Aim of study Person-centered medicine (PCM) with its focus on humanistic-biographical-oriented medicine and integrated, positive-salutogenic health is a central aspect in the patient-physician relationship in general practice. The objective of this analysis is to assess the prevalence and type of research project in academic institutions of general practice in Germany (Ger) and Austria (At) and the thematic priorities of the projects in the areas PCM, health promotion (HP), prevention (PRE) and conventional medicine (CM). Methods A search was conducted (September–December 2015) on the websites of 30 institutes and divisions of general medicine for their current research projects. The retrieved projects were assigned to five categories: PCM, HP, PRE, CM and others. Subsequently, we identified the targeted patient groups of the projects as well as the thematic focus in the categories PCM, HP, PRE and CM with focus on PCM and HP. Results 541 research projects were identified, 452 in Germany and 89 in Austria. Research projects were only included if they were explicitly indicated as research-oriented. Seventy projects addressed PCM aspects, 15 projects HP aspects, 32 projects PRE aspects and 396 projects CM aspects. The most frequently target groups in the categories PCM (24 of 70) and HP (7 of 15) were chronically ill patients. The most common thematic focus in PCM was communication (13 of 70) and in HP, physical activity (6 of 15). Conclusion The vast majority of research projects focused on conventional medical topics. PCM (13%) or PCM including HP (16%) in Ger and At is below the European average of 20%. From our point of view, PCM and HP need to be considered in general practice.

Background General practice’s population health and public health role is being promoted internationally to improve health outcomes. 1-6 This Thesis aims to: • Describe and evaluate projects which are relevant to exploring the interface of population health and public health with Australian rural general practice; and • Describe and evaluate projects which can increase population health and public health expertise and capacity amongst our future rural general practice workforce. Methods This Thesis uses a descriptive design. A series of research papers published in the peer reviewed literature are presented in each chapter. These papers are used as case studies to explore the aims of this Thesis. A variety of quantitative and qualitative methods have been used to conduct research in remote communities of the Northern Territory, rural South Australia and New South Wales from 1992 to 2005. Results Public health and population health can interface with Australian rural general practice in sustainable models described in case studies within this Thesis. There is a continuum of roles in this interface from population health in practice, public health, ‘new’ public health and leadership. Population health activities include screening and promotion of lifestyle factors to patients.7 Public health activities can be developed to extend the reach of health programs to the broader community. This may include participation in population based surveillance systems and health promotion projects. Promoters of ‘new’ public health 8,9 support an expansion of public health’s scope to include advocating social development through community participation and empowerment. Leadership can extend to policy development and liaison with general practice, population health and public health practitioners to promote collaborative models of health care. A sustainable model of increasing rural workforce recruitment via developing workforce capacity in public health and population health has been developed and evaluated as part of this Thesis. Conclusions This Thesis presents rural Australian case studies demonstrating integration of population health and public health roles with general practice. Vertically integrated workforce models have been developed, as part of this Thesis, which can facilitate recruitment to the rural health workforce. In the long term, educational models have been developed and evaluated as part of this Thesis. These models can increase the population health and public health expertise and capacity of this workforce. / MD Doctorate

During the period 1996 to 2003 the number of GP services per capita in Australia fell by 14 percent and the proportion of services bulk billed (ie provided at no cost to the patient) fell by 12 percentage points. The Government responded to these trends by outlaying hundreds of millions of dollars to increase Government medical insurance rebates, to increase the number of GPs in Australia, and to provide incentives for GPs to bulk bill. ¶ There has been no comprehensive modelling of the GP market to assist in understanding the reasons for either the declining trends or whether the Government responses were successful. This thesis aims to fill that gap. ¶ Previous Australian modelling of the GP market has been cross sectional and mostly demand focused. This thesis uses panel data to minimise the biases caused by unobserved heterogeneity and border crossing, and to estimate explicit supply and demand equations to enable the relationship between supply and demand to be explored. ¶ This approach estimates the impact on GP market outcomes of both policy decisions regarding rebates and GP numbers, and of external changes such as the trends in social attitudes and age. The likely future paths of the market without further policy change can be considered, and the measures needed to meet given policy targets determined. ¶ In addressing these questions it is also shown that supplier induced demand does apply in Australian general practice but is not material, that previous cross sectional analysis was biased due to border crossing by patients, that GPs who charge patients with concession cards less than other patients are behaving economically rationally, and that when the Government increases the Medicare rebate payment, 85% of the increase goes to the GP and 15% to the patient. The analysis also shows that GP density has no significant effect on mortality in Australia, and was unable to detect any effect of the business cycle on mortality. ¶ The demand curve for Australian general practice services is shown to be fundamentally determined by the real value of the MBS rebate in the short term, where the real value adjusted for growth in average weekly earnings. ¶ The supply curve is determined by aggregate numbers of GPs and by the number of services they each provide. The average number of services provided per GP is determined by GP age and gender, but more importantly by a trend effect thought to be due to attitudinal changes which must be explored further, and must be incorporated into any prediction of GP market outcomes. ¶ The thesis provides the first empirically based overview of the behaviour of the GP market at end of the twentieth century, and shows how Government policy levers and other trends interact to generate the market outcomes. If the Government has targets for service levels or charging patterns in general practice, these models can facilitate determination of the policy options appropriate to achieve those targets.

