National Centre of Rural Medicine in Norway: a bridge from rural practice to the academy.

CONTEXT: Rural medical practice in Norway has an honourable 400 year history, but this has diminished since the end of World War II. Despite official intention to support a decentralised population, rural and remote populations have continuously reduced in Norway over the last 10 years. A consequence of the accompanying reduction in rural and remote GP services has been a distinct reduction in opportunities for medical student and intern placements. In 1999 the University of Tromso implemented some projects to stimulate rural medical practice, funded by the government. This culminated in the 2007 foundation of the Norwegian National Centre of Rural Medicine (NCRM) in Tromso. ISSUE: A key challenge of the NCRM is to identify factors that influence young doctors to choose rural careers. This is reflected in the three concurrent aims or perspectives of the NCRM: (1) to bridge the gap between the academy and rural medical practice (the principal perspective); (2) to promote research, education and networking among rural health professionals (the operational perspective); and (3) to contribute to the recruitment, stability and quality of rural health care (the political perspective). LESSONS LEARNED: The NCRM has had a number of achievements that include a publication that provides a narrative perspective on rural practice, the role of the rural doctor, and how rural culture and context influence proper clinical decision-making. Another achievement is a professional development and research program that has been successful in fostering a number of major studies, and led to the formation of a supportive PhD research group. The NCRM has also facilitated networking between rural practitioners and academics, at conferences and via its rural doctor website, and promoted cooperative international activities. In these ways the NCRM has fostered the transformation of rural doctors' experience into theory to enhance medical knowledge, begun to redress the balance between community- and hospital-based services, and so made a favourable start to building a bridge between rural practice and the medical academy in Norway.

[Lack of doctors in rural districts--situation in Northern Norway, national challenge]. / Legemangelen i distriktene--nordnorske funn, nasjonale utfordringer.

BACKGROUND: Recruitment of general practitioners to Northern Norway has failed during the last few years, especially in municipalities with a population of less than 4,000, though some small municipalities have maintained a stable medical service. What are the differences between municipalities with stable and unstable services? MATERIAL AND METHODS: A questionnaire was mailed to the medical officers of the 89 municipalities in Northern Norway, with questions on the structure and organisation of the medical service, and factors influencing doctors' professional life and quality of life in general. RESULTS: Answers from 62 municipalities were included. Municipalities with unstable services had longer distances to the nearest hospital, and doctors in these municipalities reported heavier work-load and professional isolation. INTERPRETATION: A combination of factors concerning the structure and organisation of the primary health care seem to cause the increased difficulties in the unstable communities, hence they should have a potential for improvement.

[The use of cottage hospitals' beds in Nordkapp]. / Bruken av sykestueplassene i Nordkapp.

An analysis was made of 414 admissions during a one-year period to three general practitioner beds. Within the first day, 20% of the patients were discharged, while 22% were transferred to the main hospital after examination and primary treatment. 58% stayed more than one day. The mean stay was 5.0 days. The three major groups of medical conditions according to the International Classification of Primary Care were cardiovascular diseases, diseases of the musculoskeletal system and diseases of the lungs and the respiratory tract. Patients > or = 60 years of age constituted 55.8% of the total, taking up 80.6% of total bed days. In the age group > or = 80 years of age, there were three admissions for every five inhabitants, while two in five had one or more hospital stay. 65% of all patients (15.7%) had two stays or more, taking up a total of 60.5% of total bed days. Using the general practitioner beds as a low threshold service proved especially useful with patients suffering from heart failure, asthma or chronic obstructive lung disease. The beds had a key function in the rehabilitation of the elderly, in the care of cancer patients, and in terminal care. They were of basic importance to the organisation of daily emergencies.

[The cottage hospital model, a key to better cooperation in health care--let the cottage hospital survive!]. / Sykestuemodellen, nøkkel til bedre samhandling i helsetjenesten--la sykestuene leve!

The cottage hospital model may be defined as an intermediary service between primary care and the general hospital. On the basis of experience and studies from Finnmark county, the northern-most county in Norway, this article makes a case for a revival of the cottage hospitals. They may improve comprehensive patient care and cooperation between care levels, to the benefit of groups of patients who often are in a squeeze between care levels: the elderly, the chronically ill, and the severely ill and dying patients. The cottage hospitals may also contribute to strengthening the chain of service in acute medicine. The professional challenges of work in a cottage hospital may attract practitioners to primary health care. We suggest that 1% of the funds set aside for ongoing national programmes for the elderly, in cancer care and mental illnesses are used for cottage hospital beds, as this may contribute to increasing the viability of these programmes. The extra cost upgrading 1,000 of a total of 27,000 nursing home beds in Norway to cottage hospital standard is estimated to be modest.

