565129 research-article2015
SJP0010.1177/1403494814565129When general practitioners talk about alcoholT.G. Lid et al.
Scandinavian Journal of Public Health, 2015; 43: 153–158
Original Article
When general practitioners talk about Alcohol: Exploring facilitating and hampering factors for pragmatic case finding
Torgeir Gilje lid1,2,3, Sverre Nesvåg3 & Eivind Meland1 1Department
of Global Public Health and Primary Care, University of Bergen, Norway, 2Research Unit for General Practice, Uni health, Uni Research, Bergen, Norway, and 3Centre for Alcohol and Drug Research, Stavanger University Hospital, Norway
Abstract Background: The aim was to explore individual and system factors facilitating or hampering pragmatic case finding, an identification strategy based on clinical signs and targeted screening. Study design: Two focus groups with general practitioners were interviewed twice, in the context of a four-session seminar on alcohol and complex drug problems, and an additional focus group interview with general practitioners not attending the seminar. Interviews focused mainly on conditions for talking about alcohol, views on collaboration with colleagues, how they deal with complex issues, and strategies for learning and quality improvement. Results: The participants presented many deliberate strategies for quality improvement and learning together, but there was a tendency to avoid discussing complex case stories or potentially controversial topics with colleagues. Possible barriers to change were presented. The majority of their stories on talking about alcohol coincided well with the concept of pragmatic case finding. The duality between shame and normality, time constraints and a need for structure were the most important individual barriers to an open and respectful conversation about alcohol with patients. Conclusions: Our study supports pragmatic case finding as a relevant and viable strategy for talking about alcohol in general practice, and as an alternative to screening and brief intervention. Quality improvement in practice is strengthened when it is adapted to the clinical setting, and builds on and stimulates the GPs’ and staff ’s own strategies for learning and quality work. Key Words: Alcohol-related health problems, general practice, focus groups, quality improvement, communities of practice
Introduction The link between alcohol consumption and numerous health problems is strong [1]. General practitioners (GPs) are well placed for dealing with alcohol-related health problems, as clinicians and as gatekeepers. Screening and brief intervention (SBI), the recommended approach for identifying and treating risky or harmful drinking [2], is still not a regularly used strategy in general practice, though GPs accept responsibility for dealing with alcohol-related health problems [3,4]. The effect and feasibility of SBI are questionable [5,6]. A Cochrane review concluded that SBI is
effective [7], but a recent review of reviews found that it was primarily effective for middle-aged men with risky or harmful drinking, but without established addiction [8]. Recent intervention studies to improve GPs’ strategies for alcohol and other life-style factors have been counterproductive or without effect [9,10]. The authors of a review comparing SBI with clinical signs as identification strategy concluded that a semi-systematic method based on awareness of specific clinical signs, combined with targeted screening, is promising [11]. This is in line with our concept of pragmatic case finding [12]. Pragmatic case finding
Correspondence: Torgeir Gilje Lid, Department of Global Public Health and Primary Care, University of Bergen, Norway Giljagarden 12, N-4335 Dirdal, Norway. E-mail: [email protected] (Accepted 27 November 2014) © 2015 the Nordic Societies of Public Health DOI: 10.1177/1403494814565129
154 T.G. Lid et al. Table I. Sample distribution. Category
Variables
N
Gender Age (years) Practice size Time in this practice
Female Male 25–29 30–39 40–49 50–59 60–69 5 GPs ≤5 years >10 years
11 8 0 6 4 7 2 10 9 8 11
includes clinical situations, where the possible relevance of alcohol for the patient’s health problems or worries is explored, and routine encounters as pregnancy controls and health check-ups, where simple screening measures are called for. The study was approved by The Regional Committee for Medical Research Ethics. Two of the authors are GPs (TGL and EM), and one author is a social anthropologist (SN). The aim of the study is to explore individual and system factors facilitating or hampering pragmatic case finding as a strategy for talking about alcohol in general practice. Design, methods and material A focus group study with two groups of 14 GPs attending a four-session interactive seminar on talking about alcohol and dealing with complex drug problems was conducted. An additional focus group interview with a different group of five GPs was held after preliminary analysis (Table I). The seminar was the study context, not the focus of the study. We approached nine practices, chosen for maximum variety in size (one to seven GPs) and stability (high turnover to high stability), aiming to recruit as many as possible from each practice to the seminar. Six practices accepted the invitation, but two of them did not manage to find the time to participate. All partners and substitutes participated from the remaining four practices. None of the GPs had any special interest in alcohol or drug problems. The seminar was held in two localities, with focus group interviews performed initially on the first and third days. All sessions were held from May to August 2013, with a minimum time span of at least 2 weeks between sessions, and scheduled to the needs of the participants. The sessions were 135–180 minutes long. The first interview dealt primarily with why and how they talk about alcohol, and how they understand their group practice. The second interview dealt with feedback on the seminar, conditions for talking about