Research Doctorate - Doctor of Philosophy / This thesis explores the barriers that are preventing large numbers of permanent resident overseas-trained doctors (PROTDs) from working as general practitioners (GPs) in rural New South Wales (NSW). It focuses specifically on doctors from non-English speaking backgrounds who are permanent residents of Australia or Australian citizens, and who migrated to Australia for reasons other than employment. This thesis explores the views and perceptions of PROTDs and does not specifically consider the views of other stakeholders. Archival, qualitative and quantitative research techniques have been used to determine the suitability of the policies and practices governing the appointment and registration of PROTDs in NSW, and to identify any policy changes required. This research demonstrates that the policies governing medical registration in NSW have frequently been driven by political factors, and have, at times, been used to control the size of the medical workforce. As a consequence of these policies, many PROTDs have been prevented from working as a doctor in NSW. Of particular concern is the lack of training or clinical experience available to PROTDs and their difficulties preparing for, and passing, the Australian Medical Council (AMC) examinations. The lack of accurate information regarding the requirements and opportunities for medical practice in NSW is also a major problem. PROTDs in NSW are unable to get the training and support they need to meet the requirements for medical registration in NSW and are rapidly losing their confidence, and their clinical skills. Not all PROTDs are going to have, or be able to acquire, the skills and knowledge required for general practice in rural NSW. However the need for additional doctors is sufficiently great to warrant a proactive approach from governments and relevant agencies. In the seven years it has taken to complete this research, most of the discriminatory aspects of the assessment and registration of PROTDs in NSW have been removed. However the legacy of previous policies and practices remains and a large number of PROTDs remain out of the medical workforce.

This study has developed and evaluated two instruments, a questionnaire, the Grief Diagnostic Instrument, and an interview, the Grief Diagnostic Interview to detect and measure the extant state of grief in general practice patients. These instruments investigate grief from past, present and impending death and non-death related losses occurring directly to the patient, as well as caused indirectly through experiencing grief in sympathy with the grief of others. The unique feature of these instruments is that they investigate grief from all losses rather than merely a single loss. The questionnaire was demonstrated to be a concise, valid, reliable and sensitive measure, and acceptable to general practice patients. It is suitable for epidemiological studies to detect a broad range of losses and to investigate the prevalence and severity of grief in general practice patients. It is also suitable for comparing the course and severity of grief between losses and identifying commonalities and differences. The interview was found to be an acceptable and valid instrument for undertaking clinical studies. Suggestions for further evaluation of the instruments, and for their uses in grief research and as clinical tools have been proposed. The findings that 2/3 of the general practice population studied were experiencing loss and that over 1/4 of all subjects were suffering moderate or severe grief, demonstrate grief to be a previously unrecognised significant mental health issue for general practice. The most frequently encountered loss categories were 'quality of life', 'death', 'separation' and 'job'. Non-death related losses accounted for 4/5 of all the losses detected. The lack of recognition of grief by subjects was demonstrated, particularly relating to migration and relocation. The hypothesis that loss and grief are under diagnosed and under treated in general practice is supported. This indicates the need for a new paradigm of loss and grief in general practice and for large-scale studies to investigate grief in general practice patients and the detection rate by general practitioners. / Thesis (M.D.)--Department of General Practice, Department of Public Health, 2003.

