Understanding "revolving door" patients in general practice: a qualitative study.
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ABSTRACT: Background
'Revolving door' patients in general practice are repeatedly removed from general practitioners' (GP) lists. This paper reports a qualitative portion of the first mixed methods study of these marginalised patients.Methods
We conducted qualitative semi-structured interviews with six practitioner services staff and six GPs in Scotland, utilizing Charmazian grounded theory to characterise 'revolving door' patients and their impact from professionals' perspectives.Results
'Revolving door' patients were reported as having three necessary characteristics; they had unreasonable expectations, exhibited inappropriate behaviours and had unmet health needs. A range of boundary breaches were reported too when 'revolving door' patients interacted with NHS staff.Conclusions
We utilise the 'sensitising concepts' of legitimacy by drawing on literature about 'good and bad' patients and 'dirty work designations.' We relate these to the core work of general practice and explore the role that medical and moral schemas have in how health service professionals understand and work with 'revolving door' patients. We suggest this may have wider relevance for the problem doctor patient relationship literature.
SUBMITTER: Williamson AE
PROVIDER: S-EPMC3930014 | biostudies-literature | 2014 Feb
REPOSITORIES: biostudies-literature
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Understanding "revolving door" patients in general practice: a qualitative study.
Williamson Andrea E AE Mullen Kenneth K Wilson Philip P
BMC family practice 20140213
<h4>Background</h4>'Revolving door' patients in general practice are repeatedly removed from general practitioners' (GP) lists. This paper reports a qualitative portion of the first mixed methods study of these marginalised patients.<h4>Methods</h4>We conducted qualitative semi-structured interviews with six practitioner services staff and six GPs in Scotland, utilizing Charmazian grounded theory to characterise 'revolving door' patients and their impact from professionals' perspectives.<h4>Resu ...[more]
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Project description:BackgroundWe describe the health of "revolving door" patients in general practice in Scotland, estimate changes in their number over the timescale of the study, and explore reasons for changes, particularly related to NHS and government policy.MethodsA mixed methods predominantly qualitative study, using a grounded theory approach, set in Scottish general practice. Semi-structured interviews were conducted with professional key informants, 6 Practitioner Services staff who administer the GP registration system and 6 GPs with managerial or clinical experience of working with "revolving door" patients. Descriptive statistical analysis and qualitative analysis of patient removal episodes linked with routine hospital admissions, outpatient appointments, drug misuse treatment episodes and deaths were carried out with cohorts of "revolving door" patients identified from 1999 to 2005 in Scotland.ResultsA "revolving door" patient is removed 4 or more times from GP lists in 7 years. Patients had complex health issues including substance misuse, psychiatric and physical health problems and were at high risk of dying. There was a dramatic reduction in the number of "revolving door" patients during the course of the study.Conclusions"Revolving door" patients in general practice had significant health problems. Their numbers have reduced dramatically since 2004 and this probably resulted from improved drug treatment services, pressure from professional bodies to reduce patient removals and the positive ethical regulatory and financial climate of the 2004 GMS GP contract. This is a positive development for the NHS.
| S-EPMC3528483 | biostudies-literature
Project description:BACKGROUND:Accreditation is a widely adopted tool for quality control and quality improvement in health care, which has increasingly been employed for general practice. However, there is lack of knowledge of how accreditation is received and experienced by health professionals in general practice. This study explores how general practitioners (GPs) and their staff experienced the comprehensibility of accreditation standards and how they worked to increase their understanding of the standards. The study was conducted in Denmark where accreditation was mandatory in general practice from 2016 to 2018. METHODS:The study consists of qualitative interviews with general practitioners and staff from 11 general practices that were strategically sampled among practices set to receive their survey visit in 2017. Participants were interviewed twice; once during the preparation phase and once after the survey visit. GPs and staff were interviewed separately. The interviews were analysed inductively using thematic analysis. RESULTS:Understanding the requirements of the accreditation standards was a major challenge for the professionals when preparing for the accreditation survey visit. The participants attempted to increase their understanding of the standards in several ways including the use of regional support options and seeking out experts and colleagues. However, participants had mixed experiences with the various support options and many found the sense making work frustrating and time consuming. CONCLUSION:The results point to the importance of considering the level of specificity in accreditation standards and how to ensure an organisational set-up that can offer appropriate support to primary care clinics in terms of understanding what is required to meet the standards.
