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AbstractBackgroundObjectiveMethodsFindingsImplications\nKEY POINTSExperience-based knowing in general practice includes advanced interpretation of subjective, complex and particular phenomena in a social context. Enabling different metapositions for reflexivity may provide the accountability needed for such knowing to be recognized as evidence-based practice.To demonstrate and discuss the potential of substantive theories to enhance interpretation of complex challenges in clinical knowing in general practice.We present a fictional case to demonstrate how interdisciplinary substantive theories, with a relevant and specific match to concrete questions, can situate the clinical interaction at an accountable platform. A female patient with Parkinson’s disease consults her GP complaining that the disease is restraining her life and threatening her future. The GP has some new ideas from Bandura’s theory of self-efficacy and introduces the patient to strategies for further action.The case presents an example of how a relevant substantive theory may offer the GP: 1) a sharper focus for achievement: recognising the issues of fear and identity in chronic, progressive illness, 2) a subsequent position for individualized understanding of adequate strategies: encouraging physical and social activity in a well-known context, and 3) an invitation to consider further possibilities: finding ways to alleviate the burden of fear and progressive decline; engaging in joyful living.General practice knowledge embraces a diversity of sources with different evidence power. The transparency mediated to clinical practice when supported by relevant substantive theories may contribute to recognition of experience-based knowing as evidence-based practice.Experience-based knowing is an important capacity for interpretation of complex phenomena in general practice, but support for elaboration and analysis of such strategies is limitedInterdisciplinary substantive theories can enable reflexivity and enhance clinical practiceSubstantive theories may offer sharper focus, individualised understanding and recognition of additional possibilitiesA connection to specific theoretical ideas may augment the transparency of experience-based knowing, thus advancing attitudes for evidence-based practiceExperience-based knowing is an important capacity for interpretation of complex phenomena in general practice, but support for elaboration and analysis of such strategies is limitedInterdisciplinary substantive theories can enable reflexivity and enhance clinical practiceSubstantive theories may offer sharper focus, individualised understanding and recognition of additional possibilitiesA connection to specific theoretical ideas may augment the transparency of experience-based knowing, thus advancing attitudes for evidence-based practice [ABSTRACT FROM AUTHOR]

Background: Getting the right diagnosis is supposed to provide an explanation of a patient's health problem and inform health care decisions. As a core element of clinical reasoning, diagnosis deserves systematic and transparent analysis. Conceptual tools can make doctors become aware of and explore diagnostic knowing. Methods: We demonstrate diagnostic knowing analysed as interpretative and contextualised activity. Our analysis is based on Lonergan's theory of knowing, constituting the cognitive structures as experiencing, understanding, and judging, in a general practice case. Findings: Analysis makes the complexity of diagnostic knowing in this context more transparent, in this case concluding with four diagnostic labels: a corn, constipation, headache and atrial fibrillation. We demonstrate how a medically significant diagnosis does not necessarily evolve deductively from complaints. The opening lines from the patient give ideas of where to look for possible explanations – questions for understanding – rather than diagnostic hypotheses. Such questions emerge from the GP's experiences from meeting the patient, including imaginations and interpretations. When ideas and questions regarding diagnoses have been developed, they may be judged and subjected to reflection. Questioning may also emerge as transitory concerns, not extensively ruled out. Lonergan's theory demonstrated a strong fit with these aspects of diagnostic knowing in general practice. Implications: Analysis demonstrated systematic, transparent approaches to diagnostic knowing, relevant for clinical teaching. We argue that an interpretative understanding of diagnosis can change clinical practice, complementing hypothetico-deductive strategies by recognising additional substantial diagnostic modes and giving access to scholarly reflection. Diagnosis is a core element of clinical reasoning, deserving systematic and transparent analysis beyond hypothetico-deductive reasoning or pattern recognition Diagnostic knowing in general practice is a special instance of all human knowing with subjectivity, interpretation and reflexivity as essential elements Lonergan's theory for knowing based on experiencing, understanding, and judging allowed us to map, decode and recognise advanced acts of clinical reasoning We share our experiences of how these concepts gave us a tool for systematic analysis of the complexities taking place in the GP's office on an ordinary day [ABSTRACT FROM AUTHOR]

