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1.  Operationalising unscheduled care policy: a qualitative study of healthcare professionals’ perspectives 
The British Journal of General Practice  2013;63(608):e192-e199.
Background
UK health policy aims to reduce the use of unscheduled care, by increasing proactive and preventative management of patients with long-term conditions in primary care.
Aim
The study explored healthcare professionals’ understanding of why patients with long-term conditions use unscheduled care, and the healthcare professionals’ understanding of their role in relation to reducing the use of unscheduled care.
Design and setting
Qualitative study interviewing different types of healthcare professionals providing primary care or unscheduled care services in northwest England.
Method
Semi-structured interviews were conducted with 29 healthcare professionals (six GPs; five out-of-hours GPs; four emergency department doctors; two practice nurses; three specialist nurses; two district nurses; seven active case managers). Data were analysed using framework analysis.
Results
Healthcare professionals viewed the use of unscheduled care as a necessary component of care for patients with long-term conditions. Those whose roles involved working to targets to reduce the use of unscheduled care described a tension between this and delivering optimum patient care. Three approaches to reducing unscheduled care were described: optimising the system; negotiating the system; and optimising the patient.
Conclusion
Current policy to reduce the use of unscheduled care does not take account of the perceptions of the healthcare professionals who are expected to implement them. Lipsky’s theory of street-level bureaucrats provides a framework to understand how healthcare professionals respond to imposed policies. Healthcare professionals did not see the use of unscheduled care as a problem and there was limited commitment to the policy targets. Therefore, policy should aim for whole-system change rather than reliance on individual healthcare professionals to make changes in their practice.
doi:10.3399/bjgp13X664243
PMCID: PMC3582978  PMID: 23561786
general practice; healthcare systems; out-of-hours medical care; policy; primary health care
2.  Why do patients with long-term conditions use unscheduled care? A qualitative literature review 
Unscheduled care (UC) refers to non-routine face-to-face care, such as accident and emergency care, out-of-hours care, or walk-in centres. Current health service policy aims to reduce its use. Unscheduled care is common in people with long-term conditions such as diabetes, asthma, chronic obstructive pulmonary disease and coronary heart disease. By reviewing qualitative research literature, we aimed to understand the breadth of psychosocial and other influences on UC use in people with long-term conditions. Few qualitative papers specifically address UC in patients in these disease groups. Therefore, our literature search also included qualitative research that explored factors potentially relevant to UC use, including attitudes to healthcare use in general. By searching Medline, Embase, Psycinfo and Cinahl from inception to 2011, we identified 42 papers, published since 1984, describing relevant original research and took a meta-ethnographic approach in reviewing them. The review was conducted between Spring 2009 and April 2011, with a further search in December 2011. Most papers reported on asthma (n = 13) or on multiple or unspecified conditions (n = 12). The most common methods reported were interviews (n = 33) and focus groups (n = 13), and analyses were generally descriptive. Theoretical and ethical background was rarely explicit, but the implicit starting point was generally the ‘problem’ of UC, and health-care, use in general, decontextualised from the lives of the patients using it. Patients’ use of UC emerged as understandable, rational responses to pressing clinical need in situations in which patients thought it the only option. This belief reflected the value that they had learned to attach to UC versus routine care through previous experiences. For socially or economically marginalised patients, UC offered access to clinical or social care that was otherwise unavailable to them.
doi:10.1111/j.1365-2524.2012.01093.x
PMCID: PMC3796281  PMID: 23009718
decision-making; emergency care; long-term illness; primary care; qualitative research; use of health-care
3.  How QOF is shaping primary care review consultations: a longitudinal qualitative study 
BMC Family Practice  2013;14:103.
Background
Long-term conditions (LTCs) are increasingly important determinants of quality of life and healthcare costs in populations worldwide. The Chronic Care Model and the NHS and Social Care Long Term Conditions Model highlight the use of consultations where patients are invited to attend a consultation with a primary care clinician (practice nurse or GP) to complete a review of the management of the LTC. We report a qualitative study in which we focus on the ways in which QOF (Quality and Outcomes Framework) shapes routine review consultations, and highlight the tensions exposed between patient-centred consulting and QOF-informed LTC management.