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Project description:RATIONALE:In psychiatric disorders, interindividual differences in cytochrome P450 (CYP)2D6 (CYP2D6) enzymatic activity could be responsible of adverse drug reactions (ADRs) and therapeutic failures (TFs) for CYP2D6-metabolized drugs, contributing to the periodical hospital readmissions of the revolving door (RD) condition. PATIENT CONCERNS:We investigated CYP2D6 genotypes in a controlled series of 5 consecutive RD patients with Bipolar Disorder (BD). DIAGNOSES:Psychiatric patients affected by Bipolar Disorder. INTERVENTIONS:We defined TFs as a difference at the Brief Psychiatric Rating Scale score ?BPRS?<?25% at each 1-week of stable treatment, and ADRs as the onset of extrapyramidal symptoms and/or metabolic impairment with weight gain. OUTCOMES:At 3 months, a mean number of 2.75?±?1.26 ADR and a mean ?BPRS score of 16.07?±?0.05% were observed. At 6 months of follow-up, compared to the only patient without BD (?BPRS?<?32.10%), BD patients (n?=?4) showed TFs (?BPRS?<?25%). CYP2D6 genotyping revealed intermediate metabolizer phenotypes for BD patients and an extensive metabolizer phenotype for the patient without BD. In BD patients, the ratio of drugs maintained/discontinued for TFs or ADRs was 1.75 for non-CYP2D6 versus 0.33 for CYP2D6 interacting drugs, while the proportion of ADR:TF was 0:4 versus 6:3. LESSONS:Our findings may suggest that CYP2D6 clinically relevant genotypes may be involved in the unwanted outcomes observed in RD patients with BD.
| S-EPMC6155952 | biostudies-literature
Project description:BackgroundSince 2015, pharmacists have been integrating into English general practices and more recently into primary care networks. General practice-based pharmacists provide a range of patient-facing services, such as medication reviews, management of long-term conditions and minor ailments, prescribing duties and answering queries over the telephone. Literature reports patients' satisfaction with general practice-based pharmacists' services, however, previous research captured only limited experiences. The aim of the current study was to pursue an extensive exploration of patients' experiences of pharmacists in general practice.MethodsGeneral practice-based pharmacists, working in practices in West London, Surrey and Berkshire, handed invitation packs to patients seen during consultations. Patients that wanted to take part in the study were invited to undertake a qualitative, in-depth, face-to-face, semi-structured interview within the practice with which each patient was registered. Interviews lasted from 15 min to more than 1 h and were audio-recorded. Recruitment continued until data saturation. Audio-recordings were transcribed verbatim and transcripts analysed thematically.ResultsTwenty participants were interviewed. Four themes were discerned: awareness ("I had been coming to this practice for 24 years and I didn't know that there was a pharmacist"); accessibility ("People ring for a GP [general practitioner] appointment … it's Monday and they [receptionist] tells you 'We can slot you in on Friday' … with a pharmacist on board, they can [instantly] look at you"); interactions ("I've always had a really good interaction with them [pharmacists] and they listen and they take on board what I'm trying to say"); and feedback ("It's easier [to collect feedback instantly] because I could have forgotten half of what they [pharmacists] have told me in an hour or so's time").ConclusionsFindings indicate that pharmacists' integration into general practices could improve accessibility to, and the quality of, care received. The findings will assist policy development to provide general practice-based pharmacists' services as per patients' needs.
