A doctor close at hand: How GPs view their role in cancer care

Exploring why European primary care physicians sometimes do not think of, or act on, a possible cancer diagnosis. A qualitative study

BACKGROUND

While primary care physicians (PCPs) play a key role in cancer detection, they can find cancer diagnosis challenging, and some patients have considerable delays between presentation and onward referral.

AIM

To explore European PCPs' experiences and views on cases where they considered that they had been slow to think of, or act on, a possible cancer diagnosis.

DESIGN & SETTING

A multicentre European qualitative study, based on an online survey with open-ended questions, asking PCPs for their narratives about cases when they had missed a diagnosis of cancer.

METHOD

Using maximum variation sampling, PCPs in 23 European countries were asked to describe what happened in a case where they were slow to think of a cancer diagnosis, and for their views on why it happened. Thematic analysis was used to analyse the data.

RESULTS

A total of 158 PCPs completed the questionnaire. The main themes were as follows: patients' descriptions did not suggest cancer; distracting factors reduced PCPs' cancer suspicions; patients' hesitancy delayed the diagnosis; system factors not facilitating timely diagnosis; PCPs felt that they had acted wrongly; and problems with communicating adequately.

CONCLUSION

The study identified six overarching themes that need to be addressed. Doing so should reduce morbidity and mortality in the small proportion of patients who have a significant, avoidable delay in their cancer diagnosis. The 'Swiss cheese' model of accident causation showed how the themes related to each other.

Primary care practitioners' priorities for improving the timeliness of cancer diagnosis in primary care: a European cluster-based analysis

BACKGROUND

Diagnosing cancer at an early stage increases the likelihood of survival, and more advanced cancers are more difficult to treat successfully. Primary care practitioners (PCPs) play a key role in timely diagnosis of cancer. PCPs' knowledge of their own patient populations and health systems could help improve the planning of more effective approaches to earlier cancer recognition and referral. How PCPs act when faced with patients who may have cancer is likely to depend on how their health systems are organised, and this may be one explanation for the wide variation on cancer survival rates across Europe.

OBJECTIVES

To identify and characterise clusters of countries whose PCPs perceive the same factors as being important in improving the timeliness of cancer diagnosis.

METHODS

A cluster analysis of qualitative data from an online survey was carried out. PCPs answered an open-ended survey question on how the speed of diagnosis of cancer in primary care could be improved. Following coding and thematic analysis, we identified the number of times per country that an item in a theme was mentioned. k-means clustering identified clusters of countries whose PCPs perceived the same themes as most important. Post-hoc testing explored differences between these clusters.

SETTING

Twenty-five primary care centres in 20 European countries. Each centre was asked to recruit at least 50 participants.

PARTICIPANTS

Primary care practitioners of each country.

RESULTS

In all, 1,351 PCPs gave free-text answers. We identified eighteen themes organising the content of the responses. Based on the frequency of the themes, k-means clustering identified three groups of countries. There were significant differences between clusters regarding the importance of: access to tests (p = 0.010); access to specialists (p = 0.014), screening (p < 0.001); and finances, quotas & limits (p < 0.001).

CONCLUSIONS

Our study identified three distinct clusters of European countries within which PCPs had similar views on the factors that would improve the timeliness of cancer diagnosis. Further work is needed to understand what it is about the clusters that have produced these patterns, allowing healthcare systems to share best practice and to reduce disparities.

Specialist and Primary Physicians' Experiences and Perspectives of Collaboration While Caring for Palliative Patients-A Qualitative Study

Increasing numbers of people living with chronic and life-limiting diseases are actualising a greater need for palliative care. Physicians are an important provider for identifying the need for palliation, and effective follow-up requires physician collaboration across different service levels. This study aimed to explore and describe how physicians in hospitals and municipalities experience their roles and interactions in the care of palliative patients. Pair interviews were performed with seven physicians working in hospitals, primary care and nursing homes in Mid-Norway. Systematic text condensation was used to analyse the data, resulting in three main themes: The boundaries of palliative care, Alternating understandings of roles and Absence of planning. The physicians' interactions with palliative patients appeared as a fragmented distribution of tasks rather than a real collaboration with shared responsibility. At both levels, the physicians seemed to assume withdrawn roles as a reaction to unclear and unspoken expectations and to avoid interfering with others' responsibilities. Moreover, their understanding of palliative care and which groups should be included varied. Realising a collaboration between physicians that is beneficial for both patients and physicians, greater openness and real arenas for discussion and decision-making support are required.