alcohol, and how this relates to running a practice with colleagues. These interviews were conducted by SN. Based on preliminary analysis, two recently established practices were approached after the seminar. We wanted to recruit younger GPs who had been involved in planning their group practice. All three GPs in one practice and two of the four responsible in the other practice participated. This interview focused on system factors relevant for quality in clinical work, especially alcohol and drug-related issues, and for dealing with potential conflict and dilemmas. TGL led this interview. All interviews were audio-recorded and transcribed verbatim. Analysis was conducted as collaborative negotiations, applying systematic text condensation [13]. After acquiring an overall impression, we identified meaning units representing different aspects of the participants’ experiences of talking about alcohol and working together, dealing with complex issues. The contents of the coded groups were condensed to generalized descriptions and concepts.We focused on resistance, tension, and dilemma in the material. Results The participants shared experiences on talking about alcohol, and on system factors influencing this clinical work, collaboration, and change processes. Possible barriers to change, both in the clinical work and in their collegial strategies, were presented. They also shared reflections and experiences rarely addressed in their everyday work. When they elaborated on system factors facilitating or hampering sustainable and helpful relations with these patients, a tension between cooperation and individual freedom was revealed. The findings are elaborated below. Quotations are assigned pseudonyms. Negotiating shared responsibility and autonomy The participants talked about how they negotiated and agreed upon common procedures in their practices. It was considered important to have a close and trusting relationship, and a mutual understanding about their ambitions for the practice. Younger participants described how previous experiences from practices with little shared understanding and collaboration made them determined to achieve this in their present practice. Some had frequent meetings for learning and professional discussions. The smaller practices had interns in their clinic, and felt it positively affected their own learning. The bigger practices had a wider variety of deliberate strategies for learning and quality improvement, and some applied
When general practitioners talk about alcohol 155 strict guidelines in specific areas, e.g. for the prescription of certified drugs. They felt that strict rules and boundaries were valuable for vulnerable or demanding patients, though recognizing that patients also could feel rejected. A younger GP commented: Everyone has an involvement in what they do, and a commitment. … And we said so in the interview with our new colleagues that we expect presentations [of relevant topics], and involvement. … We want to be curious. And if I’m curious about something, then be sure that I will manage to involve the others, in a way. And I’ve missed that. Jane
However, some realized that they were more individualistic than they wanted to be, and creating something together could be a constant struggle. Sometimes they felt alone when their own views collided with the views of the group. In spite of their aspirations, complex cases were not discussed in their meetings, and advice was seldom sought. They missed supervision and more involvement from colleagues when something was challenging. Participants from the recently established practices reported very careful strategies to select new colleagues, to prevent future conflict. Others gave examples of how they avoided complex or difficult topics with colleagues. One GP told about how they still, after 10 years of weekly meetings, had not properly addressed the prescription of addictive drugs: well yes, it might turn out that we are more individualistic than we like to admit … And that’s probably the reason that we, that it wasn’t the first topic we addressed. We feel that we all have something to hide. And perhaps [we] know that we need to correct this in one way or another. Kevin
The system factors presented above may facilitate or hamper the GP’s own learning and change process. Below we will present factors specifically concerning the clinical interaction with the patient. The majority of their stories on talking about alcohol coincided well with the concept of pragmatic case finding, but there were also stories on various obstacles to open and respectful conversations about alcohol. Between normality and shame Many participants stated that it could be quite easy to ask about alcohol. They explained this by the fact that alcohol is increasingly integrated in normal life. It was easier to remember to ask when they focused on relevance for the specific situation. The patients were often more willing to disclose information than anticipated, men more so than women. An experienced GP said:
many things are somewhat taboo and difficult to talk about, but I think it’s more with us than with the patient. And therefore I’ve recently started asking just as naturally as I ask whether they smoke. ‘I assume that you drink?’ … Sometimes I forget it, but I’ve become much better. Thomas
Several participants stated that alcohol is often invisible, unlike long time smoking. It was pointed out that a high consumption in higher social circles was often less visible. They told about patients evading the topic, where they did not address the patient’s avoidance, attributing this to the fear of alienating the patient. Cultural differences were addressed by several, and they were astonished by the drinking patterns they could hear about. Normality was judged in comparison with personal experiences with alcohol, for some with a tendency to see one’s own consumption as solely based on taste. This was challenged: sometimes [you drink] not to take yourself so serious. And sometimes it’s to relax when you come home from work … and sometimes it’s because it tastes good together with something to eat. It has many functions, even for you, yes, actually, I would say so. And I think it’s somewhat dangerous to think that the way [you] think [about drinking] is essentially different from those having a problem. James
The constraints and possibilities of time Many of the participants gave examples of time as a positive factor, as when planning in advance for a lengthier consultation, or continuing talking in the next consultation. Several stated that if their efforts were futile, they could raise the question again next year. Multiple consultations might be required just to reach a mutual understanding that alcohol was important. Many saw their dealing with a patient’s other health problems as vital for building trust and confidence. A seasoned GP said: and I often see, when I take an overview … . Then I count a shockingly high number [of consultations]. There has been many stages were we’ve built a delicate construction together. Richard