Bibliography: leaves 554-636. / 637 leaves ; / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Examines aspects of teaching medical students communication skills at a time when they are entering their clinical years. Integrates reports of 12 data-gathering exercises centred on medical student communication skills with the international literature, and with the author's reflections as an experienced educator and G.P. Recommends that communication skills training in a general practice setting should be a crucial factor in all future training of medical students. / Thesis (M.D.)--University of Adelaide, Dept. of Psychiatry, 2000

Many depressed patients attend primary health care, and minority-group patients often see general practitioners for depressive symptoms. The diagnosis and classification criteria of depression and guidelines for management are based on symptoms. However,expressions of depression can vary with culture and gender but the diagnostic tools and guidelines are not adapted to gendered or cultural context and have shown to be poorly applicable in clinical practice. The purpose of this thesis was to analyse how socio-cultural factorswith focus on gender and ethnicity and their intersections- could influence the concept of depression from the perspectives of the patient and patient descriptions, of medical experts as well as general practitioners. By viewing these different perspectives I have tried to illustrate how depressive symptoms are expressed and interpreted in different gendered socio-cultural contexts and how they become a disease entity. Furthermore, I want, in particular, to illustrate a variety of difficulties that GPs may face during the process of care when meeting and treating men and women from different countries showing symptoms which may indicate depression. Study I. The aim of the study was to explore the reasons for and patterns of attendance among Roma women in primary health care and to shed light on health problems of the Roma. Four Roma women were interviewed in-depth. The data were audiotaped and analysed according to Grounded Theory. The resuIts showed that the daily life of women was characterized by marked hierarchical order and rules formed by gender, age and the collective culture. Young women had most rules to follow and if the rules were broken it was easy to end up outside the collective and display depressive symptoms or pain. The gendered, collective culture could both construct and/or form the concept of illness among the Roma women. Study II. The aim of the study was to highlight the gendered representations of lay persons´ experiences of depression by drawing on personal stories of depression that appeared in Swedish newspapers. The data were then subjected to a Qualitative Content Analysis. The mediated accounts of depression both upheld and challenged traditional gender stereotypes. The women’s stories were more detailed, relational, emotionally oriented, and embodied. The portrayal of men was less emotional and expressive, reflecting hegemonic patterns of masculinity. The media representations of gendered healthrelated beliefs and behaviours may influence the way patients, physicians and other health care professionals understand and communicate about issues of mental health and depression. Study III. The aim of the study was to explore how authors of medical articles wrote about different symptoms and expressions of depression in men and woman from various ethnic groups as well as to analyse the meaning of gender and ethnicity for expressions of depression. Through a search in the medical database PubMed 30 scientific articles were identified and included in the analysis. The result and the discussion section of each article was analysed with Qualitative Content Analysis. The analysis showed that culture and gender formed the expressions of depression, how depression was interpreted and the diagnosis of depression. The analysis of the articles identified a western point of view, which could lead to “cultural or gender gaps” and which could also influence the diagnosis of depression. Study IV. The aim of the study was to make a qualitative analysis of medical research articles in order to get a broader view of explanations of depression in men and women in various ethnic groups. Through a search in the medical database PubMed 60 scientific articles were identified and included in the analysis. The result and the discussion section of each article was analysed with Qualitative Content Analysis. The explanations for depression in our study have a strong emphasis on socio-cultural causes with focus on depressed persons from non-western minority groups. Even so, discussion about cultural or gendered explanations for depression was almost missing. We interpreted that the view of minority groups in the articles could be described as a view of “others”. The view of “othering” increases risks for cultural and gender gaps, such as biased scientific knowledge, medicalization of social problems, cultural stereotypes, risk for misdiagnosis of men´s depression, and affects the quality and care of depressed patients. Studv V. The aim of the study was to explore and analyse how GPs think and deliberate when seeing and treating patients from foreign countries who display potential depressive symptoms. The data were collected in focus group and individual interviews with GPs in northern Sweden and analysed by Qualitative Content Analysis. The study showed that patients’ early life events of importance were often unknown which blurred the accuracy. Reactions to trauma, cultural frictions and conflicts between the new and old gender norms made the diagnostic process difficult. The patient-doctor encounter comprised misconceptions, and social roles in meetings were sometimes confused. GPs based their judgement mainly on clinical intuition. Tools for management and adequate action were diffuse. There is a need for tools for multicultural, general practice care. It is also essential to be aware of the GPs’ own conceptions to avoid stereotypes and not to under-or overestimate the occurrence of depressive symptoms. Conclusion: The concept of depression is always situated. The gendered socio-cultural norms, beliefs and behaviours can both construct the concept of illness and influence patients’ experiences and expressions of depression as well as form the patient-doctor encounter. The knowledge of medical “experts” is based on a dominating, western view of knowledge, which defines diagnosis and classification criteria of depression as well as guidelines for management. GPs are struggling for clarity between the medical and the clinical practice. The multicultural appearances of depressive symptoms are a challenge for GPs but it is a challenge for society to improve the life circumstances which can lead to a depressed mood and suffering.