Talking together in rural palliative care: a qualitative study of interprofessional collaboration in Norway

Background

Caring for people with palliative care needs in their homes requires close collaboration within and between primary and hospital care. However, such close collaboration is often lacking. Transitions of care are potentially unsafe and distressing points in a patient trajectory. Few studies have explored the experiences of healthcare professionals in the community who receive patients from hospital care and provide them with palliative care at home.

Objective

To explore how rural health professionals experience local and regional collaboration on patients in need of palliative care.

Methods

This was a qualitative focus group and interview study in rural Northern Norway involving 52 primary care health professionals including district nurses, general practitioners, oncology nurses, physiotherapists, and occupational therapists. Five uni-professional focus group discussions were followed by five interprofessional discussions and six individual interviews. Transcripts were analysed thematically.

Results

“Talking together” was perceived as the optimal form of collaboration, both within primary care and with specialists. Nurses and GPs had similar perceptions of their worst-case scenario in primary palliative care: the sudden arrival after working hours of a sick patient about whom they lacked information. These situations could be the result of a short notice transfer from secondary care or an emergency presentation after a crisis in patient management locally, the latter often resulting in a hospital admission. Participants missed timely and detailed discharge letters and in complex cases a telephone call or conference. Locally, co-location was perceived as advantageous for crucial communication, mutual support, and knowledge about each other’s competencies and work schedule. Because local health professionals belonged to different units within the primary health care organisation, in some places they had limited knowledge about each other’s roles and skill sets.

Conclusions

Lack of communication, both locally and between specialist and primary care, was a key factor in the worst-case patient scenarios for GPs and nurses working in primary palliative care in rural Northern Norway. Co-location of primary care professionals promoted local collaboration and should be encouraged. Hospital discharge planning should involve the receiving primary care professionals.

General practitioner responses to concerns in chronic care consultations for patients with a history of cancer

We investigated general practitioners' (GPs') responses to patients' concerns in chronic care consultations. Video recordings of 14 consultations were analyzed with conversation analysis. We found two categories of responses: exiting and exploring the patient's concerns. Most GPs exited the concern by interrupting the patient, acknowledging the concern but then referring back to the progression of the consultation, or affiliating with the concern without exploring it. Only a few raised concerns were explored, and then most often the somatic rather than the emotional aspects of them. The findings point to the risk of missing patients' voiced concerns in consultations with a fixed agenda.

Improving communication between the general practitioner and the oncologist: a key role in coordinating care for patients suffering from cancer

Background

Patients suffering from cancers are increasingly numerous in general practice consultations. The General Practitioner (GP) should be at the heart of the management of patients. Several studies have examined the perceptions of GPs confronted with the patient suffering from cancer and the relationships of GPs with oncologists, but few studies have focused on the patients’ perspective. We studied the three-way relationship between the oncologist, the GP, and the patient, from the patient’s point of view.

Methods

A questionnaire validated by a group consisting of GPs, oncologists, nurses, an epidemiologist and quality analyst, was administered over a three-week period to patients suffering from cancer receiving chemotherapy in a day hospital.

Results

The analysis was based on 403 questionnaires. Patients had confidence in the GP’s knowledge of oncology in 88% of cases; 49% consulted their GP for pain, 15% for cancer-related advice, and 44% in emergencies. Perceived good GP/oncologist communication led patients to turn increasingly to their GP for cancer-related consultations (RR = 1.14; p = 0.01) and gave patients confidence in the GP’s ability to manage cancer-related problems (RR = 1.30; p < 0.01). Mention by the oncologist of the GP’s role increased the consultations for complications (RR = 1.82; p < 0.01) as well as recourse to the GP in an emergency (RR = 1.35; p < 0.01).

Conclusion

Patients suffering from cancer considered that the GP was competent, but did not often consult their GP for cancer-related problems. There is a discrepancy between patients’ beliefs and their behaviour. When the oncologist spoke to patients of the GP’s role, patients had recourse to their GP more often. Systematically integrating a GP consultation to conclude cancer diagnosis disclosure, could improve management and care coordination.

