Intolerance-of-uncertainty therapy versus metacognitive therapy for generalized anxiety disorder in primary health care: A randomized controlled pilot trial.

OBJECTIVE: This randomized controlled pilot study investigated the feasibility of a future full-scale RCT to compare the effects of intolerance-of-uncertainty therapy (IUT) and metacognitive therapy (MCT) in primary health care patients with generalized anxiety disorder (GAD). Preliminary treatment effects were also evaluated. MATERIALS AND METHODS: 64 patients with GAD at a large primary health care center in Stockholm, Sweden, were randomized to IUT or MCT. Feasibility outcomes included participant recruitment and retention, willingness to receive psychological treatment, and therapists' competence in and adherence to treatment protocols. Self-reported scales were used to assess treatment outcomes, including worry, depression, functional impairment, and quality of life. RESULTS: Recruitment was satisfactory, and dropout was low. On a scale from 0 to 6, participants were satisfied with participating in the study (M = 5.17, SD = 1.09). Following brief training, therapists' competence was rated as moderate, and adherence was rated as weak to moderate. From pre- to post-treatment, reductions on the primary treatment outcome measure of worry were of a large effect size and statistically significant in both the IUT and MCT conditions (Cohen's d for IUT = -2.69, 95% confidence interval [-3.63, -1.76] and d for MCT = -3.78 [-4.68, -2.90]). The between-group effect size from pre- to post-treatment was large and statistically significant (d = -2.03 [-3.31, -0.75]), in favor of the MCT condition. CONCLUSION: It is feasible to carry out a full-scale RCT to compare the effects of IUT to MCT for patients with GAD in primary health care. Both protocols seem effective, and MCT seems superior to IUT, but a full-scale RCT is needed to confirm these conclusions. TRIAL REGISTRATION: ClinicalTrials.gov (no. NCT03621371).

Medical Students' Learning About Other Professions Using an Interprofessional Virtual Patient While Remotely Connected With a Study Group: Mixed Methods Study.

BACKGROUND: Collaboration with other professions is essential in health care education to prepare students for future clinical teamwork. However, health care education still struggles to incorporate interprofessional education. Distance learning and virtual patients (VPs) may be useful additional methods to increase students' possibilities for interprofessional learning. OBJECTIVE: This study had two aims. The first was to assess if an interprofessional VP case could facilitate medical students' learning about team collaboration in online groups. The second was to assess how students experienced learning with the VP when remotely connected with their group. METHODS: A mixed methods design was used. The VP case was a 73-year-old man who needed help from different health professions in his home after a hip fracture. Questionnaires were answered by the students before and directly after each session. Qualitative group interviews were performed with each group of students directly after the VP sessions, and the interviews were analyzed using qualitative content analysis. RESULTS: A total of 49 third-year medical students divided into 15 groups participated in the study. Each group had 2 to 5 students who worked together with the interprofessional VP without a teacher's guidance. In the analysis of the group interviews, a single theme was identified: the interprofessional VP promoted student interaction and gave insight into team collaboration. Two categories were found: (1) the structure of the VP facilitated students' learning and (2) students perceived the collaboration in their remotely connected groups as functioning well and being effective. The results from the questionnaires showed that the students had gained insights into the roles and competencies of other health care professions. CONCLUSIONS: This study demonstrates that an interprofessional VP enabled insights into team collaboration and increased understanding of other professions among student groups comprising only medical students. The interprofessional VP seemed to benefit students' learning in an online, remote-learning context. Although our VP was not used as an interprofessional student activity according to the common definition of interprofessional education, the results imply that it still contributed to students' interprofessional learning.

A unified Internet-delivered exposure treatment for undifferentiated somatic symptom disorder: single-group prospective feasibility trial.