Einleitung: In Anbetracht der Qualitätssicherung und -verbesserung der Lehre finden Studentenevaluationen eine größer werdende Beachtung. Dies gilt auch für das Blockpraktikum Allgemeinmedizin. Bisherige Studien konnten belegen, dass die Studierenden diese Veranstaltung sehr positiv erleben. Jedoch gibt es keine ausreichenden Erkenntnisse darüber, ob und wenn ja, in welchem Umfang, sich das Berufsziel der Studierenden, sowie örtliche und zeitliche Rahmenbedingungen auf die studentischen Evaluationen auswirken. Das Ziel der vorliegenden Arbeit war es, die Entwicklung der Studentenzufriedenheit bezüglich des Blockpraktikums in einem Zeitraum von 2004 bis 2012 zu untersuchen. Darüber hinaus wurde überprüft, inwiefern die Dauer des Blockpraktikums (ganz- vs. halbtags), die Lage der Lehrarztpraxis (Groß- / Mittelstadt vs. Ländlich geprägter Raum), sowie das Berufsziel der Befragten die Zufriedenheit und den subjektiv bewerteten Lernerfolg von Studierenden beeinflussen. Methode: Das Blockpraktikum Allgemeinmedizin wurde an der Universität Leipzig gemäß der ärztlichen Approbationsordnung (2002) reformiert und seit 2004 in dieser Form von den Studierenden schriftlich evaluiert. Für die Teilnahme am Blockpraktikum standen hausärztliche Lehrarztpraxen in der Stadt Leipzig, im Leipziger Umland, sowie vereinzelt in benachbarten Bundesländern zur Verfügung. Die Studierenden des 7. / 8. Fachsemesters konnten dabei wählen, das Blockpraktikum entweder innerhalb des laufenden Semesters zwei Wochen lang halbtags, oder innerhalb der Semesterferien eine Woche lang ganztags zu absolvieren. Die Evaluation fand am Ende der Praktikumsphase statt. Im Rahmen der Evaluation wurden die allgemeine Zufriedenheit der Studierenden mit dem Blockpraktikum, das Erlernen von hausärztlichen Fähigkeiten und Fertigkeiten (z.B. Hausbesuche, Impfungen), sowie die didaktische Durchführung des Praktikums abgefragt. Als Antwortmöglichkeiten wurden 6 - und 10 - stufige Likert-Skalen vorgegeben. Die gesammelten Daten wurden in das Statistikprogramm SPSS 20.0 übertragen. Neben einer deskriptiven Auswertung erfolgten Gruppenvergleiche bezüglich der Dauer des Blockpraktikums, der Lage der Lehrarztpraxis und des Berufsziels, wobei verschiedene prüfstatistische Testverfahren wie der Chi -Quadrat-Test, der Mann-Whitney-U-Test und der Kruskal-Wallis-Test angewendet wurden. Ergebnisse: Im Rahmen dieser Studie konnten die Evaluationen von 2599 Studierenden (94,9 %) aus den Jahren 2004 bis 2012 ausgewertet werden. Die Teilnehmer waren mit der Qualität des Blockpraktikums insgesamt sehr zufrieden. Die Beurteilungen blieben innerhalb des untersuchten Zeitraumes konstant positiv. Es ließen sich beim Vergleich der einzelnen Jahrgänge keine tiefgreifenden Veränderungen im Sinne kontinuierlicher Tendenzen in den Evaluationen erkennen. Im Vergleich zum vormals bestehenden 2-Tages-Praktikum zeigte sich eine verbesserte Bewertung einzelner Kompetenzbereiche. Die Auswertungen der Gruppenvergleiche ergaben hinsichtlich der Studentenzufriedenheit und des Lernerfolges der Studierenden signifikante Unterschiede. So gingen die Teilnahme am Blockpraktikum innerhalb einer Woche ganztags und das Absolvieren des Blockpraktikums im ländlich geprägten Raum mit einer besseren Evaluation seitens der Studierenden einher. Zudem bewerteten Studierende mit dem definitiven Berufsziel Allgemeinmedizin die Veranstaltung noch einmal besser als ihre Kommilitonen. Schlussfolgerungen: Die Auswertung der Studentenevaluationen belegt, dass das Blockpraktikum Allgemeinmedizin von den Leipziger Studierenden überwiegend positiv wahrgenommen wurde. Die vorgestellten Ergebnisse können im Hinblick auf die zeitliche Gestaltung des Blockpraktikums und bei der Verteilung der Studierenden auf die Lehrpraxen einen wichtigen Beitrag leisten. Darüber hinaus scheinen junge Mediziner, die die Allgemeinmedizin als Karriereoption in Betracht ziehen, durch das Blockpraktikum in ihrem Berufsziel bestätigt zu werden. Weitere Studien sollten klären, inwiefern es noch weitere Faktoren gibt, die sich auf das studentische Erleben des Blockpraktikums Allgemeinmedizin auswirken.