'I had to tell my GP I had lung cancer': patient perspectives of hospital- and community-based lung cancer care

Lung cancer care spans both hospital- and community-based healthcare settings, and suboptimal communication between healthcare providers impacts on continuity and quality of care. Patients' experiences regarding: (1) communication between healthcare providers; and (2) the role of their GP during cancer treatment was explored in interviews with 47 Western Australian lung cancer patients. Thematic analysis using a phenomenological approach was undertaken to derive key themes regarding participant experiences. Poor communication between hospital cancer specialists (HCSs) influenced participants' treatment choices and perceptions of the quality of their care. Information provided by HCSs to GPs was often delayed or incomplete, and many participants perceived themselves as a messenger between healthcare settings. Participants' opinions about the GP role during cancer treatment ranged from 'no role' to an 'active member of the treating team'. A new model of cancer care is needed where the GP is considered part of the treating team. Early involvement of GPs and two-way communication between hospital and primary care during the disease continuum is required for this to occur.

How European primary care practitioners think the timeliness of cancer diagnosis can be improved: a thematic analysis

BACKGROUND

National European cancer survival rates vary widely. Prolonged diagnostic intervals are thought to be a key factor in explaining these variations. Primary care practitioners (PCPs) frequently play a crucial role during initial cancer diagnosis; their knowledge could be used to improve the planning of more effective approaches to earlier cancer diagnosis.

OBJECTIVES

This study sought the views of PCPs from across Europe on how they thought the timeliness of cancer diagnosis could be improved.

DESIGN

In an online survey, a final open-ended question asked PCPs how they thought the speed of diagnosis of cancer in primary care could be improved. Thematic analysis was used to analyse the data.

SETTING

A primary care study, with participating centres in 20 European countries.

PARTICIPANTS

A total of 1352 PCPs answered the final survey question, with a median of 48 per country.

RESULTS

The main themes identified were: patient-related factors, including health education; care provider-related factors, including continuing medical education; improving communication and interprofessional partnership, particularly between primary and secondary care; factors relating to health system organisation and policies, including improving access to healthcare; easier primary care access to diagnostic tests; and use of information technology. Re-allocation of funding to support timely diagnosis was seen as an issue affecting all of these.

CONCLUSIONS

To achieve more timely cancer diagnosis, health systems need to facilitate earlier patient presentation through education and better access to care, have well-educated clinicians with good access to investigations and better information technology, and adequate primary care cancer diagnostic pathway funding.

Teamwork in primary palliative care: general practitioners' and specialised oncology nurses' complementary competencies

BACKGROUND

Generalists such as general practitioners and district nurses have been the main actors in community palliative care in Norway. Specialised oncology nurses with postgraduate palliative training are increasingly becoming involved. There is little research on their contribution. This study explores how general practitioners (GPs) and oncology nurses (ONs) experience their collaboration in primary palliative care.

METHODS

A qualitative focus group and interview study in rural Northern Norway, involving 52 health professionals. Five uni-professional focus group discussions were followed by five interprofessional discussions and six individual interviews. Transcripts were analysed thematically.

RESULTS

The ideal cooperation between GPs and ONs was as a "meeting of experts" with complementary competencies. GPs drew on their generalist backgrounds, including their often long-term relationship with and knowledge of the patient. The ONs contributed longitudinal clinical observations and used their specialised knowledge to make treatment suggestions. While ONs were often experienced and many had developed a form of pattern recognition, they needed GPs' competencies for complex clinical judgements. However, ONs sometimes lacked timely advice from GPs, and could feel left alone with sick patients. To avoid this, some ONs bypassed GPs and contacted palliative specialists directly. While traditional professional hierarchies were not a barrier, we found that organization, funding and remuneration were significant barriers to cooperation. GPs often did not have time to meet with ONs to discuss shared patients. We also found that ONs and GPs had different strategies for learning. While ONs belonged to a networking nursing collective aiming for continuous quality improvement, GPs learned mostly from their individual experience of caring for patients.

CONCLUSIONS

The complementary competences and autonomous roles of a specialised nurse and a general practitioner represented a good match for primary palliative care. When planning high-quality teamwork in primary care, organizational barriers to cooperation and different cultures for learning need consideration.