| S-EPMC7935482 | biostudies-literature
Project description:BACKGROUND: There is little published research into the impact, on both doctor and patient, of handing over responsibility for choosing appointment length to the patient. AIM: To investigate what impact giving patients control of their appointment length has on the patient and doctor experience. DESIGN AND SETTING: A qualitative study in a single medical practice in Inverness, Scotland. METHOD: Eligible patients making a 'routine' appointment were given a choice of appointment length (5, 10, 15, or 20 minutes). After the consultation, patients were invited to take part in a focused interview. Doctors were asked to keep an audio diary and their experience was explored further in a facilitated focus group. Data were analysed using a thematic analysis approach. RESULTS: Key themes that emerged for patients included the impact of the shift in power and the impact of introducing the issue of time. For doctors, important themes that emerged were impacts on the provider, on the doctor-patient relationship, and on the consultation. CONCLUSION: Giving patients greater responsibility for choosing appointment length may improve the experience for both doctors and patients.
| S-EPMC3582977 | biostudies-other
Project description:ObjectivesTo examine patients' accounts of their use of the internet before seeing a general practitioner (GP) using thematic analysis of semistructured interviews.DesignQualitative semistructured interview study with transcripts analysed thematically.SettingPrimary care patients consulting with 10 GPs working at 7 GP practices of varying sizes and at a range of locations around London and the Southeast of England.Participants28 adult patients: 16 women and 12 men ranging in age from 18 to 75 from a range of self-defined ethnic backgrounds. Participants were selected based on instances when the patients reported having used the internet before the consultation, when patients referred to the internet in the consultation or when the physician used the internet or made reference to it during the consultation.ResultsPatients report that they can find health information online that they believe is reliable and helpful for both themselves and their GP. However, they report uncertainty about how to share internet-based findings and reluctance to disclose their efforts at researching health issues online for fear of appearing disrespectful or interfering with the flow of the consultation.ConclusionsDespite the democratisation of access to information about health due via the internet, patients continue to experience their use of the internet for health information as a sensitive and potentially problematic topic. The onus may well be on GPs to raise the likelihood (without judgement) that patients will have looked things up before consulting and invite them to talk about what they found.
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Project description:ObjectivesTo identify and describe misunderstandings between patients and doctors associated with prescribing decisions in general practice.DesignQualitative study.Setting20 general practices in the West Midlands and south east England.Participants20 general practitioners and 35 consulting patients.Main outcome measuresMisunderstandings between patients and doctors that have potential or actual adverse consequences for taking medicine.Results14 categories of misunderstanding were identified relating to patient information unknown to the doctor, doctor information unknown to the patient, conflicting information, disagreement about attribution of side effects, failure of communication about doctor's decision, and relationship factors. All the misunderstandings were associated with lack of patients' participation in the consultation in terms of the voicing of expectations and preferences or the voicing of responses to doctors' decisions and actions. They were all associated with potential or actual adverse outcomes such as non-adherence to treatment. Many were based on inaccurate guesses and assumptions. In particular doctors seemed unaware of the relevance of patients' ideas about medicines for successful prescribing.ConclusionsPatients' participation in the consultation and the adverse consequences of lack of participation are important. The authors are developing an educational intervention that builds on these findings.
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Project description:ObjectivesTo compare patients' enablement and satisfaction after teaching and non-teaching consultations. To explore patients' views about the possible impact that increased community based teaching of student doctors in their practice may have on the delivery of service and their attitudes towards direct involvement with students.DesignObservational study using validated survey instruments (patient enablement index--PEI, and consultation satisfaction questionnaire--CSQ) administered after teaching consultations and non-teaching consultations. Ten focus groups (two from each practice), comprising five with patients participating in prearranged teaching sessions and five with patients not participating in these.SettingFive general practices in west Suffolk and southern Norfolk, England, that teach student doctors on the Cambridge graduate medical course.Participants240 patients attending teaching consultations (response rate 82%, 196 patients) and 409 patients attending non-teaching consultations (response rate 72%, 294 patients) received survey instruments. Ten focus groups with a total of 34 patients participating in prearranged teaching sessions and 20 patients not participating in these.Main outcome measuresScores on the patient enablement index and consultation satisfaction questionnaire, analysed at the level of all patients, allowing for age, sex, general practitioner, and practice, and at the level of the individual general practitioner teacher. Qualitative analysis of focus group data.ResultsPatients' enablement or satisfaction was not reduced after teaching consultations compared with non-teaching consultations (mean difference in scores on the patient enablement index and consultation satisfaction questionnaire with adjustment for confounders 2.24% and 1.70%, respectively). This held true for analysis by all patients and by general practitioner teacher. Qualitative data showed that patients generally supported the teaching of student doctors in their practice. However, this support was conditional on receiving sufficient information about reasons for doctors' absence, the characteristics of students, and the nature of teaching planned. Many patients viewed their general practice as different from hospital and expected greater control over students' presence during their consultations.ConclusionsPatients' enablement and satisfaction are not impaired by students' participation in consultations. Patients generally support the teaching of student doctors in their general practice but expect to be provided with sufficient information and to have a choice about participation, so they can give informed consent. Recognising this when organising general practice based teaching is important.