BACKGROUND: Exposure-based psychological treatment appears to have beneficial effects for several patient groups that commonly report distress related to persistent somatic symptoms. Yet exposure-based treatment is rarely offered in routine care. This may be because existing treatment protocols have been developed for specific symptom clusters or specific unwanted responses to somatic symptoms, and many clinics do not have the resources to offer all these specialised treatments in parallel. In preparation for a randomised controlled trial, we investigated the feasibility of a new and unified Internet-delivered exposure treatment (OSF.io: cnbwj) for somatic symptom disorder regardless of somatic symptom domain (e.g. cardiopulmonary, fatigue, gastrointestinal, pain), combination of unwanted emotions (e.g. anger, anxiety, fear, shame) and whether somatic symptoms are medically explained or not. We hypothesised that a wide spectrum of subgroups would show interest, that the treatment would be rated as credible, that adherence would be adequate, that the measurement strategy would be acceptable and that there would be no serious adverse events. METHODS: Single-group prospective cohort study where 33 self-referred adults with undifferentiated DSM-5 somatic symptom disorder took part in 8 weeks of unified Internet-delivered exposure treatment delivered via a web platform hosted by a medical university. Self-report questionnaires were administered online before treatment, each week during treatment, post treatment and 3 months after treatment. RESULTS: Participants reported a broad spectrum of symptoms. The Credibility/Expectancy mean score was 34.5 (SD = 7.0, range: 18-47). Participants completed 91% (150/165) of all modules and 97% of the participants (32/33) completed at least two exposure exercises. The average participant rated the adequacy of the rationale as 8.4 (SD = 1.5) on a scale from 0 to 10. The post-treatment assessment was completed by 97% (32/33), and 84% (27/32) rated the measurement strategy as acceptable. The Client Satisfaction Questionnaire mean score was 25.3 (SD = 4.7, range: 17-32) and no serious adverse events were reported. Reductions in subjective somatic symptom burden (the Patient Health Questionnaire 15; d = 0.90) and symptom preoccupation (the somatic symptom disorder 12; d = 1.17) were large and sustained. CONCLUSIONS: Delivering a unified Internet-delivered exposure-based treatment protocol for individuals with undifferentiated somatic symptom disorder appears to be feasible. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04511286 . Registered on August 13, 2020.

Home visits as an interprofessional learning activity for students in primary healthcare.

AIM: To evaluate person-centred home visits as an interprofessional learning (IPL) activity for undergraduate students during clinical placements in primary healthcare. BACKGROUND: Interprofessional collaboration is known to improve patient safety, increase job satisfaction, and reduce stress among healthcare professionals. Students should already during their basic training experience interprofessional collaboration. METHODS: Students from six different educational programmes and supervisors and adjunct clinical lecturers from different professions participated in the learning activity. The students read a description of the patient history before the visit together with a supervisor. During the home visit, the students were responsible for history-taking and for performing relevant examinations. Afterwards, the students made a joint care plan for the patient. Students, supervisors, and adjunct clinical lecturers discussed the outcomes in a seminar and reflected on each other's professional roles. The students and the patients answered a questionnaire about the activity, and the supervisors and the adjunct clinical lecturers were interviewed in focus groups. FINDINGS: Thirty interprofessional home visits were conducted, involving 109 students from six different healthcare professions. The students reported that they had gained insights into how different professions could collaborate and an increased understanding of teamwork. All patients were satisfied with the visits and felt that they had been listened to. The interview analysis showed one overarching theme: 'Interprofessional home visits in primary healthcare were an appreciated and effective pedagogical learning activity with a sustainability dependent on organisational factors'. CONCLUSIONS: The students felt that participation in the activity increased their understanding of collaboration and of other professions' skills. The supervisors found the home visits to be an appreciated and effective learning activity. The results indicate that this learning activity can be used in primary healthcare settings to promote students' IPL, but organisational factors need to be considered in order to support sustainability.

Use of online knowledge base in primary health care and correlation to health care quality: an observational study.