The role of the general practitioner in cancer care: a survey of the patients' perspective

PURPOSE

Modern cancer care is provided in highly specialized structures as certificated centres and comprehensive cancer center, as well as specialized practices. In contrast, the position of the general practitioner (GP) is less well characterised and there is a lack of information about his importance in the care for cancer patients. The aim of our survey was to assess the role of GPs in German cancer care from patients' perspective.

METHODS

In several steps we developed a standardized anonymous questionnaire in cooperation with the German Association of General Practitioners and the Federal Association of German Self-Help Groups. This questionnaire was used in a print and an online version and distributed by the self-help organizations to their members.

RESULTS

Seven hundred and forty participants took part in the survey, 66.5% women and 30.1% men. 71% had visited the GP during cancer therapy and 34.5% discussed decisions concerning diagnostics and therapy with him. The most relevant reasons to visit the GP during cancer therapy were to get a blood test (63.3%), comorbidities (42.7%) and complaints and side effects (38.3%). For the latter, most often a detailed discussion ensued (57%), fooled by a prescription (37.7%). In 63.4% the GP offered support when patients had some questions or worries concerning their cancer. Yet, 17% of the patients reported that the GP did not try to help. 85.5% of the participants thought that it is important that their GP is informed about the therapy on a regular basis. For 77.0%, a simultaneous care provided by the GP is important or very important.

CONCLUSION

Our survey points to the importance of the GP during cancer therapy from the patient's point of view. Patients want their GP to take an active part in the cancer therapy. Furthermore, early integration of the GP may also enhance early integration of palliative care and also help family members and caregivers. A strategy to integrate GPs is the establishment of shared care models, in which GPs are supported by specialists and get additional training in cancer care.

Primary Care Physicians' Perspectives of Their Role in Cancer Care: A Systematic Review

BACKGROUND

As survival rates improve, cancer is increasingly considered a chronic illness associated with significant long-term burden and sequelae, both physical and psychological. Various models of cancer care, including primary care physician (PCP)-led and shared-care, have been proposed, though a systematic review of PCPs' perspectives of their role and challenges in providing cancer care remains lacking. This systematic review summarises available literature on PCPs' perspectives of their role in cancer care.

METHODS

Five databases (MEDLINE, MEDLINE In-Process, EMBASE, PsycINFO and CINAHL) were systematically searched using keywords and MeSH headings for articles from 1993-2015 exploring PCPs' views of their role in the care of patients/survivors of both child and adult cancers. Two independent reviewers screened abstracts for full-text review, abstracted data and performed a quality assessment.

RESULTS

Thirty-five articles representing the perspectives of 10,941 PCPs were captured. PCPs' confidence to provide care varied according to cancer phase (e.g. treatment versus survivorship), care domain (e.g. acute medical care versus psychological late effects), and disease prevalence (e.g. breast malignancies versus childhood cancers), with preferences for shared- versus independent-care models varying accordingly. Barriers included a lack of timely and specific information/communication from oncologists and limited knowledge/lack of guidelines, as well as lack of time, remuneration and patient trust.

LIMITATIONS

The data was limited by a lack of consideration of the preferences of patients and oncologists, leading to uncertainty about the acceptability and feasibility of suggested changes to cancer care.

DISCUSSION

PCPs appear willing to provide cancer care for patients/survivors; however, they report barriers and unmet needs related to providing such care. Future research/interventions should take into account the preferences and needs of PCPs.

How to report professional practice in nursing? A scoping review

BACKGROUND

Nursing professional practice in different contexts of care has been widely described in evidence-based literature. Currently, there is no consensus on a common structure for these descriptions. Understanding and comparing similar practices is made difficult by the varying nature of descriptions provided in scientific literature.

PURPOSE OF THE STUDY

1) to report research methods found in the scientific literature that were used to describe the practice of different health professionals; 2) to report on the main concepts used to describe the practice of these health professionals; 3) to propose a structure for the description of the practice in nursing.