Time is also a challenge. Not asking about alcohol when being behind schedule was common. Sometimes they did not ask because the patient had several other problems that needed attention. It was also pointed out that you have to know that you can wrap it up again, too. One senior GP pointed out: and we have a problem with the time factor … . We have to get him through. Or we may choose to [think] that we
156 T.G. Lid et al. see there is a problem here beyond what he came for. We may sneak behind and take some blood tests and say “and then you come for a follow-up in a couple of weeks, and then we’ll go through the blood tests and talk some more”. But he says “couldn’t you just text me the results.” George
Presenting an opportunity for change, when relevant Many participants reported specific clinical problems where pragmatic case finding is relevant, such as overweight, medications, gastric symptoms, hypertension, and repeated sick leaves. They gave diverse examples of relevant routine situations, such as pregnancy controls and health check-ups. They also told about situations without a clear-cut medical problem, but where a gut feeling inspired them to think about alcohol. One GP explained: it’s something you don’t quite grasp … so, it becomes inexplicable for the head. Then you have to feel it in your stomach. And then you have a gut feeling. Lynn
In the second focus group interview, held after they were taught about pragmatic case finding, a few participants also challenged the lack of structure. They wanted more predefined strategies, and reassurance that it was worthwhile. A senior GP said: if the plan is that you see the patient every fortnight and ask how it’s going. If that actually is a good enough formula and it actually works, then I would be superhappy. But I might consider it a tiny bit meaningless if I didn’t have anything proper. Something I could refer to. But if you had told me that this actually works, so and so percent better, then I would be happy. Linda
with varying age, gender, size, experience with and stability in group practices. This strengthens the external validity of our findings [13]. A possible weakness is that all participants were interviewed together with their colleagues, perhaps holding back on vulnerable topics. However, the participants discussed several difficult topics and also disagreed during the interviews. Reflections together with colleagues brought up important common topics and stimulated group dynamics promoting openness and transparence. Practices with a high degree of tension and unsolved conflicts would probably not agree to take part in a study based on and exploring group dynamics. Two focus group interviews with each group in the seminar enabled us to explore their experiences with and reflections on the process, and to follow up on previously discussed topics [15]. The highly interactive seminar was inspired by self-determination theory and motivational interviewing, and the participants could influence both scheduling and content [16,17]. We aimed at recruiting practices, not the GPs individually, using situated learning and communities of practice (CoP) as a frame of reference [18,19]. A CoP is defined as a group of people sharing a concern or a passion for something they do, and learning how to do it better as they interact regularly [18]. CoP has recently gained interest in the healthcare sector, both as a study context and as a means to improve clinical practice [20]. Preliminary analyses revealed a wider spectrum of deliberate common strategies than expected, and the additional focus group interview was performed to further explore these system factors.We chose younger GPs from recently started group practices, as they had created a group practice from scratch. In addition, they were not influenced by the study context.
Discussion The participants in this study elaborated on many factors, both individual and system related, that can facilitate or hamper pragmatic case finding and its implementation. They also gave numerous examples of how they talk about alcohol, corresponding well with pragmatic case finding, strengthening the assumption that this may be a valuable strategy. Below we will discuss strengths and limitations of the study design and the possible impact of our findings. Sample and preconceptions We have chosen a focus group design as this is well suited for the study of experiences and attitudes, and the interactions within the groups help to unveil cultural norms and values [14]. Our sample is diverse,
Conditions for increasing GPs’ awareness of alcohol There is an increasing body of research questioning the effect of and the validity of both the screening and the intervention of SBI [6,9,10,21]. We know that identification has an effect, but we know little more. There is reason to believe that some patients have an increased vulnerability, and thus addressing alcohol in diverse clinical situations is important [22]. The patients may also more readily accept that alcohol is relevant [23]. In this study we have explored conditions for increasing GPs’ awareness of alcohol as a relevant factor in many health problems and clinical situations, based on pragmatic case finding, first described by Lid and Malterud [12]. Pragmatic case finding
