[General practice adrift. Explosion of knowledge, technological development and population]. / Almen praksis på åbent hav. Videnseksplosion, teknologisk udvikling og befolkning.

The explosion of biomedical research, and in turn, the far-reaching specialisation, which accompanies it, makes the health service field increasingly obscure and confusing. The general practitioner as gatekeeper occupies a central and much needed role in health care. Inherent this role are the professional core qualities of continuity, entirety, and a personal doctor-patient relationship, which ideally allow the GP to sort out and co-ordinate available services so that they suit the individual patient. These GP qualities also have the merit of making patients more content, they contribute to shared decision making, and they limit costs through more co-ordinated services. General practice today is faced with a dilemma. Increasing specialisation, consumerism, and liberalizsation threaten to eliminate the generalist role in health care, precisely at a time when it is most acutely needed.

Situational disease.

The American sociologist Angelo Alonzo has put down the premises for a theory of illness behaviour based on an interactionist-situational framework. In this article I suggest that a disease concept of 'situational disease' based on this framework would be well suited for clinical work in general practice. The outlines of the theory is given and compared with a more traditional diagnostic model, especially with regard to consequences for treatment and research methods. I argue that there is a narrow relationship of disease models and research methodology and that e.g. a rigorous enforcement of the prevailing methodology of controlled clinical trials is liable to uphold an anachronistic disease model. Practice guidelines which originate from a situational understanding of disease should be encouraged and to this end general practice needs to develop a broad range of research methods suited to its distinctive professional role.

Self-referral and self-payment in Danish primary care.

This study aims at characterizing the group of people who want to have the right to consult any general practitioner or practising specialist without referral on condition of part self-payment, as opposed to the group of people who choose to be registered with a general practice that offers free services but controls further access to the health care system. All adults or a 10% sample of those listed in nationwide Danish registers were examined cross-sectionally for social and demographic factors and utilization of primary and secondary health care. A minority, which totals 3% of the population, chose free choice of doctor and part self-payment. On average, this group is older and has a higher income. Its mortality and its utilization of general practice and hospital services are lower, and its use of practising specialists is higher, than the majority. Among the persons who chose free choice and self-payment, the pattern of utilization is more likely to be due to a wish for free choice and for specialized medical care than to high morbidity. Dissatisfaction caused by restrictions on self-referral to specialists can be met by offering an option of a parallel system of free choice of doctor on condition of part self-payment.

[Epidemiologic study of persons having group 2 insurance in Denmark. 3. A questionnaire study. Attitudes and knowledge of persons insured in group 2 concerning their insurance]. / En epidemiologisk undersøgelse af de gruppe 2 sikrede i Danmark. 3. En spørgeskemaundersøgelse. De gruppe 2 sikredes viden om og syn på sikringsgruppe 2.

A questionnaire investigation among established persons insured in Group 2 and persons who have recently been transferred from Group 1 to Group 2 or vice versa shows that all three groups find that there are considerable advantages in insurance in Group 2. In particular, the right to free choice of general practitioner is emphasized. Under the present arrangement this is associated with geographic and temporal restrictions. In addition, it is regarded as an advantage to be able to change one's doctor (including specialist) from time to time. Approximately 1/3 emphasize that their way through the health system is easier in Group 2 and that they are treated more kindly. The reason for changing from Group 2 to Group 1 was mainly of economical nature. Where a number of persons were concerned, this was associated with retiral. Information about the health of this group also suggest that deterioration in health may also play a part in their choice. Nevertheless, the advantages of Group 2 insurance were not contested. The results of a series of investigations suggest that new Group 2 insured persons are considerably different from the established members of this group. This group consists mainly of young women. The transfer to insurance Group 2 was motivated mainly by definite dissatisfaction and where a number of these were concerned the change was merely temporary. It is concluded that the Group 2 form of health insurance has assumed new perspectives and forms of employment.

[Diagnosis and treatment in general practice. 5. Attitudes of general practitioners--a review]. / Diagnostik og behandling i almen praksis. 5. Praktiserende laegers holdninger--en oversigt.

The word "attitude" means continuing orientation of the individual towards the world. Attitudes consist of cognitive beliefs and affective reactions, which predispose the individual towards certain action patterns and which have emotional (positive/negative) value. Doctors' attitudes are developed by the joint influences of selection and socialization. Doctors are predominantly recruited from the middle classes and are therefore characterized by middle class attitudes, valuing hard work, activity, self-discipline and rationality. The curriculum of medical school has a further and independent influence on the personalities of physicians-to-be, shaping their attitudes towards patients and medical work. This study gives a review of the official professional ideology of general practitioners (GP's) which, in some respects, differs from the ideology of other doctors. The basic issues, according to general practitioners' commission reports, textbooks, and research can be subdivided into four main principles: 1. A holistic model of disease, 2. The GP as a family doctor (a continuous and personal doctor-patient relationship), 3. The GP as a "gate-keeper" (the central referring role), 4. General practice as a "free enterprise". The two first principles deal with the substance of the GP's work and they stress holism, continuity and dialogue. The two last principles on the other hand deal with the structure of GP's work, stressing freedom and power. Thus general practitioners' ideology and attitudes serve to emphasize differences between hospital medicine and general practice. Differentiation between GP roles and roles of their psycho-social co-workers in the primary health care is not equally marked. Demarcation of general practice ideology in this respect is needed.

