"So you think I'll survive?": a qualitative study about doctor-patient dialogues preceding high-risk cardiac surgery or intervention.

OBJECTIVE: To explore doctor-patient interactions and decision-making processes before high-risk cardiac surgery or intervention with special attention to existential challenges. DESIGN, SETTING AND PARTICIPANTS: We conducted a qualitative study with data drawn from doctor-patient dialogues preceding high-risk procedures. The study setting was the cardiac department of a university hospital with 24-hour emergency service. We recruited a purposive sample of 10 patients and eight doctors. The patients were categorised as high-risk patients in accordance with EuroSCORE and established angiographic procedural high-risk criteria. Transcripts from the dialogues were analysed with systematic text condensation, inspired by discourse analysis. MAIN OUTCOME MEASURE: Accounts of doctor-patient interaction reflecting existential aspects of the decision-making process. RESULTS: The main existential concerns identified in the doctor-patient interactions were surviving uncertainty, negotiating responsibility and trusting the doctor's proficiency. When handling uncertainty, doctors imparted complex information about risk, warnings and recommendations, while patients sought and trusted the doctors' advice. Though the decisions were made in asymmetrical power relations, they were based on a shared responsibility discussed and defined throughout the dialogues. The patients expressed a profound confidence in the doctor's ability to get them through the high-risk treatment and give the best help possible. CONCLUSIONS: Uncertainty, mortality, responsibility and trust are fundamental existential issues concerning both patients and doctors before high-risk procedures, with an impact on decision-making processes. Increasing focus on underlying existential conditions, ethical reasoning and power relations in medical education may improve the quality of shared decision-making and informed consent related to high-risk treatment.

"If you cannot tolerate that risk, you should never become a physician": a qualitative study about existential experiences among physicians.

BACKGROUND AND OBJECTIVES: Physicians are exposed to matters of existential character at work, but little is known about the personal impact of such issues. METHODS: To explore how physicians experience and cope with existential aspects of their clinical work and how such experiences affect their professional identities, a qualitative study using individual semistructured interviews has analysed accounts of their experiences related to coping with such challenges. Analysis was by systematic text condensation. The purposeful sample comprised 10 physicians (including three women), aged 33-66 years, residents or specialists in cardiology or cardiothoracic surgery, working in a university hospital with 24-hour emergency service and one general practitioner. RESULTS: Participants described a process by which they were able to develop a capacity for coping with the existential challenges at work. After episodes perceived as shocking or horrible earlier in their career, they at present said that they could deal with death and mostly keep it at a distance. Vulnerability was closely linked to professional responsibility and identity, perceived as a burden to be handled. These demands were balanced by an experience of meaning related to their job, connected to making a difference in their patients' lives. Belonging to a community of their fellows was a presupposition for coping with the loneliness and powerlessness related to their vulnerable professional position. CONCLUSIONS: Physicians' vulnerability facing life and death has been underestimated. Belonging to caring communities may assist growth and coping on exposure to existential aspects of clinical work and developing a professional identity.

Identification of epoxybergamottin as a CYP3A4 inhibitor in grapefruit peel.

