PubMed Health⌕ Search

Biomedical subjects

T Timpka

Publications and source records attributed to T Timpka.

At least 19 recordsLinked to original sources
PubMed1992

Patients comment on video-recorded consultations--the "good" GP and the "bad".

The aim of this study was to describe and understand patients' positive and negative experiences of General Practitioners (GPs). Forty-six consultations were videotaped in four primary health care centres in Sweden. Afterwards the patients commented on the recorded consultations. The comments were categorized and analyzed using an exploratory qualitative approach. An image of the "good" GP emerged that had two major characteristics: that of being a caring human; an individual who listens, understands, and is concerned. At the same time, the good GP acts like an ordinary person and treats the patient as an equal. The personal relationship with the GP also influenced the choice and course of medical interventions. For the patient, the manner in which an intervention is seen is linked to whether the GPs treats the patient with respect or not. A typical experience of a "bad" GP was that the GP appeared unreachable as a person. An example is when the patient feels that the GP was not taking his or her symptoms seriously. Another characteristic of the bad GP is failure to communicate to the patient his or her standpoint on issues raised during consultations.

Adult↗
PubMed1992

Dilemmas at a primary health care center: a baseline study for computer-supported cooperative health care work.

For the development of computer-supported cooperative health care work this study investigated, based upon activity theory, daily dilemmas encountered by the members of interprofessional primary health care work groups. The entire staff at four Swedish primary health care centers were surveyed, 199 personal interviews being conducted by the Critical Incident Technique. Medical dilemmas were mainly reported by general practitioners and nurses, organizational dilemmas by laboratory staff, nurses' aides, and secretaries, and dilemmas in the patient-provider relation by nurses, nurses' aides, and secretaries. Organizational and communication dilemmas reported by nurses, nurses' aides, and secretaries often had their cause outside the control of the individual professional. These dilemmas were often "caused" by other group members (general practitioners or nurses), e.g., by not keeping appointment times or by not sharing information with patients. The implication for computer-supported cooperative health care work is that computer support should be planned on two levels. Collective work activity as a whole should benefit from individual clinical decision support for general practitioners and nurses. However, since most patient communication and organizational problems occurred at group level, group process support is required in these areas.

Ambulatory Care Information Systems↗
PubMed1992

Developing a clinical hypermedia corpus: experiences from the use of a practice-centered method.

This paper outlines a practice-centered method for creation of a hypermedia corpus. It also describes experiences with creating such a corpus of information to support interprofessional work at a Primary Healthcare Center. From these experiences, a number of basic issues regarding information systems development within medical informatics will be discussed.

Hospital Information Systems↗
PubMed1991

What is going on when the general practitioner doesn't grasp the situation?

Forty-six consultations with 12 GPs in four primary health centres were videotaped. Afterwards the GPs commented on the tapes. Fourteen consultations, in which it was obvious that the GP felt uncertain and did not grasp the situation, were especially studied. One important contributing factor was that the GP often did not fully understand the patient's reason for the consultation. A general outcome was that the GP usually did not allow himself to use his feelings of uncertainty as useful information about the situation.

Adult↗
PubMed1991

Comparison of patients' and doctors' comments on video-recorded consultations.

To compare patient and doctor views of the consultation process, 46 consultations were videotaped in four primary health care centres. Twelve general practitioners and 46 patients participated. Later, the patients and the doctors (on different occasions) spontaneously commented on the recorded consultations. Qualitative methods were used for the analysis. The patients seemed to have a perspective oriented towards relationships, while the doctors were more oriented towards medical tasks. There was an association of power between the parties that implies a relationship of mutual dependency. The doctors depended on the patients to obtain the information they needed about the symptoms to be able to fulfil their professional task. The patients depended on the doctor to get their important needs satisfied; everything from a particular medicine to being treated as a human being. The major differences in the comments by the patients and the doctors reflected their different roles and the asymmetry in the relationship.

Adult↗
PubMed1991

Medical reasoning and patient requests in decision-making for female genitourinary infections.