When general practitioners talk about alcohol 157 combines a focus on the relevance of alcohol in a wide variety of clinical situations, and simple screening measures in routine encounters. Most of the participants’ stories on alcohol were in line with pragmatic case finding. Hence, increasing GPs’ knowledge on the multitude of clinical situations where alcohol can be relevant, both causally and as a complicating factor, may be an easily adaptable strategy to increase identification of risky or harmful drinking [11]. We have focused on tension and dilemma, to explore factors hampering the implementation of pragmatic case finding, and to avoid bias and improper confirmations. This has also been aided by the different perspectives of the authors. One significant finding was the tendency to sometimes avoid potential conflict or vulnerable issues, both when the patient evades questions about alcohol and when difficult topics are not addressed among their colleagues. Not asking when inclined to ask can be understood as “mindful prioritizing” [24], but may also be a strategy to avoid awkwardness or failure. Addressing this tendency is necessary to increase relatedness and competence, both with patients and with colleagues. Lack of consideration or intentionally trying to evoke a response might also be the case [25]. The balance between necessary interventions and respect for the “nearness zone” for patients and colleagues alike may be difficult to strike [26]. The tendency not to discuss the most challenging case stories with colleagues hints to a feeling of shame related to incompetence, but it might also hamper the development of competence. The practices, especially the bigger ones, facilitate learning and support among colleagues, but they do not seem to utilize this to address complex patient cases or their own collaboration. But the fact that this was addressed in the group interviews illustrates the potential for developing these processes further. Alcohol interventions are complex interventions, depending on the GP’s values, knowledge, and competencies, as well as on the present situation and the work climate [27]. All medical conversations, with both patients and colleagues, are uncertain and open to multiple interpretations and outcomes [28]. Normality is questionable, and insight in one’s own attitudes and values may be blurred [29]. This is particularly challenging when alcohol is in question, as our informants show. Many clinical situations call for open ended dialogue on difficult and vulnerable topics for both parties. Open and frank interactions are needed both with patients and colleagues. Preliminary analysis of the first interviews gave richer results in line with CoP than expected. In the additional focus group interview we aimed to explore
experiences and expectations that had guided their planning process. These informants gave more elaborated examples of common strategies for clinical work and for learning. CoP is a promising perspective on change processes and quality in general practice, but challenging to evaluate [20]. Our study adds support to CoP as a viable concept for implementation research and the study of change processes. A group practice is not necessarily a CoP, but with the amount of common strategies for quality and support described by the participants in this study, they are clearly CoPs [18]. This does not imply absence of tension and conflict, but a culture that facilitates collaboration, learning, and shared understanding, vital when dealing with complexity and dilemma [30]. In this study we have not included the rest of the staff, and we advocate that future research should also include staff and collaborators, when relevant. Implications Our study supports pragmatic case finding as a relevant and viable strategy for talking about alcohol in general practice, as an alternative to SBI. Quality improvement in practice is strengthened when it is adapted to the clinical setting, and builds on and stimulates the GPs’ and staff’s own strategies for learning and quality work. Pragmatic case finding warrants testing in randomized controlled trials in everyday practice. Conflict of interest We are aware of no potential, perceived, or real conflicts of interest for each author. Funding The study was funded by Fund for research in General Practice, Norwegian Medical Association and Alcohol and Drug Research Western Norway. References [1] Norstrom T and Ramstedt M. Mortality and population drinking: A review of the literature. Drug Alcohol Rev 2005;24:537–47. [2] Pilling S, Yesufu-Udechuku A, Taylor C and Drummond C. Diagnosis, assessment, and management of harmful drinking and alcohol dependence: Summary of NICE guidance. BMJ 2011;342:d700. [3] Holmqvist M, Bendtsen P, Spak F, Rommelsjo A, Geirsson M and Nilsen P. Asking patients about their drinking. A national survey among primary health care physicians and nurses in Sweden. Addict Behav 2008;33:301–14. [4] Nygaard P, Paschall MJ, Aasland OG and Lund KE. Use and barriers to use of screening and brief interventions for alcohol problems among Norwegian general practitioners. Alcohol Alcohol 2010;45:207–12. [5] Beich A, Thorsen T and Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general
158 T.G. Lid et al. practice: Systematic review and meta-analysis. BMJ 2003;327: 536–42. [6] Kaner E, Bland M, Cassidy P, et al. Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): Pragmatic cluster randomised controlled trial. BMJ 2013;346:e8501. [7] Kaner EF, Dickinson HO, Beyer F, et al. The effectiveness of brief alcohol interventions in primary care settings: A systematic review. Drug Alcohol Rev 2009;28:301–23. [8] O’Donnell A, Anderson P, Newbury-Birch D, et al. The impact of brief alcohol interventions in primary healthcare: A systematic review of reviews. Alcohol Alcohol 2014;49:66–78. [9] van Beurden I, Anderson P, Akkermans RP, et al. Involvement of general practitioners in managing alcohol problems: A randomized controlled trial of a tailored improvement programme. Addiction 2012;107:1601–11. [10] Butler CC, Simpson SA, Hood K, et al. Training practitioners to deliver opportunistic multiple behaviour change counselling in primary care: A cluster randomised trial. BMJ 2013;346:f1191. [11] Reinholdz HK, Bendtsen P and Spak F. Different methods of early identification of risky drinking: A review of clinical signs. Alcohol Alcohol 2011;46:283–91. [12] Lid TG and Malterud K. General practitioners’ strategies to identify alcohol problems: A focus group study. Scand J Prim Health Care 2012;30:64–9. [13] Malterud K. Qualitative research: Standards, challenges, and guidelines. Lancet 2001;358:483–8. [14] Miller WL and Crabtree BF. Doing Qualitative Research. Thousand Oaks, CA: Sage, 1999. [15] Hummelvoll JK. The multistage focus group interview. Norsk Tidsskrift for Sykepleieforskning 2008;10:3–14. [16] Vansteenkiste M and Sheldon KM. There’s nothing more practical than a good theory: Integrating motivational interviewing and self-determination theory. Br J Clin Psychol 2006;45:63–82. [17] Lundahl B, Moleni T, Burke BL, et al. Motivational interviewing in medical care settings: A systematic review and meta-analysis of randomized controlled trials. Patient Educ Couns 2013;93:57–68.