BACKGROUND: Evidence-based information available at the point of care improves patient care outcomes. Online knowledge bases can increase the application of evidence-based medicine and influence patient outcome data which may be captured in quality registries. The aim of this study was to explore the effect of use of an online knowledge base on patient experiences and health care quality. METHODS: The study was conducted as a retrospective, observational study of 24 primary health care centers in Sweden exploring their use of an online knowledge base. Frequency of use was compared to patient outcomes in two national quality registries. A socio-economic Care Need Index was applied to assess whether the burden of care influenced the results from those quality registries. Non-parametric statistical methods and linear regression were used. RESULTS: Frequency of knowledge base use showed two groups: frequent and non-frequent users, with a significant use difference between the groups (p < 0.001). Outcome data showed significant higher values for all seven National Primary Care Patient Survey dimensions in the frequent compared to the non-frequent knowledge base users (p < 0.001), whereas 10 out of 11 parameters in the National Diabetes Register showed no differences between the groups (p > 0.05). Adjusting for Care Need Index had almost no effect on the outcomes for the groups. CONCLUSIONS: Frequent users of a national online knowledge base received higher ratings on patient experiences, but figures on health care quality in diabetes showed near to no correlation. The findings indicate that some effects may be attributed to the use of knowledge bases and requires a controlled evaluation.

A virtual patient model for students' interprofessional learning in primary healthcare.

OBJECTIVES: Interprofessional education is important for increasing the quality of patient care, but organising it in primary healthcare is still challenging. The aim of this study was to develop and assess a virtual patient model for primary healthcare and to investigate students' perceptions of learning with this interprofessional virtual patient model. METHODS: The virtual patient case described a patient with several medical conditions who had returned home after surgery. The virtual patient included text files, short videos, and links to illustrate different health professions' roles in home care. Ten interprofessional groups with 39 students assessed the virtual patient from four different study programmes: nursing, physiotherapy, medicine, and occupational therapy. The students answered a questionnaire about how they perceived the usability of the virtual patient and participated in group interviews. Qualitative content analysis was used to analyse the data from the semi-structured group interviews. RESULTS: The analysis of the interviews resulted in four main categories: The virtual patient model facilitated the learning process; It was beneficial to have students from different programmes in the group when working with the virtual patient; Working with the virtual patient helped the students to understand the roles and competencies of their own and other professions and All professions are needed in clinical work in order to help the patient. The students perceived that the mixture of text and multimedia made the virtual patient seem authentic and stimulated their group discussions, which they valued most. The students gave generally high points for usability in the questionnaire, but they also gave input for improvement of the program in their comments. CONCLUSIONS: The interprofessional virtual patient model facilitated interactions and discussions between students and may be a useful complement for interprofessional education in clinical contexts and might be a suitable tool in preparing students for future teamwork.

Swedish adaptation of the General Medical Council's multisource feedback questionnaires: a qualitative study.

OBJECTIVES: to explore potential users' opinions of a translated and culturally adapted Swedish version of the General Medical Council's MultiSource Feedback Questionnaires. METHODS: In this qualitative study, we used content analysis on semi-structured interviews from 44 resident doctors, 29 medical colleagues and 28 patients to analyse their opinions of the Swedish adapted version, created through translation and expert review. Transcribed interview data concerning the informants' general thoughts about the tool were coded manually by three independent coders into categories, compiled as themes, and exemplified by citations. Data regarding specific question wording and relevance were used as a basis for final questionnaire revision. RESULTS: The informants valued the tool's potential to provide essential feedback to support the development of residents' medical competences and communication skills. Resident doctors welcomed support in their self-reflection. Colleagues saw it as a valuable tool for assessment that needs to be used sensitively. Patients appreciated opportunities to communicate feedback.  Ambiguous or irrelevant questions and response options were identified. Some colleague-related questions about specific skills and knowledge appeared ambiguous to residents. The final questionnaire revision - based on the expert review and the interview analysis - resulted in a number of changes: four questions were deleted, twelve were reformulated, and six were added. CONCLUSIONS: Potential users perceived the Swedish adapted version as a beneficial tool for residents in their professional development. Further research is needed to explore how this tool can influence doctors' development when used in real-life settings.

