General Practice and Primary Care - Theses
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ItemGPimED: General Practice: improving management of Eating Disorders: Can a one hour online educational intervention improve the detection and management of patients with Eating Disorders by General Practice Trainees?( 2020)GPimED: Can a one- hour on-line learning module improve early diagnosis and management of Eating Disorders by General Practice Trainees? PROBLEM STATEMENT Eating disorders are a serious and potentially life-threatening group of illnesses within the community. The literature shows that diagnosis and management of these illnesses are inadequately covered during medical school and subsequent General Practice training. This can result in a delay in diagnosis and appropriate referral thus significantly contributing to patient morbidity and mortality plus increased financial burden on the community. The literature demonstrates that patients with ED present repeatedly to General Practice (GP) with a myriad of signs and symptoms There is often delay in diagnosis due to varied reasons. The literature also finds that this delay coupled with lack of appropriate management can greatly exacerbate the morbidity and potential mortality. For example, within this group of disorders, Anorexia Nervosa (AN) has the highest mortality rate of any psychiatric illness with suicide rates 32 times higher than the general population and a mortality rate of 10%. General Practitioners (GPs) are often time poor and lack the knowledge to adequately manage patients with ED Online education for GPs is becoming more popular as it is cost effective, convenient and allows rural and remote GPs access to educational material they might not otherwise be able to access if it is available only via face to face delivery AIM The aim of this study is to determine whether a one-hour online learning module developed to upskill General Practitioners in the recognition and management of Eating Disorders improves the performance of GP trainees. SIGNFICANCE This study will shed light on the effectiveness of online education in upskilling GP trainees and if the ED module is successful, it may lead to improved treatment of patients with evolving or established eating disorders in the General Practice setting. It will potentially reduce the rates of delayed diagnosis resulting in improved outcomes. The literature indicates that patients with an ED present up to 5 times more frequently to primary care than demographically matched peers. General Practice is thus ideally placed to recognize these patients, to make a timely diagnosis and initiate appropriate investigation, management and referrals. The literature also indicates when diagnosis and appropriate intervention occurs within the first three years of the disorder developing, there is a greater than 40% chance of complete recovery. On November 1st 2019, the Federal Government initiated $110 million in extra funding for increased support for patients with a serious ED. This support can only be accessed if the patient as an Eating Disorder Plan completed is be done by the GP who has performed appropriate screening and provided the requisite history, examination and investigations. METHODS The trial design was a randomized, parallel-group study. Participants were recruited from the Victorian General Practice Training Consortia MCCC and EVGPT. The comparator was a general Youth Mental health module. Baseline surveys including demographic details plus a clinical case designed to assess baseline competence in recognising a probable eating disorder case and management thereafter. Following randomisation to either the ED module arm (intervention) or control arm, follow up surveys were completed after 6 weeks, quantitative evaluation was conducted using clinical scenarios presented as case studies in the format of Key Feature Problems (KFPs) which are a component of the FRACGP examination. RESULTS Despite our best efforts, there were only small number of recruits- 15 respondents with 8 completing all components of the study. Despite the small sample, there was measurable improvement in many parameters assessed cross both arms of the trial. In particular, an increase in the identification of ED as a differential diagnosis and improved referrals to health professionals considered integral to the evidence based best practice multidisciplinary team approach to ED management.
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ItemWe understand our gender best: gender diverse young people and their experiences with general practitioners( 2017)Gender diverse young people are a marginalised population with specific health care needs. Studies suggest that these needs are not being met by their general practitioners (GPs), but existing research focuses on gender diverse adults or non-Australian populations. The experiences of Australian gender diverse young people with GPs have not been studied in depth. Thirty-seven young gender diverse people shared their experiences with GPs. Many had negative experiences with GPs, with a majority of non-binary people having had mostly negative experiences. Participants’ experiences were positively impacted by GPs showing respect for gender diverse people, GPs being knowledgeable about gender diversity, a positive and friendly attitude from GPs, a welcoming clinic environment in which gender diverse patients were called by their chosen names, and GPs treating gender diverse patients like autonomous individuals. Negative experiences were characterised by GPs being uninformed or misinformed about gender diversity, GPs being insulting or demeaning, clinics requiring that patients be known by their birth names and assigned genders, GPs and staff misgendering gender diverse patients, and GPs attributing gender diversity to mental illness or vice versa. This study was conducted through an online survey, asking open-ended questions which provided answers suitable for qualitative analysis. Answers were analysed through thematic analysis, using a framework based on that of phenomenology. The recommendations put forth are that GPs must be educated on gender diversity; paperwork and computer systems should be able to accept input of genders other than male and female; GPs should respect gender diverse patients as individuals who know themselves; clinic waiting rooms should be welcoming and staff educated about gender diversity; GPs should not assume that gender diversity causes or is caused by mental illness; and GPs should believe, listen to, and respect the input of gender diverse patients. Further study on this topic could focus on the experiences of gender diverse Indigenous people, people born outside of Australia, or people living in regional areas; or on the experience of gender diverse people with other healthcare practitioners.