Introduction: The aim of this study was to assess the patient, practice and practice management related factors contributing to non-adherence of type 2 diabetes mellitus clinical practice guideline in Estonia.Methods: Descriptive postal survey using a self-administered questionnaire. Results: Of the 354 doctors who received the questionnaire 46% (n=163) responded. 76% of them have type 2 diabetes guidelines. Low awareness of diabetes and its complications among patients as well as their low motivation to change their lifestyle were considered to be the biggest difficulties in managing individual patients. In addition to the most often listed problems, non-compliance with medical regimen, patients’ financial problems and their non-attendance were mentioned. The greatest health care systems related barriers to practices providing desirable care wereinadequate number of patients` educational materials, the lack of special diabetes education for nurses and underfunding. The patient related issues were regarded as problems in 96% of the cases and health care system related factors were mentioned in 79% of the cases. / <p>ISBN 91-7997-114-8</p>

Cardiovascular absolute risk (CVAR) assessment, which involves estimation of the probability of developing a cardiovascular event over time based on assessment of multiple risk factors, has been recommended by many clinical guidelines to improve cardiovascular disease (CVD) primary prevention. However, a lack of implementation strategies has hindered widespread translation of the guidelines into practice and little research has been conducted on developing and testing implementation strategies. The aim of this research was to develop an implementation model of CVAR assessment and management in Australian general practice. It consisted of development and feasibility studies, which were carried out in three phases. In Phase 1, I conducted focus groups and interviews to explore the views of general practitioners (GPs), patients and key informants on how the CVAR assessment and management should be implemented. My themes were based on a literature review, research done in preparation for this study, and relevant theoretical models. Key findings were used to develop a multi-strategy CVAR implementation model encompassing appropriate patient selection and preparation as well as the conduct of appropriate CVAR assessment and management. In Phase 2, using mixed methods research, I explored the application of the model and its impact on GPs and patients. This confirmed that appropriate patient selection, use of a patient self-assessment (SA) form, electronic CVAR calculator and management guideline, length of consultation, and training of GPs to develop skills in communicating CVAR results and in shared decision making (SDM) were important in improving CVAR assessment and management, and supporting patient involvement and active self-management. In Phase 3, using mixed methods research (including consultation recording analysis), I focused on the detailed process and content of CVAR consultations. This showed that at least 15 minutes??? consultation may be necessary. Quantifying the CVAR score using an electronic calculator was important to help motivate patients. Greater emphasis was needed in GP training on use of the patient SA form, SDM and intensification of medications and referrals in response to patient???s high CVAR. Barriers to referral also need to be addressed. This research demonstrated that the proposed implementation model was feasible in promoting the better use of CVAR assessment and management. This has important implications for future research, practice and policy. Further research is needed to investigate the effectiveness of the proposed model in reducing CVD risk and improving clinical outcomes and its applicability in other cultures and contexts.