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1.  The consultants’ role in the referring process with general practitioners: partners or adjudicators? a qualitative study 
BMC Family Practice  2013;14:153.
Background
Within the health system, communication between the different levels of care is essential for the patients’ clinical pathways and medical treatment. This includes the referral process: how and why patients are sent from the primary care level to specialist health services. We wanted to identify and describe hospital consultants’ reflections on and attitudes to the referral process and cooperation with general practitioners (GPs).
Methods
A qualitative study of semi-structured interviews with 13 hospital consultants representing eight different specialties, analyzed using systematic text condensation. Interviews conducted from February 2011 to October 2012.
Results
The consultants reported a considerable workload assessing referrals from GPs and prioritizing patients for specialist services. National guidelines were used as well as individual standards and guidelines. Good referrals could make the prioritization process easier. The specialists expressed a deep concern about securing a fair priority of patients and a willingness to give reasonable advice back to the referring GP when rejecting a referral. Better communication, such as a telephone call to confer with a hospital specialist before referral, was wanted.
Conclusions
Better communication and cooperation between hospital consultants and GPs could make the referral process more balanced, and the participants more like partners.
doi:10.1186/1471-2296-14-153
PMCID: PMC3852119  PMID: 24118941
2.  General practitioners’ reflections on referring: An asymmetric or non-dialogical process? 
Objective
Identify and describe general practitioners’ (GPs’) reflections on and attitudes to the referral process and cooperation with hospital specialists.
Design
Qualitative study using semi-structured focus-group interviews with GPs analysed using Giorgi's method as modified by Malterud.
Setting
Interviews conducted over four months from November 2010 to February 2011.
Subjects
17 female and 14 male GPs aged 29 to 61 years from 21 different practices, who had practised for 3–35 years.
Main outcome measures
Description of GPs’ views on the referral process.
Results
GPs wished for improved dialogue with the hospital specialists. The referral process was often considered as asymmetric and sometimes humiliating. GPs saw the benefit of using templates in the referral process, but were sceptical concerning the use of mandatory fixed formats.
Conclusions.
The referral process is essential for good patient care between general practice and specialist services. GPs consider referring as asymmetric and sometimes humiliating. The dichotomy between the wish for mutual dialogue and the convenience of using templates should be kept in mind when assuring quality of the referral process.
doi:10.3109/02813432.2012.711190
PMCID: PMC3520419  PMID: 23050793
Family practice; general practice; general practitioner; Norway; qualitative research; referral process
3.  Career choice and place of graduation among physicians in Norway 
Objective
To investigate to what extent a physician's place of graduation is associated with the physician choosing a career as a general practitioner (GP), and identify factors in the curriculum that could predict a general practice career.
Design
Cross-sectional study based on the membership database of the Norwegian Medical Association.
Setting
Physicians working in Norway who graduated from four domestic medical schools, five other countries, and three groups of countries. Physicians were categorized according to their main professional activity as GPs, hospital physicians, and researchers.
Subjects
A total of 2836 medical physicians who were working in Norway during 2010 and graduated from medical school between 2002 and 2005.
Main outcome measures
Percentage and odds ratio for subjects working as a GP in Norway during 2010. Descriptive data for pre-graduate general practice education in Norwegian medical schools were also analysed.
Results
Compared with the University of Oslo, there was a significantly higher proportion of GPs among physicians who had graduated from Denmark (OR 2.9, 95% CI 1.9–4.5), Poland (OR 2.0, 95% CI 1.4–2.9), Sweden (OR 1.8, 95% CI 1.0–3.1), and Trondheim (Norway) (OR 1.5, 95% CI 1.1–2.0). Across the four Norwegian medical schools, there were significant associations between choosing a general practice career and the sum of pre-graduate educational hours regarding general practice, general practice preceptorship, and the number of GP teachers.
Conclusion
The physician's place of graduation appears to be associated with career choice. The universities’ total contribution in pre-graduate general practice education may be associated with future GP career choice.
doi:10.3109/02813432.2012.654195
PMCID: PMC3337528  PMID: 22324633
General practice; hospital physician; medical education; research personnel
4.  Empirical treatment of uncomplicated cystitis 
doi:10.3109/02813432.2012.649629
PMCID: PMC3337529  PMID: 22348511
5.  Observed communication skills: how do they relate to the consultation content? A nation-wide study of graduate medical students seeing a standardized patient for a first-time consultation in a general practice setting 
Background
In this study, we wanted to investigate the relationship between background variables, communication skills, and the bio-psychosocial content of a medical consultation in a general practice setting with a standardized patient.
Methods
Final-year medical school students (N = 111) carried out a consultation with an actor playing the role of a patient with a specific somatic complaint, psychosocial stressors, and concerns about cancer. Based on videotapes, communication skills and consultation content were scored separately.