Methods
A longitudinal qualitative study. We audio-recorded consultations of primary care practitioners with patients with LTCs. We then interviewed both patients and practitioners using tape-assisted recall. Patient participants were followed for three months during which the research team made weekly contact and invited them to complete weekly logs about their health service use. A second interview at three months was conducted with patients. Analysis of the data sets used an integrative framework approach.
Results
Practitioners view consultations as a means of ‘surveillance’ of patients. Patients present themselves, often passively, to the practitioner for scrutiny, but leave the consultation with unmet biomedical, informational and emotional needs. Patients perceived review consultations as insignificant and irrelevant to the daily management of their LTC and future healthcare needs. Two deviant cases, where the requirements of the ‘review’ were subsumed to meet the patient’s needs, focused on cancer and bereavement.
Conclusions
Routine review consultations in primary care focus on the biomedical agenda set by QOF where the practitioner is the expert, and the patient agenda unheard. Review consultations shape patients’ expectations of future care and socialize patients into becoming passive subjects of ‘surveillance’. Patient needs outside the narrow protocol of the review are made invisible by the process of review except in extreme cases such as anticipating death and bereavement. We suggest how these constraints might be overcome.
doi:10.1186/1471-2296-14-103
PMCID: PMC3726490  PMID: 23870537
Primary care; Long-term conditions; Quality and Outcomes Framework (QOF); Consultations; Longitudinal qualitative research
4.  Faith and Protection: The Construction of Hope by Parents of Children with Leukemia and Their Oncologists 
The Oncologist  2012;17(3):398-404.
How pediatric oncologists manage parents' hope in practice and how they address parents' needs are examined.
Background.
Oncologists are criticized for fostering unrealistic hope in patients and families, but criticisms reflect a perspective that is oversimplified and “expert” guidance that is ambiguous or impractical. Our aim was to understand how pediatric oncologists manage parents' hope in practice and to evaluate how they address parents' needs.
Methods.
Participants were 53 parents and 12 oncologists whom they consulted across six U.K. centers. We audio recorded consultations approximately 1–2, 6, and 12 months after diagnosis. Parents were interviewed after each consultation to elicit their perspectives on the consultation and clinical relationship. Transcripts of consultations and interviews were analyzed qualitatively.
Results.
Parents needed hope in order to function effectively in the face of despair, and all wanted the oncologists to help them be hopeful. Most parents focused hope on the short term. They therefore needed oncologists to be authoritative in taking responsibility for the child's long-term survival while cushioning parents from information about longer-term uncertainties and being positive in providing information about short-term progress. A few parents who could not fully trust their oncologist were unable to hope.
Conclusion.
Oncologists' pivotal role in sustaining hope was one that parents gave them. Most parents' “faith” in the oncologist allowed them to set aside, rather than deny, their fears about survival while investing their hopes in short-term milestones. Oncologists' behavior generally matched parents' needs, contradicting common criticisms of oncologists. Nevertheless, oncologists need to identify and address the difficulty that some parents have in fully trusting the oncologist and, consequently, being hopeful.
doi:10.1634/theoncologist.2011-0308
PMCID: PMC3316926  PMID: 22371382
6.  Sexual abuse in childhood and postoperative depression in women with breast cancer who opt for immediate reconstruction after mastectomy 
INTRODUCTION
Breast reconstruction is routinely offered to women who undergo mastectomy for breast cancer. However, patient-reported outcomes are mixed. Child abuse has enduring effects on adults’ well-being and body image. As part of a study into damaging effects of abuse on adjustment to breast cancer, we examined: (i) whether women with history of abuse would be more likely than other women to opt for reconstruction; and (ii) whether mood problems in women opting for reconstruction can be explained by greater prevalence of abuse.
PATIENTS AND METHODS
We recruited 355 women within 2-4 days after surgery for primary breast cancer; 104 had mastectomy alone and 29 opted for reconstruction. Using standardised questionnaires, women self-reported emotional distress and recollections of childhood sexual abuse. Self-report of distress was repeated 12 months later.
RESULTS
Women who had reconstruction were younger than those who did not. Controlling for this, they reported greater prevalence of abuse and more distress than those having mastectomy alone. They were also more depressed postoperatively, and this effect remained significant after controlling for abuse.
