Professionals' perspectives on caring for cancer patients with pre-existing severe mental disorders.

INTRODUCTION: Cancer trajectories among patients with pre-existing severe mental disorders (SMD) are challenging and these pateints' prognosis is poor. This study aimed at exploring barriers in cancer trajectories among patients with pre-existing SMD as experienced by Danish healthcare professionals. METHODS: Semi-structured interviews were conducted with healthcare professionals who were sampled by purposive sampling. Data were analysed using inductive qualitative content analysis. RESULTS: The participants wanted to optimise treatment, but several barriers were reported, including lack of knowledge of supportive social systems. Oncological participants experienced a lack of knowledge of psychiatric disorders and a reluctance to deal with patients with SMD among some colleagues. Furthermore, participants expressed a lack of time and continuity. CONCLUSIONS: Concerns about how to create optimal cancer care trajectories for people with pre-existing SMD exist among healthcare professionals. Even so, stigmatisation, lack of knowledge and system barriers such as a lack of time and continuity must be addressed to optimise care for this population. FUNDING: This study was funded by The Danish Cancer Society (R283-A16499). TRIAL REGISTRATION: This study is registered in the internal register of research projects of the Central Denmark Region (R. no. 1-16-02-227-21).

Managing the new wave of weight loss medication in general practice: A qualitative study.

In early 2023, a new type of weight loss medication, Wegovy (semaglutide), was made available in Denmark. Both subsequent media coverage and public demand were huge. Wegovy is only available by prescription, primarily via general practitioners. However, there is very little knowledge about how healthcare professionals (HCPs) in general practice might deal with the great demand for and attention surrounding a new weight loss drug. The aim of this qualitative study was, therefore, to explore how Wegovy is managed and negotiated in general practice, particularly in terms of prescribing and follow-up. We conducted a focused ethnography study based on direct observation of consultations and both formal and informal interviews with seven doctors and four nurses from three general practices in Denmark. Using discourse analysis, we identified four central discourses revolving around trust in medicine, individual responsibility for health, the cost of weight loss medication, and the importance of shared decision-making. This study shows that the availability of a new, sought-after weight loss medication presents both opportunities and challenges for HCPs in general practice. The management of Wegovy involves numerous factors, including medical, economic, organizational, interpersonal and moral concerns.

Communication about weight-related issues with adult patients with obesity in general practice: A scoping review.

Background: Primary care providers see patients with obesity in general practice every day but may be challenged regarding communication about obesity. The research question of this study is: how do general practitioners and general practice staff and adult patients with obesity communicate about weight-related issues? Methods: A scoping review approach was used, searching PubMed, Scopus and CINAHL for peer-reviewed studies - of both quantitative and/or qualitative study designs, and published between 2001 and 2021. Results: Twenty articles were included. The weight-related issues discussed were by far physical issues, and only one study mentioned psychosocial issues. Most of the included studies contained information on who initiates the communication, how the weight-related issues are addressed and handled, and also obstacles and challenges in relation to the communication. The studies lacked information of when the weight-related issues are addressed and differences in views and experiences when discussing weight-related issues in general practice. Conclusion: Studies with the main focus communication about obesity and overall health in general practice are needed. Findings also indicate, that non-stigmatizing communication tools and guidelines are needed on this area to promote these types of conservations.

Perceptions, behaviours and potential barriers to effective obesity care. Results from the ACTION-DK study.

AIM: Weight bias, stigma and discrimination are pervasive in the health care system and society and may result in biased treatment of people living with obesity (PwO). We aimed to identify perceptions, attitudes and potential barriers that exist between people with obesity and health care professionals (HCPs) in Denmark. METHODS: The ACTION-DK survey was a cross-sectional, non-interventional, descriptive study conducted in Denmark. The cohort included 879 PwO (body mass index ≥30.0 kg/m2 ) based on self-reported height and body weight, and 100 HCPs from the primary and secondary sectors who frequently encountered PwO. RESULTS: Several discrepancies between PwO and HCPs were identified, including recognition of obesity as a chronic disease (PwO: 49% vs. HCPs: 84%) and whether PwO were responsible for their weight loss (PwO: 81% vs. HCPs: 17%). Among PwO, 46% were motivated to lose weight, but only 28% of HCPs shared this perception. Untimely initiation of obesity care consultations was also identified as a potential barrier to proper obesity care, as PwO waited 7 years, on average, from their initial decision to lose weight before having their first obesity care consultation. In addition, only 24% of PwO had a follow-up consultation after the initial obesity care discussion. Almost half of HCPs (46%) considered weight loss medication effective, but only 10% brought up this possibility during an obesity care discussion. CONCLUSIONS: Our findings suggest that it is pivotal to improve obesity care in Denmark by ensuring a better follow-up and alignment of the perceptions and attitudes toward obesity between PwO and HCPs.

