BackgroundThe prevalence of depression is high and results in huge costs for society. Internet-based cognitive behavioural treatment (ICBT) has been suggested for use in primary care and has been shown to be more effective when combined with human support. However, non-completion rates remain a challenge. Current recommendations state that steps to improve persistence with ICBT should be determined and the impact of therapist support on persistence explored. A few earlier studies have explored motivations to persist with ICBT without face-to-face therapist support. The present study explored the motivation to persist as experienced by a group of patients who sought help in primary care and used “blended care”, i.e. ICBT supported by short face-to-face consultations.MethodsTo elucidate motivation in an everyday context and the meaning of patients’ experiences we chose a phenomenological hermeneutical approach. We interviewed participants in the intervention group of a randomized controlled trial that evaluated the efficacy of an ICBT programme called MoodGYM, an eHealth intervention used to treat depression. Fourteen participants, both completers and non-completers, went through individual, semi-structured interviews after they ended their treatment.ResultsHope of recovery and a desire to gain control of one’s life were identified as intrinsic motivators. The feeling of being able to freely choose how, when and where to complete the ICBT modules was identified as an important supporting condition and satisfied the participants’ need for autonomy. Furthermore, the importance of a sense of belonging towards partners, friends or family was essential for motivation as was the ability to identify with ICBT content. Another supporting condition was the experience of connectedness when met with acknowledgement, flexibility and feedback from a qualified therapist in the face-to-face consultations.ConclusionsA key finding was that participants were motivated to persist with ICBT when their overall need for relatedness was satisfied. This was achieved through a sense of belonging towards partners, friends and family. Connectedness with the therapist and the participant’s ability to identify with the ICBT modules also gave a sense of relatedness. Improving these motivational aspects may increase patients’ persistence with ICBT.

Please cite this article as: Johansen May-Lill, Risor Mette Bech.What is the problem with medically unexplained symptoms for GPs? A meta-synthesis of qualitative studies.Patient Education and Counseling http://dx.doi.org/10.1016/j.pec. 2016.11.015 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Highlights:-For GPs, dominant disease models (biomedical or psychosocial) often do not fit with reality -Both patients and doctors struggle with and suffer from this incongruence -In the lack of congruent disease models, a validating doctorpatient relationship can be a lifeline 2 Abstract:Objective To gain a deeper understanding of challenges faced by GPs when managing patients with MUS. MethodsWe used meta-ethnography to synthesize qualitative studies on GPs' perception and management of MUS. ResultsThe problem with MUS for GPs is the epistemological incongruence between dominant disease models and the reality of meeting patients suffering from persistent illness. GPs have used flexible approaches to manage the situation, yet patients and doctors have had parallel negative experiences of being stuck, untrustworthy and helpless. In the face of cognitive incongruence, GPs have strived to achieve relational congruence with their patients. This has led to parallel positive experiences of mutual trust and validation. With more experience, some GPs seem to overcome the incongruences, and later studies point towards a reframing of the MUS problem. ConclusionFor GPs, the challenge with MUS is most importantly at an epistemological level. Hence, a full reframing of the problem of MUS for GPs (and for patients) implies broad changes in basic medical knowledge and education. 3Practice Implications Short-term: Improve management of patients with MUS by transferring experience-based, reality-adjusted knowledge from senior GPs to juniors. Long-term: Work towards new models of disease that integrate knowledge from all relevant disciplines.199 words

Background. Only a few patients on a GP ' s list develop cancer each year. To fi nd these cases in the jumble of presented problems is a challenge. Objective. To explore how general practitioners (GPs) come to think of cancer in a clinical encounter. Design. Qualitative interviews with Norwegian GPs, who were invited to think back on consultations during which the thought of cancer arose. The 11 GPs recounted and refl ected on 70 such stories from their practices. A phenomenographic approach enabled the study of variation in GPs ' ways of experiencing. Results. Awareness of cancer could arise in several contexts of attention: (1) Practising basic knowledge : explicit rules and skills, such as alarm symptoms, epidemiology and clinical know-how; (2) Interpersonal awareness : being alert to changes in patients ' appearance or behaviour and to cues in their choice of words, on a background of basic knowledge and experience; (3) Intuitive knowing : a tacit feeling of alarm which could be diffi cult to verbalize, but nevertheless was helpful. Intuition built on the earlier mentioned contexts: basic knowledge, experience, and interpersonal awareness; (4) Fear of cancer : the existential context of awareness could affect the thoughts of both doctor and patient. The challenge could be how not to think about cancer all the time and to fi nd ways to live with insecurity without becoming over-precautious. Conclusion : The thought of cancer arose in the relationship between doctor and patient. The quality of their interaction and the doctor ' s accuracy in perceiving and interpreting cues were decisive.

BackgroundGeneralists such as general practitioners and district nurses have been the main actors in community palliative care in Norway. Specialised oncology nurses with postgraduate palliative training are increasingly becoming involved. There is little research on their contribution. This study explores how general practitioners (GPs) and oncology nurses (ONs) experience their collaboration in primary palliative care.MethodsA qualitative focus group and interview study in rural Northern Norway, involving 52 health professionals. Five uni-professional focus group discussions were followed by five interprofessional discussions and six individual interviews. Transcripts were analysed thematically.ResultsThe ideal cooperation between GPs and ONs was as a “meeting of experts” with complementary competencies. GPs drew on their generalist backgrounds, including their often long-term relationship with and knowledge of the patient. The ONs contributed longitudinal clinical observations and used their specialised knowledge to make treatment suggestions. While ONs were often experienced and many had developed a form of pattern recognition, they needed GPs’ competencies for complex clinical judgements. However, ONs sometimes lacked timely advice from GPs, and could feel left alone with sick patients. To avoid this, some ONs bypassed GPs and contacted palliative specialists directly.While traditional professional hierarchies were not a barrier, we found that organization, funding and remuneration were significant barriers to cooperation. GPs often did not have time to meet with ONs to discuss shared patients. We also found that ONs and GPs had different strategies for learning. While ONs belonged to a networking nursing collective aiming for continuous quality improvement, GPs learned mostly from their individual experience of caring for patients.ConclusionsThe complementary competences and autonomous roles of a specialised nurse and a general practitioner represented a good match for primary palliative care. When planning high-quality teamwork in primary care, organizational barriers to cooperation and different cultures for learning need consideration.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-2955-7) contains supplementary material, which is available to authorized users.

Reentry and nonreentry women were compared on their reasons for being in school, goals associated with education, and campus services used or wanted. Eighty-two California State University, Hayward, undergraduate students volunteered to participate in the questionnaire survey. Reentry women were found to be more self-motivated, with higher educational goals, and higher grade point averages than nonreentry women. Reentry women also made less use of currently available student services. Reasons for this lack of use, and suggestions for future services were explored.Requests for reprints should be sent to M. Kelly Johansen,