Results
The mean level of overall communication skills had a significant impact upon the counts of psychosocial issues, the patient's concerns about cancer, and the information and planning parts of the consultation content being addressed. Gender and age had no influence upon the relationship between communication skills and consultation content.
Conclusion
Communication skills seem to be important for final-year students' competence in addressing sensitive psychosocial issues and patients' concerns as well as informing and planning with patients being representative for a fairly complex case in general practice. This result should be considered in the design and incorporation of communication skills training as part of the curriculum of medical schools.
doi:10.1186/1472-6920-7-43
PMCID: PMC2213643  PMID: 17996053
6.  Curriculum factors influencing knowledge of communication skills among medical students 
Background
Communication training builds on the assumption that understanding of the concepts related to professional communication facilitates the training. We know little about whether students' knowledge of clinical communication skills is affected by their attendance of communication training courses, or to what degree other elements of the clinical training or curriculum design also play a role. The aim of this study was to determine which elements of the curriculum influence acquisition of knowledge regarding clinical communication skills by medical students.
Methods
The study design was a cross-sectional survey performed in the four Norwegian medical schools with different curricula, spring 2003. A self-administered questionnaire regarding knowledge of communication skills (an abridged version of van Dalen's paper-and-pencil test) was sent to all students attending the four medical schools. A total of 1801 (59%) students responded with complete questionnaires.
Results
At the end of the 1st year of study, the score on the knowledge test was higher in students at the two schools running communication courses and providing early patient contact (mean 81%) than in the other two medical schools (mean 69–75%, P ≤ 0.001), with students studying a traditional curriculum scoring the lowest. Their scores increased sharply towards the end of the 3rd year, during which they had been subjected to extensive patient contact and had participated in an intensive communication course (77% vs. 72% the previous year, P ≤ 0.01). All students scored generally lower in academic years in which there was no communication training. However, at the end of the final year the difference between the schools was only 5% (81% vs. 86%, P ≤ 0.001).
Conclusion
The acquisition of knowledge regarding communication skills by medical students may be optimised when the training is given together with extensive supervised patient contact, especially if this teaching takes place in the initial years of the curriculum.
doi:10.1186/1472-6920-7-35
PMCID: PMC2089059  PMID: 17925041
7.  Assessing medical students' attitudes towards learning communication skills – which components of attitudes do we measure? 
Background
The Communication Skills Attitudes Scale (CSAS) created by Rees, Sheard and Davies and published in 2002 has been a widely used instrument for measuring medical students' attitudes towards learning communication skills. Earlier studies have shown that the CSAS mainly tests two dimensions of attitudes towards communication; positive attitudes (PAS) and negative attitudes (NAS). The objectives of our study are to explore the attitudes of Norwegian medical students towards learning communication skills, and to compare our findings with reports from other countries.
Methods
The CSAS questionnaire was mailed simultaneously to all students (n = 3055) of the four medical schools in Norway in the spring of 2003. Response from 1833 students (60.0%) were analysed by use of SPSS ver.12.
Results
A Principal component analysis yielded findings that differ in many respects from those of earlier papers. We found the CSAS to measure three factors. The first factor describes students' feelings about the way communication skills are taught, whereas the second factor describes more fundamental attitudes and values connected to the importance of having communication skills for doctors. The third factor explores whether students feel that good communication skills may help them respecting patients and colleagues.
Conclusion
Our findings indicate that in this sample the CSAS measures broader aspects of attitudes towards learning communication skills than the formerly described two-factor model with PAS and NAS. This may turn out to be helpful for monitoring the effect of different teaching strategies on students' attitudes during medical school.
doi:10.1186/1472-6920-7-4
PMCID: PMC1851955  PMID: 17394673
8.  Must undergraduate medical education be hospital-based? 
doi:10.1080/02813430701494355
PMCID: PMC3379769  PMID: 17846928
9.  General practitioners’ views on radiology reports of plain radiography for back pain 
Objective
To identify and describe general practitioners’ (GPs’) views on radiology reports, using plain radiography for back pain as the case.
Design
Qualitative study with three focus-group interviews analysed using Giorgi's method as modified by Malterud.
Setting
Southern Norway.
Subjects
Five female and eight male GPs aged 32–57 years who had practised for 3–15 years and were from 11 different practices.
Main outcome measures
Descriptions of GPs’ views.
Results
GPs wanted radiology reports to indicate more clearly the meaning of radiological terminology, the likelihood of disease, the clinical relevance of the findings, and/or the need for further investigations. GPs stated that good referral information leads to better reports.
