions Cancer patients' attitudes to cancer and their strategies for coping with their illness can constrain their wish for information and their efforts to obtain it. In developing recommendations, the government's cancer information strategy should attend to variations in patients' desires for information and the reasons for them.

Objectives

To explore why cancer patients do not want or seek information about their condition beyond that volunteered by their physicians at times during their illness.

Design

Qualitative study based on in-depth interviews.

Setting

Outpatient oncology clinics at a London cancer centre.

Participants

17 patients with cancer diagnosed in previous 6 months.

Main outcome measures

Analysis of patients' narratives to identify key themes and categories.

Results

While all patients wanted basic information on diagnosis and treatment, not all wanted further information at all stages of their illness. Three overarching attitudes to their management of cancer limited patients' desire for and subsequent efforts to obtain further information: faith, hope, and charity. Faith in their doctor's medical expertise precluded the need for patients to seek further information themselves. Hope was essential for patients to carry on with life as normal and could be maintained through silence and avoiding information, especially too detailed or “unsafe” information. Charity to fellow patients, especially those seen as more needy than themselves, was expressed in the recognition that scarce resources—including information and explanations—had to be shared and meant that limited information was accepted as inevitable.

Conclusions

Cancer patients' attitudes to cancer and their strategies for coping with their illness can constrain their wish for information and their efforts to obtain it. In developing recommendations, the government's cancer information strategy should attend to variations in patients' desires for information and the reasons for them.