Background: Patients dealing with severe mental illnesses (SMI) often face suboptimal clinical outcomes and higher mortality rates due to a range of factors, including undetected physical health conditions. The provision of care for individuals with SMI is frequently disjointed, as they engage with diverse healthcare providers. Despite this fragmentation, primary care, particularly general practitioners (GPs), assumes a pivotal role in the care of SMI patients. Our study aimed to delve into the first-hand experiences of GPs in delivering somatic care to SMI patients, concentrating on the challenges they encounter and the strategies they employ to navigate these difficulties. Methods: We conducted in-depth interviews with fifteen GPs, utilizing a semi-structured interview guide, supplemented by ethnographic observations during clinical consultations in general practice. Through inductive coding, interview transcripts and observational field notes were systematically analysed using interpretative phenomenological analysis (IPA). The findings were then deliberated upon within the author group. Results: GPs revealed that managing the chronic somatic care of SMI patients posed significant challenges. These challenges encompassed the multifaceted needs of patients, their behavior tied to symptoms, a lack of care continuity, and overarching time constraints. To tackle these challenges, the GPs had devised various strategies. However, all participants underscored the critical importance of having adequate time to properly prepare for, conduct, and follow up on consultations. Conclusion: The GPs' interactions with SMI patients brought numerous challenges, although treating these patients were concurrently acknowledged as vital and fulfilling. The findings suggest that increased allocated time in general practice consultations for patients with SMI is important to support the somatic treatment requirements of this patient group. [ABSTRACT FROM AUTHOR]

Quality standards play an increasingly important role in primary care through their inscription in various technologies for improving professional practice. While 'hard' biomedical standards have been the most common and debated, current quality development initiatives increasingly seek to include standards for the 'softer' aspects of care. This article explores the consequences of both kinds of quality standards for chronic care consultations. The article presents findings from an explorative qualitative field study in Danish general practice where a standardized technology for quality development has been introduced. Data from semi-structured interviews and observations among 17 general practitioners were analysed using an iterative analytical approach, which served to identify important variations in the uses and impacts of the technology. The most pronounced impact of the technology was observed among general practitioners who strictly adhered to the procedural standards on the interactional aspects of care. Thus, when allowed to function as an overall frame for consultations, those standards supported adherence to general recommendations regarding which elements to be included in chronic disease consultations. However, at the same time, adherence to those standards was observed to narrow the focus of doctor-patient dialogues and to divert general practitioners' attention from patients' personal concerns. Similar consequences of quality standards have previously been framed as manifestations of an inherent conflict between principles of patient-centredness and formal biomedical quality standards. However, this study suggests that standards on the 'softer' aspects of care may just as well interfere with a clinical approach relying on situated and attentive interactions with patients. [ABSTRACT FROM AUTHOR]

Objective To explore how patients enact presentations of self in consultations dealing with lifestyle in general practice. Methods We conducted a qualitative observational study with thematic, cross-case analysis of video-recorded consultations inspired by discourse analysis. Results Patients presented themselves with an orientation toward responsibility in dialog about lifestyle. They described how they were taking care of themselves and doing their best. In this respect, they demonstrated their achievements as matters of honor. If one lifestyle issue was considered problematic, in some cases patients shifted attention to another, of which they were more proud. In areas where they were not doing well, some patients revealed shame for not acting responsibly. In such cases, patients spoke of themselves in terms of self-deprecation or admitted not living up to expected standards. Conclusion Negotiations of shame and honor, revolving around personal responsibility, are embedded in clinical discourse about lifestyle. Patients take a proactive role in presenting and defending the self against shame. Practice implications GPs should pay more attention to the tacit role of shame in consultations. Failure to do so could lead to distance and hostility while a strategy to acknowledge the impact of shame could help develop and strengthen the doctor–patient relationship. [ABSTRACT FROM AUTHOR]