How doctors build community and socialize into a clinical department through morning reports. A positioning theory study.

PHENOMENON: The morning report is one of the longest surviving hospital practices. Most studies of the morning report focus on the effectiveness of formal medical training, while focus on social and communicative aspects is rarer. This study explores the social interactions and communication in morning reports, examining the ways in which they contribute to the construction of professional identity and socialization into the community of the clinical department. APPROACH: We used a qualitative explorative design with video observations of morning reports. Our data consisted of 43 video-recorded observations (in all, 15.5 hours) from four different hospital departments in Denmark. These were analyzed using the theoretical framework of positioning theory. FINDINGS: A key finding was that each department followed its own individual structure. This order was not articulated as such but played out implictly. Two alternative storylines unfolded in the elements of the morning report: 1) being equal members of the specialty and department, and 2) preserving the hierarchical community and its inherent positions. INSIGHTS: The morning report can be seen as playing an important role in community making. It unfolds as a "dance" of repeated elements in a complex collegial space. Within this complexity, the morning report is a space for positioning oneself and others as a collegial "we", i.e., equal members of a department and specialty, at the same time as "having a place" in a hierarchal community. Thus, morning reports contribute to developing professional identity and socialization into the medical community.

Barriers in cancer trajectories of patients with pre-existing severe mental disorders-A systematic review.

BACKGROUND: Patients with pre-existing severe mental disorders are significantly less likely to receive guideline-recommended cancer treatment and seems to have a significantly lower rate of cancer survival compared to patients with cancer without mental disorders. AIM: To perform a systematic review on barriers at patient-, provider- and system-levels in cancer trajectories of patients with pre-existing severe mental disorders. METHOD: A systematic review was performed following the PRISMA guidelines (PROSPERO ID: CRD42022316020). RESULTS: Nine eligible studies were identified. Barriers at patient-level included lack of self-care and ability to recognize physical symptoms and signs. Provider-level barriers included stigma from health care professionals on mental disorders, whereas system-level barriers included fragmented health care and consequences of this. CONCLUSION: This systematic review found that barriers at patient-, provider- and system-levels exist in cancer trajectories for patients with severe mental disorders, causing disparities in cancer care. Further research is needed to improve cancer trajectories for patients with severe mental disorder.

Obesity stigma.

Obesity stigma refers to the pervasive sociocultural disapproval and prejudice against people with obesity which is associated with different negative traits. The stigmatisation of people with obesity manifests itself in different social areas, both privately and publicly, including in the health care system, often resulting in negative physical, social, and psychological consequences for people with obesity. Consequently, it is imperative that healthcare professionals seek to avoid and take action against this type of stigmatisation, e.g. when communicating about weight.

Communication about weight-related issues with patients with obesity.

This review focuses on communication about weight-related issues with patients with obesity in general practice. Primary care providers still lack knowledge and tools to address and communicate about the topic of weight and weight-related issues - with focus on minimizing stigmatization and a person centered approach. A few communication tools on the topic have been developed but it seems that the use of those is limited, suggesting an urgent need for making a fast, easy and simple tool for the use in general practice.

What works in appraisal meetings for newly graduated doctors? - and what doesn't?

