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TitlePersonal accounts in medical encounters
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Table of Contents
                            Blank Page
73480_Paper1_83.pdf
	Introduction
	Methods and materials
		Group 1 - Senior GPs
		Group 2 - Junior GPs
		Interview Settings
		Transcription
		Analysis and interpretation
		Phenomenological-Hermeneutical Analysis
		Discourse Analysis
		Research Ethics
	Results
		Part A: Phenomenological-Hermeneutical Analysis
		Interpretation based on the doctors’ self-understanding
		Interpretation based on general understanding - the object-centered approach
		Interpretation based on general understanding – the subject-centered approach
	Part B: Discourse Analysis
		Structural Features – external
		Structural Features – internal
		Linguistic Features – language
		Linguistic Features – syntax
		Linguistic Features – metaphors
		Exploration and Reflection
		Different ways of knowing
		Conflicting Values
		Ethics Versus Law
		Wider Frameworks
		Reflections on Validity
	Conclusions and Implications
	Acknowledgements
		Declaration of Conflicting Interests
		Funding
	References
                        
Document Text Contents
Page 1

Bente Prytz Mjølstad

KNOWING PATIENTS
AS PERSONS

A theory-driven, qualitative study of the
relevance of person-related knowledge
in primary health care

Thesis for the degree of Philosophiae Doctor

Trondheim, September 2015

Norwegian University of Science and Technology
Faculty of Medicine
Department of Public Health and General Practice,
General Practice Research Unit

Page 2

NTNU
Norwegian University of Science and Technology

Thesis for the degree of Philosophiae Doctor

Faculty of Medicine
Department of Public Health and General Practice,
General Practice Research Unit

© Bente Prytz Mjølstad

ISBN 978-82-326-1100-3 (print)
ISBN 978-82-326-1101-0 (digital)
ISSN 1503-8181

Doctoral theses at NTNU, 2015:222

Printed by NTNU Grafisk senter

Page 107

103



Results

Each GP made rehabilitation recommendations which included statements regarding both the

patient’s personality and life circumstances. GPs who had developed a personal, long-term

doctor-patient relationship formulated recommendations more in accordance with the

patients’ own preferences than did the GPs who were less familiar with their patients’ lives.

Despite their physical and/or mental impairments, every patient was able to delineate,

coherently and in detail, her or his specific needs for rehabilitation. A wide variety of issues

were at the core of the patients’ actual needs, the specificity of which mirrored fundamental

particularities of their individual life-world. Certain wishes could easily be integrated into the

institutional program while others seemed to go beyond the scope of the institution’s

repertoire.

A comparison of the GPs’ recommendations and the patients’ wishes on the one hand and the

actual rehabilitation scheme on the other revealed a series of minor and major mismatches.

The nursing home staff made an individualized selection of therapeutic interventions based on

pre-defined and standardized treatment approaches, yet without personalizing these.

Conclusions

We found that the institutional voice of medicine tended to override the voice of the patient’s

life-world; that is, patients’ stories were subordinated the institution’s routines. Consequently,

and despite the institution’s best intentions, the staff’s efforts to provide appropriate

rehabilitation in every case was, to some extent, jeopardized.

Implications

We propose a closer collaboration between the GP and the institution aimed at eliciting and

exploring information specific to the context of every particular patient. Furthermore, we

advise the development of a more flexible and person-oriented conceptualization and

application of patient care plans, more genuinely and precisely tailored to allow for the “best

possible approach to this specific person’s life-world.”

6.2 Results not published in the papers

Both GP groups participating in the focus group study were asked for advice concerning the

eventual role of GPs in the intervention study, regarding both the most appropriate way to

Page 108

104



approach GPs and the potential ethical problems linked to exploring person-related

knowledge. As discussed in paper 1, both groups associated medico-ethical consideration

with the various types of knowledge being discussed.

Confident of the significance of person-related knowledge, the seniors said they would not

hesitate to relate such knowledge, provided the patient had given consent (or, were the patient

incapable of consenting, with the consent of the patient’s next of kin). As the nature of this

knowledge is tacit and not easy to articulate in written language, they felt that the best way to

transmit it would be verbally, ideally in a face-to-face encounter between the GP and the

health personnel at the nursing home. Being realistic about the time constraints in primary

health care, however, a phone call would be considered a good alternative.

The junior GPs, on the other hand, said they would be hesitant to share their subjective

experiences of the patient with an unknown colleague calling from a nursing home, though

they clearly acknowledged the potential medical relevance of this knowledge. Their primary

concern, as described in paper 1, regarded the risk of being criticized for basing medical

advice on their personal (subjective) judgments. Both groups of GPs mentioned that some

patients might object to having information about their personal situation be transmitted, and

thereby risking to prejudice the health personnel they met and to deprive them of an

opportunity to make a new start, to “turn over a new leaf” (e.g. hoping to avoid stigmatization

by not having their “old” alcoholism mentioned to new health personnel).

Conclusions

The initial study documented that GPs’ reflections and decisions were strongly impacted by

experience, leading them to become increasingly oriented towards solutions adapted to each

patient’s life circumstances. We propose using the term “situated gaze” to conceptualize

experienced GPs’ purposeful application of person-oriented knowledge.

Page 213

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Appendix:

Example of stepwise analysis patient A.

GP A’s recommendations:

-Important to focus on the stressful home situation

involving marital strain.

-Important to provide relief for caretaker (wife).

Patient A’s expressed concerns and wishes:

-Worried about the difficult situation at home due to

marital strain.

-Existential worries regarding sickness and death due to

Parkinson’s disease.

-Desire to receive physical training to improve his ability

to walk.

Patient A’s biographical record:

‘‘Patient A is worried about his strained marriage

and very difficult home situation. He wants to receive

physical training to help improve his ability to walk.

He has many questions about his chronic disease;

he knows two people who died from Parkinson’s

and is anxious regarding whether he too will die of

the disease. His GP emphasizes that the most

import issue to address during the patient’s stay is

how to safeguard his care in the future, which seems

endangered by marital strain.’’

Actual interventions as identified in patient’s

medical records:

-Medical examination (report from consulting physician)

-Structured physiotherapy (report from physiotherapist)

-Social activity, training of activities of daily living

(ADL) (reports from nurses)

Observation concerning the actual interven-

tions as recorded in the field notes:

‘‘The consulting physician has not talked to the

patient about his stated concerns and neither has

anyone else (nurses).’’

Standardization meets stories

Citation: Int J Qualitative Stud Health Well-being 2013;8: 21498 - http://dx.doi.org/10.3402/qhw.v8i0.21498 17
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Page 214

Patient A’s comment on actual interventions

(from vignette in Box 1):

I: Did the consulting physician talk to you about these

matters?

PA: Well � hello! [Ironic, meaning ‘‘No way!’’]
I: So the doctor didn’t talk to you?

PA: The doctor came by my room the other day and

asked; ‘‘How are you doing?’’ What else could I answer

but: ‘‘Fine � under the circumstances.’’
I: So you did have a conversation with the doctor?

PA: I wouldn’t call it a conversation. The doctor just

popped in and then left.

B. P. Mjølstad et al.

18
(page number not for citation purpose)

Citation: Int J Qualitative Stud Health Well-being 2013; 8: 21498 - http://dx.doi.org/10.3402/qhw.v8i0.21498

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