CONCLUSIONS
One interpretation of these findings is that history of abuse influences women's decisions about responding to the threat of mastectomy, but it is premature to draw inferences for practice until the findings are replicated. If they are replicated, it will be important to recognise increased vulnerability of some patients who choose reconstruction. Studying the characteristics and needs of women who opt for immediate reconstruction and examining the implications for women's adjustment should be a priority for research.
doi:10.1308/003588411X12851639107593
PMCID: PMC3293301  PMID: 21054923
Breast cancer; Reconstruction; Childhood sexual abuse
7.  Facilitating understanding of mental health problems in GP consultations: a qualitative study using taped-assisted recall 
Background
Mental health problems are common in primary care and most are managed solely by the GP. Patients strive to understand their mental health problems, and facilitating patients' understanding may be important in their care, yet little is known about this process in GP consultations.
Aim
To explore how patients' understanding of common mental health problems is developed in GP consultations.
Design of study
Qualitative study.
Setting
Ten general practices in North Central London.
Method
Fourteen patients and their GPs were interviewed using the taped-assisted recall (TAR) method, and asked how understanding of the patients' mental health problems had been discussed in a recent consultation. The resulting 42 transcripts of the GP–patient consultations and separate GP and patient TAR interviews were analysed using qualitative thematic and process analytic methods.
Results
Patients considered understanding their mental health problems to be important, and half reported their GP consultations as helpful in this respect. The process of coming to an understanding was predominantly patient-led. Patients suggested their own explanations, and these were facilitated and focused by the doctors' questioning, listening, validating, and elaborating aspects they considered important. Both doctors and patients experienced constraints on the extent to which developing understanding of problems was possible in GP consultations.
Conclusion
GPs can help patients understand their mental health problems by recognising patients' own attempts at explanation and helping to shape and develop these.
doi:10.3399/bjgp10X532567
PMCID: PMC2965968  PMID: 20939945
doctor–patient relations; mental health; primary care; qualitative research
8.  Balancing high accrual and ethical recruitment in paediatric oncology: a qualitative study of the 'look and feel' of clinical trial discussions 
Background
High accrual to clinical trials enables new treatment strategies to be tested rapidly, accurately and with generalisability. Ethical standards also must be high so that participation is voluntary and informed. However, this can be difficult to achieve in trials with complex designs and in those which are closely embedded in clinical practice. Optimal recruitment requires a balance of both ethical and accrual considerations. In the context of a trial of stratified treatments for children with acute lymphoblastic leukaemia (UKALL2003) we examined how recruitment looked to an observer and how it felt to the parents, to identify how doctors' communication could promote or inhibit optimal recruitment.
Methods
We audio-recorded, transcribed and analysed routine doctor-patient consultations (n = 20) and interviews between researchers and parents (n = 30 parents) across six UK treatment centres. Analysis was informed by the constant comparative method. For consultation transcripts, analysis focussed on how doctors presented the trial. We compared this with analysis of the interview transcripts which focussed on parents' perceptions and understanding of the trial.
Results
Parents and doctors discussed the trial in most consultations, even those that did not involve a decision about randomisation. Doctors used language allying them both with the trial and with the parent, indicating that they were both an 'investigator' and a 'clinician'. They presented the trial both as an empirical study with a scientific imperative and also as offering personalisation of treatment for the child. Parents appeared to understand that trial involvement was voluntary, that it was different from routine care and that they could withdraw from the trial at any time. Some were confused about the significance of the MRD test and the personalisation of treatment.
Conclusions
Doctors communicated in ways that generally promoted optimal recruitment, indicating that trials can be embedded into clinical practice. However, parents were unclear about some details of the trial's rationale, suggesting that recruitment to trials with complicated designs, such as those involving stratified treatments, might need enhanced explanation.
doi:10.1186/1471-2288-10-101
PMCID: PMC2972295  PMID: 20969763
9.  Primary Care Consultations About Medically Unexplained Symptoms: How Do Patients Indicate What They Want? 
Background
Patients with medically unexplained physical symptoms (MUS) are often thought to deny psychological needs when they consult general practitioners (GPs) and to request somatic intervention instead. We tested predictions from the contrasting theory that they are transparent in communicating their psychological and other needs.