OBJECTIVE: The oral availability of many drugs metabolised by the enzyme cytochrome P(450) 3A4 (CYP3A4) is increased if co-administered with grapefruit juice. Extracts from grapefruit peel have also demonstrated inhibitory activity and, during commercial manufacturing of grapefruit juice, inhibitory components might be squeezed into the juice from the peel. Thus, the aim of this in vitro study was to identify CYP3A4 inhibitors in grapefruit peel. METHODS: Grapefruit peel was extracted with diethyl ether, and the extract was further fractionated by normal-phase chromatography. Fractions demonstrating significant CYP3A4 inhibitory activity, as measured by the relative reduction in N-demethylation of diltiazem in transfected human liver epithelial cells, were subsequently separated by preparative thin-layer chromatography. Constituents of the fractions and isolated compounds were identified by nuclear magnetic resonance spectroscopy. Analysis of diltiazem and N-demethyl-diltiazem was performed using high-performance liquid chromatography. RESULTS: Of the identified components in grapefruit peel, only epoxybergamottin demonstrated a concentration-dependent inhibition of the CYP3A4-mediated N-demethylation of diltiazem. The IC(50) value was calculated to be 4.2+/-1.1 micro M. Coumarins without the furan ring and flavonoids isolated from grapefruit peel did not interfere with the metabolism of diltiazem. The results indicated the presence of other CYP3A4 inhibitors in grapefruit peel, but these agents were lost during the purification process excluding their identification. CONCLUSION: The furanocoumarin epoxybergamottin, present in grapefruit peel, is an inhibitor of CYP3A4. In commercial manufacturing of grapefruit juice, epoxybergamottin is possibly distributed into the juice. During manufacturing, however, epoxybergamottin may be hydrolysed to 6',7'-dihydroxybergamottin, which has been suggested as an important CYP3A4 inhibitor in grapefruit juice.

The purpose of the general practice consultation from the patient's perspective--theoretical aspects.

BACKGROUND: Medical practice and research are paying increasing attention to what patients want, as reflected by the growth of routine surveys of patients' satisfaction and more formal studies of patients' views of medical care. However, the field lacks conceptual clarity. OBJECTIVES: The aim of this study was to propose a theoretical clarification of the concept of the patients' purpose of a consultation by presenting a patient-centred definition, applicable for clinical work and research in general practice. METHODS: An extensive literature review was conducted to explore presumptions and definitions reported by previous studies. Most authors failed to define or distinguish the concept under investigation. We took these shortcomings as our starting point, added some significant dimensions drawn from a few selected authors who had discussed relevant perspectives in their work and arrived at a proposed working definition of the 'purpose' concept. RESULTS: The proposed definition allows for multiple purposes for the consultation. We incorporate what the patient hopes to gain from the consultation, as opposed to their 'expectations of the most likely outcome'. Our working definition aims to identify patients' a priori wishes and hopes for a specific process and outcome, while acknowledging that these may not be voiced and may be modified by the patient during the consultation. General characteristics of the doctor, such as being considerate or professionally skillful, are not included.

Management of dementia in primary health care: the experiences of collaboration between the GP and the district nurse.

OBJECTIVE: The objective of this study was to explore the context and experiences of collaboration between the GP and the district nurse (DN) in diagnosing dementia, in order to identify possible procedures to improve care. METHODS: Two group interviews were conducted with four DNs and five GPs, respectively, working in the municipality of Copenhagen. RESULTS: The group interviews revealed that the suboptimized collaboration could be due to different inter-professional diagnostic strategies and a lack of understanding of the importance of early, shared, decision making. This could create conflicts between the groups. CONCLUSIONS: This study indicates a possibility for improved collaboration between the two professional groups in diagnosing dementia. Possible approaches for improved care should focus on an inter-professional understanding of the importance of early, shared, decision making, emphasizing early identification and care of diagnosed demented patients. Establishing a shared collaboration model including out-patient memory clinics, GPs and DNs could be a first step. This model should also take into account an evaluation of possible consequences for the diagnosed demented patients in terms of treatment and care and consider the indication for referrals to a comprehensive diagnostic evaluation. We are at present planning a study to address these aspects.

Gendered health resources and coping--a study from general practice.

AIM: The aim of this study was to explore gender and coping in primary health care patients, by comparing self-assessed health resources in men and women. METHODS: Female and male patients' self-assessed health resources were identified by mean of key questions, developed separately for men and women. Patients' answers were audiotaped and analyzed qualitatively. An explorative gender comparative analysis was done. The setting comprised two women GPs and their consultations. The subjects were 37 consecutive female patients and 39 consecutive male patients aged 19-85 years. RESULTS: The analysis indicated notable differences in spite of apparent similarities in self-assessed personal health resources in men and women. In men, personal strength was part of a proud identity, while women reported that they were able to manage because they just had to. Work was often mentioned as a health resource, but while men emphasized their well-being at work and a capacity to relax at home, women handled stressful tensions by diving into household activities. While men spoke of gaining health from being with others, women talked about social relations as contexts for gaining as well as giving health. CONCLUSION: None of the phenomena described by the respondents can be reasonably categorized as respectively problem-focused, emotion-focused or avoidance coping strategies. Asking people about their own ideas regarding health resources may provide more complex understandings of coping and gender. In a clinical setting skilful listening can prevent gender essentialism, where all men are regarded as different from all women.