Improving pulmonary auscultation as a tool in the diagnosis of bronchial obstruction--results of an educational intervention.

OBJECTIVE: To study the effect of an educational intervention on general practitioners' (GPs') ability to diagnose bronchial obstruction after clinical examination. DESIGN: Based on physical chest examination 11 GPs assessed the degree of bronchial obstruction by estimating the patient's predicted forced expiratory volume in one second (FEV1%). Half way in the study the GPs were taught new knowledge on associations between lung sounds and bronchial airflow. The agreements between estimated and measured FEV1% predicted before and after this educational intervention were compared. SETTING: 11 GPs in five health centres in northern Norway took part. PATIENTS: 351 adult patients were included in phase 1, and 341 in phase 2. MAIN OUTCOME MEASURES: Estimated and measured FEV1% predicted were compared in subgroups of patients according to clinical findings in phase 1 and 2. The effect of the intervention on the doctors' weighting of various chest signs could thus be evaluated. Kappa agreement and correlation between estimated and measured FEV1% predicted in both phases were determined. RESULTS: The agreement between estimated and measured FEV1% predicted increased from Kw (weighted Kappa) = 0.33 in phase 1 to Kw = 0.43 in phase 2 (95% confidence interval 0.35-0.52). The GPs laid more relevant emphasis on rhonchi in their estimates after the educational intervention, while too much weight was laid on uncertain chest findings in phase 2. CONCLUSION: The study shows a potential for better use of physical chest examination in the diagnosis of bronchial obstruction.

Is the general practitioner hospital a potential "patient trap"? A panel study of emergency cases transferred to higher level hospitals.

OBJECTIVES: 1. To find out whether a stay in local general practitioner hospitals (GP hospitals) prior to an emergency admission to higher level hospitals aggravated or prolonged the course of the disease, or contributed to permanent health loss for some patients. 2. To detect cases where a transitory stay in a GP hospital might have been favourable. DESIGN: A retrospective expert panel study based on records from GP hospitals and general hospitals. The included patients had participated in a previous prospective study of consecutive admissions to GP hospitals during 8 weeks. SETTING: Fifteen out of 16 GP hospitals in Finnmark county, Norway. SUBJECTS: Seventy-three patients transferred to higher level hospitals from a total of 395 admitted to GP hospitals. MAIN OUTCOME MEASURES: Three outcome categories were considered for each patient: "possible permanent health loss", "possible significantly prolonged or aggravated disease course", and "possible favourable effect on the disease course". RESULTS: There was agreement about the possibility of negative effects in two patients (2.7%), while a possible favourable influence was ascribed to six cases (8.2%). CONCLUSION: Negative health effects due to transitory stays in GP hospitals are uncommon and moderate, and balanced by benefits, particularly with regard to early access to life saving treatment for critically ill patients.

GPs' motives for referrals to general hospitals: does access to GP hospital beds make any difference?

OBJECTIVES: We aimed to explore the relative impact of medical and other situational motives on GP's decisions to refer patients to specialist care in a general hospital, and to assess whether having access to a GP hospital influences the decisions. METHODS: We carried out a prospective study of consecutive doctor-patient contacts during one week. The effects of main motives, medical, social/nursing, general hospital advice, distance from the nearest general hospital and access to GP hospitals on referral decisions were explored by logistic regression. The motives for different referral decisions were also explored through frequency analyses. The study was set in general practices in the county of Finnmark in North Norway, which included 40 GPs from rural practices with access to a GP hospital and eight GPs working closer to a general hospital without access to GP hospital. We studied 2496 doctor-patient contacts, which resulted in 411 patients being considered for any kind of referral, of which 205 were referred to the general hospital. RESULTS: Medical needs were recorded as the only referral motive of major importance in about half of the cases considered for referral, while additional motives were recorded in the other half. The rationale for admissions to general hospitals and GP hospitals (in-patient care) was compatible in terms of the relative importance of the medical arguments. The GP hospital option was mainly chosen because of the long distance from the general hospital, nursing needs and the preferences of the patient and the family, and resulted in a lower proportion of patients being referred to general hospitals from GPs with access to a GP hospital. CONCLUSION: Medical motives dominate the decision to refer patients to general hospitals, but access to a GP hospital, in cases where nursing needs and long distances to the general hospital are supplementary considerations, reduces the proportion of patients being referred to general hospitals.