BACKGROUND: In Denmark a national formal advisory program (NFAP) is mandatory in Postgraduate Medical Education (PGME). According to this, an educational advisor is assigned to each doctor in every clinical rotation to guide and oversee the work and learning progress of the trainee. This study explores why newly graduated trainees evaluated the appraisal meetings in the advisory program as either beneficial (successes) or not beneficial (non-successes). METHODS: Inspired by the Success Case Method, a survey was conducted among all 129 doctors employed in their first six-month clinical rotation of postgraduate medical education (PGY1) in the Central Denmark Region. A cluster analysis resulted in a group with eight successes respectively seven non-successes. Semi-structured interviews were conducted with six successes and five non-successes. RESULTS: In contrast to non-successes, the successes had longer appraisal meetings and their advisor introduced them to purpose and process of meetings including use of the personal learning plan. Successes received feedback on clinical skills, overall global performance and career plans. The successes perceived their advisors as prepared, skilled and motivated and the advisor acted as a contact person. To the successes, the appraisal meetings fostered clarification of and reflections on educational goals, progress and career as well as self-confidence and a sense of security. CONCLUSION: Success with appraisal meetings seemed to depend on advisor's skills and motivation including willingness to prioritize time for this task. The results from this study indicate the importance of faculty development. It also raises the question if all doctors should serve as advisors or if this task should be assigned to the most motivated candidates.

Ambivalence and moral dilemmas in women's lived experiences of obesity and pregnancy: Qualitative insights for maternal lifestyle interventions.

BACKGROUND: Maternal obesity is a global health concern that is associated with significant effects on both short- and long-term health of both mother and child. However, maternal lifestyle interventions tend to focus solely on diet and physical activity in ways that disembody and disengage the social context in which women live their lives. AIMS: The aim of this study was to explore the lived experiences of maternal obesity and delve into how experiences of the body and motherhood affect women's motivation for participating in a postpartum lifestyle intervention. METHOD: A qualitative study using in-depth semi-structured interviews based on participant-generated photographs was used to allow the women to openly express their lived experiences of maternal obesity. The study emanated from a gynaecological department of a major Danish hospital, and five pregnant or postpartum women living with obesity participated. Interviews were audio recorded, transcribed and analysed using an Interpretive Phenomenological Approach. RESULTS: The analysis identified an overall theme of ambivalence and four subthemes among the participating women. The themes reflected contrasting feelings where the obese body was simultaneously an arena for aesthetic failure, functional success and moral dilemmas. Experiences of weight stigma and moral accusations in healthcare settings further increased the women's sense of ambivalence and challenged their strong desire to lose weight. CONCLUSION: This study highlights an ambivalent and vulnerable situation of maternal obesity which makes moral sensitivity towards weight and body concerns crucial to consider in future maternal health interventions. Our data suggest that an emphasis on functionality and capability rather than aesthetics and measured ideals would be useful in providing care and support in postpartum lifestyle interventions for women living with obesity.

Advance care planning and place of death, hospitalisation and actual place of death in lung, heart and cancer disease: a randomised controlled trial.

OBJECTIVES: Advance care planning (ACP) can be a way to meet patients' end-of-life preferences and enhance awareness of end-of-life care. Thereby it may affect actual place of death (APOD) and decrease the rate of hospitalisations. The aim was to investigate if ACP among terminally ill patients with lung, heart and cancer diseases effects fulfilment of preferred place of death (PPOD), amount of time spent in hospital and APOD. METHODS: The study was designed as a randomised controlled trial. Patients were assessed using general and disease-specific criteria and randomised into groups: one received usual care and one received usual care plus ACP. The intervention consisted of a discussion between a healthcare professional, the patient and their relatives about preferences for end-of-life care. The discussion was documented in the hospital file. RESULTS: In total, 205 patients were randomised, of which 111 died during follow-up. No significant differences in fulfilment of PPOD (35% vs 52%, p=0.221) or in amount of time spent in hospital among deceased patients (49% vs 23%, p=0.074) were found between groups. A significant difference in APOD was found favouring home death in the intervention group (17% vs 40%, p=0.013). CONCLUSION: Concerning the primary outcome, fulfilment of PPOD, and the secondary outcome, time spent in hospital, no differences were found. A significant difference concerning APOD was found, as more patients in the intervention group died at home, compared with the usual care group. TRIAL REGISTRATION NUMBER: NCT01944813.

Focused ethnography as an approach in medical education research.