Qualitative research: standards, challenges, and guidelines.

Qualitative research methods could help us to improve our understanding of medicine. Rather than thinking of qualitative and quantitative strategies as incompatible, they should be seen as complementary. Although procedures for textual interpretation differ from those of statistical analysis, because of the different type of data used and questions to be answered, the underlying principles are much the same. In this article I propose relevance, validity, and reflexivity as overall standards for qualitative inquiry. I will discuss the specific challenges in relation to reflexivity, transferability, and shared assumptions of interpretation, which are met by medical researchers who do this type of research, and I will propose guidelines for qualitative inquiry.

Synthesis of a triantioxidant compound: combination of beta-apo-8'-carotenoic acid, selenacapryloic acid and trolox in a triglyceride.

Carotenoids, vitamin-E and selenium show similar or complementary physiological properties and protect against a variety of pathological processes. Mixtures of these antioxidants are found in nutritional supplements and are used to prevent several diseases. The synthetic connection of carotenoids, vitamin-E and selenium may increase the chemopreventive activity of the individual compounds. A carotenoic acid, a selena fatty acid and the vitamin-E derivative trolox were successively esterified with glycerol to 1-(beta-apo-8'carotenoyl)-2-(7-selenaoctanoyl)-3-(6-hydroxy-2,5,7,8-tetramethylchroman-2-acyl)-glycerol. This triantioxidant compound revealed, in the DPPH (1,1-diphenyl-2-picrylhydrazyl) test, an additive affect, consisting of the radical quenching activity of the carotenoid and trolox. The DPPH test was not sensitive for the Se moiety in the triantioxidant compound.

The art and science of clinical knowledge: evidence beyond measures and numbers.

Medical doctors claim that their discipline is founded on scientific knowledge. Yet, although the ideas of evidence based medicine are widely accepted, clinical decisions and methods of patient care are based on much more than just the results of controlled experiments. Clinical knowledge consists of interpretive action and interaction-factors that involve communication, opinions, and experiences. The traditional quantitative research methods represent a confined access to clinical knowing, since they incorporate only questions and phenomena that can be controlled, measured, and counted. The tacit knowing of an experienced practitioner should also be investigated, shared, and contested. Qualitative research methods are strategies for the systematic collection, organisation, and interpretation of textual material obtained from talk or observation, which allow the exploration of social events as experienced by individuals in their natural context. Qualitative inquiry could contribute to a broader understanding of medical science.

Unravelling empowering internal voices-a case study on the interactive use of illness diaries.

BACKGROUND: The article is part of a study of an illness diary method for improving clinical communication with patients suffering from long-standing illness without clinical findings. OBJECTIVE: The aim of this study was to demonstrate how patient empowering can be approached through a process of shared insight in a personal illness description. METHODS: This was a single case study from three encounters with a 48-year-old woman suffering from headache, who participated in the illness diary study. Theoretical sampling was used to select the presented case from the sample. The material comprises sections of notes and transcripts from audiotapes. RESULTS: During the encounters, the medical dialogue is changed to include the patient's internal dialogues on her illness and her ways of coping. Her body language is approached and met, and its empowering potential is explored in the dialogue. CONCLUSION: The reflective practitioner may contribute to transform a consultation from repetitive patterns to a dialogue based on the patient's own coping resources.

[A shared room of reflection where the patient's symptoms are valid sources of knowledge]. / Et felles refleksjonsrom med pasientens symptomer som gyldige kunnskapskilder.