General practitioners (GPs) treat more than 90% of common mental disorders. Their approaches to psychological interventions have been little studied and their process of understanding patients remains unexplored. This qualitative interview and observation study aimed to explore Danish GPs' approaches to emotional problems and mental disorders in 'talking therapy' and in routine consultations. Different typical approaches were identified and could be described using the concept of mentalisation. Some participants used a basic reflective approach but no well-described method. Others were satisfied with the biomedical professional identity and did not engage in patients' emotional problems. The individual participant's approach in talking therapy was mirrored in routine consultations. Training a mentalising or reflective stance might promote more uniform therapeutic approaches to patients' emotional problems. [ABSTRACT FROM AUTHOR]

Objectives. Parents of sick children frequently visit their general practitioners (GPs). The aim was to explore parents' interpretation of their child's incipient signs and symptoms when falling ill and their subsequent unsatisfactory experience with the GP in order to make suggestions for improvements in the medical encounter. Design. Semi-structured interviews. Setting and subjects. Twenty strategically selected families with a child from a birth cohort in Frederiksborg County, Denmark were interviewed. Results. Parents wanted to consult their GP at the right time, i.e. neither too early nor too late. Well-educated parents experienced a discrepancy between their knowledge about their child, the information they had sought about the illness and the consultation with the GP, when they were dismissed with phrases such as ''it will disappear'' or ''it is just a virus''. The parents went along with the GP's advice if the child only occasionally became sick. However, parents of children with recurrent illnesses seemed very frustrated. During the course of several consultations with their GP, they started to question the GP's competence as the child did not regain health. Conclusions. Parents want to be acknowledged as competent collaborators. The GP's failure to acknowledge the parents' knowledge of their child's current illness, and the parents' attempt to identify what is wrong with the child and make the child feel better before the encounter may have consequences for the GP's credibility. It is therefore recommended that parents of children with recurrent illnesses receive extra attention and information. [ABSTRACT FROM AUTHOR]

General practitioners (GPs) treat more than 90 per cent of patients with mental disease. Time restriction is often seen as a hindrance to their engagement in psychological treatment. This study aimed to explore GPs' experiences of time when delivering 'talking therapy' and to analyse how time influenced the treatment of emotional problems in routine consultations. A qualitative approach was chosen, the data consisted of interviews with 14 GPs and observation of consecutive consultations in four of the participants' practices. Analysis was made by Interpretative Phenomenological Analysis. Eleven participants delivered talking therapy, five (therapeutically minded participants) often. Three aspects of time emerged: (1) the chronological time of the schedule; (2) the inner time with another rhythm and flow of thought; (3) the longitudinal time where meeting repeatedly for short consultations promoted a trusting relationship where problems were disclosed gradually and a narrative was created. With therapeutic participants the same aspects of time could be identified in routine consultations. Stress and a heavy workload counteracted the perception of inner time. Theories of time and narrative from psychotherapeutic thinking could be applied, form links to the unconscious and the narrative time and could possibly be made more explicit in general practice. Awareness of the different time aspects is necessary for improving the treatment of mental health in primary care. Political and organizational willingness to secure the necessary working conditions is, however, equally important for optimal treatment. [ABSTRACT FROM AUTHOR]

The language of risk has many meanings, and in this article we demonstrate a discrepancy between individually perceived risk and the medical understanding of risk as understood and communicated by general practitioners (GPs). Risk is experienced and interpreted by people in a cultural context, i.e. the same objective risk can be perceived in many different ways and given a different meaning in daily life. GPs' evaluation of risk is made on the basis of our epidemiological knowledge, the medical culture of risk perception and the GP's personal experience and interpretation. The theoretical focus in the article is a synthesis of two theories: patient-centred general practice and theory based in anthropology about risk as culturally and socially constructed. We use empirical data from a qualitative study to illuminate the discussion. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the feasibility and fidelity of implementing and assessing the SOFIA coordinated care program aimed at lowering mortality and increasing quality of life in patients with severe mental illness by improving somatic health care in general practice. Design: A cluster-randomised, non-blinded controlled pilot trial. Setting: General Practice in Denmark. Intervention: The SOFIA coordinated care program comprised extended structured consultations carried out by the GP, group-based training of GPs and staff, and a handbook with information on signposting patients to relevant municipal, health, and social initiatives. Patients: Persons aged 18 years or older with a diagnosis of psychotic, bipolar, or severe depressive disorder. Main outcome measures: We collected quantitative data on the delivery, recruitment and retention rates of practices and patients, and response rates of questionnaires MMQ and EQ-5D-5 L. Results: From November 2020 to March 2021, nine practices were enrolled and assigned in a 2:1 ratio to the intervention group (n = 6) or control group (n = 3). Intervention group practices included 64 patients and Control practices included 23. The extended consultations were delivered with a high level of fidelity in the general practices; however, thresholds for collecting outcome measures, and recruitment of practices and patients were not reached. Conclusion: Our findings suggest that delivering the coordinated care program in a fully powered trial in primary care is likely feasible. However, the recruitment methodology requires improvement to ensure sufficient recruitment and minimize selective inclusion. Trial registration: The date of pilot trial protocol registration was 05/11/2020, and the registration number is NCT04618250. [ABSTRACT FROM AUTHOR]

