Working behaviour of competent general practitioners: Personal styles and deliberate strategies

Abstract

Objective. To study how competent GPs perform their work within the consultation and in relation to the team and practice organization. Design. Ethnographic study with thick description. A participant observation of the GP was followed by a personal interview. A substantial description was elaborated that was analysed qualitatively. Setting. Primary care surgeries in Sweden. Subjects. A number of competent GPs. Results. Two main categories emerged, deliberated strategy and personal style. These categories set up the individual pattern of working behaviour for each GP. A behaviour that is a deliberate strategy for one GP for the other belongs to his or her personal style. Common denominators in the overall working behaviour were attention to the patient as a person, practising patient-centred medicine, saving the consultations from disturbances, rejecting taking over responsibilities from the patients, and safeguarding own autonomy. Conclusion. The transition of deliberate, favourable strategies into one's personal style is an important aspect of professional development. A well-developed personal style is necessary to obtain the spontaneous interchange between attentive listening and detachment characteristic of patient-centeredness.

• Clinical strategies
• consultation
• general practitioner
• participant observation
• patient-centeredness
• personal style
• work performance

In the declarations of Leeuwenhorst 1974 [1], WONCA 1991 [2], and WONCA Europe 2002 [3] principles of good general practice are published. The patient-centred clinical method – PCCM [4], [5]–is the clinical method naturally linked to these declarations. Research has underlined positive correlations between patient-centredness and patient satisfaction and clinical outcome [6–10]. Ian R. McWhinney [11], the bearer of the philosophy of the PCCM, has presented a deepened version of the method. He underlines the importance of attentive listening [12], which is not just a skill but a moral stand towards the patient as well.

The declarations and the PCCM, however, do not catch the complexity of practice. In general practice distinct disease categories are often missing. Instead well-tried and experienced strategies support decision-making. Judgements of probability accompany daily assessments.

The real performance of GPs has not been much studied. Some authors have stressed the importance of personal characteristics for medical work and training.

• Participant observation is appropriate for studying the working styles of GPs.

• Competent GPs display a mix of spontaneous behaviours closely linked to the personality – personal style – and deliberate strategies.

• The transition of deliberate strategies into personal style might be an important element of professional development.

In our opinion the concept of PCCM is not fundamentally different from dialogue-centred medicine described by Olesen in a recent editorial [13]. If PCCM is seen as the inducement for patient consultation and not as a demand to do what the patient wishes the difference is small and does not mark a shift in focus.

The general practitioner (GP) sees patients in the surgery, talks to them on the phone, and interacts with colleagues and staff members. He/she passes through a vast array of decisions, does paperwork, and constantly runs the risk of being interrupted. During a working day a balance has to be maintained between the focus on the patient and the relations within the team. This balance is important especially now that there are signs of a widening cleavage between patients’ expectations of care and what GPs see as medically justified [14].

Working behaviours and styles

GPs work mostly alone. They meet each other in the breaks between busy surgeries. So as a GP it is difficult to achieve comprehension of the working qualities and styles of colleagues.

Huygen [6] categorizes GPs into three working styles. He calls them integrated, interventional, and minimal diagnostic. His categorization applies to the behaviours in patient communication and medical decision-making. This categorization is driven by a specific research aim linked to patient-centredness. Descriptive research approaches to GPs’ working styles might add to the knowledge of those skills and strategies that are operating successfully in practice.

A Swedish researcher has approached working behaviour through participant observation of 40 doctors (GPs, surgeons, and internists) [15]. Compared with the surgeons and internists, the GPs were inclined to use psychological strategies such as “attention and involvement” and “doing things at once, being decisive”.

Fiona Patterson [16] constructed–using behavioural descriptions from GPs and patients and observation of GP consultations–a competence model comprising 11 categories for general practice. Five competences were elicited from all three sources. These were: empathy, communication skills, clinical knowledge, conceptual thinking, and personal attributes. Patterson concludes that these core competences should be of help to the medical student/doctor/GP. This professional can use core competences in self-choice, recruitment selection, and training applications in general practice to prevent a mismatch between the personal outlook of the GP and professional demands.

The aim of the study was to describe how a number of competent GPs perform their work, both within the consultation and in “outer” relations with the team and practice organization, and to relate those findings to the ongoing discussion on the selection and training of GPs.

Material and methods

We asked a small number of GPs from the county of western Sweden involved in general practice development and education to recommend colleagues in the county. The colleagues’ task was to give examples of competent GPs they knew of. The competence should be both the inner professional quality and the quality seen from the patient's point of view. A variety of GPs were aimed at: young and old, males and females, city and country GPs. Consensus in selection was achieved after a couple of meetings.

Five GPs (A–E) were chosen, three women and two men between 35 and 60 years of age, with representatives from both town and country. They had experience as GPs between a few years and 25 years.

We chose a participant observation approach in order to try to give the general practitioner, in all its complexity, a thorough description within his/her personal context. We were inspired by Michael Agars's concept of rich points used in ethnography [17–19].