[18] Wenger E. Communities of Practice. Learning, Meaning and Identity. Cambridge: Cambridge University Press, 1998. [19] Lave J and Wenger E. Situated Learning. Legitimate Peripheral Participation. Cambridge: Cambridge University Press, 1991. [20] Ranmuthugala G, Plumb JJ, Cunningham FC, et al. How and why are communities of practice established in the healthcare sector? A systematic review of the literature. BMC Health Serv Res 2011;11:273. [21] Gaume J, McCambridge J, Bertholet N, et al. Mechanisms of action of brief alcohol interventions remain largely unknown – A narrative review. Front Psychiatry 2014;5:108. [22] Hallgren M, Ahlin J, Forsell Y, et al. Increased screening of alcohol habits among patients with depression is needed. Scand J Public Health 2014;42:658–659. [23] Nilsen P, Bendtsen P, McCambridge J, et al. When is it appropriate to address patients’ alcohol consumption in health care-national survey of views of the general population in Sweden. Addict Behav 2012;37:1211–6. [24] Moriarty HJ, Stubbe MH, Chen L, T, et al. Challenges to alcohol and other drug discussions in the general practice consultation. Fam Pract 2012;29:213–22. [25] Abildsnes E, Walseth LT, Flottorp SA, et al. Lifestyle consultation in general practice–the doctor’s toolbox: A qualitative focus group study. Fam Pract 2011;28:220–5. [26] Løgstrup KE. Den etiske fordring. København: Gyldendal, 1957. [27] Sussman AL, Williams RL, Leverence R, et al. The art and complexity of primary care clinicians’ preventive counseling decisions: Obesity as a case study. Ann Fam Med 2006;4:327–33. [28] Ahluwalia S and Launer J. Training for complexity and professional judgement: Beyond ‘communication skills plus evidence’. Educ Prim Care 2012;23:317–9. [29] Kaner E, Rapley T and May C. Seeing through the glass darkly? A qualitative exploration of GPs’ drinking and their alcohol intervention practices. Fam Pract 2006;23:481–7. [30] Soubhi H, Bayliss EA, Fortin M, et al. Learning and caring in communities of practice: Using relationships and collective learning to improve primary care for patients with multimorbidity. Ann Fam Med 2010;8:170–7.
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SJP0010.1177/1403494814565129When general practitioners talk about alcoholT.G. Lid et al.
Scandinavian Journal of Public Health, 2015; 43: 153–158
Original Article
When general practitioners talk about Alcohol: Exploring facilitating and hampering factors for pragmatic case finding
Torgeir Gilje lid1,2,3, Sverre Nesvåg3 & Eivind Meland1 1Department
of Global Public Health and Primary Care, University of Bergen, Norway, 2Research Unit for General Practice, Uni health, Uni Research, Bergen, Norway, and 3Centre for Alcohol and Drug Research, Stavanger University Hospital, Norway
Abstract Background: The aim was to explore individual and system factors facilitating or hampering pragmatic case finding, an identification strategy based on clinical signs and targeted screening. Study design: Two focus groups with general practitioners were interviewed twice, in the context of a four-session seminar on alcohol and complex drug problems, and an additional focus group interview with general practitioners not attending the seminar. Interviews focused mainly on conditions for talking about alcohol, views on collaboration with colleagues, how they deal with complex issues, and strategies for learning and quality improvement. Results: The participants presented many deliberate strategies for quality improvement and learning together, but there was a tendency to avoid discussing complex case stories or potentially controversial topics with colleagues. Possible barriers to change were presented. The majority of their stories on talking about alcohol coincided well with the concept of pragmatic case finding. The duality between shame and normality, time constraints and a need for structure were the most important individual barriers to an open and respectful conversation about alcohol with patients. Conclusions: Our study supports pragmatic case finding as a relevant and viable strategy for talking about alcohol in general practice, and as an alternative to screening and brief intervention. Quality improvement in practice is strengthened when it is adapted to the clinical setting, and builds on and stimulates the GPs’ and staff ’s own strategies for learning and quality work. Key Words: Alcohol-related health problems, general practice, focus groups, quality improvement, communities of practice
Introduction The link between alcohol consumption and numerous health problems is strong [1]. General practitioners (GPs) are well placed for dealing with alcohol-related health problems, as clinicians and as gatekeepers. Screening and brief intervention (SBI), the recommended approach for identifying and treating risky or harmful drinking [2], is still not a regularly used strategy in general practice, though GPs accept responsibility for dealing with alcohol-related health problems [3,4]. The effect and feasibility of SBI are questionable [5,6]. A Cochrane review concluded that SBI is
effective [7], but a recent review of reviews found that it was primarily effective for middle-aged men with risky or harmful drinking, but without established addiction [8]. Recent intervention studies to improve GPs’ strategies for alcohol and other life-style factors have been counterproductive or without effect [9,10]. The authors of a review comparing SBI with clinical signs as identification strategy concluded that a semi-systematic method based on awareness of specific clinical signs, combined with targeted screening, is promising [11]. This is in line with our concept of pragmatic case finding [12]. Pragmatic case finding
Correspondence: Torgeir Gilje Lid, Department of Global Public Health and Primary Care, University of Bergen, Norway Giljagarden 12, N-4335 Dirdal, Norway. E-mail: [email protected] (Accepted 27 November 2014) © 2015 the Nordic Societies of Public Health DOI: 10.1177/1403494814565129
154 T.G. Lid et al. Table I. Sample distribution. Category
Variables
N
Gender Age (years) Practice size Time in this practice
Female Male 25–29 30–39 40–49 50–59 60–69 5 GPs ≤5 years >10 years
11 8 0 6 4 7 2 10 9 8 11