METHODS

A scoping review following a five-stage approach: 1) identifying the research question; 2) identifying relevant studies; 3) selecting studies; 4) charting data; 5) reporting results. The Medline, CINAHL, psychARTICLES, psyCRITIQUES, psycEXTRA, Psychology and Behavioral Science Collection and psycINFO databases were searched. Each study was analyzed and extracted data were classified by categories and structures used to describe the health professional practices.

RESULTS

Forty-nine studies were included. In these studies, quantitative, qualitative or mixed methods were used to describe professional practice in different health disciplines. Three major concepts were reported most frequently in describing professional practice: roles, domains and activities. The concepts varied greatly among authors. We found that to define roles or to characterize a professional practice, activities must be described and organized on the basis of different domains.

CONCLUSIONS

A promising structure for describing nursing professional practice is proposed by the authors of this review. The structure facilitates the accurate description of all domains and activities performed by nurses in different contexts of practice, and will contribute to the development of knowledge about nursing practice in different contexts based on shared concepts.

The role of the GP in follow-up cancer care: a systematic literature review

PURPOSE

The purpose of the present study is to explore the role of the general practitioners, family physicians and primary care physicians (GP) in the provision of follow-up cancer care.

METHODS

PubMed, MEDLINE and CINAHL were systematically searched for primary research focussing on the role of the GP from the perspective of GPs and patients. Data were extracted using a standardised form and synthesised using a qualitative descriptive approach.

RESULTS

The initial search generated 6487 articles: 25 quantitative and 33 qualitative articles were included. Articles focused on patients' and GPs' perspectives of the GP role in follow-up cancer care. Some studies reported on the current role of the GP, barriers and enablers to GP involvement from the perspective of the GP and suggestions for future GP roles. Variations in guidelines and practice of follow-up cancer care in the primary health care sector exist. However, GPs and patients across the included studies supported a greater GP role in follow-up cancer care. This included greater support for care coordination, screening, diagnosis and management of physical and psychological effects of cancer and its treatment, symptom and pain relief, health promotion, palliative care and continuing normal general health care provision.

CONCLUSION

While there are variations in guidelines and practice of follow-up cancer care in the primary health care sector, GPs and patients across the reviewed studies supported a greater role by the GP.

IMPLICATIONS FOR CANCER SURVIVORS

Greater GP role in cancer care could improve the quality of patient care for cancer survivors. Better communication between the tertiary sector and GP across the cancer phases would enable clear delineation of roles.

Preparing general practitioners to receive cancer patients following treatment in secondary care: a qualitative study

Background

Many patients consider the interface between secondary and primary care difficult, and in particular, the transition of care between these different parts of the healthcare system presents problems. This interface has long been recognized as a critical point for quality of care. The purpose of our study is to formulate solutions to problems identified by cancer patients and healthcare professionals during the transition from hospital back to general practice on completion of primary treatment for cancer.

Methods

A qualitative study based on focus groups at a seminar for professionals in both primary and secondary healthcare. Participants discussed solutions to problems which had previously been identified in patient interviews and in focus groups with general practitioners (GPs), hospital doctors, and nursing staff. The data were analyzed using framework analysis.

Results

Solutions, endorsed by all groups at the seminar to improve transition back to general practice after primary treatment for cancer, were: 1) To add nurses’ discharge letters addressing psychosocial matters to medical discharge letters; 2) To send medical discharge letters earlier from some hospital departments to GPs; 3) To provide plans and future affiliations for patients when they leave a department, and 4) To arrange a return visit to general practice dedicated to discussion of the patients’ cancer disease and the treatment experience.

Conclusions

The transition of care of cancer patients appears too complex to be coordinated by administrative standards alone. We recommend that healthcare professionals are more engaged and present in the coordination of care across organizational boundaries.

General practitioners' attitudes toward follow-up after cancer treatment: A cross-sectional questionnaire study

OBJECTIVE

An increasing number of cancer patients place a significant workload on hospital outpatient clinics, and health authorities are considering alternative follow-up regimens. It has been suggested that follow-up of cancer patients could be provided by GPs. This study aimed to explore GPs' experiences with the provision of follow-up care for cancer patients, and their views on assuming greater responsibility in the future.

DESIGN

Electronic questionnaire study.

SUBJECTS

GPs in seven regions in Norway.