CONTEXT: Over recent decades, the use of qualitative methodologies has increased in medical education research. These include ethnographic approaches, which have been used to explore complex cultural norms and phenomena by way of long-term engagement in the field of research. Often, however, medical education consists of short-term episodes that are not bound to single sites, but take place in a myriad of locations and contexts such as classrooms, examination stations, clinical settings and online. This calls for methodologies that allow us to grasp what is at stake in an increasingly multifaceted and diverse field. METHODS: In this article, we direct attention to focused ethnography, which has emerged as a useful, suitable and feasible applied qualitative research approach, and which uses adapted classic ethnographic methods, such as direct observation, to gain new insights and nuanced understandings of distinct phenomena, themes and interactions in specific settings in medical education (eg the learning potential of ward rounds, or how hierarchical positions affect learning situations). We introduce methodological key features of focused ethnography to give insights into how the approach can be used, and we offer examples of how the method has been used in medical education research to show how it has contributed in different ways to the field of medical education research. Furthermore, we address and discuss some of the main challenges and limitations of the approach. CONCLUSIONS: Focused ethnography offers a methodological approach that sheds light over limited and well-defined social episodes and interactions. Precisely because the field of medical education consists to a large degree of such fragmented interactions, focused ethnography can be seen as a methodology tailored to these characteristics and should become an integrated part of the toolkit of medical education research.

How are formative assessment methods used in the clinical setting? A qualitative study.

OBJECTIVES: To explore how formative assessment methods are used and perceived by second-year junior doctors in different clinical settings. METHODS: A focused ethnography study was carried out. Ten second-year junior doctors from different specialties were selected using purposive sampling. The junior doctors were observed during a day in their clinical workplace where formative assessment was in focus. They were subsequently phone interviewed using a semi-structured interview guide regarding their experiences and attitudes towards formative assessment. Field notes from observations and interview transcriptions were analyzed using an inductive content analysis approach, and the concept of "everyday resistance" was used as a theoretical lens. RESULTS: Three themes were identified: First, there were several barriers to the use of formative assessment methods in the clinical context, including subtle tactics of everyday resistance such as avoidance, deprioritizing, and contesting formative assessment methods.  Secondly, junior doctors made careful selections when arranging a formative assessment. Finally, junior doctors had ambiguous attitudes towards the use of mandatory formative assessment methods and mixed experiences with their educational impact. CONCLUSIONS: This study emphasizes that the use of formative assessment methods in the clinical setting is not a neutral and context-independent exercise, but rather is affected by a myriad of factors such as collegial relations, educational traditions, emotional issues, and subtle forms of resistance. An important implication for the health care sector will be to address these issues for formative assessment methods to be properly implemented in the clinic.

Advance care planning for patients and their relatives.

BACKGROUND: Advance care planning (ACP) has been suggested to improve the quality of life (QoL) and mental wellbeing in severely ill patients and their relatives. AIM: To investigate the effects of ACP among patients with lung, heart and cancer diseases with an estimated life-span of up to 12 months. METHODS: Patients and relatives were randomised into two groups: one receiving usual care and one receiving ACP and usual care. Themes from the ACP discussion were documented in patients' electronic medical file. Participants completed self-reported questionnaires four to five weeks after randomisation. FINDINGS: In total, 141 patients and 127 relatives participated. No significant differences were found according to outcomes. However, patients with non-malignant diseases had the highest level of anxiety and depression; these patients seemed to benefit the most from ACP, though not showing statistically significant results. CONCLUSION: No significant effects of ACP among patients with lung, heart, and cancer diseases and their relatives regarding HRQoL, anxiety, depression, and satisfaction with healthcare were found.

A SWOT analysis of how the youngest doctors perceive the formal Danish educational advisory programme.

INTRODUCTION: A national formal advisory programme (NFAP) was introduced in Denmark in 1998. This study investigates the implementation of the NFAP and identifies areas to improve. METHODS: In March 2017, a survey was conducted among all 129 doctors employed in the first rotation of postgraduate medical education in the Central Denmark Region. A priority chart was created to appoint strengths, weaknesses, op-portunities and threats (SWOT). RESULTS: The response rate was 67%. The questionnaire showed good reliability and discriminant validity. Almost all respondents had completed the recommended appraisal meetings and a personal learning plan, both of which - in contrast to the NFAP's coherence to everyday clinical practice - showed to have much influence on the overall value of the NFAP. Strengths found were that appraisal meetings and learning plans support the development of clinical competencies, the latter identifying learning objectives and how to achieve them. Threats identified included learning plans that were not prepared sufficiently early, were not regularly adjusted and that did not describe when each learning objective is to be achieved, or when, by whom or how assessment will take place. CONCLUSIONS: Appraisal meetings and learning plans seem to be well implemented and to support the development of clinical competencies. Even so, improvements are needed, particularly to ensure an earlier preparation, inclusion of plans for assessment and regular adjustment of the learning plans. FUNDING: The study was funded by the Central Denmark Region. TRIAL REGISTRATION: Data collection was approved by the Danish Health Data Authority.