Qualitative methodology is gaining increasing attention and esteem in medical research, with general practice research taking a lead. With these methods, human and social interaction and meaning can be explored and shared by systematic interpretation of text from talk, observation or video. Qualitative studies are often included in Ph.D. theses from general practice in Scandinavia. Still, the Ph.D. programs across nations and institutions offer only limited training in qualitative methods. In this opinion article, we draw upon our observations and experiences, unpacking and reflecting upon values and challenges at stake when qualitative studies are included in Ph.D. theses. Hypotheses to explain these observations are presented, followed by suggestions for standards of evaluation and improvement of Ph.D. programs. The authors conclude that multimethod Ph.D. theses should be encouraged in general practice research, in order to offer future researchers an appropriate toolbox. [ABSTRACT FROM AUTHOR]

Objective:Little is known about how strategies of retaining patients are acted out by general practitioners (GPs) in the clinical encounter. With this study, we apply Grimens’ (2009) analytical connection between trust and power to explore how trust and power appear in preventive health checks from the GPs’ perspectives, and in what way trust and power affect and/or challenge strategies towards retaining patients without formal education. Design:Data in this study were obtained through semi-structured interviews with GPs participating in an intervention project, as well as observations of clinical encounters. Results:From the empirical data, we identified three dimensions of respect: respect for the patient’s autonomy, respect for professional authority and respect as a mutual exchange. A balance of respect influenced trust in the relationship between GP and patients and the transfer of power in the encounter. The GPs articulated that a balance was needed in preventive health checks in order to establish trust and thus retain the patient in the clinic. One way this balance of respect was carried out was with the use of humour. Conclusions:To retain patients without formal education in the clinical encounter, the GPs balanced trust and power executed through three dimensions of respect. In this study, retaining patients was equivalent to maintaining a trusting relationship. A strategic use of the three dimensions of respect was applied to balance trust and power and thus build or maintain a trusting relationship with patients.KEY POINTS  Little is known about how strategies for retaining patients are acted out by GPs in preventive health checks. •  Retaining patients requires a balance of trust and power, which is executed through three dimensions of respect by the GPs. •  Challenges of recruiting and retaining patients in public health initiatives might be associated with the balance of respect. [ABSTRACT FROM PUBLISHER]

Background: Many elderly people wish to die at home but end up dying at the hospital. If the patient wishes to die at home, palliative care provided by General Practitioners (GPs) may increase the chance of dying at home, however, there is a lack of knowledge on how GPs should provide palliative care. We aimed to identify roles, tasks and approaches of GPs enabling palliative care, by exploring the experiences of GPs, other healthcare professionals, patients, and relatives through a systematic review of the qualitative literature. Methods: We searched PubMed, EMBASE, PsycINFO, Web of Science, and CINAHL in March 2022. Thematic analysis was used for synthesizing the results. Results: Four thousand five hundred sixty three unique records were retrieved, and 12 studies were included for review. Of these, ten were interview or focus group studies and two were survey studies with additional open-ended questions. Only qualitative findings from the studies were used in synthesizing the results. Thematic analysis produced four main themes describing the roles, tasks and approaches of GPs enabling palliative care to increase the chance for patients to die at home. GPs can support patients in the final phases of life by applying a holistic, patient-centred, and proactive approach to palliative care and by having sufficient education and training. Furthermore, the palliative care consultation should include symptom management, handling psychosocial and spiritual needs, maintaining a fragile balance, and proper communication with the patient. Lastly, GPs must address several palliative care elements surrounding the consultation including initiating the palliative care, being available, being the team coordinator/collaborator, providing continuous care and having sufficient knowledge about the patient. Conclusions: The roles, tasks and approaches of the GPs enabling palliative care include being aware of elements in the palliative care consultation and elements surrounding the consultation and by having sufficient education and training and a broad, proactive, and patient-centred approach. [ABSTRACT FROM AUTHOR]

