BackgroundClinical guidelines for single diseases often pose problems in general practice work with multimorbid patients. However, little research focuses on how general practice is affected by the demand to follow multiple guidelines. This study explored Norwegian general practitioners’ (GPs’) experiences with and reflections upon the consequences for general practice of applying multiple guidelines.MethodsQualitative focus group study carried out in Mid-Norway. The study involved a purposeful sample of 25 Norwegian GPs from four pre-existing groups. Interviews were audio-recorded, transcribed and analyzed using systematic text condensation, i.e. applying a phenomenological approach.ResultsThe GPs’ responses clustered around two major topics: 1) Complications for the GPs of applying multiple guidelines; and, 2) Complications for their patients when GPs apply multiple guidelines. For the GPs, applying multiple guidelines created a highly problematic situation as they felt obliged to implement guidelines that were not suited to their patients: too often, the map and the terrain did not match. They also experienced greater insecurity regarding their own practice which, they admitted, resulted in an increased tendency to practice ‘defensive medicine’. For their patients, the GPs experienced that applying multiple guidelines increased the risk of polypharmacy, excessive non-pharmacological recommendations, a tendency toward medicalization and, for some, a reduction in quality of life.ConclusionsThe GPs experienced negative consequences when obliged to apply a variety of single disease guidelines to multimorbid patients, including increased risk of polypharmacy and overtreatment. We believe patient-centered care and the GPs’ courage to non-comply when necessary may aid in reducing these risks. Health care authorities and guideline developers need to be aware of the potential negative effects of applying a single disease focus in general practice, where multimorbidity is highly prevalent.

Background and Aims: Life experience and existential circumstances have an impact on health. Within medicine, however, the significance to patient care of person-related, biographical knowledge receives only rudimentary emphasis and its substantial theoretical underpinnings are inadequately understood and infrequently applied. This study explores the types and extent of some Norwegian general practitioners' (GPs') person-related knowledge, exemplified by patients on the GPs respective lists who are currently in a state of frail health. Methods: Nine GPs were interviewed regarding one of their patients who had recently been admitted to the rehabilitation unit of a nursing home. Subsequent interviews with the individual patients served both to validate the GPs' information and as a starting point for further inquiry into patient life stories. Interview transcripts were analyzed within a phenomenological-hermeneutical framework.

BackgroundRepeated encounters over time enable general practitioners (GPs) to accumulate biomedical and biographical knowledge about their patients. A growing body of evidence documenting the medical relevance of lifetime experiences indicates that health personnel ought to appraise this type of knowledge and consider how to incorporate it into their treatment of patients. In order to explore the interdisciplinary communication of such knowledge within Norwegian health care, we conducted a research project at the interface between general practice and a nursing home.MethodsIn the present study, nine Norwegian GPs were each interviewed about one of their patients who had recently been admitted to a nursing home for short-term rehabilitation. A successive interview conducted with each of these patients aimed at both validating the GP's information and exploring the patient's life story. The GP's treatment opinions and the patient's biographical information and treatment preferences were condensed into a biographical record presented to the nursing home staff. The transcripts of the interviews and the institutional treatment measures were compared and analysed, applying a phenomenological–hermeneutical framework. In the present article, we compare and discuss: (1) the GPs’ specific recommendations for their patients; (2) the patients’ own wishes and perceived needs; and (3) if and how this information was integrated into the institution's interventions and priorities.ResultsEach GP made rehabilitation recommendations, which included statements regarding both the patient's personality and life circumstances. The nursing home staff individualized their selection of therapeutic interventions based on defined standardized treatment approaches, without personalizing them.ConclusionWe found that the institutional voice of medicine consistently tends to override the voice of the patient's lifeworld. Thus, despite the institution's best intentions, their efforts to provide appropriate rehabilitation seem to have been jeopardized to some extent.

Background Patients in need of palliative care often want to reside at home. Providing palliative care requires resources and a high level of competence in primary care. The Norwegian guideline for palliative care points to the central role of the regular general practitioner (RGP), specifying a high expected level of competence. Guideline implementation is known to be challenging in primary care. This study investigates adherence to the guideline, the RGPs experience with, and view of their role in palliative care. Methods A questionnaire was distributed, by post, to all 246 RGPs in a Norwegian county. Themes of the questionnaire focused on experience with palliative and terminal care, the use of recommended work methods from the guideline, communication with partners, self-reported role in palliative care and confidence in providing palliative care. Data were analyzed descriptively, using SPSS. Results Each RGP had few patients needing palliative care, and limited experience with terminal care at home. Limited experience challenged RGPs possibilities to maintain knowledge about palliative care. Their clinical approach was not in agreement with the guideline, but most of them saw themselves as central, and were confident in the provision of palliative care. Rural RGPs saw themselves as more central in this work than their urban colleagues. Conclusions This study demonstrated low adherence of the RGPs, to the Norwegian guideline for palliative care. Guideline requirements may not correspond with the methods of general practice, making them difficult to adopt. The RGPs seemed to have too few clinical cases over time to maintain skills at a complex and specialized level. Yet, there seems to be a great potential for the RGP, with the inherent specialist skills of the general practitioner, to be a key worker in the palliative care trajectory.

Objectives The aim of the study was to identify general practitioners’ (GPs) strategies to avoid unnecessary diagnostic imaging when encountering patients with such expectations and to explore how patients experience these strategies. Design, setting and subjects We conducted a qualitative study that combined observations of consultations and interviews with GPs and patients. A total of 24 patients visiting nine different GPs in two Norwegian urban areas were included in the study. Of these, 12 consultations were considered suitable for studying GP strategies and were therefore selected for a more thorough analysis. Main outcome measures GPs’ communication strategies to avoid unnecessary medical imaging and patients’ experiences with such strategies. Results Five categories of strategies were identified: (1) wait and see – or suggest an alternative; (2) the art of rejection; (3) seek support from a professional authority; (4) partnership and shared decision-making and (5) reassurance, normalisation and recognition. The GPs often used multiple strategies. Factors related to a long-term doctor–patient relationship seemed to influence both communication and how both parties experienced the decision. Three important factors were evident: the patient trusted the doctor, the doctor knew the patient’s medical history and the doctor knew the patient as a person. The patients seemed to be generally satisfied with the outcomes of the consultations. Conclusion GPs largely combine different strategies when meeting patients’ expectations of diagnostic imaging that are not strictly medically indicated. Continuity of the doctor–patient relationship with good personal knowledge and trust between doctor and patient appeared crucial for patients to accept the doctors' decisions. Key points GPs usually combine a broad range of strategies to avoid unnecessary medical imaging The patients appeared generally satisfied regardless of the strategy the strategy used by the GPs and even where their referral request were rejected Factors related to a long-term doctor–patient relationship appeared decisive