BACKGROUND: The consultation is supposed to clarify the origin of the patient's complaints and what can be done to alleviate them. Diagnostic work and interaction are challenged by subjective symptoms with no objective findings. In our project "Symptoms as a source of knowledge" we studied women's medically unexplained disorders from the viewpoint that the patient's knowledge represents significant potential for creative understanding. MATERIAL AND METHODS: Concepts and hypotheses about symptoms applied as diagnostic sources of knowledge were drawn from qualitative analysis of findings from the subprojects. We have explored issues of relevance and validity that shape the consultation as a medical and cultural space. RESULTS: Symptoms beyond established categories can disturb a room of reflection which includes patient as well as doctor. The patient may feel dismissed as a person, the process of objectivising becomes defocused, and the diagnostic activity deals with the patient's credibility. Signs related to "either-or" appear as a more comprehensible medical pattern than signs of 'more-or-less'. The probability of a common room of reflection may be related to cultural attitudes to time, blame, and womanliness. INTERPRETATION: When traditional medical analytic tools fail, alternative rooms of reflection can be established from recognition, resources, and dialogue, enhancing surprises and curiosity.

[Subjective symptoms without objective findings--a challenge for theory and practice of general medicine]. / Subjektive symptomer uden objektive fund--en udfordring for almen medicinsk teori og praksis.

Most practitioners know patients who suffer from subjective symptoms, although the doctor cannot find any objective findings or causal explanations. The majority of patients with medically unexplained disorders are women. In this article, I challenge the idea that these disorders are really unexplainable and inaccessible to diagnosis, treatment, or therapy. I present some experiences and findings from the research project "Symptoms as a source of medical knowledge", where an objective is to develop strategies where the patient's symptom experiences can be used to enhance the doctor's understanding of apparently unexplained disorders, their origins and consequences. Applying the theoretical framework of "recognition" and "empowerment", I propose some strategies intended to help the practitioner to encounter these challenges in everyday clinical practice.

From exercise and education to movement and interaction. Treatment groups in primary care for women with chronic muscular pain.

OBJECTIVE: To develop a group-based treatment programme in primary health care for women with chronic muscle pain, and adjust programme development according to experiences obtained by the participating women and health personnel. The aim of the programme was to help the women develop a tool for handling their chronic state of pain. The article describes and discusses experiences essential for elaboration of the treatment programme. DESIGN: Action research design. SETTING: Existing therapy groups in Stovner for women with chronic muscle pain. SUBJECTS: We arranged eight treatment groups, each lasting 12 weeks, and three groups lasting 10 months, with a total of 133 participants. MAIN OUTCOME MEASURES: Experiences were systematised by means of pragmatic analysis of qualitative data from field notes, tape recordings of focus group interviews, and video recordings of training and discussion groups. RESULTS: While initially the training programme aimed at increasing physical fitness and muscle strength, it gradually developed into activity based on movement with an emphasis on noticing and experiencing. The instruction programme initially aimed at providing information, and developed towards discussion groups with emphasis on mutual understanding and recognition. CONCLUSIONS: The training programme is now concentrated on a few, simple exercises and is characterised by awareness of the relationship between breathing and muscle tension. Groups were found to be the main pillar of the programme, characterised by security and a feeling of belonging with room for reflection and development.

Men's self-assessed personal health resources: approaching patients' strong points in general practice.

OBJECTIVE: To explore resource-oriented, gender-sensitive approaches in general practice by identifying what men perceive to be their personal health resources. METHODS: A key question was developed to invite men to tell their GPs about personal health resources during ordinary visits. The answers of 39 consecutive male patients (aged 19-84 years) visiting two female GPs were audio taped and analysed, qualitatively inspired by Giorgi's phenomenological approach, supported by theories on salutogenesis, patient-centredness and gender perspectives. The main outcome measures were personal qualities and strategies considered by men to be their health resources. RESULTS: Men considered that the following were personal health resources: optimism, good self-esteem, job satisfaction, ability to cope with stress at work, leisure activities and relaxation with friends producing energy, and fitness and lifestyle activities. CONCLUSION: A key question can give a doctor access to men's thoughts about their strong points. Self-assessed personal health resources can be identified and mobilized by the GP and support a salutogenic approach, which contrasts with the tendency of contemporary medical practice to focus on risk. Asking people about their own ideas may reveal that coping patterns are more complex than reflected in prevailing research.

