Den kompetenta allmänläkaren - mottagningsrummets praxis utmanar idealbilden

Sammanfattning: The skilful general practitioner – ideals challenged by practice Background and aim: The world organization for general practitioners, Wonca, has formulated research based core competencies for general practice. However the real performances of GPs are not much studied in practice. The aim of the first three studies was to investigate and describe the working behaviour of competent general practitioners from the background of the literature of the field, and to compare their working behaviour with the Wonca core competencies. The aim of the fourth study was to investigate medical students´ views of general practice and to find out if there were certain views associated with regarding general practice as a possible career choice. Method: The thesis is based on three qualitative studies and one quantitative. In paper 1 data was gathered by participant observation and interviews with GPs. In paper 2 data was collected by group interviews. In paper 3 data was collected from reflective writing by final-year medical students. In paper 4 data was gathered from a questionnaire among medical students. Data was analyzed using text condensation (paper 1), qualitative content analysis (paper 2 and 3) and statistical descriptions and comparisons (paper 4). Findings: Paper 1: Two main categories, dimensions of competence, were constructed: “deliberate strategies” and “personal style”. Common denominators of the overall working behaviour were attention to the patient as a person, practicing patient-centred medicine, saving the consultations from disturbances, rejecting taking over responsibilities from the patients and safeguarding own autonomy. A well-developed personal style is necessary to obtain the spontaneous interchange between attentive listening and detachment characteristic to patient-centredness. Paper 2: Two main categories reflected the competence: “professional readiness” and “working behaviour”. Professional readiness comprises the inclination of understanding and acting based on the subcategories: medical knowledge modified by experience, knowing the patient, involvement and uncertainty. Working behaviour describes in a more concrete way the doctoring approach and is formed by the subcategories: preparation, the current problem, body attention, cooperation with other professionals, use of time and taking notes as a work aid. Paper 3: Three themes were identified to explain the conditions of a general practitioner (GP). They were: “prerequisites”, “patients’ problems” and “clinical judgment” which reflect the specific features of primary care, of the presentation of symptoms by patients and of the way that GPs approach an actual encounter. The students regarded the importance of unselected patient problems, straightforwardness in contact and care as being the characteristics of a competent GP. Paper 4: The medical students regarded general practice positively. They found work environment good, to be aware of patients living conditions as necessary and that GP work requires medical breadth. A statistical association was found between stated intentions to work as a GP in the future with statements about general practice offering good work environment and proposing a major share of general practice in undergraduate training. Students negative to working as a GP were also negative to a major share of general practice in undergraduate training. Conclusion: The skilful GP: “Through patient continuity and holism the GP can offer patients attention in the encounters, closeness to care and clinical breadth. The GP is capable of patientcentredness and bodily empathy, being aware of uncertainty and is protecting own autonomy. All the aspects of competence are integrated into the personal style of the GP”. Our studies provided reality for four out of six Wonca core competencies: commitment to what is most important for the patient, preparedness for the unexpected in body examination, seeing the human and the breadth of any clinical situation.