The doctor, his patients, their diseases

This issue of the European Journal of General Practice (SGEN) harbours articles that illustrate well the variety and complexity of our profession. The soft side of our work passes in review in articles on patient centred care, an integrative approach, the doctor-patient relationship, and ‘gut feelings’. In addition, the lovers of facts and evidence will come into their own with papers on drug interactions, long-term use of antidepressants, and self-monitoring of blood glucose. Finally, international organizations of general practice and primary care present their news.

The series on the ‘Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe’ (1), continues with part three, a review of the state of the art of our professional core competencies ‘person centred care’, ‘comprehensive approach’ and ‘holistic approach’ (pp. 113). These terms are used to describe the complexity of the world in which general practitioners want to be significant actors. GPs want to deliver care that ranges from prevention, through curative care to palliative care. In our diagnostic and therapeutic decisions, we feel the need to take as much account of clinical knowledge as of contextual factors. The authors conclude that these aspects of our work all are not well defined, and that ‘comprehensive’ and ‘holistic’ models of care are hardly studied at all. Amongst other things, they recommend the development of measures for the components of these competencies, including patient satisfaction, patient knowledge and quality of life.

In her Commentary on the Research Agenda (pp. 67), Nicky Britten states that if we want to proceed from ideology (‘general practice/family medicine is different from hospital medicine’) to evidence, we need to identify the salient aspects of our ideological claims. If we want to study not only ‘disease’ but also ‘the patient’ (‘relationship centred medicine’), we need to develop measures that reflect the patient’s life. Therefore, she advocates the engagement of patients as partners in research as well as in clinical practice. Within the clinical domain, she strongly suggests GPs to research the real world of multi-morbidity, including the adaptation of simplistic clinical guidelines and the support of self-management routines for patients.

An example of how measurement instruments on the doctor-patient relationship can be developed and used, is the study from Sweden by Andén et al., on the GP’s and patient’s perspective of the outcome of consultations (pp. 80). In their quantitative study, they use two different questionnaires, one for GPs (nine items) and one for patients (six items), measuring similar perceptions of consultation outcomes. These questionnaires were the result of previously conducted qualitative research among GPs and patients respectively (2,3). Although concordance between GPs and patients was high regarding ‘satisfaction’, it was lowest regarding ‘understanding’ and ‘cure/symptom relief’. The patient’s perception of increased understanding was associated with the GP’s belief in patient reassurance, understanding, coping and satisfaction.

Coping with minor and major ailments may be a challenge for the patient, dealing with uncertainties in medical decision-making is a challenge for the doctor. Stolper et al., present two studies on ‘gut feelings’ the doctor may experience in certain consultations. In an earlier study among Dutch and Flemish GPs, they had reached consensus on a definition of ‘a sense of alarm’ and ‘a sense of reassurance’ (4). In a survey among GPs from 16 European countries, they were able to confirm that GPs from a variety of European countries, speaking various languages, recognize this phenomenon (pp. 72). In a second paper, they describe how they used a qualitative research method to establish a research agenda on ‘gut feelings’ in general practice, i.e. relevant research questions and proposed study designs, to be used in collaborative research (pp. 75). In his Commentary, Harm van Marwijk acknowledges the pioneering work by Stolper and colleagues. However, he questions whether the concept of ‘gut feelings’ is unique to general practice and wonders why the authors did not connect to a theoretical framework on ‘conscious’ versus ‘unconscious’ decision making, known from the cognitive psychology (pp. 70). It is for the future to show the results of collaborative studies on this challenging topic.

The Spanish study by Lopez-Picazo et al., is an example of a completely different approach towards relevant primary care research. They used a database of more than 400 000 electronic records of patients older than 14 years of age, to study the occurrence, nature and relevance of potential drug interactions (pp. 92). In their study population (15% over 65 years old), 30% took at least one medication. Of the drug-taking patients, almost 75% were taking more than one drug (median four, mean five drugs). Interactions were classified according to two criteria: pharmacological relevance and remedial action to be taken, taking age, gender and relevant chronic conditions into account. The study quantifies the most common, clinically relevant drug interactions in Spanish primary care. The authors recommend the implementation of prescription alert systems linked with electronic medical records.

Another paper addressing our prescription behaviour is the review by Piek et al., on long-term use of antidepressants in primary care (pp. 106). They conclude that recommendations on maintenance treatment with antidepressants as expressed in guidelines for the treatment of depression in primary care cannot be considered evidence based.

Despite existing guidelines for diabetes care, many patients find it hard to reach the recommended targets that indicate that they are in control of their diabetes (and not the other way round). In a study from Estonia, Rätsep et al., found that only half of their diabetic patients were aware that HbA1c is the most important indicator of glycaemic control. Awareness of this parameter was associated with better glycaemic control. Remarkably, not having a self-monitoring device to measure blood glucose also was associated with better glycaemic control. (pp. 85).

In the Communication and Information section, various international organizations present their news. I would like to highlight that Wonca Europe currently discusses the role the ‘special interest groups’ should play within their organization; the Vasco da Gama Movement would like to build up and maintain international research networks; and the European Forum for Primary Care (EFPC) has started a discussion group using LinkedIn.

Finally, did you never wonder what happens with abstracts presented at scientific conferences? Will they ever make it to full publications in renowned medical journals? The contribution of the European General Practice Research Network (EGPRN) to this issue gives you the answer for abstracts presented at their conferences (pp. 100).