[Diagnosis and treatment in general practice. I. The course of illness in primary health service]. / Diagnostik og behandling i almen praksis. 1. Forløbsundersøgelser i den primaere sundhedstjeneste.

The purpose of this review is to present an outline of the use of the unifying concepts of "episodes of medical care" and "episodes of illness" in recent research. The review focuses on theoretical and methodical problems connected with the use of these concepts in research related to general practice. The concept of "episodes of medical care" has been accepted as a valid and useful method of clustering discrete units of services into cohesive entities in previous literature. The concept of "episodes of illness" is, on the other hand, not yet fully defined and further development of this concept is suggested in the paper. The major methodical problem in connection with the use of these concepts is how to define when an episode starts and ends. Three typical examples on how research workers have dealt with this problem are presented and the consequences their choice of definitions have on the results from such studies are outlined. The concept of "episodes of medical care" has hitherto been used mostly in various utilization and morbidity studies in the primary health care sector and psychiatry. In the last decade the concept has also been used especially in American research in connection with studies focussing on the performance of medical care systems. The concept of "episodes of illness" has only been used in connection with relatively few population studies.

[Diagnosis and treatment in general practice. 2. Episodes of medical care of health problems during a period of 3 months]. / Diagnostik og behandling i almen praksis. 2. Kontaktforløb af helbredsproblemer over 3 måneder.

The object of this article is to describe the working process in general practice. One hundred general practices were selected at random in the County of Copenhagen. Fifty-five general practices participated and registered the contacts during the period 13.9.1982 and the next three months for a random sample of group I patients from the low income group of the Danish Health Insurance and born on the 13th of a month. Where each contact is concerned, the individual health problems were registered together with the form of contact, the reason for contact, the wishes of the patient and the doctor's actions and also the diagnosis. Thirty-six % of the low income insurance group men and 37% of the women had at least one contact with general practice in the course of the three-month period. Seventy-nine episodes of medical care per 100 persons were found in a period of investigation of three months and women had nearly twice as many episodes of medical care as the men. In 59% of the episodes of medical care, the patients had at least one symptom. In 22% of the episodes of medical care, the patients were referred to other persons or instances. In 73% of the episodes of medical care, the general practitioner established the final diagnosis.

[Diagnosis and treatment in general practice. 3. Reasons for contact and diagnoses in episodes of medical care]. / Diagnostik og behandling i almen praksis. 3. Kontaktårsager og diagnoser ved kontaktforløb i almen praksis.

The object of this article is to describe the reasons for contact and the diagnoses in general practice by following the course of health problems in a random sample of patients (group 1 in the National Health Insurance System) for three months. In 55 general practices in the County of Copenhagen, all contacts concerning a given health problem in the single individuals were registered. This totalled 1,974 episodes of medical care in approximately 1,200 persons who formed 47% of the random sample. This investigation assessed the various classifications of reasons for encounter with primary health care as regards employability for central coding, information value and agreement with the general medical disease model. Employing the Reason for Visit Classification (USA) supplemented by classifications elaborated by the authors, three dimensions of the concept of "reasons for encounter" could be described: symptoms, the patient's wishes for contact with the doctor and reasons for the current problem. Health problems are described as episodes of one or more contacts. In single-contact episodes, the symptoms and diagnoses are most frequently those of respiratory diseases whereas multi-contact episodes are most frequently found where musculo-skeletal diseases are concerned. It is concluded that a multi-dimensional description of the reasons for contact and a description of the disease pattern on the basis of episodes of medical care can provide more differentiated knowledge about health problems in general practice.

[Diagnosis and treatment in general practice. 4. General practitioners' knowledge of their patients]. / Diagnostik og behandling i almen praksis. 4. Praktiserende laegers kendskab til deres patienter.