Psychometric analysis of the Swedish version of the General Medical Council's multi source feedback questionnaires.

OBJECTIVES: To determine the internal consistency and the underlying components of our translated and adapted Swedish version of the General Medical Council's multisource feedback questionnaires (GMC questionnaires) for physicians and to confirm which aspects of good medical practice the latent variable structure reflected. METHODS: From October 2015 to March 2016, residents in family medicine in Sweden were invited to participate in the study and to use the Swedish version to perform self-evaluations and acquire feedback from both their patients and colleagues. The validation focused on internal consistency and construct validity. Main outcome measures were Cronbach's alpha coefficients, Principal Component Analysis, and Confirmatory Factor Analysis indices. RESULTS: A total of 752 completed questionnaires from patients, colleagues, and residents were analysed. Of these, 213 comprised resident self-evaluations, 336 were feedback from residents' patients, and 203 were feedback from residents' colleagues. Cronbach's alpha coefficients of the scores were 0.88 from patients, 0.93 from colleagues, and 0.84 in the self-evaluations. The Confirmatory Factor Analysis validated two models that fit the data reasonably well and reflected important aspects of good medical practice. The first model had two latent factors for patient-related items concerning empathy and consultation management, and the second model had five latent factors for colleague-related items, including knowledge and skills, attitude and approach, reflection and development, teaching, and trust. CONCLUSIONS: The current Swedish version seems to be a reliable and valid tool for formative assessment for resident physicians and their supervisors. This needs to be verified in larger samples.

Virtual patients in primary care: developing a reusable model that fosters reflective practice and clinical reasoning.

BACKGROUND: Primary care is an integral part of the medical curriculum at Karolinska Institutet, Sweden. It is present at every stage of the students' education. Virtual patients (VPs) may support learning processes and be a valuable complement in teaching communication skills, patient-centeredness, clinical reasoning, and reflective thinking. Current literature on virtual patients lacks reports on how to design and use virtual patients with a primary care perspective. OBJECTIVE: The objective of this study was to create a model for a virtual patient in primary care that facilitates medical students' reflective practice and clinical reasoning. The main research question was how to design a virtual patient model with embedded process skills suitable for primary care education. METHODS: The VP model was developed using the Open Tufts University Sciences Knowledgebase (OpenTUSK) virtual patient system as a prototyping tool. Both the VP model and the case created using the developed model were validated by a group of 10 experienced primary care physicians and then further improved by a work group of faculty involved in the medical program. The students' opinions on the VP were investigated through focus group interviews with 14 students and the results analyzed using content analysis. RESULTS: The VP primary care model was based on a patient-centered model of consultation modified according to the Calgary-Cambridge Guides, and the learning outcomes of the study program in medicine were taken into account. The VP primary care model is based on Kolb's learning theories and consists of several learning cycles. Each learning cycle includes a didactic inventory and then provides the student with a concrete experience (video, pictures, and other material) and preformulated feedback. The students' learning process was visualized by requiring the students to expose their clinical reasoning and reflections in-action in every learning cycle. Content analysis of the focus group interviews showed good acceptance of the model by students. The VP was regarded as an intermediate learning activity and a complement to both the theoretical and the clinical part of the education, filling out gaps in clinical knowledge. The content of the VP case was regarded as authentic and the students appreciated the immediate feedback. The students found the structure of the model interactive and easy to follow. The students also reported that the VP case supported their self-directed learning and reflective ability. CONCLUSIONS: We have built a new VP model for primary care with embedded communication training and iterated learning cycles that in pilot testing showed good acceptance by students, supporting their self-directed learning and reflective thinking.

Implementing a clinical decision-support system in practice: a qualitative analysis of influencing attitudes and characteristics among general practitioners.