Objective
To test predictions that what patients tell GPs when they consult about MUS is related transparently to their desire for (1) emotional support, (2) symptom explanation and (3) somatic intervention.
Design
Prospective naturalistic study. Before consultation, patients indicated what they wanted from it using a self-report questionnaire measuring patients’ desire for: emotional support, explanation and reassurance, and physical investigation and treatment. Their speech during consultation was audio-recorded, transcribed and coded utterance-by-utterance. Multilevel regression analysis tested relationships between what patients sought and what they said.
Participants
Patients (N = 326) consulting 33 GPs about symptoms that the GPs designated as MUS.
Results
Patients who wanted emotional support spoke more about psychosocial problems, including psychosocial causes of symptoms and their need for psychosocial help. Patients who wanted explanation and reassurance suggested more physical explanations, including diseases, but did not overtly request explanation. Patients’ wish for somatic intervention was associated only with their talk about details of such interventions and not with their requests for them.
Conclusions
In general, patients with medically unexplained symptoms provide many cues to their desire for emotional support. They are more indirect or guarded in communicating their desire for explanation and somatic intervention.
doi:10.1007/s11606-008-0898-0
PMCID: PMC2659147  PMID: 19165548
primary care consultation; medically unexplained symptoms (MUS); psychological needs
10.  What Do Patients Choose to Tell Their Doctors? Qualitative Analysis of Potential Barriers to Reattributing Medically Unexplained Symptoms 
BACKGROUND
Despite both parties often expressing dissatisfaction with consultations, patients with medically unexplained symptoms (MUS) prefer to consult their general practitioners (GPs) rather than any other health professional. Training GPs to explain how symptoms can relate to psychosocial problems (reattribution) improves the quality of doctor–patient communication, though not necessarily patient health.
OBJECTIVE
To examine patient experiences of GPs’ attempts to reattribute MUS in order to identify potential barriers to primary care management of MUS and improvement in outcome.
DESIGN
Qualitative study.
PARTICIPANTS
Patients consulting with MUS whose GPs had been trained in reattribution. A secondary sample of patients of control GPs was also interviewed to ascertain if barriers identified were specific to reattribution or common to consultations about MUS in general.
APPROACH
Thematic analysis of in-depth interviews.
RESULTS
Potential barriers include the complexity of patients’ problems and patients’ judgements about how to manage their presentation of this complexity. Many did not trust doctors with discussion of emotional aspects of their problems and chose not to present them. The same barriers were seen amongst patients whose GPs were not trained, suggesting the barriers are not particular to reattribution.
CONCLUSIONS
Improving GP explanation of unexplained symptoms is insufficient to reduce patients’ concerns. GPs need to (1) help patients to make sense of the complex nature of their presenting problems, (2) communicate that attention to psychosocial factors will not preclude vigilance to physical disease and (3) ensure a quality of doctor–patient relationship in which patients can perceive psychosocial enquiry as appropriate.
doi:10.1007/s11606-008-0872-x
PMCID: PMC2659146  PMID: 19089505
doctor–patient communication; medically unexplained symptoms; reattribution
11.  The Perception of Support Received from Breast Care Nurses by Depressed Patients Following a Diagnosis of Breast Cancer 
INTRODUCTION
Due to their specialist training, breast care nurses (BCNs) should be able to detect emotional distress and offer support to breast cancer patients. However, patients who are most distressed after diagnosis generally experience least support from care staff. To test whether BCNs overcome this potential barrier, we compared the support experienced by depressed and non-depressed patients from their BCNs and the other main professionals involved in their care: surgeons and ward nurses.
PATIENTS AND METHODS
Women with primary breast cancer (n = 355) 2–4 days after mastectomy or wide local excision, self-reported perceived professional support and current depression. Analysis of variance compared support ratings of depressed and non-depressed patients across staff types.
RESULTS
There was evidence of depression in 31 (9%) patients. Depressed patients recorded less surgeon and ward nurse support than those who were not depressed but the support received by patients from the BCN was high, whether or not patients were depressed.