Do general practitioner hospitals reduce the utilisation of general hospital beds? Evidence from Finnmark county in north Norway.

STUDY OBJECTIVE: To assess whether populations with access to general practitioner hospitals (GP hospitals) utilise general hospitals less than populations without such access. DESIGN: Observational study comparing the total rates of admissions and of occupied bed days in general hospitals between populations with and without access to GP hospitals. Comparisons were also made separately for diagnoses commonly encountered in GP hospitals. SETTING: Two general hospitals serving the population of Finnmark county in north Norway. PATIENTS: 35,435 admissions based on five years' routine recordings from the two hospitals. MAIN RESULTS: The total rate of admission to general hospitals was lower in peripheral municipalities with a GP hospital than in central municipalities without this kind of institution, 26% and 28% lower for men and women respectively. The corresponding differences were 38% and 52%, when analysed for occupied bed days. The differences were most pronounced for patients with respiratory diseases, cardiac failure, and cancer who are primarily or intermediately treated or cared for in GP hospitals, and for patients with stroke and fractures, who are regularly transferred from general hospitals to GP hospitals for longer term follow up care. CONCLUSION: GP hospitals seem to reduce the utilisation of general hospitals with respect to admissions as well as occupied bed days.

Are general practitioner hospitals cost-saving? Evidence from a rural area of Norway.

OBJECTIVE: We aimed to determine whether general practitioner GP hospitals, compared with alternative modes of health care, are cost-saving. METHODS: Based on a study of admissions (n = 415) to fifteen GP hospitals in the Finnmark county of Norway during 8 weeks in 1992, a full 1-year patient throughput in GP hospitals was estimated. The alternative modes of care (general hospital, nursing home or home care) were based on assessments by the GPs handling the individual patients. The funds transferred to finance GP hospitals were taken as the cost of GP hospitals, while the cost of alternative care was based on municipality and hospital accounts, and standard charges for patient transport. RESULTS: The estimated total annual operating cost of GP hospitals was 32.2 million NOK (10 NOK = 1 Pound) while the cost of alternative care was in total 35.9 million NOK. Sensitivity analyses, under a range of assumptions, indicate that GP care in hospitals incurs the lowest costs to society. CONCLUSION: GP hospitals are likely to provide health care at lower costs than alternative modes of care.

The Finnmark general practitioner hospital study. Patient characteristics, patient flow and alternative care level.

OBJECTIVES: In a study assessing the role of general practitioner hospitals (GPHs) in the health service two main questions were addressed: 1) Are general practitioner beds used for short-term medical observations, or as a supplement for long-term geriatric care? 2) What are the alternatives to stays in GPHs? DESIGN: In a prospective design GPH stays during 8 weeks were recorded. SETTING: 15 GPH units in Finnmark county in Norway. SUBJECTS: 395 completed stays were recorded. MAIN OUTCOME MEASURES: The patients' sex, age and diagnosis, flow of patients, length of stays, bed occupancy rate, and doctors' assessments of alternative level of care. RESULTS: 60% of the patients were admitted from and discharged to their home after a mean stay of 6.8 days. The 19% who were transferred to higher level hospitals stayed significantly shorter than the rest (3.6 days), while 9% transferred from hospital stayed significantly longer (22.3 days). Of the 395 patients discharged 61% were assessed as candidates for higher level hospitals, if GPHs did not exist. 45% of the GPH stays seem to replace higher level hospital admissions. CONCLUSION: The GPHs have a pre-hospital "buffer" function by preventing patients with acute symptoms from being unnecessarily admitted to general hospitals through short-term observation stays. A post-hospital function was also demonstrated, since GPHs allow for long-term follow up stays for patients transferred from general hospitals.

[The value of C-reactive protein testing in suspected lower respiratory tract infections. A study from general practice on the effect of a rapid test on antibiotic research and course of the disease in adults]. / Nytten av å teste C-reaktivt protein ved mulig nedre luftveisinfeksjon. En undersøkelse fra allmennpraksis av en hurtigtests innvirkning på antibiotikaforskrivning og sykdomsforløp hos voksne.