The aim of this study was to investigate General Practitioners' (GPs') collection and analysis of data on women presenting with lower genitourinary (GU) complaints, also taking into account patient preferences. For 135 patients seen after nurse triage, eleven GPs recorded the clinical data they had explored, an evaluation of the patient's desire (or not) for medical interventions, a preliminary diagnosis with certainty estimate, and management actions. Whether a clinical data item was explored varied between 97% of the patients for fever to 15% for pelvic examination. Decisions regarding diagnosis followed to a large extent results from screening laboratory tests. For prescription of antibiotics the patient's desire (or not) for medical interventions was a significant discriminant. The GPs reported the lowest diagnostic certainty for diagnosis of urethritis, the highest for cystitis. Factors contributing to physicians' uncertainty in their decision-making were assumed patient reluctance for medical interventions and negative screening tests. In conclusion, patient requests and preferences significantly influenced the GPs, even though results from screening laboratory tests were mainly used as the basis for decisions. The high reliance on screening tests may often cause other clinical information to be neglected. Thus, the uncertainty regarding patients with negative laboratory test results may reflect that important information is not included in the clinical analysis.

Adult↗
PubMed1990

General practitioners' comments on video recorded consultations as an aid to understanding the doctor-patient relationship.

The aim of this study was to describe, understand and interpret physicians' experiences of consultations. Forty-six consultations were videotaped in four primary health care centres. Twelve general practitioners and 46 patients participated. Afterwards the patients and the physicians (on different occasions) commented on the recorded consultations. The comments were analysed from an inductive as well as a hypothetical-deductive model. The analyses agreed well with each other. The result demonstrated that the physicians often had difficulties understanding the patient, that they did not really know how to handle the conversation and felt that they did not really understand the context. The perceived relation to the patient was mainly related to the patients' ability to give adequate information. It is concluded that a key factor in communication is the difficulty which the physician has in understanding what the patient in fact wants-the failure to be on the same wavelength so that the message from the patient can be received.

Adult↗
PubMed1990

Urea kinetics and clinical evaluation of the haemodialysis patient.

Urea kinetic modelling (UKM) was performed on 62 patients in a haemodialysis unit not normally using kinetic methods. Without knowledge of the results, four nephrologists, four nurses and the patients themselves evaluated adequacy of dialysis (eAD) and daily protein intake (eDPI). Thirty-two patients had Kt/V less than 1.0, and 17 patients had Kt/V less than 0.9. Estimated improvement of the efficacy of treatment after the intervention of a physician was minor. Seven patients had a protein catabolic rate (pcr) at less than 0.8 g/kg per day. On average physicians identified five of these. Both nurses and doctors exhibited highly significant correlations between Kt/V and eAD, and between pcr and eDPI, but the correlation coefficients were generally modest (typically below 0.4). When patients evaluated themselves, no significant correlations were found. Examined individually, all four physicians' decisions about eAD correlated better with model-generated decisions than with eAD stated by their colleagues. It is concluded that UKM should be used to secure adequate and more uniform treatment prescription. There is no 'clinical standard' competing with UKM. Nurses make satisfactory evaluations compared to doctors, but the patients are unable to assess the adequacy of their dialysis or diet.

Adult↗
PubMed1990

The primary-care nurse's dilemmas: a study of knowledge use and need during telephone consultations.

In Sweden (population 8 million) there are 20 million calls every year to receptionist nurses at health-care centres. The aim of this study was, first, to develop a general description of these telephone consultations in terms of the decision-making process and interpersonal communication. Second, the dilemmas that receptionist nurses encounter were to be recorded and analysed. A two-level video method was used. At the first level, a video recording of the consultation was used to draw a 'consultation map'. At the second level, the receptionist nurses reviewed and commented on the video-recording using a 'freeze frame' technique for stimulated recall and the comments were categorized. Analysis of the consultation maps showed that the receptionist nurses focused mainly on tasks related to medical diagnosis and management strategy, with less time spent on the patient's concerns, ideas and expectations. Analysis of the dilemmas showed that medical dilemmas were the most frequent, occurring in two consultations out of three. Dilemmas in the area of interpersonal communication frequently concerned distrust, either in what the patient presented, or in what the patient was said to have understood. The conclusions are that the receptionist nurses were oriented towards medical management, and that they employed an informing rather than counselling strategy. Measures must be considered to support the receptionist nurses in the medical decision-making process. Action research is suggested to apply these results in the development of the work-role of the receptionist nurse.