Conclusion
These results can help to improve communication between radiologists and GPs. The issues identified in this study could be further investigated in studies that can quantify GPs’ satisfaction with radiology reports in relation to characteristics of the GP, the radiologist, and the referral information.
doi:10.1080/02813430600973459
PMCID: PMC3389447  PMID: 17354154
Back pain; family practice; general practitioner; qualitative research; radiography; radiology report
10.  Analysis of role-play in medical communication training using a theatrical device the fourth wall 
Background
Communication training is a central part of medical education. The aim of this article is to explore the positions and didactic functions of the fourth wall in medical communication training, using a role-play model basically similar to a theatrical performance.
Method
The empirical data stem from a communication training model demonstrated at an international workshop for medical teachers and course organizers. The model involves an actress playing a patient, students alternating in the role of the doctor, and a teacher who moderates. The workshop was videotaped and analyzed qualitatively.
Results
The analysis of the empirical material revealed three main locations of the fourth wall as it moved and changed qualities during the learning session: 1) A traditional theatre location, where the wall was transparent for the audience, but opaque for the participants in the fiction. 2) A "timeout/reflection" location, where the wall was doubly opaque, for the patient on the one side and the moderator, the doctor and the audience on the other side and 3) an "interviewing the character" location where the wall enclosed everybody in the room. All three locations may contribute to the learning process.
Conclusion
The theatrical concept 'the fourth wall' may present an additional tool for new understanding of fiction based communication training. Increased understanding of such an activity may help medical teachers/course organizers in planning and evaluating communication training courses.
doi:10.1186/1472-6920-6-51
PMCID: PMC1621062  PMID: 17040575
11.  Feedback on video recorded consultations in medical teaching: why students loathe and love it – a focus-group based qualitative study 
Background
Feedback on videotaped consultations is a useful way to enhance consultation skills among medical students. The method is becoming increasingly common, but is still not widely implemented in medical education. One obstacle might be that many students seem to consider this educational approach a stressful experience and are reluctant to participate. In order to improve the process and make it more acceptable to the participants, we wanted to identify possible problems experienced by students when making and receiving feedback on their video taped consultations.
Methods
Nineteen of 75 students at the University of Bergen, Norway, participating in a consultation course in their final term of medical school underwent focus group interviews immediately following a video-based feedback session. The material was audio-taped, transcribed, and analysed by phenomenological qualitative analysis.
Results
The study uncovered that some students experienced emotional distress before the start of the course. They were apprehensive and lacking in confidence, expressing fear about exposing lack of skills and competence in front of each other. The video evaluation session and feedback process were evaluated positively however, and they found that their worries had been exaggerated. The video evaluation process also seemed to help strengthen the students' self esteem and self-confidence, and they welcomed this.
Conclusion
Our study provides insight regarding the vulnerability of students receiving feedback from videotaped consultations and their need for reassurance and support in the process, and demonstrates the importance of carefully considering the design and execution of such educational programs.
doi:10.1186/1472-6920-5-28
PMCID: PMC1190180  PMID: 16029509
12.  Factors affecting general practitioners' decisions about plain radiography for back pain: implications for classification of guideline barriers – a qualitative study 
Background
General practitioners often diverge from clinical guidelines regarding spine radiography. This study aimed to identify and describe A) factors general practitioners consider may affect their decisions about ordering plain radiography for back pain and B) barriers to guideline adherence suggested by such factors.
Methods
Focus group interviews regarding factors affecting ordering decisions were carried out on a diverse sample of Norwegian general practitioners and were analysed qualitatively. Results of this study and two qualitative studies from the Netherlands and USA on use of spine radiography were interpreted for barriers to guideline adherence. These were compared with an existing barrier classification system described by Dr Cabana's group.
Results
The factors which Norwegian general practitioners considered might affect their decisions about ordering plain radiography for back pain concerned the following broader issues: clinical ordering criteria, patients' wishes for radiography and the general practitioner's response, uncertainty, professional dignity, access to radiology services, perception of whether the patient really was ill, sense of pressure from other health care providers/social security, and expectations about the consequences of ordering radiography. The three studies suggested several attitude-related and external barriers as classified in a previously reported system described by Dr Cabana in another study. Identified barriers not listed in this system were: lack of expectancy that guideline adherence will lead to desired health care process, emotional difficulty with adherence, improper access to actual/alternative health care services, and pressure from health care providers/organisations.
Conclusions
Our findings may help implement spine radiography guidelines. They also indicate that Cabana et al.'s barrier classification system needs extending. A revised system is proposed.
doi:10.1186/1472-6963-3-8
PMCID: PMC153534  PMID: 12659640
13.  Empirical treatment of uncomplicated cystitis  
BMJ : British Medical Journal  2001;323(7323):1197-1198.
PMCID: PMC1121680  PMID: 11719397

Results 1-13 (13)