CONCLUSIONS
BCNs were able to provide as much support to depressed patients as to non-depressed patients, whereas depressed patients felt less supported by surgeons and ward nurses than did non-depressed patients. Future research should examine the basis of BCNs' ability to overcome barriers to support in depressed patients. Our findings confirm the importance of maintaining the special role of the BCN.
doi:10.1308/003588409X359006
PMCID: PMC2752242  PMID: 18990271
Breast cancer; Breast care nurses; Depression; Support
12.  Dependence and caring in clinical communication: The relevance of attachment and other theories 
Patient Education and Counseling  2009;74(3):331-338.
Objective
Clinical relationships are usually asymmetric, being defined by patients’ dependence and practitioners’ care. Our aims are to: (i) identify literature that can contribute to theory for researching and teaching clinical communication from this perspective; (ii) highlight where theoretical development is needed; and (iii) test the utility of the emerging theory by identifying whether it leads to implications for educational practice.
Methods
Selective and critical review of research concerned with dependence and caring in clinical and non-clinical relationships.
Results
Attachment theory helps to understand patients’ need to seek safety in relationships with expert and authoritative practitioners but is of limited help in understanding practitioners’ caring. Different theories that formulate practitioners’ care as altruistic, rewarded by personal connection or as a contract indicate the potential importance of practitioners’ emotions, values and sense of role in understanding their clinical communication.
Conclusion
Extending the theoretical grounding of clinical communication can accommodate patients’ dependence and practitioners’ caring without return to medical paternalism.
Practice implications
A broader theoretical base will help educators to address the inherent subjectivity of clinical relationships, and researchers to distinguish scientific questions about how patients and clinicians are from normative questions about how they should be.
doi:10.1016/j.pec.2008.12.011
PMCID: PMC3764431  PMID: 19157761
Communication; Attachment; Dependence
13.  General practitioners' views on reattribution for patients with medically unexplained symptoms: a questionnaire and qualitative study 
BMC Family Practice  2008;9:46.
Background
The successful introduction of new methods for managing medically unexplained symptoms in primary care is dependent to a large degree on the attitudes, experiences and expectations of practitioners. As part of an exploratory randomised controlled trial of reattribution training, we sought the views of participating practitioners on patients with medically unexplained symptoms, and on the value of and barriers to the implementation of reattribution in practice.
Methods
A nested attitudinal survey and qualitative study in sixteen primary care teams in north-west England. All practitioners participating in the trial (n = 74) were invited to complete a structured survey. Semi-structured interviews were undertaken with a purposive sub-sample of survey respondents, using a structured topic guide. Interview transcripts were used to identify key issues, concepts and themes, which were grouped to construct a conceptual framework: this framework was applied systematically to the data.
Results
Seventy (95%) of study participants responded to the survey. Survey respondents often found it stressful to work with patients with medically unexplained symptoms, though those who had received reattribution training were more optimistic about their ability to help them. Interview participants trained in reattribution (n = 12) reported that reattribution increased their confidence to practice in a difficult area, with heightened awareness, altered perceptions of these patients, improved opportunities for team-building and transferable skills. However general practitioners also reported potential barriers to the implementation of reattribution in routine clinical practice, at the level of the patient, the doctor, the consultation, diagnosis and the healthcare context.
Conclusion
Reattribution training increases practitioners' sense of competence in managing patients with medically unexplained symptoms. However, barriers to its implementation are considerable, and frequently lie outside the control of a group of practitioners generally sympathetic to patients with medically unexplained symptoms and the purpose of reattribution. These findings add further to the evidence of the difficulty of implementing reattribution in routine general practice.
doi:10.1186/1471-2296-9-46
PMCID: PMC2533666  PMID: 18713473
14.  Why do General Practitioners Decline Training to Improve Management of Medically Unexplained Symptoms? 
Background
General practitioners’ (GPs) communication with patients presenting medically unexplained symptoms (MUS) has the potential to somatize patients’ problems and intensify dependence on medical care. Several reports indicate that GPs have negative attitudes about patients with MUS. If these attitudes deter participation in training or other methods to improve communication, practitioners who most need help will not receive it.
Objective
To identify how GPs’ attitudes to patients with MUS might inhibit their participation with training to improve management.
Design
Qualitative study.
Participants
GPs (N = 33) who had declined or accepted training in reattribution techniques in the context of a research trial.