Adult↗
PubMed1990

Audit of decision-making regarding female genitourinary infections in outpatient practice.

Patient data, diagnosis, work-up measures, and prescriptions were collected from 63 consultations by general practitioners (GPs) to study day-to-day management of women with complaints suggestive of genitourinary (GU) infections. The collected patient data were thereafter presented to a panel of 9 specialist physicians for their individual recommendations. On drug prescriptions, the panel supported 81% of the decisions, did not support 14%, and remained undecided on 5% of the cases. In all but one of the unsupported cases, the GP had prescribed antibiotics. On diagnoses, the panel supported 62% of the decisions, did not support 13%, and was undecided on 25% of the cases. The most frequent discordance concerned diagnosis of urethritis. On collection of medical data by history and physical examination, the panel found 22% of the consultations unsatisfactory. Discordance in both diagnosis and drug prescription were related to remarks about data collection. The results suggest that the body of knowledge available for GPs for management of female GU infections in outpatient practice is incomplete.

Adolescent↗
PubMed1990

In what way may videotapes be used to get significant information about the patient-physician relationship?

The aim of this study is to describe a two-step video method, where patients and physicians (on different occasions) comment on the recorded consultations, and to evaluate the method regarding the kind of information received and the influence of the video-camera on patients' and physicians' behaviour. We chose to depart from a phenomenological method introduced by Frankel and Beckman. Their method was modified with regard to the review procedure; the instructions, for example, were changed. Forty-six consultations were videotaped in four primary health care centres. Twelve general practitioners and 46 patients participated. Only a few patients (4) commented without any substantial content or in a completely neutral way. The remaining patients, and all the physicians, gave nuanced descriptions of their experiences during the consultations. Few (1/5) comments dealt with the videotaping itself; e.g. explanations to the research personnel and other irrelevant issues. The influence of the video-camera seemed to be stronger for the physicians than for the patients, but the effects were only marginal. The conclusion is, that by this modified video-method the ability to obtain knowledge to help to understand/interpret the patient-physician relationship was increased. Nowadays video-recording is an established method in behavioural science. In a study about the patient-physician relationship, we plan to use a two-step method of video-recording as the basis for analysing the key factors in the communication. Thus, it is important first to study the possibilities of obtaining valid and reliable information with the method, and then to make a decision about advantages and disadvantages.

Adult↗
PubMed1990

Inter-observer variation in decision-making regarding patients on chronic hemodialysis: a study using the kappa index.

To examine inter-observer variation in the monitoring of patients with chronic disease, four nephrologists independently assessed 62 patients on maintenance hemodialysis. Deviation from normal was determined for adequacy of dialysis, protein intake, and metabolic state. The kappa-index, which allows to adjust for chance agreement, was used to analyze each monitoring diagnosis. Low agreement was found on decisions concerning adequacy of dialysis (kappa 0.12-0.26), while agreement was higher about protein intake (kappa 0.21-0.46), and metabolic state (kappa 0.24-0.52). Two physicians classified no patient as overdialyzed, while 16-18% were thus categorized by the other two. Routines for review of recent medical history also differed significantly between the physicians. Measures are needed to increase the reliability of decisions regarding the monitoring of chronic hemodialysis. A long lasting physician-patient relationship is not a sufficient prerequisite for diminishing decision variation. Medical audit as part of the clinical routine, and use of additional sources of information, exemplified by urea kinetic modeling, are discussed.

Adult↗
PubMed1990

The GP's dilemmas: a study of knowledge need and use during health care consultations.