RESULTS

A total of 317 GPs responded. Many GPs reported experience in providing follow-up care to cancer patients, during the years following initial diagnosis primarily in collaboration with hospital specialists. More than half of the GPs were satisfied with their collaboration. Most GPs preferred to be involved at an early stage in follow-up care and, generally, GPs felt confident in their skills to provide this type of service. Fewer than 10% were willing to assume responsibility for additional cancer patients, citing potentially increased workload as the main reason.

CONCLUSIONS

GPs acknowledged the importance of providing follow-up care to cancer patients, and the majority felt confident in their own ability to provide such care. However, they were hesitant to assume greater responsibility primarily due to fears of increased workload. Key Points It has been suggested that follow-up of cancer patients can be provided by general practitioners (GPs). The viewpoints and attitudes of GPs regarding such follow-up were investigated. GPs reported broad experience in providing follow-up care to patients after active cancer treatment. GPs acknowledged the importance of follow-up care, and they felt confident in their own ability to provide such care. Fewer than 10% of GPs were willing to assume responsibility for additional cancer patients, citing potentially increased workload as the main reason.

Increased primary health care use in the first year after colorectal cancer diagnosis

OBJECTIVE

The view that the general practitioner (GP) should be more involved during the curative treatment of cancer is gaining support. This study aimed to assess the current role of the GP during treatment of patients with colorectal cancer (CRC).

DESIGN

Historical prospective study, using primary care data from two cohorts.

SETTING

Registration Network Groningen (RNG) consisting of 18 GPs in three group practices with a dynamic population of about 30,000 patients.

SUBJECTS

Patients who underwent curative treatment for CRC (n = 124) and matched primary care patients without CRC (reference population; n = 358).

MAIN OUTCOME MEASURES

Primary healthcare use in the period 1998-2009.

FINDINGS

Patients with CRC had higher primary healthcare use in the year after diagnosis compared with the reference population. After correction for age, gender, and consultation behaviour, CRC patients had 54% (range 23-92%) more face-to-face contacts, 68% (range 36-108%) more drug prescriptions, and 35% (range -4-90%) more referrals compared with reference patients. Patients consulted their GP more often for reasons related to anaemia, abdominal pain, constipation, skin problems, and urinary infections. GPs also prescribed more acid reflux drugs, laxatives, anti-anaemic preparations, analgesics, and psycholeptics for CRC patients.

CONCLUSIONS

The GP plays a significant role in the year after CRC diagnosis. This role may be associated with treatment-related side effects and psychological problems. Formal guidelines on the involvement of the GP during CRC treatment might ensure more effective allocation and communication of care between primary and secondary healthcare services.

German general practitioners' views on their involvement and role in cancer care: a qualitative study

BACKGROUND

The multidisciplinary and sequential nature of cancer care makes continuity of care for patients difficult. Cancer patients have often known their general practitioners (GPs) for years and are often in constant contact with them. Objective(s). We examined German GPs' views on their involvement in the care of cancer patients.

METHODS

We conducted semi-structured interviews with 30 German GPs. Purposeful sampling was applied to secure maximum heterogeneity. Interviews were recorded, transcribed and then analyzed using qualitative content analysis according to Mayring.

RESULTS

GPs perceive a clear involvement in the latter phase of cancer care but a mainly sporadic role (as and when required) in earlier phases. They think that greater care contributions from GPs are generally beneficial to cancer patients, as their ability to take the patient's history, surroundings and co-morbidities into account enables them to provide more patient-centred care. GPs want to stay involved and to know how their cancer patients are progressing, and they complain about slow or non-existent information sharing between providers, as well as insufficient care coordination. They pro-actively try to overcome these obstacles through direct contact with patients and physicians, and by building networks of trusted care providers.

CONCLUSIONS

Given their long-lasting and close relationships with cancer patients, GPs are in a position to accompany them throughout the whole process of cancer care. However, such general involvement is as yet uncommon. Shared care models may have the potential to take into account the complementary character of primary and specialist care.