Approach
GPs were interviewed and their accounts analysed qualitatively.
Results
Although attitudes that devalued patients with MUS were common in practitioners who had declined training, these coexisted, in the same practitioners, with evidence of intuitive and elaborate psychological work with these patients. However, these practitioners devalued their psychological skills. GPs who had accepted training also described working psychologically with MUS but devalued neither patients with MUS nor their own psychological skills.
Conclusions
GPs’ attitudes that suggested disengagement from patients with MUS belied their pursuit of psychological objectives. We therefore suggest that, whereas negative attitudes to patients have previously been regarded as the main barrier to involvement in measures to improve patient management, GPs devaluing of their own psychological skills with these patients may be more important.
doi:10.1007/s11606-006-0094-z
PMCID: PMC1855690  PMID: 17443362
medically unexplained symptoms; general practitioners; management; psychological skills; attitudes
15.  PREVALENCE OF SOMATIZATION AND MINOR PSYCHIATRIC MORBIDITY IN PRIMARY HEALTHCARE IN SAUDI ARABIA: A PRELIMINARY STUDY IN ASIR REGION 
Objective:
To determine the prevalence of psychological disorders and somatization among primary care patients from a semi-urban area of the Kingdom of Saudi Arabia.
Design:
Screening of consecutive patients with the 12-item and 28-item versions of the General Health Questionnaires and assessments of physical symptoms associated with somatization, using the HSCL-12. Eight primary care health centres in Assir, Saudi Arabia.
Results:
About half of the sample had one or more psychological disorders. The prevalence of somatization detected by the GHQ-28 was 16%. The prevalence of somatization indicated by GPs’ identification of medically unexplained symptoms was 14%. Women displayed higher levels of somatization than men.
Conclusion:
This study reported prevalence of psychological disorders that was as high as found in the more modern areas of Saudi Arabia such as Riyadh. The view that individuals in less open areas are protected from psychological disorders associated with stress and lifestyle pressure seems to be unsubstantiated. The results highlight the potential value of screening for psychological disorders using such simple instruments as the GHQ
PMCID: PMC3377053  PMID: 23012164
Psychological disorders; somatization; primary health care; Saudi Arabia
16.  Why do General Practitioners Decline Training to Improve Management of Medically Unexplained Symptoms? 
Background
General practitioners’ (GPs) communication with patients presenting medically unexplained symptoms (MUS) has the potential to somatize patients’ problems and intensify dependence on medical care. Several reports indicate that GPs have negative attitudes about patients with MUS. If these attitudes deter participation in training or other methods to improve communication, practitioners who most need help will not receive it.
Objective
To identify how GPs’ attitudes to patients with MUS might inhibit their participation with training to improve management.
Design
Qualitative study.
Participants
GPs (N = 33) who had declined or accepted training in reattribution techniques in the context of a research trial.
Approach
GPs were interviewed and their accounts analysed qualitatively.
Results
Although attitudes that devalued patients with MUS were common in practitioners who had declined training, these coexisted, in the same practitioners, with evidence of intuitive and elaborate psychological work with these patients. However, these practitioners devalued their psychological skills. GPs who had accepted training also described working psychologically with MUS but devalued neither patients with MUS nor their own psychological skills.
Conclusions
GPs’ attitudes that suggested disengagement from patients with MUS belied their pursuit of psychological objectives. We therefore suggest that, whereas negative attitudes to patients have previously been regarded as the main barrier to involvement in measures to improve patient management, GPs devaluing of their own psychological skills with these patients may be more important.
doi:10.1007/s11606-006-0094-z
PMCID: PMC1855690  PMID: 17443362
medically unexplained symptoms; general practitioners; management; psychological skills; attitudes
17.  Health professionals' and service users' interpretation of screening test results: experimental study 
BMJ : British Medical Journal  2006;333(7562):284.
Objective To investigate the accuracy of interpretation of probabilistic screening information by different stakeholder groups and whether presentation as frequencies improves accuracy.
Design Between participants experimental design; participants responded to screening information embedded in a scenario.
Setting Regional maternity service and national conferences and training days.
Participants 43 pregnant women attending their first antenatal appointment in a regional maternity service; 40 companions accompanying the women to their appointments; 42 midwives; 41 obstetricians. Participation rates were 56%, 48%, 89%, and 71% respectively.