includes clinical situations, where the possible relevance of alcohol for the patient’s health problems or worries is explored, and routine encounters as pregnancy controls and health check-ups, where simple screening measures are called for. The study was approved by The Regional Committee for Medical Research Ethics. Two of the authors are GPs (TGL and EM), and one author is a social anthropologist (SN). The aim of the study is to explore individual and system factors facilitating or hampering pragmatic case finding as a strategy for talking about alcohol in general practice. Design, methods and material A focus group study with two groups of 14 GPs attending a four-session interactive seminar on talking about alcohol and dealing with complex drug problems was conducted. An additional focus group interview with a different group of five GPs was held after preliminary analysis (Table I). The seminar was the study context, not the focus of the study. We approached nine practices, chosen for maximum variety in size (one to seven GPs) and stability (high turnover to high stability), aiming to recruit as many as possible from each practice to the seminar. Six practices accepted the invitation, but two of them did not manage to find the time to participate. All partners and substitutes participated from the remaining four practices. None of the GPs had any special interest in alcohol or drug problems. The seminar was held in two localities, with focus group interviews performed initially on the first and third days. All sessions were held from May to August 2013, with a minimum time span of at least 2 weeks between sessions, and scheduled to the needs of the participants. The sessions were 135–180 minutes long. The first interview dealt primarily with why and how they talk about alcohol, and how they understand their group practice. The second interview dealt with feedback on the seminar, conditions for talking about
alcohol, and how this relates to running a practice with colleagues. These interviews were conducted by SN. Based on preliminary analysis, two recently established practices were approached after the seminar. We wanted to recruit younger GPs who had been involved in planning their group practice. All three GPs in one practice and two of the four responsible in the other practice participated. This interview focused on system factors relevant for quality in clinical work, especially alcohol and drug-related issues, and for dealing with potential conflict and dilemmas. TGL led this interview. All interviews were audio-recorded and transcribed verbatim. Analysis was conducted as collaborative negotiations, applying systematic text condensation [13]. After acquiring an overall impression, we identified meaning units representing different aspects of the participants’ experiences of talking about alcohol and working together, dealing with complex issues. The contents of the coded groups were condensed to generalized descriptions and concepts.We focused on resistance, tension, and dilemma in the material. Results The participants shared experiences on talking about alcohol, and on system factors influencing this clinical work, collaboration, and change processes. Possible barriers to change, both in the clinical work and in their collegial strategies, were presented. They also shared reflections and experiences rarely addressed in their everyday work. When they elaborated on system factors facilitating or hampering sustainable and helpful relations with these patients, a tension between cooperation and individual freedom was revealed. The findings are elaborated below. Quotations are assigned pseudonyms. Negotiating shared responsibility and autonomy The participants talked about how they negotiated and agreed upon common procedures in their practices. It was considered important to have a close and trusting relationship, and a mutual understanding about their ambitions for the practice. Younger participants described how previous experiences from practices with little shared understanding and collaboration made them determined to achieve this in their present practice. Some had frequent meetings for learning and professional discussions. The smaller practices had interns in their clinic, and felt it positively affected their own learning. The bigger practices had a wider variety of deliberate strategies for learning and quality improvement, and some applied
When general practitioners talk about alcohol 155 strict guidelines in specific areas, e.g. for the prescription of certified drugs. They felt that strict rules and boundaries were valuable for vulnerable or demanding patients, though recognizing that patients also could feel rejected. A younger GP commented: Everyone has an involvement in what they do, and a commitment. … And we said so in the interview with our new colleagues that we expect presentations [of relevant topics], and involvement. … We want to be curious. And if I’m curious about something, then be sure that I will manage to involve the others, in a way. And I’ve missed that. Jane
However, some realized that they were more individualistic than they wanted to be, and creating something together could be a constant struggle. Sometimes they felt alone when their own views collided with the views of the group. In spite of their aspirations, complex cases were not discussed in their meetings, and advice was seldom sought. They missed supervision and more involvement from colleagues when something was challenging. Participants from the recently established practices reported very careful strategies to select new colleagues, to prevent future conflict. Others gave examples of how they avoided complex or difficult topics with colleagues. One GP told about how they still, after 10 years of weekly meetings, had not properly addressed the prescription of addictive drugs: well yes, it might turn out that we are more individualistic than we like to admit … And that’s probably the reason that we, that it wasn’t the first topic we addressed. We feel that we all have something to hide. And perhaps [we] know that we need to correct this in one way or another. Kevin