O papel do profissional da Atenção Primária à Saúde em cuidados paliativos

Introdução: O cuidado a pacientes em fase final da vida é cada vez mais frequente nos serviços de saúde devido ao progressivo envelhecimento da população e o consequente aumento de pacientes com doenças graves. No Brasil, os poucos serviços de cuidados paliativos geralmente estão ligados a hospitais especializados, mas, em vários países, a Atenção Primária à Saúde (APS) é considerada o melhor nível de assistência para a prestação e coordenação dos cuidados paliativos de seus usuários. Métodos: Neste estudo realizou-se uma revisão integrativa de literatura, objetivando compreender quais os papéis dos profissionais da APS em cuidados paliativos. Resultados: Os textos selecionados foram submetidos à análise temática, emergindo oito categorias que descrevem o papel dos profissionais de APS em cuidados paliativos e evidenciam que sua participação é essencial: 1) Possibilitar o cuidado domiciliar; 2) Garantir assistência com integralidade; 3) Utilizar a longitudinalidade como ferramenta de cuidado; 4) Responsabilizar-se pelo cuidado paliativo com a família; 5) Buscar aprimoramento profissional em cuidados paliativos; 6) Viabilizar a coordenação do cuidado; 7) Facilitar o acesso do paciente a cuidados paliativos e sua família; 8) Trabalhar em parcerias dentro e fora da APS. Conclusão: O acesso facilitado a cuidados paliativos, próximo ao lar, associado ao manejo constante dos sintomas e à sensibilidade para com a realidade das famílias, faz toda a diferença para os pacientes em fase final da vida.

The impact of knowledge, attitudes and beliefs on the engagement of primary and community-based healthcare professionals in cancer care: a literature review

BACKGROUND

Primary health services are well placed to reinforce prevention, early intervention, and connected care. Despite this important role, primary care providers (PCPs) have a limited capacity to meet the varied needs of people with cancer and their carers - furthermore, the reasons for this largely remain unexplored.

SCOPE

To identify: (1) the knowledge, attitudes, and beliefs held by health professionals and patients that can influence the engagement of PCPs with the early detection of cancer and follow-up care; (2) evidence that attitudes and beliefs can be modified with measureable impact on the engagement of PCPs with cancer care; and (3) potential targets for intervention. This was achieved through a review of English publications from 2000 onwards, sourced from six academic databases and complemented with a search for grey literature.

FINDINGS

A total of 4212 articles were reviewed to identify studies conducted in the UK, Canada, Holland (or The Netherlands), Australia, or New Zealand given the comparable role of PCPs. Several factors hinder PCP participation in cancer care, all of which are related to knowledge, attitudes, and beliefs. Patients and specialists are uncertain about the role that primary care could play and whether their primary care team has the necessary expertise. PCPs have varied opinions about the ideal content of follow-up programs. Study limitations include: the absence of well accepted definitions of key terms; the indexing systems used by databases to code publications, which may have obscured all relevant publications; the paucity of robust research; and possible researcher bias which was minimized through independent review by trained reviewers and the implementation of rigorous inter-rater reliability measures.

CONCLUSIONS

Knowledge, attitudes, and beliefs influence PCP engagement in cancer care. It is important to develop shared understandings of these terms because the knowledge, attitudes, and beliefs of PCPs, specialists, patients, and their families can influence the effectiveness of treatment plans.

Patients' experience with cancer care: a qualitative study in family practice

BACKGROUND

Continuity is an important aspect of cancer care that is often a challenge owing to the movement of patients between family practice, cancer clinics, and hospitals.

OBJECTIVES

To investigate the experiences of cancer patients in relation to continuity of care.

METHODS

A qualitative study was conducted in a family practice setting. Semi-structured interviews were used for data collection. 10 cancer patients with a wide variation in their disease duration and experiences with medical care were interviewed. Open questions were used to encourage patients to express their personal experiences with cancer care. The interviews were recorded, transcribed and analysed by three researchers using thematic analysis.

RESULTS

Cancer patients experienced a lack of information concerning cancer and its treatment. They also perceived that the cancer treatment made them suffer. In the patients' opinion, the family doctor has a limited role in cancer care. However, the patients felt that the family doctor should be aware of their health. The patients' satisfaction with the oncologist's care was high. They considered that their role in cancer care was to mediate an exchange of information between the oncologist and the family doctor.

CONCLUSION

Cancer patients experience continuity of care in several ways: continuity in cancer care should be implemented by co-ordinating activities, such as regular check-ups, a clear timeframe and provision of adequate information. In addition, communication between the primary and secondary sector could be improved.