Objective.The aim of this study is to analyse the interaction between patients and GPs in preventive consultations with an emphasis on how patients answer GPs’ questions about lifestyle, and the conditions these answers impose on the process of establishing agreement about lifestyle as a problem or not.Design.Six general practitioners (GPs) video-recorded 15 annual preventive consultations. From these, 32 excerpts of discussions about lifestyle were analysed using conversation analysis (CA).Results.GPs used an interview format to assess risk in patients’ lifestyles. In some cases patients adhered to this format and answered the GPs’ questions, but in many cases patients gave what we have termed “anticipatory answers”. These answers indicate that the patients anticipate a response from their GPs that would highlight problems with their lifestyle. Typically, in an anticipatory answer, patients bypass the interview format to give their own evaluation of their lifestyle and GPs accept this evaluation. In cases of “no-problem” answers from patients, GPs usually encouraged patients by adding support for current habits.Conclusion.Patients anticipated that GPs might assess their lifestyles as problematic and they incorporated this possibility into their responses. They thereby controlled the definition of their lifestyle as a problem or not. GPs generally did not use the information provided in these answers as a resource for further discussion, but rather relied on standard interview procedures. Staying within the patients’ frame of reference and using the patients’ anticipatory answers might provide GPs with a better point of departure for discussion regarding lifestyle. [ABSTRACT FROM PUBLISHER]

Objectives. Some parents with a sick infant contact a doctor, while others do not. The reasons underlying such parental decisions have not been thoroughly studied. The purpose of this study was to explore how the actual symptoms in the infant were associated with parent-rated illness, illness severity, and the probability of the parents contacting a doctor. Design. A retrospective questionnaire and a prospective diary study covering 14 months of the participating infants'' lives. Setting and subjects. The 194 participating infants were followed for three months prospectively from the age of 11 to 14 months using diary cards, and retrospectively from birth until the age of 11 months by a questionnaire. Results. During the three months of the diary card prospective follow-up, the infants had symptoms on average every second day, and the vast majority (92%) had 10 or more days with at least one symptom; 38% of the infants were reported to have had five or more symptoms for more than five days. Fever, earache, and vomiting were the symptoms most likely to cause parents to rate their infant as ill. Earache was the symptom that triggered doctor contact most immediately. The parent-rated illness severity was strongly related to the tendency to contact a doctor. However, this association was markedly weaker when adjustment was made for the infant not eating normally, having a cough, or running a fever. Conclusion. Specific symptoms such as fever, earache, and vomiting were strongly associated with the probability of parents rating the infant as ill. An earache would cause the parents to contact a doctor. Fever and vomiting were other symptoms triggering doctor contacts. First, these symptoms could cause the parents to want a doctor's expert evaluation of the infant's illness; second, the parents could expect medication to be necessary; or third, it could just be difficult for the parents to handle the ill infant. [ABSTRACT FROM AUTHOR]

Objective . To explore situations in which parents with an ill child consult a physician and to identify trigger factors for consultation. Design and settings . Qualitative interviews with parents of young children. Parents were asked to describe the situation in which the decision to contact the physician was made. Subjects . A total of 20 families selected from a birth cohort from Frederiksborg County. The cohort numbered 194 of 389 children born between 1 and 28 February 2001. The cohort was followed prospectively from the age of 9 to 12 months by diary (January–April), and retrospectively from birth to the age of 9 months by questionnaire. Families were chosen on the basis of information provided in a questionnaire, diary illness pattern and a telephone conversation. Results . Nine trigger factors associated with physician contacts were identified. Parents’ answers demonstrated how their feelings and logical reasoning while caring for an ill child led them to consult the physician. The main reasons for consultation were children's protracted or aggravated symptoms. Parents initially tried to handle the situation but when unsuccessful information and advice was sought by consulting a physician. Conclusions . Parents consult the physician when they feel overtaxed, afraid, or inadequately prepared to care for their ill child. They considered seriously whether to consult a physician or not. [ABSTRACT FROM AUTHOR]