The system factors presented above may facilitate or hamper the GP’s own learning and change process. Below we will present factors specifically concerning the clinical interaction with the patient. The majority of their stories on talking about alcohol coincided well with the concept of pragmatic case finding, but there were also stories on various obstacles to open and respectful conversations about alcohol. Between normality and shame Many participants stated that it could be quite easy to ask about alcohol. They explained this by the fact that alcohol is increasingly integrated in normal life. It was easier to remember to ask when they focused on relevance for the specific situation. The patients were often more willing to disclose information than anticipated, men more so than women. An experienced GP said:
many things are somewhat taboo and difficult to talk about, but I think it’s more with us than with the patient. And therefore I’ve recently started asking just as naturally as I ask whether they smoke. ‘I assume that you drink?’ … Sometimes I forget it, but I’ve become much better. Thomas
Several participants stated that alcohol is often invisible, unlike long time smoking. It was pointed out that a high consumption in higher social circles was often less visible. They told about patients evading the topic, where they did not address the patient’s avoidance, attributing this to the fear of alienating the patient. Cultural differences were addressed by several, and they were astonished by the drinking patterns they could hear about. Normality was judged in comparison with personal experiences with alcohol, for some with a tendency to see one’s own consumption as solely based on taste. This was challenged: sometimes [you drink] not to take yourself so serious. And sometimes it’s to relax when you come home from work … and sometimes it’s because it tastes good together with something to eat. It has many functions, even for you, yes, actually, I would say so. And I think it’s somewhat dangerous to think that the way [you] think [about drinking] is essentially different from those having a problem. James
The constraints and possibilities of time Many of the participants gave examples of time as a positive factor, as when planning in advance for a lengthier consultation, or continuing talking in the next consultation. Several stated that if their efforts were futile, they could raise the question again next year. Multiple consultations might be required just to reach a mutual understanding that alcohol was important. Many saw their dealing with a patient’s other health problems as vital for building trust and confidence. A seasoned GP said: and I often see, when I take an overview … . Then I count a shockingly high number [of consultations]. There has been many stages were we’ve built a delicate construction together. Richard
Time is also a challenge. Not asking about alcohol when being behind schedule was common. Sometimes they did not ask because the patient had several other problems that needed attention. It was also pointed out that you have to know that you can wrap it up again, too. One senior GP pointed out: and we have a problem with the time factor … . We have to get him through. Or we may choose to [think] that we
156 T.G. Lid et al. see there is a problem here beyond what he came for. We may sneak behind and take some blood tests and say “and then you come for a follow-up in a couple of weeks, and then we’ll go through the blood tests and talk some more”. But he says “couldn’t you just text me the results.” George
Presenting an opportunity for change, when relevant Many participants reported specific clinical problems where pragmatic case finding is relevant, such as overweight, medications, gastric symptoms, hypertension, and repeated sick leaves. They gave diverse examples of relevant routine situations, such as pregnancy controls and health check-ups. They also told about situations without a clear-cut medical problem, but where a gut feeling inspired them to think about alcohol. One GP explained: it’s something you don’t quite grasp … so, it becomes inexplicable for the head. Then you have to feel it in your stomach. And then you have a gut feeling. Lynn
In the second focus group interview, held after they were taught about pragmatic case finding, a few participants also challenged the lack of structure. They wanted more predefined strategies, and reassurance that it was worthwhile. A senior GP said: if the plan is that you see the patient every fortnight and ask how it’s going. If that actually is a good enough formula and it actually works, then I would be superhappy. But I might consider it a tiny bit meaningless if I didn’t have anything proper. Something I could refer to. But if you had told me that this actually works, so and so percent better, then I would be happy. Linda
with varying age, gender, size, experience with and stability in group practices. This strengthens the external validity of our findings [13]. A possible weakness is that all participants were interviewed together with their colleagues, perhaps holding back on vulnerable topics. However, the participants discussed several difficult topics and also disagreed during the interviews. Reflections together with colleagues brought up important common topics and stimulated group dynamics promoting openness and transparence. Practices with a high degree of tension and unsolved conflicts would probably not agree to take part in a study based on and exploring group dynamics. Two focus group interviews with each group in the seminar enabled us to explore their experiences with and reflections on the process, and to follow up on previously discussed topics [15]. The highly interactive seminar was inspired by self-determination theory and motivational interviewing, and the participants could influence both scheduling and content [16,17]. We aimed at recruiting practices, not the GPs individually, using situated learning and communities of practice (CoP) as a frame of reference [18,19]. A CoP is defined as a group of people sharing a concern or a passion for something they do, and learning how to do it better as they interact regularly [18]. CoP has recently gained interest in the healthcare sector, both as a study context and as a means to improve clinical practice [20]. Preliminary analyses revealed a wider spectrum of deliberate common strategies than expected, and the additional focus group interview was performed to further explore these system factors.We chose younger GPs from recently started group practices, as they had created a group practice from scratch. In addition, they were not influenced by the study context.