How does the thought of cancer arise in a general practice consultation? Interviews with GPs

BACKGROUND

Only a few patients on a GP's list develop cancer each year. To find these cases in the jumble of presented problems is a challenge.

OBJECTIVE

To explore how general practitioners (GPs) come to think of cancer in a clinical encounter.

DESIGN

Qualitative interviews with Norwegian GPs, who were invited to think back on consultations during which the thought of cancer arose. The 11 GPs recounted and reflected on 70 such stories from their practices. A phenomenographic approach enabled the study of variation in GPs' ways of experiencing.

RESULTS

Awareness of cancer could arise in several contexts of attention: (1) Practising basic knowledge: explicit rules and skills, such as alarm symptoms, epidemiology and clinical know-how; (2) Interpersonal awareness: being alert to changes in patients' appearance or behaviour and to cues in their choice of words, on a background of basic knowledge and experience; (3) Intuitive knowing: a tacit feeling of alarm which could be difficult to verbalize, but nevertheless was helpful. Intuition built on the earlier mentioned contexts: basic knowledge, experience, and interpersonal awareness; (4) Fear of cancer: the existential context of awareness could affect the thoughts of both doctor and patient. The challenge could be how not to think about cancer all the time and to find ways to live with insecurity without becoming over-precautious.

CONCLUSION

The thought of cancer arose in the relationship between doctor and patient. The quality of their interaction and the doctor's accuracy in perceiving and interpreting cues were decisive.

'I deal with the small things': the doctor-patient relationship and professional identity in GPs' stories of cancer care

An important part of GPs' work consists of attending to the everyday and existential conditions of human being. In these life world aspects, biomedicine is often not the relevant theory to guide the GP; nevertheless they are a part of GPs' professional domain. In cancer care, previous studies have shown that GPs with a biomedical perspective on medicine could feel subordinate to specialists, and that doctors with a curative focus could see disease progression as a personal failure. The aim of this study was to explore in depth the experiences of being a GP for people with advanced cancer. Fourteen Norwegian GPs were interviewed about accompanying patients through a cancer illness. Their stories were analysed using a narrative approach. The GPs expressed a strong commitment to these patients, a loyalty which in some cases could be weakened due to judgements of distant specialists. In view of the GPs' close knowledge of their patients' background and history this subordination was a paradox, mirroring a hierarchy of medical knowledge. The GPs had an ideal of honesty and openness about death, which they sometimes failed. To reach the ideal of honesty, clinicians would have to abandon the biomedical ideal of mastering human nature through interventions and acknowledge the fundamental uncertainty and finiteness of human life. GPs may learn from being with their patients that bodily and existential suffering are connected, and thus learn implicitly to overlook the body-mind dualism. This practical wisdom lacks a theoretical anchoring, which is a problem not only for general practice.

Can the APO method be used for measuring soft data?: a pilot study

OBJECTIVES

The aims were to develop auditing according to the APO (Audit Project Odense) method for measuring soft data, exemplified by a holistic view, and to test the instrument.

DESIGN

A descriptive study of the development of an APO chart and a test registration.

SETTING

Primary health care, Blekinge County, Sweden.

SUBJECTS

Ten general practitioners (GPs) were invited to transform categories of the concept of a holistic view obtained in an earlier study, into 30 variables on an APO registration chart. The participants chose to study different kinds of knowledge as aspects of holistic care.

MAIN OUTCOME MEASURE

An APO registration chart and test of the instrument.

RESULTS

After three meetings the group had drawn up an APO registration chart supplemented with Likert scales. A pilot audit was performed. Eight doctors registered 255 consultations. In assessment of the patients' problems, factual medical knowledge was important in 83% of the cases, familiarity in 53%, and a capacity for judgement in 36%. In decision-making factual medical knowledge was used in 88% and capacity for judgement in 58%. A holistic view was necessary for the outcome in 43% and valuable in 25%. The GPs used the Likert scales in a majority of the cases.

CONCLUSIONS

In this first step in developing an instrument, the results indicate that the APO method could be an alternative for studying what happens in the consultation, and the occurrence of an abstract phenomenon such as the use of different kinds of knowledge as part of a holistic view.