Background: There are few areas of health care where sufficient research-based evidence exists and primary health care is no exception. In the absence of such evidence, the development of assisted support must be based on the opinions and experience of professionals with knowledge of the relevant field. The purpose of this research project is to explore how the nominal group technique can be used to establish consensus by analysing how it supported the development of structured, knowledge-based, electronic health records for preventive child health examinations in Danish general practice. Methods: We convened an expert panel of five general practitioners with a special interest in the preventive child health examinations. We introduced the panel to the nominal group technique, a well-established, structured, multistep, facilitated, group meeting technique used to generate consensus. The panel used the technique to agree on the key clinical and socioeconomic themes to include in new electronic records for the seven preventive child health examinations in Denmark. The panel met three times over a four-month period between 2013 and 2014 and their meetings lasted between two-and-a-half and five hours. Results: 1) The structured and stepwise process of the nominal group technique supported our expert panel's focus as well as their equal opportunities to speak. 2) The method's flexibility enabled participants to work as a group and in pairs to discuss and refine thematic classifications. 3) Serial meetings supported continual evaluation, critical reflection, and knowledge searches, enabling our panel to produce a template that could be adapted for all seven preventive child health examinations. Conclusion: The nominal group technique proved to be a useful method for reaching consensus by identifying key quality markers for use in daily clinical practice. Our study focused on the development of content and a layout for systematic, knowledge-based, electronic health records. We recommend the method as a suitable working tool for dealing with complex questions in general practice or similar settings, and we present and discuss modifications to the original model. [ABSTRACT FROM AUTHOR]

Background: Accreditation is used increasingly in health systems worldwide. However, there is a lack of evidence on the effects of accreditation, particularly in general practice. In 2016 a mandatory accreditation scheme was initiated in Denmark, and during a 3-year period all practices, as default, should undergo accreditation according to the Danish Healthcare Quality Program. The aim of this study is primarily to evaluate the effects of a mandatory accreditation scheme.Methods/design: The study is conducted as a cluster-randomized controlled trial among 1252 practices (clusters) with 2211 general practitioners in Denmark. Practices allocated to accreditation in 2016 serve as the intervention group, and practices allocated to accreditation in 2018 serve as controls. The selected outcomes should meet the following criteria: (1) a high degree of clinical relevance; (2) the possibility to assess changes due to accreditation; (3) availability of data from registers with no self-reporting data. The primary outcome is the number of prescribed drugs in patients older than 65 years. Secondary outcomes are changes in outcomes related to other perspectives of safe medication, good clinical practice and mortality. All outcomes relate to quality indicators included in the Danish Healthcare Quality Program, which is based on general principles for accreditation.Discussion: The consequences of accreditation and standard-setting processes are generally under-researched, particularly in general practice. This is the largest study in general practice with a randomized implementation approach to evaluate the clinical effects of a nation-wide mandatory accreditation scheme in general practice.Trial Registration: ClinicalTrials.gov, NCT02762240 . Registered on 24 May 2016. [ABSTRACT FROM AUTHOR]

