General Practice and Primary Care - Theses
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ItemChronicity and character: patient centredness and health inequalities in general practice diabetes care( 2006)This study explores the experiences of General Practitioners (GPs) and patients in the management of type 2 diabetes in contemporary Australia. I focus on the way the socioeconomic position of patients is a factor in that experience as my underlying interest is in exploring how health inequalities are understood, approached and handled in general practice. The study is thus a practical and grounded exploration of a widely debated theoretical issue in the study of social life, namely the relationship between the micro day-to-day interactions and events in the lives of individuals and the broad macro structure of society and the position of the individual within that. There is now wide acceptance and evidence that people’s social and economic circumstances impact on their health status and their experiences in the health system. However, there is considerable debate about the role played by primary medical care. Nevertheless, better theoretical understanding of the importance of psychosocial processes in generating social inequalities in health suggests medical care may well be important, as such processes are crucial in the care of chronic illnesses such as diabetes which are now such a large part of general practice work. I approach this study through an exploration of patient centred clinical practice. Patient centredness is a pragmatic, idealised prescriptive framework for clinical practice, particularly general practice. Patient centredness developed in part in response to critiques of biomedicine, and is premised on a notion of a more equal relationship between GP and patient, and one that places importance on the context of patients’ lives. It contains an implicit promise that it will help GP and patient engage with and confront social disadvantage.
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ItemSame-sex attracted women and their relationship with GPs: identity, risk and disclosure( 2009)Patient-doctor relationships between same-sex attracted women and general practitioners (GPs) have been presented as problematic in the literature. The problems arise from women’s concerns about the potential for negative attitudes amongst GPs. They also relate to GPs’ concerns about offending patients if they ask about sexual orientation due to the stigmatised nature of minority sexual orientation. As a result, disclosure of sexual orientation can be difficult and the patient-doctor relationship can be compromised. The aim of this study was to explore the nature of patient-doctor relationships in this context and how optimal relationships can be achieved. Using a critical hermeneutic approach, I conducted in-depth interviews with 33 same-sex attracted women and 28 doctors. This included 24 pairs of people in a current patient-doctor relationship. I found that women commonly experienced silencing of their minority sexual orientation within general practice settings, but that this was occasionally desired and not problematic for some women and most GPs. For other women and for many GPs, the silence resulting from a lack of disclosure was a response to perceived risks to women’s personal identity and GPs’ professional identity. Few GPs asked directly about sexual orientation, placing the burden of responsibility for disclosure on same-sex attracted women. Building reciprocal trust could overcome the perceived risks inherent in revealing minority sexual orientation. I initially defined optimal patient-doctor relationships in terms of existing models of cultural competence and patient-centredness; however I found that such relationships were built on cultural sensitivity rather than cultural competence, and relationship-centredness rather than patient-centredness. I developed a new model of sexual identity disclosure that demonstrated the key influences on disclosure of sexual orientation to GPs for same-sex attracted women. These influences were women’s sexual identity experience, risk perceptions, and the level of knowing within the patient-doctor relationship. The model depicts women’s range and fluidity of sexual identity experiences and challenges current assumptions that disclosure is essential for effective health care. The model has transformative potential for general practice education and research. It could assist GPs to understand that not all women desire disclosure, but that the majority of women are happy to disclose if asked. GPs would be encouraged to take note of the socio-political environment in which women live and its influence on women’s fears and actual experiences of discrimination. Finally, understanding the role of trust and reciprocal knowing in mitigating perceived risks would encourage GPs to focus more on relationship building. This could also assist GPs to overcome their own perceptions of risk and encourage them to broach the subject of sexual orientation, ultimately enhancing the patient-doctor relationship.
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ItemInfluences on opioid pharmacotherapy prescribing in general practice in Victoria( 2009)Opioid dependence is a chronic relapsing condition resulting in significant individual and community harms, for which the most effective treatment is long term opioid pharmacotherapy (OP). In contrast to other Australian states and territories, in Victoria, 80-85 % of OP prescribing is undertaken by GPs, and while demand for this treatment is difficult to estimate, all evidence indicates that the current and future GP workforce is inadequate to meet projected need. GPs have shown a reluctance to become actively involved in the treatment of patients with drug dependence, especially where illicit drugs are involved. In order to prescribe OP, Australian medical practitioners are required to complete a specific training program. Little is known of the reasons why GPs decline to undertake this training, and why the majority who complete training, subsequently prescribe to very few or no patients. Using in-depth interviews and an analysis of existing data from the Victorian Department of Human Services, this thesis not only explores why GPs are unwilling to complete OP training, and why many subsequently fail to prescribe, but also identifies both barriers and facilitators which influence GPs in their decisions regarding these issues. The results have not only provided new information on the reasons GPs decline the offer of training but also supported existing research.