Discussion The participants in this study elaborated on many factors, both individual and system related, that can facilitate or hamper pragmatic case finding and its implementation. They also gave numerous examples of how they talk about alcohol, corresponding well with pragmatic case finding, strengthening the assumption that this may be a valuable strategy. Below we will discuss strengths and limitations of the study design and the possible impact of our findings. Sample and preconceptions We have chosen a focus group design as this is well suited for the study of experiences and attitudes, and the interactions within the groups help to unveil cultural norms and values [14]. Our sample is diverse,
Conditions for increasing GPs’ awareness of alcohol There is an increasing body of research questioning the effect of and the validity of both the screening and the intervention of SBI [6,9,10,21]. We know that identification has an effect, but we know little more. There is reason to believe that some patients have an increased vulnerability, and thus addressing alcohol in diverse clinical situations is important [22]. The patients may also more readily accept that alcohol is relevant [23]. In this study we have explored conditions for increasing GPs’ awareness of alcohol as a relevant factor in many health problems and clinical situations, based on pragmatic case finding, first described by Lid and Malterud [12]. Pragmatic case finding
When general practitioners talk about alcohol 157 combines a focus on the relevance of alcohol in a wide variety of clinical situations, and simple screening measures in routine encounters. Most of the participants’ stories on alcohol were in line with pragmatic case finding. Hence, increasing GPs’ knowledge on the multitude of clinical situations where alcohol can be relevant, both causally and as a complicating factor, may be an easily adaptable strategy to increase identification of risky or harmful drinking [11]. We have focused on tension and dilemma, to explore factors hampering the implementation of pragmatic case finding, and to avoid bias and improper confirmations. This has also been aided by the different perspectives of the authors. One significant finding was the tendency to sometimes avoid potential conflict or vulnerable issues, both when the patient evades questions about alcohol and when difficult topics are not addressed among their colleagues. Not asking when inclined to ask can be understood as “mindful prioritizing” [24], but may also be a strategy to avoid awkwardness or failure. Addressing this tendency is necessary to increase relatedness and competence, both with patients and with colleagues. Lack of consideration or intentionally trying to evoke a response might also be the case [25]. The balance between necessary interventions and respect for the “nearness zone” for patients and colleagues alike may be difficult to strike [26]. The tendency not to discuss the most challenging case stories with colleagues hints to a feeling of shame related to incompetence, but it might also hamper the development of competence. The practices, especially the bigger ones, facilitate learning and support among colleagues, but they do not seem to utilize this to address complex patient cases or their own collaboration. But the fact that this was addressed in the group interviews illustrates the potential for developing these processes further. Alcohol interventions are complex interventions, depending on the GP’s values, knowledge, and competencies, as well as on the present situation and the work climate [27]. All medical conversations, with both patients and colleagues, are uncertain and open to multiple interpretations and outcomes [28]. Normality is questionable, and insight in one’s own attitudes and values may be blurred [29]. This is particularly challenging when alcohol is in question, as our informants show. Many clinical situations call for open ended dialogue on difficult and vulnerable topics for both parties. Open and frank interactions are needed both with patients and colleagues. Preliminary analysis of the first interviews gave richer results in line with CoP than expected. In the additional focus group interview we aimed to explore
experiences and expectations that had guided their planning process. These informants gave more elaborated examples of common strategies for clinical work and for learning. CoP is a promising perspective on change processes and quality in general practice, but challenging to evaluate [20]. Our study adds support to CoP as a viable concept for implementation research and the study of change processes. A group practice is not necessarily a CoP, but with the amount of common strategies for quality and support described by the participants in this study, they are clearly CoPs [18]. This does not imply absence of tension and conflict, but a culture that facilitates collaboration, learning, and shared understanding, vital when dealing with complexity and dilemma [30]. In this study we have not included the rest of the staff, and we advocate that future research should also include staff and collaborators, when relevant. Implications Our study supports pragmatic case finding as a relevant and viable strategy for talking about alcohol in general practice, as an alternative to SBI. Quality improvement in practice is strengthened when it is adapted to the clinical setting, and builds on and stimulates the GPs’ and staff’s own strategies for learning and quality work. Pragmatic case finding warrants testing in randomized controlled trials in everyday practice. Conflict of interest We are aware of no potential, perceived, or real conflicts of interest for each author. Funding The study was funded by Fund for research in General Practice, Norwegian Medical Association and Alcohol and Drug Research Western Norway. References [1] Norstrom T and Ramstedt M. Mortality and population drinking: A review of the literature. Drug Alcohol Rev 2005;24:537–47. [2] Pilling S, Yesufu-Udechuku A, Taylor C and Drummond C. Diagnosis, assessment, and management of harmful drinking and alcohol dependence: Summary of NICE guidance. BMJ 2011;342:d700. [3] Holmqvist M, Bendtsen P, Spak F, Rommelsjo A, Geirsson M and Nilsen P. Asking patients about their drinking. A national survey among primary health care physicians and nurses in Sweden. Addict Behav 2008;33:301–14. [4] Nygaard P, Paschall MJ, Aasland OG and Lund KE. Use and barriers to use of screening and brief interventions for alcohol problems among Norwegian general practitioners. Alcohol Alcohol 2010;45:207–12. [5] Beich A, Thorsen T and Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general
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