Publicly funded GPs in Sweden work mostly at primary care centres together with district and practice nurses, nurses’ aides, and secretaries, and sometimes biomedical analysts. The consultation length is usually 15–30 minutes and afterwards the GP dictates and the secretary completes computerized records.

Procedure

The observer–BL who has been a Swedish GP since 1988 interested in anthropology and film studies, and has been member of a Balint group for 15 years –informed the chosen GP about the aim of the study and asked if he could accompany him/her during one day in the surgery. All were somewhat surprised as to why they were chosen but all accepted his suggestion. Every patient was asked if the observer could attend and all but two patients agreed.

An observation scheme was constructed. The scheme includes various aspects of practice in a pragmatic approach. It is mainly chronological and fits for description and some of its points are influenced by the ideas of patient-centredness.

• The encounter: preparation (attitudes towards notes); initial contact (where and how); the opening of communication (individual behaviours); verbal, non-verbal and emotional communication; other behaviours (such as taking notes); bodily examination (place, touch, speed, concentration, skilfulness, emotional temperature, the occurrence of dialogue during examination); summing up (information and planning, the degree of patient involvement, and establishing common ground).

• Interruptions in the consultation: who and when and reactions of the GP.

• Paperwork: The notes (dictation, when); referrals and prescriptions (when and how).

• Between patients: Taking a pause or not.

• Overriding aspects: Time management.

Field notes and the creation of a description

BL was the observer in the consulting room. Field notes (observations, quotations, and reflections) were made between patients and during transition periods in the consultation.

The field notes were brought together immediately after the observation day according to the “scheme of observation” into a coherent description of seven to eight printed pages for each GP.

Interviews

A tape-recorded follow-up interview was undertaken with each GP within two months. Throughout the interview, the descriptions from the observations were presented, and comments were asked for. The interviews had three (additional) aims, concerning with validity:

1. to obtain clarity about observations not fully understood;

2. to give the GPs an opportunity to add comments about important aspects of practice that perhaps did not show up on the particular day of observation;

3. to get responses to the questions generated by the observations, and by the elaboration of field notes.

Elaborated description and key characteristics

The analysis was then undertaken as follows. First, the field notes and the comments from the interview were condensed into an elaborated description of about 500 words on the working behaviour of each doctor. Second, the five descriptions were compared in an effort to grasp, on a general level, how the working behaviours differed between the doctors. Two main categories of working behaviour stood out in this reading. Third, for each doctor, BL and CER then, in a refining procedure, selected a set of key characteristics within the two main categories against the robust description. Finally, BL compared the sets of key features with the notes and recognitions from the participant observations [17].

The first version of the study was published as a Swedish report [20]. As a response to the report BL was invited to a number of academic seminars and postgraduate courses to talk about his experiences. The findings were also presented as a poster at a congress on advances in qualitative methods in Canada in 2003.

In the first Swedish report the basic observations were the main results. Afterwards, in relation to the various presentations, a deepening and elaboration of the manuscript was carried out. Data have thus been discussed, appraised, and comments have usually been supportive. A triangulation has been done. By this means we think that the trustworthiness of the findings is satisfactory.

Results

Elaborated descriptions

The elaborated descriptions form the baseline result of the study. In Figure 1 a shortened version of the elaborated description is presented (Dr B).

Figure 1.  A shortened version of the elaborated description of one GP (Dr B).

Main categories

Two categories became apparent from the elaborated descriptions. Every GP exposed a mixture of deliberate strategies and the features of a personal style. This mix acts both in the encounter and in organizing the working situation.

The deliberate strategy implies the way the doctor actively chooses to manage specific aspects of work. For Dr B a deliberate strategy is not to abandon the patient without reaching common ground. Another such strategy is her action for organized working conditions.

The personal style is the expression of the personality in spontaneous action and not so much by means of a choice. A feature of Dr B's personal style is her concentration on the patient during the beginning of a consultation. Another feature is her inborn resistance towards her free time being invaded by work.

Key characteristics within the personal style and deliberate strategies

The individual working behaviours of the five GPs are described below within the frame of the categories: personal style and deliberate strategies.

Dr A: Personal style: Immediate and intensive involvement, action, temper, sensitive to disturbances. Deliberate strategies: Inserting quick questions and advice, short moments of solitude, scrupulous about diagnosis, longer lunch, and time management.

Dr B: Personal style: Concentration and intensive involvement, avoiding invasion by work, methodological, informing. Deliberate strategies: Deliberate emotional response, rejecting claims of service, striving to reach common ground, reflecting on workload, and acting for balance.

Dr C: Personal style: Changing between relaxation and concentration – looking around now and then, spontaneously observing the patient's bodily awareness, posing ingenious questions and improvising, moving around in the room, no clear needs for structure. Deliberate strategies: Devoted bodily examination, makes a diagnosis but with doubts (“these bloody diagnoses”), working part time as a coping strategy.

Dr D: Personal style: Tranquil and tending to lean back but still involved. Peering gaze, long pauses, calming rather than explaining, exposing doctorial authority. Deliberate strategies: Stops to be able to listen if patient talks during the bodily examination, limiting his open attention to medical problems, interest in practical skill, bases his patient knowledge on long continuity.