Measures Participants estimated the probability that a positive screening test result meant that a baby actually had Down's syndrome on the basis of all the relevant information, which was presented in a scenario. They were randomly assigned to scenarios that presented the information in percentage (n = 86) or frequency (n = 83) format. They also gave basic demographic information and rated their confidence in their estimate.
Results Most responses (86%) were incorrect. Obstetricians gave significantly more correct answers (although still only 43%) than either midwives (0%) or pregnant women (9%). Overall, the proportion of correct answers was higher for presentation as frequencies (24%) than for presentation as percentages (6%), but further analysis showed that this difference occurred only in responses from obstetricians. Many health professionals were confident in their incorrect responses.
Conclusions Most stakeholders in pregnancy screening draw incorrect inferences from probabilistic information, and health professionals need to be aware of the difficulties that both they and their patients have with such information. Moreover, they should be aware that different people make different mistakes and that ways of conveying information that help some people will not help others.
doi:10.1136/bmj.38884.663102.AE
PMCID: PMC1526944  PMID: 16840441
18.  Voiced but unheard agendas: qualitative analysis of the psychosocial cues that patients with unexplained symptoms present to general practitioners. 
BACKGROUND: Symptomatic investigation and treatment of unexplained physical symptoms is often attributed to patients' beliefs and demands for physical treatments. AIM: To test the influential assumption that patients who present symptoms that the general practitioner (GP) considers to be medically unexplained do not generally provide the opportunity for discussion of psychological issues. DESIGN OF STUDY: Qualitative analysis of audiotaped consultations between patients and GPs. SETTING: Seven general practices in Merseyside, United Kingdom. METHODS: Transcripts of audiotaped consultations between 21 GPs and 36 patients with medically unexplained symptoms were analysed inductively to identify opportunities that patients presented for their doctors to address emotional problems or their need for explanation. RESULTS: All but two patients provided psychological opportunities. They described social or emotional difficulties as problems of stress or mood. They presented their need for explanation by: explicit questions; statements of concern about symptoms; suggestions that disease might be absent; or tentative references to serious disease. In general, GPs did not engage with these cues. CONCLUSIONS: Patients with unexplained symptoms present opportunities for GPs to address psychological needs. By taking these opportunities, GPs might be able to avoid unnecessary symptomatic intervention.
PMCID: PMC1314826  PMID: 15006121
19.  Normalisation of unexplained symptoms by general practitioners: a functional typology. 
BACKGROUND: Patients often present in primary care with physical symptoms that doctors cannot readily explain. The process of reassuring these patients is challenging, complex and poorly understood. AIM: To construct a typology of general practitioners' (GPs') normalising explanations, based on their effect on the process and outcome of consultations involving patients with medically unexplained symptoms. DESIGN OF STUDY: Qualitative analysis of audiotaped consultations between patients and GPs. SETTING: Seven general practices in Merseyside, United Kingdom. METHODS: Transcripts of audiotaped consultations between 21 GPs and 36 patients with medically unexplained symptoms were analysed inductively, to identify types of normalising speech used by GPs. RESULTS: Normalisation without explanation included rudimentary reassurance and the authority of a negative test result. Patients persisted in requesting explanation and elaborated or extended their symptoms, rendering somatic management more likely. Normalisation with ineffective explanation provided a tangible physical explanation for symptoms, unrelated to patient's expressed concerns. This was also counterproductive. Normalisation with effective explanation provided tangible mechanisms grounded in patients' concerns, often linking physical and psychological factors. These explanations were accepted by patients; those linking physical and psychological factors contributed to psychosocial management outcomes. CONCLUSIONS: The routine exercise of normalisation by GPs contains approaches that are ineffective and may exacerbate patients' presentation. However, it also contains types of explanation that may reduce the need for symptomatic investigation or treatment. These findings can inform the development of well-grounded educational interventions for GPs.
PMCID: PMC1314825  PMID: 15006120
21.  Do patients with unexplained physical symptoms pressurise general practitioners for somatic treatment? A qualitative study 
BMJ : British Medical Journal  2004;328(7447):1057.