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ItemAn exploration of monitoring people with depression in the general practice setting( 2015)This study is about how general practitioners monitor the effectiveness of the care they provide for people experiencing depression. It seeks to better understand how the monitoring of people with depression should occur in the general practice setting, from the perspective of general practitioners, patients and carers. It does this with the intention of contributing to the debate about how to improve the quality of general practice care for people experiencing depression. The study comprises three main parts, beginning with a literature review in two sections. The first chapter discusses key concepts including depression, primary care’s role in depression care and what defines effective depression care. The second chapter is a scoping review of the primary care depression literature outlining what is known about monitoring practice in this context. The second part of the thesis presents the findings of a survey of 576 people with depressive symptoms who attend general practice, regarding how they recognise recovery from depression. The third part of the thesis reports on findings from eight in-depth case studies, which explore the views and experiences of GPs, patients and carers involved in the giving and receiving of depression care in the general practice setting. The findings of the case studies confirm that monitoring practice is a highly complex, iterative process. Broadly speaking, there are three key phases of monitoring that must be addressed as care proceeds, beginning with engagement in care (including ‘watchful waiting’), moving through a phase of ‘paying attention’ (to the individual patient’s experience) and the ultimate phase of ‘getting better’, where monitoring practice may help or hinder the attainment of recovery from depression. The case study data also show that from the very earliest phases of monitoring (commonly beginning before a diagnostic label has actually been applied), work must be done to achieve a shared understanding of the problem, to set priorities for care amidst competing demands, and to revisit issues regarding who and what can help in dealing with the problem. The thesis concludes by presenting four propositions for depression monitoring practice, which are intended to provide a framework to assist GPs in pragmatically addressing both technical and relational aspects of depression care.
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ItemExploring social constructions of, and the use of power to deal with, patient aggression in general practice( 2015)This thesis investigates the meaning of patient aggression in general practice and the use of power to deal with it, through a multi-case comparison of four general practices sampled on the basis of different business models. Much debate on the topic has focused on encapsulating the concept so that prevalence and associated factors could be determined. Current accounts highlight aggression directed towards general practitioners, but pay less attention to the experiences of other workers. Previous research has overlooked the contested nature of the concept along with contextual and interactional circumstances surrounding patient aggression. This thesis addresses these gaps by exploring how general practice workers from different occupational backgrounds understand patient aggression and how various types of general practice organisations use power to deal with the phenomenon. I adopt a social constructionist approach to argue that the meaning of patient aggression arises from the type of interaction. Qualitative methodologies underpin this multiple case study, which involved semi-structured interviews, observation, and document analysis. To explore the use of power, I draw on an analytical framework based on Steven Lukes’ (2005) critical conceptualisation of power. I discovered two interactional prototypes in general practice: front-line interactions between practice gatekeepers and patients, and rapport-building interactions between health professionals and patients. Gatekeepers tend to normalise patient aggression, whilst health professionals lean towards trivialisation. Normalisation renders the frequent exposure to aggression at the front line an acceptable and normal ‘part of the job’. In contrast, trivialisation enables health professionals to suppress perceptions of heightened vulnerability and avoid victimisation. Both interactional prototypes employ medicalisation and stigmatisation. To understand the use of power to deal with patient aggression, I compare a small partnership practice, a community health service, a large group practice, and a corporate-owned practice. I discuss how these practices manage the meaning of their interactions with patients differently. I interpret this management of meaning as an exercise of power in the third dimension, which is the most sophisticated way to deal with patient aggression. The current understanding of how to deal with patient aggression aligns with the use of power in the first dimension and, therefore, overlooks less manifest types of power. This thesis makes three contributions to the literature on patient aggression. First, it offers insights into different constructions of meaning based on the nature of the interaction. Second, it clarifies how business models shape ways general practices interact with their patients. In departing from a mere behavioural focus, data analysis focuses on processes behind the social construction of ‘patient aggression’ and examines organisational characteristics that determine the use of power to deal with aggression. Third, this thesis contributes to the literature that applies Lukes’ (2005) framework to the examination of organisational phenomena. The findings help in identifying organisational features that influence interactions with patients. Implications for further research include the application of a similar design to a rural-urban comparison, specialist care settings, and a cross-national study. It is also of interest to further explore the impact of the organisational context on other phenomena.
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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.