Dr E: Personal style: Works in close everyday contact with the patient – sitting near, shifting in a flexible way between listening and asking questions – calming, caring, visualizing to herself with her hands on her body while dictating, friendly decisiveness. Deliberate strategies: Quick decisions, systematic and strict in organizing, takes a breather with the nurse.

We found that the five GPs showed characteristics in working behaviour that we call common denominators. These five denominators involved all five GPs so we considered might they constitute a central feature of the core competence.

Common denominators…

• Common to the five GPs is the attention to the patient as a person; the patients were actively engaged in the encounters.

• All GPs also practise the key elements of patient-centred medicine such as finding out the motive(s) for the visit.

• All GP were successful in saving the consultation from disturbances.

• They also were successful in not taking over too much responsibility from their patients.

• An overall attitude and asset of a competent GP seems to be safeguarding his/her own autonomy and still attending to the needs of patients and colleagues.

…and personal styles at the same time

At the same time, they very definitely express their personalities in the ways professional standards are maintained, and professional and personal autonomy is secured. Being present is to one GP leaning back and peering. To another GP it is more a question of an active and upright position. To one GP pauses in solitude during the day are necessary to ease the workload, while another GP finds limiting the working hours the best solution.

Discussion

Comments on the method

The GPs are not representative of all skilful GPs in Sweden. There are, however, good reasons to believe that their competence is of good quality. The selection process makes that judgement valid. The group displayed both conformity and variation and the material was rich enough to explore individual features of work performance.

The method of thick description, which implies catching as many observations as possible in the field notes, is often used in ethnography. Describing all the details, however, is not that important as the meanings of many acts and manoeuvres lie open to the observer [21]. The identification of specific key situations will be quite a straightforward matter, such as when doctor A inserts quick questions and advises while the patient talks.

The observer is studying his own profession and the studied context is well known. It might imply a tendency to take things for granted and to marginalize certain issues. However, few field notes deal with disease-oriented knowledge and skills. The interpretation ought to be that the observer had no major objections concerning competence.

A limitation of the study concerns an omission of important power relations between the GP and the patient. For example in drug prescription and the concordance with medication the patient's autonomy might be hampered. Too much striving towards common ground could interfere with the patient's independence [22]. Murtagh has also stressed the principle of sovereignty “because it is detached from the construction of meaning and the self and makes invisible the relations of power of which it is a part” [23].

Comments on the findings

In our analysis the concept of working behaviour divides into two main categories, personal style and deliberate strategy. A working manner or attitude may to one GP come quite naturally as an expression of his/her personal style. The same manner has for another to be understood as a strategy. This distinction between personal style and deliberate strategy is of course not clear in the observation situation. However, with the interview added and in the discussion among the authors it can be made in most cases. Dr B says that she uses “emotional response” deliberately, while Dr E apparently cannot help being emotionally empathetic. An assumption is that the more the desirable behaviours are the aspects of personal style, the easier it is to be a GP.

The behaviours displayed by the five GPs correspond very well with the competences elicited in Patterson's study [16]. This brings us back to her view that personal characteristics must be more in focus in the selection and training of GPs. An important dimension of developing as a GP should be the transition of deliberate strategies into aspects of personal style. This process corresponds to the learning career path from novice to expert discussed by Dreyfus & Dreyfus [24]. If, on the other hand, the personality of the doctor resists the integration of favourable behaviours into personal style, professional development will probably be seriously hampered. In a new study Wahlqvist [25] discovered that during undergraduate training there is an instrumental influence on communication with patients. The listening attitude at the beginning of training decreases towards the end of physician education and then perhaps increases again with postgraduate consultation training – it is called the “hourglass metaphor”. We think that this finding is in accordance with Dreyfus's learning career.

In our material Drs B and E, who have fairly short experience, express a greater need for control than do Drs C and D. In Dr E another aspect of the relation between personal style and strategy is exemplified. She has found out that, to be able to cope, the caring element in her personal style must be balanced through her organizing work quite strictly.

Conclusion

We believe that a well-developed personal style is necessary to obtain the balance between “attentive listening” and “detachment” described by McWhinney [12]. In “attentive listening” the doctor temporarily forgets about him/herself and the abstract concepts of biomedicine. Instead the doctor listens with a “readiness of understanding” [26] of high professional potential. It is just not any person, but this unique professional, who is listening. The moral impulse to take responsibility then helps the doctor to step back, without much effort, to reflect on what has been learnt from the patient. The doctor is spontaneous but still professional, which formulates the meaning of the personal style of a skilful GP. So the resolved paradox would be: it is in the presence of the patient that the personality of the doctor can find its expression. By this we can hope that high professional skill is within reach of most GPs, not in spite of but rather thanks to their differing individual prerequisites.

The authors would like to thank Ingela Krantz, professor at The Skaraborg Institute Skövde and the five GPs who offered the opportunity to study their working behaviour.

The study was approved by the ethical committee of Sahlgrenska Academy in Gothenburg. The study was funded by the Primary Care Research Center Skaraborg and the Skaraborg Institute, Västra Götaland Region.