Objective is to explore how multimorbidity is defined in the scientific literature, with a focus on the roles of diseases, risk factors, and symptoms in the definitions. Design: Systematic review. Methods: MEDLINE (PubMed), Embase, and The Cochrane Library were searched for relevant publications up until October 2013. One author extracted the information. Ambiguities were resolved, and consensus reached with one co-author. Outcome measures were: cut-off point for the number of conditions included in the definitions of multimorbidity; setting; data sources; number, kind, duration, and severity of diagnoses, risk factors, and symptoms. We reviewed 163 articles. In 61 articles (37%), the cut-off point for multimorbidity was two or more conditions (diseases, risk factors, or symptoms). The most frequently used setting was the general population (68 articles, 42%), and primary care (41 articles, 25%). Sources of data were primarily self-reports (56 articles, 42%). Out of the 163 articles selected, 115 had individually constructed multimorbidity definitions, and in these articles diseases occurred in all definitions, with diabetes as the most frequent. Risk factors occurred in 98 (85%) and symptoms in 71 (62%) of the definitions. The severity of conditions was used in 26 (23%) of the definitions, but in different ways. The definition of multimorbidity is heterogeneous and risk factors are more often included than symptoms. The severity of conditions is seldom included. Since the number of people living with multimorbidity is increasing there is a need to develop a concept of multimorbidity that is more useful in daily clinical work.Key pointsThe increasing number of multimorbidity patients challenges the healthcare system. The concept of multimorbidity needs further discussion in order to be implemented in daily clinical practice.Many definitions of multimorbidity exist and most often a cut-off point of two or more is applied to a range of 4–147 different conditions.Diseases are included in all definitions of multimorbidity.Risk factors are often included in existing definitions, whereas symptoms and the severity of the conditions are less frequently included. [ABSTRACT FROM PUBLISHER]

Objective. To explore views and attitudes among general practitioners (GPs) and researchers in the field of general practice towards problems and challenges related to treatment of patients with multimorbidity. Setting. A workshop entitled Patients with multimorbidity in general practice held during the Nordic Congress of General Practice in Tampere, Finland, 2013. Subjects. A total of 180 GPs and researchers. Design. Data for this summary report originate from audio-recorded, transcribed verbatim plenary discussions as well as 76 short questionnaires answered by attendees during the workshop. The data were analysed using framework analysis. Results. (i) Complex care pathways and clinical guidelines developed for single diseases were identified as very challenging when handling patients with multimorbidity; (ii) insufficient cooperation between the professionals involved in the care of multimorbid patients underlined the GPs' impression of a fragmented health care system; (iii) GPs found it challenging to establish a good dialogue and prioritize problems with patients within the timeframe of a normal consultation; (iv) the future role of the GP was discussed in relation to diminishing health inequality, and current payment systems were criticized for not matching the treatment patterns of patients with multimorbidity. Conclusion. The participants supported the development of a future research strategy to improve the treatment of patients with multimorbidity. Four main areas were identified, which need to be investigated further to improve care for this steadily growing patient group. [ABSTRACT FROM AUTHOR]

Background: Patients with severe mental illness (SMI) have shorter life expectancy than people without SMI, mainly due to overmortality from physical diseases. They are treated by professionals in three different health and social care sectors with sparse collaboration between them, hampering coherent treatment. Previous studies have shown difficulties involved in establishing such collaboration. As the preparatory phase of an intervention to improve physical health of people with SMI and increase collaboration across sector borders, we explored different actors' experiences of barriers for collaboration. Method: We collected qualitative data from patients, professionals in general practice, psychiatry and social psychiatry involved in the treatment of these patients. Data consisted of notes from meetings and observations, interviews, focus groups and workshops. Analysis was by Interpretative Phenomenological Analysis. Results: The study revealed many obstacles to collaboration and coherent treatment, including the consultation structures in general practice, sectors being subject to different legislation, and incompatible IT systems. Professionals in general practice and social psychiatry felt that they were left with the responsibility for actions taken by hospital psychiatry without opportunity to discuss their concerns with psychiatrists. There were also cultural differences between health care and social psychiatry, expressed in ideology and language. Social psychiatry had an existential approach to recovery, whereas the views of health professionals were linked to symptom control and based on outcomes. Meanwhile, patients were left in limbo between these separate ideologies with no leadership in place to promote dialogue and integrate treatments between the sectors. Conclusion: Many obstacles to integrated trans-sectoral treatment of patients with SMI seem related to a lack of an overriding leadership and organizational support to establish collaboration and remove barriers related to legislation and IT. However, professional and ideological barriers also contribute. Psychiatry does not consider general practice to be part of the treatment team although general practitioners are left with responsibility for decisions taken in psychiatry; and different ideologies and treatment principles in psychiatry and municipal social psychiatry hamper the dialogue between them. There is a need to rethink the organization to avoid that the three sectors live autonomous lives with different cultures and lack of collaboration. [ABSTRACT FROM AUTHOR]