Objectives To identify the ways in which patients with medically unexplained symptoms present their problems and needs to general practitioners and to identify the forms of presentation that might lead general practitioners to feel pressurised to deliver somatic interventions.
Design Qualitative analysis of audiorecorded consultations between patients and general practitioners.
Setting 7 general practices in Merseyside, England.
Participants 36 patients selected consecutively from 21 general practices, in whom doctors considered that patients' symptoms were medically unexplained.
Main outcome measures Inductive qualitative analysis of ways in which patients presented their symptoms to general practitioners.
Results Although 34 patients received somatic interventions (27 received drug prescriptions, 12 underwent investigations, and four were referred), only 10 requested them. However, patients presented in other ways that had the potential to pressurise general practitioners, including: graphic and emotional language; complex patterns of symptoms that resisted explanation; description of emotional and social effects of symptoms; reference to other individuals as authority for the severity of symptoms; and biomedical explanations.
Conclusions Most patients with unexplained symptoms received somatic interventions from their general practitioners but had not requested them. Though such patients apparently seek to engage the general practitioner by conveying the reality of their suffering, general practitioners respond symptomatically.
doi:10.1136/bmj.38057.622639.EE
PMCID: PMC403850  PMID: 15056592
22.  Doctors' communication of trust, care, and respect in breast cancer: qualitative study 
BMJ : British Medical Journal  2004;328(7444):864.
Objective To determine how patients with breast cancer want their doctors to communicate with them.
Design Qualitative study.
Setting Breast unit and patients' homes.
Participants 39 women with breast cancer.
Main outcome measure Patients' reports of doctors' characteristics or behaviour that they valued or deprecated.
Results Patients were not primarily concerned with doctors' communication skills. Instead they emphasised doctors' enduring characteristics. Specifically, they valued doctors whom they believed were technically expert, had formed individual relationships with them, and respected them. They therefore valued forms of communication that are currently not emphasised in training and research and did not intrinsically value others that are currently thought important, including provision of information and choice.
Conclusions Women with breast cancer seek to regard their doctors as attachment figures who will care for them. They seek communication that does not compromise this view and that enhances confidence that they are cared for. Testing and elaborating our analysis will help to focus communication research and teaching on what patients need rather than on what professionals think they need.
doi:10.1136/bmj.38046.771308.7C
PMCID: PMC387476  PMID: 15054034
25.  Patients’ perceptions of medical explanations for somatisation disorders: qualitative analysis 
BMJ : British Medical Journal  1999;318(7180):372-376.
Objectives
To describe, from the perspective of patients, distinguishing features of doctors’ attempts to explain the symptoms of somatisation disorders.
Design
Qualitative analysis of verbatim records of interviews in which patients recounted doctors’ explanations of their symptoms.
Setting
Patients with persistent somatising symptoms referred from general practices in Liverpool and St Helens and Knowsley were interviewed before entry into a treatment programme.
Subjects
228 of 324 patients referred were interviewed. Initial interviews were used to develop the process and technique, and the final analysis was based on a subsample of 68 records, randomly chosen from the transcripts of 188 subjects who were interviewed subsequently.
Results
Doctors’ explanations were often at odds with the patients’ own thinking. Analysis showed that medical explanations could be grouped into one of three categories, defined by the patients’ perceptions. Most explanations were experienced as rejecting the reality of the symptoms. An intermediate category comprised explanations that were viewed as colluding, in which the doctor acquiesced with the patients’ own biomedical theories. However, a few explanations were perceived by patients as tangible, exculpating, and involving. These explanations were experienced by patients as satisfying and empowering.
Conclusions
Patients with somatisation disorders feel satisfied and empowered by medical explanations that are tangible, exculpating, and involving. Empowering explanations could improve these patients’ wellbeing and help to reduce the high demands they make on health services.
Key messagesPatients with somatisation disorders make disproportionately heavy demands on health servicesDoctors’ explanations of their symptoms are often at odds with these patients’ own thinkingPatients with somatisation disorders describe three types of medical explanation—rejecting, colluding, and empoweringEmpowering explanations are tangible, exculpating, and involve patients in managing their illnessPatients’ reactions to empowering explanations suggest that these have the potential to reduce demand for health care
PMCID: PMC27727  PMID: 9933202

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