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Project description:ObjectivesTo explore general practice staff, pharmacist and patient experiences with pharmacist services in Australian general practice clinics within the Pharmacists in Practice Study.DesignQualitative study.SettingTwo general practice clinics in Melbourne, Australia, in which pharmacists provided medication reviews, patient and staff education, medicines information and quality assurance services over a 6-month period.ParticipantsPatients, practice staff and pharmacists.MethodSemi-structured telephone interviews with patients, focus groups with practice staff and semi-structured interviews and periodic narrative reports with practice pharmacists. Data were analysed thematically and theoretical frameworks used to explain the findings.Results34 participants were recruited: 18 patients, 14 practice staff (9 general practitioners, 4 practice nurses, 1 practice manager) and 2 practice pharmacists. Five main themes emerged: environment; professional relationships and integration; pharmacist attributes; staff and patient benefits and logistical challenges. Participants reported that colocation and the interdisciplinary environment of general practice enabled better communication and collaboration compared to traditional community and consultant pharmacy services. Participants felt that pharmacists needed to possess certain attributes to ensure successful integration, including being personable and proactive. Attitudinal, professional and logistical barriers were identified but were able to be overcome. The findings were explained using D'Amour's structuration model of collaboration and Roger's diffusion of innovation theory.ConclusionsThis is the first qualitative study to explore the experiences of general practice staff, pharmacists and patients on their interactions within the Australian general practice environment. Participants were receptive of colocated pharmacist services, and various barriers and facilitators to integration were identified. Future research should investigate the feasibility and sustainability of general practice pharmacist roles.
| S-EPMC3773653 | biostudies-literature
Project description:IntroductionResearch suggests that general practice can play an important role in managing long COVID. However, studies investigating the perspectives of general practitioners (GPs) and patients are lacking and knowledge regarding optimal long COVID care in general practice is therefore limited.AimTo investigate GPs' and patients' perspectives on the topic of long COVID and its management in general practice.MethodsBrief questionnaires (GP n = 11, Patient n = 7) and in-depth semi-structured interviews (GP n = 10, Patient n = 7) were conducted with GPs and patients from Irish general practices during July 2022-January 2023. Interviews were conducted via telephone and audio recordings were transcribed. A phenomenological analysis involving reflexive thematic analysis and constant comparison techniques was adopted.ResultsAnalysis of interviews with GPs (male = 7, female = 3; median age = 50yrs (IQR = 39.5-56)) and patients (males = 2, female = 5; median age = 58yrs (IQR = 45-62yrs) generated four themes. These were (1) Complex presentations (2) the value of standardising care, (3) choosing the right path, and (4) supportive and collaborative doctor-patient relationships. Strong agreement was observed among GPs and patients regarding the need for holistic and integrated multidisciplinary care. Supportive and collaborative doctor-patient relationships were largely well received by GPs and patients also. GPs strongly endorsed standardising long COVID care operations.ConclusionGPs and patients indicated that structured, integrated, and collaborative care can help optimise long COVID management in general practice. GPs are advised to incorporate these elements into their long COVID care practices going forward. Future research examining stakeholder's perspectives using larger and longitudinal samples is advised to enhance the generalisability of evidence in this area.
| S-EPMC11207167 | biostudies-literature