Science in the clinic: a qualitative study of the positioning of MD-PhDs in the everyday clinical setting.

BACKGROUND: MD-PhDs have been hailed as significant to the advancement of medicine and health care. Yet when it comes to which positions MD-PhDs should be holding in the clinic and the academic world, there seems to be no real consensus. This article examines the ways in which a PhD-degree may contribute to medical doctors' professional practice in the clinic and discusses the positioning of MD-PhDs in the clinic. METHODS: The study is explorative and qualitative, based on interviews with MD-PhDs, their physician colleagues without a PhD-degree, and their leaders. Positioning theory was applied as the analytical framework for data analysis. RESULTS: We found two opposing positions cutting across the groups of informants with one side critiquing the MD-PhDs for not doing enough research and for using the PhD-degree to climb the career ladder, while the other side emphasized the ways in which MD-PhDs increase the clinical focus on evidence-based medicine and integrate it with clinical decision making, thereby enhancing patient care. CONCLUSIONS: A debate is needed to establish more clearly how we wish to position MD-PhDs in the clinic, which in turn will give us a better idea of how many to educate and how to make better use of their competencies.

"We're at a watershed": The positioning of PhD nurses in clinical practice.

AIM: The aim of this study was to explore different perspectives on the positioning (i.e. the perceived rights and duties) of PhD nurses and how they contribute to clinical nursing practice. BACKGROUND: The number of PhD nurses is growing worldwide, but we only have little knowledge of what is expected of PhD nurses and what their actual impact is in the clinic. DESIGN: The findings of this article stem from a qualitative, explorative interview study. METHODS: Semi-structured interviews were carried out with six PhD nurses, nine nurse colleagues and six clinical nurse leaders. Data collection took place from April - June 2016 in Central Denmark Region. Data were analysed using positioning theory. FINDINGS: The PhD nurses were positioned as responsible for implementing evidence-based practice in the clinic and in nursing culture as such. Emphasis was put on the importance of PhD nurses staying close to the clinic to do practice-based research of immediate effect for patient care. CONCLUSION: The study reveals several positive effects of PhD nurses in the clinic but also problematizes the many and diverse duties they are expected to carry out.

Preferred Place of Care and Death in Terminally Ill Patients with Lung and Heart Disease Compared to Cancer Patients.

OBJECTIVES: The dual aim of this study is, first, to describe preferred place of care (PPOC) and preferred place of death (PPOD) in terminally ill patients with lung and heart diseases compared with cancer patients and second, to describe differences in level of anxiety among patients with these diagnoses. BACKGROUND: Previous research on end-of-life preferences focuses on cancer patients, most of whom identify home as their PPOC and PPOD. These preferences may, however, not mirror those of patients suffering from nonmalignant fatal diseases. DESIGN: The study was designed as a cross-sectional study. SETTING: Eligible patients from the recruiting departments filled in questionnaires regarding sociodemographics, PPOC and PPOD, and level of anxiety. RESULTS: Of the 354 eligible patients, 167 patients agreed to participate in the study. Regardless of their diagnosis, most patients wished to be cared for and to die at home. Patients with cancer and heart diseases chose hospice as their second most common preference for both PPOC and PPOD, whereas patients with lung diseases chose nursing home and hospice equally frequent as their second most common preference. Regardless of their diagnosis, all patients had a higher level of anxiety than the average Danish population; patients with heart diseases had a much higher level of anxiety than patients with lung diseases and cancer. CONCLUSION: Patient preferences for PPOC and PPOD vary according to their diagnoses; tailoring palliative needs to patients' preferences is important regardless of their diagnosis.

[Care and treatment can be planned in advance with advance care planning].

Advance care planning (ACP) is a discussion between an incurably ill patient, a healthcare professional and if possible, a relative about preferences for end-of-life care, and ACP may improve the communication in this situation. However, in the Danish healthcare system there is no formalized and systematically used standard procedure for discussions with patients about their knowledge of their treatment options, values and preferences. In this article we review the concept of ACP, including definition, experiences from abroad and the status of ACP in Denmark.