The object of this work is to describe aspects of general practitioners' knowledge of their patients and to analyse the connection between this knowledge and certain activities involving the patients in the practice (examination in the practice, prescription of medicine, information and referral). Fifty-five practices with a clientele of 81,600 patients in the lower income group of the Danish National Health Insurance over the age of 15 years participated. A random sample of 1/30 of the insured persons were characterized by the practice prior to a period of observation of three months on the basis of the doctors' knowledge of the persons. During the period of observation, all practice-patient contacts were registered. The characteristics of the patients included: curation of attachment to the practice, degree of knowledge, previous problems etc. Contact data included information about diagnoses, symptoms, patient's wishes, prescriptions, referrals, information given and examinations in the practice. During the three months, a total of 1,974 episodes of medical care occurred. We did not find any connection between the duration of knowledge (as a measure of knowledge) and the number of abovementioned activities in the practice. This investigation, however, cannot exclude such a connection. Information is still required to illustrate the significance of the knowledge of the patients for the solution of their problems and, in particular, for the course of their health problems.

[Diagnosis and treatment in general practice. 6. Attitudes of general practitioners--a study in Copenhagen County]. / Diagnostik og behandling i almen praksis. 6. Praktiserende laegers holdninger--en undersøgelse fra Københavns Amt.

We assume that general practitioners' (GPs) attitudes have considerable significance for their daily work, partly because the "free enterprise" structure permits GPs a fair degree of work autonomy, partly because several studies point to notable variations in GP behaviour which have not been explained by other variables. General practitioners seem to have developed an official professional ideology which differs in some respects from the ideology of other doctors. The core issues of Danish GP ideology, according to commission reports, textbooks and research can be summarized into four main principles: 1. A holistic (bio-psycho-social) model of disease, 2. The GP as a family doctor, 3. The GP as a "gate-keeper" (the central referral role) and 4. General practice as a "free enterprise". We mailed attitude questionnaires to a random sample of 100 practices in the county of Copenhagen. The purpose of the study was to establish the extent to which GPs would agree to the above ideology, and also to look for systematic differences between groups of doctors. The response rate was 76%. We found overall agreement to the family doctor principle among GPs which is in accordance with earlier studies. Attitudes to the "free enterprise" principle of practice organization were favorable in a similarly homogeneous way, and a significant minority favored even further liberalization. Disagreements were more pronounced concerning the holistic (bio-psychosocial) model of disease. Just over half of respondents adhered fully to the model, but doctors from high-income areas were significantly less enthusiastic than other doctors about the model. Similarly, most general practitioners favored the "gate-keeper" role.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diagnosis and treatment in general practice. Referral courses over a period of 1 year]. / Diagnostik og behandling i almen praksis. Kontaktforløb af helbredsproblemer over 1 år.

This study examined episodes of medical care in five practices, representing a number of municipalities in The Copenhagen County. For comparison of results, data from a similar survey from a 55 practices' study by Hollnagel et al were also used. In these two surveys all encounters were recorded, over period of one year and three months, respectively, each time a health problem or condition was presented to the general practitioner following a personal, telephone or written contact between the patient, or other person representing the patient, and physician. The study population analyzed here consists of 189 and 2,293 adults respectively, who were all registered as group 1 members of the Danish National Health Care system. The date and nature of each contact were registered, including information of the date of any previous contact concerning the same health problem, so that the contacts could be chronicled into episodes of medical care. In addition, detailed data concerning encounter form, reason for encounter, patient's expressed whished to obtain specific services, general practitioners treatment including referrals, and diagnosis were recorded. Compared with the study covering a period of three months, the data covering a period of one year include episodes which represent a larger fraction of the study population in all age groups, 85-95% compared with 55-68%. Similarly a greater number of contacts in the episodes with a total of more than one contact are recorded over a period of one year especially concerning the episodes in the age group 45-64 years of age and the group over 65 years.

Lay concepts and strategies for handling symptoms of disease. A sample of adult men and women experiencing back pain symptoms.

A population sample of 60 men and women who had experienced back pains were interviewed in-depth with semi-structured techniques. Though two thirds of the sample had symptoms of severe or moderately severe character, less than half had any current contact with doctors. Interviews were taped and analysed qualitatively. Results show that almost all respondents continually develop ideas and concepts about their disease built upon the experiences and experiments of everyday activities over a long period, rather than upon medical information. Most respondents subscribed to a multifactorial view of the disease and some had quite sophisticated models of processes leading to symptom emergence. However, models almost invariably were of the "black-box type", specifying influences and outcomes but being blank on what was going on inside the body. Most respondents preferred not to see themselves as ill. They were nevertheless concerned with disease concepts and causes because correct disease modelling would give them information on the likely future development of symptoms, i.e. prognostic information, which in turn reduced anxiety and strengthened their mental and practical control of illness. Control of illness was practiced in several ways. We identified four main types of strategy towards illness: Ignoring/neclecting symptoms of disease. Routine treatment during symptom periods (professional/self-care). Preventive behaviour. Permanent change or modification of life situation. Roughly half of respondents were strategy-two users. The current concept and policy of individual health responsibility is discussed in light of the results.