For use in system development, a method based on both qualitative and quantitative data was employed to study the difficulties--the dilemmas--a general practitioner (GP) faces during daily consultations. Video recordings were used for stimulated recall of the consultation. From 46 consultations, 262 dilemmas were identified by the 12 GPs involved. Medical dilemmas were encountered during three out of four consultations. Dilemmas in the communication with the patient occurred during two consultations out of three, while dilemmas in the organizational environment and dilemmas challenging the GP's personal competence occurred during one consultation out of three, respectively. A phenomenological analysis of the comments showed that few dilemmas were described as problems during "hypothetico-deductive reasoning". In many cases the GP found it difficult to understand the situation as a whole. Based on these qualitative data, a model of the GP's management of ill-structured complex dilemmas is discussed and proposed, to be taken into account in the development of decision support systems for outpatient practice.

Adult↗
PubMed1989

Introducing hypertext in primary health care: a study on the feasibility of decision support for practitioners.

A study on the feasibility of the introduction of hypertext systems for communication of medical knowledge in primary care is described. Shortliffe's constraints on areas for application of decision support are evaluated (i.e., theoretical barriers, observable and recognized needs among users, sources of usable knowledge, available system development method). Considering the barriers derived from the knowledge types and forms used by practitioners, hypertext was found suitable as support at 'breakdowns' in practice routines, to generate 'alarms', as well as for continued medical education. A survey of the a priori acceptance of decision support systems by general practitioners showed that 84% would use the computer support if it was available today and that full-text databases, such as hypertext, were given highest priority for introduction. Local specialist physicians were identified as knowledge sources for therapy advice. Implementation of prototype systems envisioned use of hypertext in primary care as the introduction of a communication medium for co-operative health care decision making. A model for the introduction into the work environment is described.

Attitude to Computers↗
PubMed1989

The semantics of diagnosis and management of genitourinary infections: a cross-specialty study.

To investigate agreement between physicians about diagnosis and management concepts of genitourinary infection, data from 63 symptomatic women was collected and distributed to a panel consisting of three general practitioners, three urologists and three nephrologists. Using double-blind methods, the panel was asked individually to give a preliminary diagnosis and a management recommendation for each case. Pairwise comparison of the evaluations showed 66% agreement for diagnosis and 79% agreement for prescription of antibiotics. Adjusting for chance agreement, the kappa index was 0.43 for prescription of antibiotics, 0.31 for diagnosis of cystitis, 0.20 for vulvovaginitis, 0.21 for pyelonephritis and 0.09 for urethritis. The specialist groups ordered significantly more laboratory investigations, resulting in a 75-95% more expensive work-up compared with general practitioners. The findings imply a need for more distinct use of the concept of 'urethritis' and are consistent with previously demonstrated differences in resource use between general practitioners and specialist physicians.

Anti-Bacterial Agents↗
PubMed1989

Information needs and information seeking behaviour in primary health care.

A questionnaire survey of 186 general practitioners in Sweden showed that 67% saw the overall supply of medical information as less satisfactory or unsatisfactory, and that 80% experienced major hindrances in seeking relevant information. The most frequent need for information concerned general medicine, with respect to both diagnosis and choice of therapy. Of situations which required additional information, only every second was completely resolved. These results imply a need for a reorganization of the supply of information to general practitioners. As they cannot depend on conventional medical libraries for day-to-day information, personal libraries should be improved and updated regularly, and be readily to hand. Computer technology should be considered for communication between health care providers, and as support for differential diagnosis in general medicine.

Consumer Behavior↗
PubMed1987

Knowledge-based decision support for general practitioners: an integrated design.

Most decision-support systems (DSSs) in medicine have been developed in hospital environments, for use in hospitals. Only a few are designed for use by general practitioners (GPs) in primary care. The work reported in this paper aims to (a) design DSSs for GPs in primary care, taking into consideration that primary care is the first level in a health care organization, where the reasons for the patients attendance are seen in a social context; and (b) integrate three approaches-Hypertext, Knowledge-Based Systems and Online Library-since any one of these will not suffice for the varying needs of GPs.

Academic Medical Centers↗