In order to obtain a better understanding of barriers to the implementation of clinical decision-support systems (CDSSs) in primary health care, we explored general practitioners' (GPs) handling of a CDSS during the implementation process. An Internet-based application for the management of chronic heart failure was used that was an adaptation of established clinical guidelines for computer use. The whole implementation process was followed closely, using a combination of different methods for data collection: repeated interviews with the five participating GPs, observations of patient visits, patient interviews, and detection of usage. We analysed the data using qualitative content analysis. The results showed that GPs' attitudes and characteristics constituted different profiles that seemed to be associated with the degree of acceptance of the CDSS. Those profiles were related to conceptions about the GPs' professional role and their attitudes towards the computer's function in disease management and in decision-making. Some additional barriers were insufficient level of computer skills and time constraints in everyday work. These findings can help us identify groups of GPs with definable needs during the implementation of a CDSS and make it easier to meet those needs with individually tailored interventions.

A guideline-based computerised decision support system (CDSS) to influence general practitioners management of chronic heart failure.

OBJECTIVES: To explore the influence of a guideline-based computerised decision support system (CDSS) on general practitioners' (GPs') management of patient cases of chronic heart failure in a pragmatic clinical situation. We assessed changes in the GPs' confidence in the diagnosis, their considerations about investigations and medications and the support they perceived from using the CDSS. STUDY DESIGN: Five GPs assessed the medical records of 48 of their own authentic patient cases using a guideline-based CDSS accessible on the internet for the diagnosis and treatment of chronic heart failure, and completed a questionnaire for each case. OUTCOME MEASURES: Number of cases where the GP reported a change in confidence in the diagnosis, where the GP considered further investigations or changes in medication and the perceived support marked on a visual analogue scale. RESULTS: The GPs' confidence in the diagnosis changed in 25% of the cases, with equal numbers of increases and decreases in confidence. The GPs considered further investigations in 31% of the cases and medication changes in 19%. Fourteen of the 31 considered investigations and four of the ten considered changes in medications which were in agreement with the CDSS's suggestions. The GPs tended to consider further investigations more often in cases when the CDSS found the diagnosis uncertain. There was a wide range in the values for perceived support, but it could be described as substantial in 35% of the cases. CONCLUSION: Using a guideline-based CDSS for the GPs' own patient cases had an impact on the GPs' confidence in the diagnosis of chronic heart failure and their considerations about investigations and medications: they also perceived substantial support in every third case. Applying a CDSS developed using evidence-based guidelines for chronic heart failure in primary care could have a significant influence on GPs' disease management.

Clinical effect of computer generated physician reminders in health screening in primary health care--a controlled clinical trial of preventive services among the elderly.

OBJECTIVES: To apply and evaluate the effects of a program for computer generated physician reminders, integrated with an electronic patient record (EPR) system, for opportunistic health screening in elderly patients. DESIGN: A pilot study designed as a 20-month clinical trial with a control group and a 20-month non-intervention follow-up using a computer reminder program that selects patients for screening in five intervention areas (diabetes, hypertension, cobalamin deficiency, hypothyroidism and anaemia). SETTING: Four primary health care (PHC) centres in suburban Stockholm. SUBJECTS: The intervention was designed for patients 70 years or older from one health care centre who visited a general practitioner (GP) during the first 20-month period. Patients from the three remaining centres served as controls. MAIN OUTCOME MEASURES: The number of patients who underwent the tests, who had pathological test results, new diagnoses and new pharmacological treatments in both patient groups. RESULTS: In total, 602 patients underwent screening and 1989 were controls. There was a statistically significant, moderate or marked increase (13-75%) in the number of patients who were tested in all five intervention areas. An increase in pathological test results (1-8%) was found in two areas: hypertension and cobalamin deficiency. There was an increase in the number of patients with the diagnosis of cobalamin deficiency during the study. At follow-up a decrease in new diagnoses for anaemia was found. CONCLUSION: The system seems to be associated with a moderate to large increase in laboratory and manual screening tests for both established and new screening areas. The effect on clinical outcomes was found mainly in a not-yet-established screening area (cobalamin deficiency), indicating that the system may be clinically useful when introducing new screening services.