We wanted to assess whether routine use of a rapid test for C-reactive protein (CRP) could reduce prescription of antibiotics for adults with possible lower respiratory tract infection. 239 patients were randomized into a CRP group, tested with the rapid test (n = 108) and a control group (n = 121). Before knowing to which group the patient belonged the doctors made a preliminary decision about antibacterial treatment. The C-reactive protein value was then released if the patient belonged to the CRP group, and the therapy could be adjusted in light of the result. Antibacterial courses prescribed during the consultations and in the following three weeks were registered. The clinical course was evaluated by interview after one week and again after three weeks. Antibiotics were prescribed for altogether 56% of the patients in the CRP group and 60% in the control group. The difference was not statistically significant. Prescription of antibiotics was strongly associated with the finding of crackles and wheezes, but not with cough, dyspnoea or chest pain. Slow recovery was associated with high age, absence of fever and a normal value of C-reactive protein. No significant benefit of the CRP test was demonstrated. We discuss whether the doctors made full practical use of the information provided by the test. Bronchial obstruction should probably be considered to be the problem more often in coughing patients with a normal CRP value.

Stuck with the patient--what would my colleague have done? A videorecorded consultation experiment with an actor simulating as the same patient for different doctors.

The aim of the experiment, in which four general practitioners met an actress who played a patient, was to explore how different doctors approach an identical patient problem. According to the patient role the actress had two reasons for encounter: (i) tachycardia and (ii) fear of HIV infection, which she had great difficulty in telling and presented only by indirect cues. The doctors knew they were meeting an actress, but the patient role description was unknown. Most of the time in each consultation was spent on tachycardia, the first presented symptom. None of the doctors paid real attention to the patient's signals of emotional distress and did not discover her fear of being HIV positive. Evaluation of the recordings and transcripts revealed some keys to understand why the doctors missed essential signals from the patient and felt stuck. It was difficult for the doctors to see their own role in blocking communication until the patient perspective was fully explored during the process of evaluation.

["Hello, doctor's office? May I talk to the doctor?" An analysis of telephone accessibility in offices of general practitioners. A survey of patients in northern Norway 1987]. / "Hallo, er det legekontoret--kan jeg få snakke med legen?" En analyse av telefontilgjengelighet ved allmennpraktikerkontorer. Pasientundersøkelsen i Nord-Norge 1987.

In a survey among 3,739 patients belonging to 36 general practices in northern Norway, 33% reported difficult access to their local surgery by telephone. 43% reported difficulty in obtaining access to the doctor once they had obtained contact with the reception. The proportion of patients reporting problems of accessibility by telephone varied greatly, from 5 to 75%. Patients belonging to practices located in towns, with long waiting lists and many doctors, were most dissatisfied with the telephone service. Stable doctor/patient-relationships made direct contact with the doctor easier, while a scheduled time when patients could call the office made direct contact more difficult. We discuss ways to improve accessibility by telephone.

[What do patients think of primary health care? A questionnaire study among patients in Northern Norway in 1987]. / Hva mener pasienter om primaerlegetjenesten? En spørreundersøkelse blant pasienter i Nord-Norge 1987.

Doctors and professional health administrators have been the principal decision-makers and the patients have hardly had any direct influence on the planning and organization of primary health care in Norway. In 1987, in order to draw attention to patient opinions, the Institute of Community Medicine, University of Tromsø, conducted a questionnaire survey among patients attending general practices in North Norway. The question were selected to cover issues in the contemporary debate on the ideology, organization and standards of services of general practitioners. 36 teaching practices in the region were included in the survey. Altogether 3,739 questionnaires were returned, a response rate of over 60%. The respondents reported more than 16,000 consultations during the last year. This paper presents the methods used and the main findings concerning the representativeness of the results and the potential for generalization. Subsequent publications will present detailed results from the study within the framework of patient experiences, preferences and expectations.

[A personal physician, wishes and realities in Northern Norway. A patient study in Northern Norway in 1987]. / Fast lege, ønsker og realiteter i Nord-Norge. Pasientundersøkelsen i Nord-Norge 1987.

Among patients consulting general practitioners in northern Norway, 57% had a stable relationship with one doctor, according to answers to a questionnaire. Rather than having a free choice between several doctors, 85% preferred to have a personal doctor. About half the patients wanted the same doctor for the whole family. Even if they had to wait longer for the consultation, 63% would prefer to meet their own doctor. A personal doctor was much less common in northern Norway than in the rest of the country, which could be put down to lower stability in the practices.