"I could not lift my arm holding the fork...". Living with chronic fatigue syndrome.

OBJECTIVES: To explore and describe symptoms and their consequences for patients suffering from chronic fatigue syndrome (CFS). DESIGN: Qualitative data from a group interview, written answers to a questionnaire and a follow-up meeting analysed in accordance with Giorgi's phenomenological approach. SUBJECTS: Purposeful sample of 10 women and 2 men of various ages recruited from the local self-help patient organisation. MAIN OUTCOME MEASURES: Descriptions reflecting the nature, extent and consequences of symptoms regarded as the most substantial by the informants across the group. RESULTS: Extreme exhaustion exceeding the nature of everyday weariness was reported as the worst symptom. The informants perceived reduced muscular strength, continuous weakness and recurrent pain, problems related to memory and concentration, sleep disturbances and excessive sensitivity towards smell, light and sound. Learning abilities had deteriorated, and housework, conversation, reading and watching TV were characterised as exhausting, leading to an unpredictability of everyday life-disturbing social relations. CONCLUSION: The extent and nature of symptoms suggest that CSF is an essentially different and far more serious condition than the strains of everyday life. Our findings suggest immunological processes affecting the neuromuscular and central neural system comparable to the effects of cytostatic medication.

Inhibitors of 15-lipoxygenase from orange peel.

A series of polymethoxylated flavonoids has been isolated from orange peel, and their inhibitory activity toward soybean 15-lipoxygenase was determined. The strongest inhibition was shown by 3,5,6,7,3',4'-hexamethoxyflavone (IC(50) = 49 +/- 5 microM). Sinensetin, nobiletin, tangeretin, tetramethylscutellarein, and 3,5, 6,7,8,3',4'-heptamethoxyflavone were somewhat less active, with IC(50) values of 70-86 microM, comparable to the positive control quercetin (IC(50) = 68 +/- 5 microM). Demethylation apparently results in less active compounds, with 5-O-demethylsinensetin having an IC(50) value of 144 +/- 10 microM. Some other orange peel constituents were isolated and tested as well, hesperidin (IC(50) = 180 +/- 10 microM) and ferulic acid (111 +/- 2 microM), showing moderate activity. The polymethoxylated flavonoids were virtually inactive as scavengers of the diphenylpicrylhydrazyl radical. Hesperidin was only slightly active (24.2 +/- 0.7% scavenged at a concentration of 2 mM), and ferulic acid showed good activity (IC(50) = 86.4 +/- 0.7 microM). From this, it appears that orange peel constituents may counteract enzymatic lipid peroxidation processes catalyzed by 15-lipoxygenase in vitro. The radical scavenging activity of orange peel extracts is only modest.

Symptoms as a source of medical knowledge: understanding medically unexplained disorders in women.

In cases where a traditional medical frame of reference does not fully offer an adequate tool for understanding, the resident may find it perplexing to apply knowledge from medical school, where disease implies symptoms, findings, diagnosis, and cure. Medically unexplained disorders, mostly occurring in women, are chronic and disabling conditions, presenting with extensive subjective symptoms, although objective findings or causal explanations are lacking. Acquiring the knowledge and skills needed for adequate care of patients with chronic fatigue or pain syndromes is not an easy task. This paper presents a strategy for teaching, intended to facilitate understanding through appreciation of symptoms as a source of knowledge. The clinical approach is based on empowering practices supported by theoretical perspectives about signs, narratives, knowing, and gender. Also examined is the impact of commonly occurring teaching traps related to gender, psychosocial labeling, universalistic understanding, omnipotence, and power.